Final Project Milestone Two: Literature Review

AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES AAIDD 2016, Vol. 121, No. 6, 520–532 DOI: 10.1352/1944-7558-121.6.520 Food Insecurity Among Young Adults With Intellectual and Developmental Disabilities in the United States:

Evidence From the National Health Interview Survey Debra L. Brucker and Derek Nord Abstract People with intellectual or developmental disabilities (IDD) face higher levels of poverty than others, which can lead to concerns regarding areas of well-being, such as food security.

Young adults with IDD who are, in many cases, transitioning from the system of educational, health care, and income supports of their youth into the adult world may be particularly vulnerable. Using pooled data from the 2011–2014 National Health Interview Survey, we find that young adults with IDD have significantly higher levels of food insecurity than young adults without disabilities, even when controlling for poverty. Young adults with IDD who are living in low-income households are not significantly more likely to participate in the Supplemental Nutrition Assistance Program (SNAP) than young adults without disabilities who are also living in low-income households. Although our results suggest that SNAP is effectively reaching many young adults with IDD in need of nutrition assistance, further research is needed to determine the specific effects of food insecurity and SNAP participation on overall economic and health outcomes for this population. Key Words:intellectual disability; developmental disabilities; food security; Supplemental Nutrition Assistance Program Developmental disabilities, severe long-term dis- abilities that appear before age 22, can be cognitive, physical, or both (American Association on Intellectual and Developmental Disabilities, 2013). Examples include blindness from birth, cerebral palsy, epilepsy, Down syndrome, and fetal alcohol syndrome (National Institutes of Health, 2015). Intellectual disability, a type of develop- mental disability with an onset prior to age 18, includes significant limitations in both intellectual functioning and adaptive behavior (American Association on Intellectual and Developmental Disabilities, 2013). In the United States, people with intellectual or developmental disabilities (IDD) face higher levels of poverty than other people, for several reasons. First, poverty is associated with a higher prevalence of IDD in the general population (Emerson, 2007). Second, people with IDD have lower levels of employ-ment. Lastly, many people with IDD confront high costs in accessing necessary adaptive equip- ment, medical care, and supportive services (New- acheck & Kim, 2005; Parish & Cloud, 2006). This combination of factors can result in lower overall levels of economic stability, which, in turn, can influence other areas of well-being. Food security, for example, may be at risk for this population.

Levels of food security among young adults with IDD are of particular interest, as they are, in many cases, transitioning from the system of education- al, health care, and income supports of their youth into the adult world. Using data from the National Health Interview Survey, we find that young adults with IDD are more likely to live in food insecure households than other young adults. On a positive note, many of the young adults with IDD who are living in food insecure households are accessing available nutrition assistance through 520Food Insecurity the Supplemental Nutrition Assistance Program (SNAP). Following a review of the relevant literature, our analysis and results are described in more detail. Literature Review Food security can be conceptualized as having enough food for a healthy, active life. Where food security is lacking, government programs can provide some measure of assistance. In the United States, many federal, state, and local public agencies provide income and in-kind support to enhance economic stability for low-income indi- viduals and families. Some of these programs specifically target food security and are available to any person or family that meets economic eligibility criteria. SNAP, for example, provides monthly benefits to families who meet resource and income guidelines. SNAP benefits can only be used to purchase food. Other programs offer more general financial assistance and are targeted specifically towards certain subpopulations, in- cluding people with disabilities. For instance, Supplemental Security Income (SSI) is a means- tested program that provides monthly income support to eligible persons who are aged, blind, or disabled. Recipients can use SSI funds as needed to address economic needs, including food security. The Social Security Disability Insurance (SSDI) program, a social insurance program that provides income support to disabled workers and their dependents, is another important source of support to many people with disabilities, provid- ing monthly income that can be used for household expenses.

In addition to the income and in-kind supports mentioned above, many people with IDD access formal, specialized supports through existing public education, health care, and voca- tional rehabilitation systems. These supports play an important role, allowing many people with IDD to achieve their educational, employment, residential, and other community living goals.

Despite the availability of community-based supports, however, poverty disproportionately affects people with IDD. Compared to families that do not include a child with IDD, past research has shown that having a child with IDD is related to greater work instability and higher rates of poverty for single mothers (Parish, Roderick, Swaine, Dababnah, & Mayra, 2012) and higherlevels of financial distress and food insecurity for two-parent households (Parish, Seltzer, Greenberg, & Floyd, 2004). These are notable relationships considering that the majority of people with IDD, even as adults, live with their families (Braddock et al., 2013; Fujiura, 1998; Williamson & Perkins, 2014). In addition, many people with IDD have support-related expenses, such as adaptive equip- ment or specialized therapies, that can result in a financial burden (Parish, Rose, & Swaine, 2010).

Poverty is closely tied to a lack of employment opportunities in general and, more specifically, to a lack of access to quality jobs. Much of the national disability policy attention is focused on the economic needs of young adults who are transitioning from the system of supports available for youth with disabilities to a more fragmented adult system. Several initiatives, including the Workforce Innovation and Opportunity Act and the Promoting Readiness Among Minors in Supplemental Security Income demonstration project, target education and employment as ways to improve the long-term economic stability of people with disabilities. Employment among people with IDD is low. Recent data from the National Core Indicators Project suggest that, in 2012-2013, only 10% of people with IDD receiving long-term services and supports worked in individual competitive or supported jobs (Bradley et al., 2015). Those who are employed typically work limited hours while earning near the federal minimum wage (Boeltzig, Timmons, & Butterworth, 2009; Nord & Nye-Lengerman, 2015). Although programs to increase employ- ment opportunities are clearly necessary, research is needed to understand the current effects of poverty on young adults with IDD.

Overall, people with disabilities are more likely to live in households that are food insecure and are more likely to participate in SNAP than other populations in the United States (Brucker, Mitra, Chaitoo, & Mauro, 2015; Coleman-Jensen & Nord, 2013; Houtenville & Brucker, 2014; RTI International, 2014). The population of people with disabilities is heterogeneous, however, and people with different types of disabilities experi- ence vastly different economic outcomes (Brucker, Houtenville, & Lauer, 2015). Risks of food insecurity and levels of SNAP participation may vary by disability type as well. Past research has suggested that college-aged young adults experi- ence lower levels of food security (Chaparro, Zaghloul, Holck, & Dobbs, 2009; Maroto, Snel- D. L. Brucker and D. Nord 521 AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES AAIDD 2016, Vol. 121, No. 6, 520–532 DOI: 10.1352/1944-7558-121.6.520 ling, & Linck, 2014; Resnikoff, 2014). Our population of interest here—young adults with IDD—may, therefore, have levels of food security that differ not only from those experienced by the general young adult population but also from levels of food security experienced by young adults with other types of disabilities. Young adults with IDD face a unique set of circumstances when transitioning to adulthood, which may significantly impact their economic well-being (Foley, Dyko, Girdler, Bourke, & Leonard, 2012).

This leads to our first set of hypotheses:

1. Young adults with IDD are more likely to live in food insecure households than other young adults, holding all other variables constant.

2. Young adults with IDD are more likely to live in food insecure households than other young adults with disabilities, holding all other variables constant.

Although poverty among people with IDD can increase the risk of food insecurity, high levels of participation by peoples with IDD in other public programs may increase the likeli- hood of participating in public nutrition assis- tance programs. SNAP is an important source of support for low-income families facing food insecurity, as SNAP has been found to decrease levels of food insecurity (Gunderson & Ziliak, 2015; Nord & Golla, 2009). Research on SNAP participation among people with IDD has been limited thus far. Seo, Abbott, and Hawkins (2008) found that young adults who had learning disabilities were significantly more likely to participate in public income and in-kind support programs, including SNAP. People with IDD are likely to participate in public disability benefit programs such as SSI and SSDI, programs that have high levels of cross-participation with SNAP (Houtenville & Brucker, 2014). In most states, SSI recipients are automatically eligible to receive SNAP (Trenkamp & Wiseman, 2007). In addi- tion, SNAP applications are available at Social Security Administration field offices, which handle eligibility screening for SSI and SSDI.

This leads to our final two hypotheses:

3. Controlling for levels of food security as well as demographic variables, young adults with IDD are more likely to participate in SNAP than other young adults.4. Controlling for levels of food security as well as demographic variables, young adults with IDD are more likely to participate in SNAP than young adults with other disabilities. Methods Data Pooled cross-sectional data from the National Health Interview Survey (NHIS), years 2011–2014, were used. The NHIS is a nationally representative annual household survey conducted by the U.S.

Centers for Disease Control and Prevention (CDC). This survey is the primary data source studying illness and disability of the civilian, noninstitutionalized population in the United States, and it is widely used in public health and public policy circles to understand demographic and socioeconomic factors related to these char- acteristics, as well as to evaluate programs.

Using a complex sampling process, the NHIS routinely collects data on health behaviors, health conditions, health care utilization, and health care coverage for the United States. Additional mod- ules to the survey collect complementary data.

The Food and Nutrition Service of the U.S.

Department of Agriculture began funding the collection of a 30-day adult food security module as part of the NHIS in 2011. This module was the source of the food security information analyzed here. The NHIS also includes information about disability, capturing detailed questions about disabilities, other health conditions, and receipt of public disability benefits.

The NHIS randomly samples one adult per family and the responses are self-reported. In the event the respondent is unable to participate due to physical or cognitive limitations, a proxy who knows the respondent is allowed to respond (Centers for Disease Control and Prevention, 2015). This approach allows for greater represen- tation of people with more significant disabilities.

The 4-year sample was restricted to adults age 18–25 (unweightedN¼44,080). This sample was the basis for most of the analysis described in this article. In addition, for a portion of the analysis, this sample was further restricted to only those adults age 18–25 who were living in food insecure households (unweightedN¼6,793). In all cases, data were weighted using guidance from the CDC to achieve annualized results.

522Food Insecurity AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES AAIDD 2016, Vol. 121, No. 6, 520–532 DOI: 10.1352/1944-7558-121.6.520 Measures Food insecurity.Food insecurity was mea- sured at the family level as a lack of consistent access to enough food for active, healthy lives.

Since 2011, 10 questions have been included in the NHIS to assess adult 30-day food security. The questions measure different facets of food security:

being worried that food would not last, food not lasting until there was money to buy more, not eating balanced meals, eating less than one should, being hungry but not eating, losing weight because there was not enough food, cutting or skipping a meal, not eating for a whole day, the number of days that a meal was skipped, and the number of days that a person did not eat for a whole day. The NHIS uses this information to create a family food security status variable, categorizing people as living in families that are food secure or food insecure. For the analyses conducted here, this variable was flipped to create a food insecurity variable that assigned a value of one for‘‘food insecure’’and a value of zero for‘‘food secure.’’ Disability.Given that many people with disabilities experience food insecurity, a categori- cal variable was constructed to measure disability.

Respondents who did not indicate IDD, any of the six disability limitations commonly used to measure disability in federal surveys, nor any SSA disability benefit receipt were assigned a value of zero. People with IDD were assigned a value of one. For this study, IDD was measured following guidelines used by other researchers who have used the NHIS to identify people with IDD. Boyle and colleagues (2011) used the NHIS to identify youth with developmental disabilities and others have verified that the NHIS is a reasonable source to identify people with IDD (Bonardi, Lauer, Noblett, Taub, & Bershadksy, 2011; Zablotzky, Black, Maenner, Schieve, & Blumberg, 2015). The following limitations were therefore grouped into a broader‘‘intellectual and developmental disabil- ity’’indicator: attention-deficit/hyperactivity dis- orders (ADHD), autism spectrum disorders, epilepsy/seizures, genetic disorders, learning dis- abilities, intellectual disability, other developmen- tal disabilities (e.g., cerebral palsy), and stammering/stuttering. Of the unweighted sample of 44,080 young adults, 605 (1.38%) had one of these conditions. Lastly, people without IDD who had a positive indication either on any of the six questions used to identify disability in federal surveys or on receipt of SSA disability benefits were assigned a value of two.For comparison purposes, we also ran our analyses using a narrower definition of IDD that did not include ADHD, learning disabilities, or stammering/stuttering. The main results were similar and are available from the authors.

SNAP.Teasing out the relationship between SNAP participation and food insecurity is com- plicated by the fact that much of the publicly available survey data that capture information about SNAP receipt face issues of both underre- porting and selection bias (Currie, 2003; Kreider, Pepper, Gundersen, & Jolliffe, 2012; Meyer, Mok, & Sullivan, 2009). We thus do not include SNAP as a covariate of food insecurity in our first regression. We do include SNAP receipt in our second regression as the dependent variable, however, and attempt to correct somewhat for selection bias by restricting our sample for that analysis to only those young adults who are living in households that may be eligible for SNAP and by controlling for levels of food insecurity.

Given that food insecurity is measured on a 30-day basis and SNAP participation is measured as‘‘any participation over the past year,’’a variable was created to indicate past month participation in SNAP. The NHIS collects information about how many months a family participated in SNAP during the past year. Families that reported continual use of SNAP over the past 12 months were therefore assumed to have participated in SNAP during the past 30 days. A value of one was assigned to people living in households that met this condition.

Although using this process helps to guard against overestimating past month SNAP receipt as would occur by using the‘‘any use over the past year’’variable, it might also underestimate usage to some extent, as it will miss people who used SNAP in the last month and possibly other months but only for a portion of the year. We erred on the side of providing a conservative estimate of SNAP receipt.

Control variables.Control variables included age as well as those mentioned in the literature as possibly influencing economic and food security for people with disabilities. Variables were dichot- omized to assign a value of one to indicators associated with higher levels of economic and food security (White, non-Hispanic, male, income greater than 150% of the federal poverty line, high school education or higher, and employment in the past week). Dummy variables were created to indicate different family types (multiple adults, no D. L. Brucker and D. Nord 523 AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES AAIDD 2016, Vol. 121, No. 6, 520–532 DOI: 10.1352/1944-7558-121.6.520 children under age 18; one adult, one or more children under age 18; multiple adults, one or more children under age 18). One adult with no children under age 18 was used as the reference group for family type.

Analytical Plan Univariate statistics were first used to examine the focal variables of interest for young adults with IDD, comparing them to those for young adults without disabilities. Next, logistic regressions were conducted to test our hypotheses. To test the hypotheses examining food insecurity, the model followed the specification below:

Findicates the outcome of interest (food insecurity) of individualiwho lives in locationj.

F ijis a function of his or her underlying disability (H ij), personal characteristics (X ij), SNAP partici- pation (Z ij), and unobservable factors (e ij)as follows:

F ij¼fðH ij;X ij;Z ij;eijÞ For the analysis conducted here,Xcontained gender, age, race, Hispanic ethnicity, employment, educational attainment, poverty status, and living arrangements.Zcontained SNAP participation.

SSI and SSDI receipt could not be included as control variables because they were used to construct the disability variable.

A similar process was used to examine the hypotheses related to SNAP participation, with several small changes. First, the sample was restricted to only those young adults who were living in households with incomes below 125 percent of the federal poverty line, as a rough approximation of people who might be living in households eligible for SNAP. Second, employment and food insecu- rity were added as covariates. The interaction of food insecurity status with disability type was included as well. Lastly, SNAP participation was not included as a control variable but as the dependent variable. Although multivariate, all of these regressions are descriptive in nature and are not meant to establish causality. Such limitations are discussed later. All analyses were conducted using Stata, allowing for appropriate weighting and consideration of sampling design effects. Results Table 1 shows the demographics of the young adult sample. The sample was evenly split bygender. Most (76%) of the sample was White.

Seventy-nine percent were non-Hispanic. Nearly 58% worked in the past week. Most of the sample lived in households with multiple adults, with or without children under the age of 18. Over 30% of the sample was living in households with incomes below 125 percent of the poverty line. Only 1.4% of the sample had IDD. Nearly twice as many (2.5%) had some other type of disability. In terms of public disability benefit receipt, less than 2% of the sample was receiving SSI, less than 1% was receiving SSDI, and only a small portion (0.3%) was receiving both SSDI and SSI.

Table 2 shows the demographics of the young adult sample by disability status. Overall, people with disabilities (IDD or other limitations) were more likely to be male, White, and non-Hispanic.

Large differences existed in terms of educational attainment and employment, with young adults with IDD having the lowest levels of educational attainment and employment. Young adults with IDD were more likely to live in households with multiple adults than young adults with other limitations, but were slightly less likely to live in households with incomes less than 125 percent of the poverty line. An estimated 44% of young adults with IDD received SSI, 21% received SSDI, and 10% received SSI and SSDI.

Table 3 shows differences in food insecurity, any SNAP participation, and all year SNAP participation by disability status. Although rates of household food insecurity were fairly similar between young adults with IDD and other limitations, significantly fewer people with IDD lived in households that participated in SNAP compared to people with other types of limita- tions, at any time or for an entire year.

Table 4 shows results from the logistic regression used to test our first two hypotheses.

Young adults with IDD had significantly higher odds (OR: 2.90,p,.001) of living in food insecure households than young adults who do not have a disability, confirming our first hypothesis. Young adults with other limitations had slightly higher odds (OR: 3.02,p,.001) of living in a food insecure household than young adults with IDD, however. Young adults who were White, non-Hispanic, better educated, employed, or lived in families with higher incomes had lower odds of living in food insecure households.

Gender and age were not significantly related to food insecurity. Those living in households with 524Food Insecurity AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES AAIDD 2016, Vol. 121, No. 6, 520–532 DOI: 10.1352/1944-7558-121.6.520 multiple people had higher odds of experiencing food insecurity.

Table 5 shows results from the logistic regression used to test our final two hypotheses.

Among young adults who were living in house- holds with incomes below 125 percent of the poverty line, young adults with IDD did not have significantly higher odds of past month SNAP participation compared to young adults without disabilities. People living in food insecure house- holds had significantly higher odds of SNAP participation. Households with multiple adults or children under the age of 18 also had increased SNAP participation, compared to households that Table 1 Sample Characteristics, Youth Age 18–25, 2011– 2014 National Health Interview Survey Weighted Unweighted Total 34,514,090 44,080 %% s.e.

Gender Male 50.43 49.79 0.28 Female 49.57 50.21 0.28 Race White 75.80 71.40 0.41 Black 15.01 16.21 0.37 Asian 5.16 6.98 0.18 Multiple 2.73 3.21 0.11 American Indian 1.08 1.46 0.12 Not reported 0.00 0.31 Ethnicity Non-Hispanic 79.25 71.89 0.44 Hispanic 20.75 28.11 0.44 Educational attainment Less than high school 17.86 19.42 0.35 High school 26.22 27.31 0.36 Some college 43.09 41.70 0.53 Bachelor’s 11.61 10.41 0.30 Master’s or more 1.22 1.16 0.08 Employment status Worked past week 57.83 57.26 0.41 Not 42.17 42.74 0.41 (Table 1 continued) Table 1 Continued Weighted Unweighted Family type One adult, no children under 1815.48 14.3 0.86 Multiple adults, no children under 1844.09 42.25 0.50 One adult, 1 or more children under 181.98 2.32 0.00 Multiple adults, 1 or more children under 1838.45 41.13 0.61 Poverty Less than 125% 30.75 15.44 0.78 Not 69.25 84.56 0.78 Disability IDD 1.38 1.37 0.00 Non IDD limitation 2.53 2.52 0.00 Disability benefit receipt Supplemental Security Income (SSI)1.69 1.66 0.00 Social Security Disability Insurance (SSDI)0.81 0.82 0.00 SSI & SSDI 0.33 0.33 0.00 Note. IDD¼intellectual and developmental disabilities.

Source: Authors’ analysis of 2011–2014 NHIS data.

Civilian, noninstitutionalized, aged 18–25. D. L. Brucker and D. Nord 525 AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES AAIDD 2016, Vol. 121, No. 6, 520–532 DOI: 10.1352/1944-7558-121.6.520 Table 2 Demographics by Limitations, Young Adults Age 18–25, 2011–2014 National Health Interview Survey IDD Other limitation No limitation Sig.

%% % s.e.s.e.s.e.

Gender Male 54.52 57.19 50.12 *** 2.31 1.38 0.28 Female 45.48 42.81 49.88 2.31 1.38 0.28 Race White 72.21 71.70 76.01 *** 2.23 1.39 0.40 Black 18.16 21.11 14.74 1.80 1.24 0.36 Asian 2.98 2.53 5.29 0.72 0.41 0.18 Multiple 5.53 3.85 2.64 1.18 0.53 0.11 American Indian 1.09 0.77 1.09 0.44 0.23 0.12 Ethnicity Non-Hispanic 82.37 84.70 79.08 *** 1.73 1.06 0.45 Hispanic 17.63 15.30 21.00 1.73 1.06 0.45 Educational attainment Less than high school 41.38 34.95 16.89 *** 2.53 1.39 0.35 High school 43.78 33.57 25.70 2.42 1.26 0.37 Some college 13.12 27.14 44.11 1.71 1.29 0.53 Bachelor’s 1.34 3.95 12.04 0.52 0.63 0.31 Master’s or more 0.38 0.39 1.26 0.27 0.21 0.00 Employment status Worked past week 22.53 32.25 59.3 *** 2.29 1.35 0.43 Not 77.47 67.75 40.7 2.29 1.35 0.43 Family type One adult, no children under 18 7.72 13.09 15.68 *** 1.31 1.09 0.88 (Table 2 continued) 526Food Insecurity AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES AAIDD 2016, Vol. 121, No. 6, 520–532 DOI: 10.1352/1944-7558-121.6.520 included only one adult. Males, Whites, people living in homes with incomes over 150 percent of the poverty line, those with a high school education or higher, and those who worked during the past week had significantly lower odds of SNAP participation. Discussion Overall, our results confirm that young adults with IDD are more likely to live in food insecure households than other young adults, holding all other variables constant. Odds of living in a food insecure household were high for young adults with IDD (OR: 2.67,p,.001) or other types of disability (OR: 2.79,p,.001), suggesting that young adults with IDD fare similarly to young adults with other types of disabilities in terms of household food insecurity. Even when controlling for key variables such as employment and poverty, young adults with disabilities face a significantly higher risk of living in food insecure households.

Federal, state, and local programs and policiesdeveloped to improve community living and economic security for people with IDD must, therefore, take into account the very real challeng- es of food security.

As solutions are considered, it is important to consider the added costs of living with a disability. These costs may arise from specialized medical and dietary care (Academy of Nutrition and Dietetics, 2015), equipment (Parish, Rose, & Swaine, 2010), and supports. Such costs could be contributing factors to poverty, food insecurity, and SNAP participation. The level of economic support provided to young adults with IDD through public income assistance, social insur- ance, and in-kind programs may not be fully recognizing these costs, creating a critical policy and programmatic gap that directly relates to food insecurity.

We also find that, among young adults living in households with incomes below 125 percent of the poverty line, young adults with IDD are not more likely to participate in SNAP than other young adults who live in similar households. This Table 2 Continued IDD Other limitation No limitation Sig.

%% % s.e.s.e.s.e.

Multiple adults, no children under 18 50.41 46.56 43.90 2.35 1.48 0.52 One adult, 1 or more children under 18 1.14 2.88 1.96 0.44 0.46 0.00 Multiple adults, 1 or more children under 18 40.73 37.47 38.46 2.26 1.54 0.61 Poverty Less than 125% poverty 39.99 47.71 29.94 *** 2.56 1.80 0.80 Not 60.01 52.29 70.06 2.56 1.80 0.60 Social Security Administration benefits Supplemental Security Income (SSI) 43.97 30.56 — *** 2.44 1.38— Social Security Disability Insurance (SSDI) 20.48 14.99 — *** 2.01 0.97— SSI & SSDI 10.03 5.50 — *** 1.50 0.61— Note. IDD¼intellectual and developmental disabilities.

***p,.001.

D. L. Brucker and D. Nord 527 AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES AAIDD 2016, Vol. 121, No. 6, 520–532 DOI: 10.1352/1944-7558-121.6.520 is not to say that people with IDD are not likely to receive SNAP overall, but, rather, that their odds of living in a family that receives SNAP are similar to the odds found among other young adults who live in low-income families. Young adults with other limitations are more likely to live in households that participate in SNAP. These results suggest SNAP is successfully reaching many low- income households that include young adults with disabilities, at least at rates similar to thosefound among young adults without disabilities.

Additional research is needed, however, to under- stand how SNAP benefits are influencing the overall economic stability of households that include a young adult with IDD or other types of disabilities. As people with disabilities are more likely to participate in income and in-kind assistance programs, the flow of resources through- out the month is an area in need of further research. Both SSI and SNAP benefits, for Table 3 Food Insecurity and SNAP Receipt by Disability Status, Young Adults Age 18–25, 2011–2014 National Health Interview Survey IDD Other limitation No limitation Sig.

%% % s.e.s.e.s.e.

Food insecure 36.80 37.90 14.90 *** 3.01 2.14 0.36 Any SNAP participation 31.30 41.60 17.40 *** 2.40 1.60 0.37 All year SNAP 23.50 28.40 10.70 *** 2.04 1.46 0.27 Note. SNAP¼Supplemental Nutrition Assistance Program. IDD¼intellectual and developmental disabilities.

***p,.001.

Table 4 Food Insecurity Among Young Adults Age 18–25, 2011–2014 National Health Interview Survey ORs.e. Sig. 95% CI, LL 95% CI, UL IDD 2.90 0.39 *** 2.25 3.72 Other limitation 3.02 0.30 *** 2.49 3.66 (Reference group: No limitation) Male 1.00 0.04 NS 0.92 1.09 Age 1.00 0.01 NS 0.98 1.03 White 0.69 0.04 *** 0.61 0.78 Non-Hispanic 0.67 0.04 *** 0.60 0.75 Multiple adults, no kids 1.29 0.11 ** 1.08 1.53 One adult, 1þkids 1.44 0.20 ** 1.10 1.88 Multiple adults, 1þkids 1.50 0.13 *** 1.27 1.78 (Reference group: One adult, no kids) Not,125% poverty 0.51 0.03 *** 0.46 0.56 High school education or more 0.54 0.03 *** 0.49 0.59 Worked last week 0.88 0.04 ** 0.80 0.96 Constant 0.51 0.13 ** 0.31 0.84 Obs¼22017 F(12, 289)¼85.04,p¼.000 Note. IDD¼intellectual and developmental disabilities.

***p,.001.

528Food Insecurity AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES AAIDD 2016, Vol. 121, No. 6, 520–532 DOI: 10.1352/1944-7558-121.6.520 example, are provided electronically on the first day of each month. Families that rely on these benefits to meet expenses must therefore develop budgets that are effective in lasting throughout the month. Families that include a person with a disability, however, may have additional health care or other support expenses that arise and make such budgeting difficult.

Young adults with IDD may need access to more structured educational opportunities that address issues of budgeting, food purchasing, and nutrition. The federal Department of Agriculture currently promotes SNAP-Ed interventions within states, with a goal of reducing obesity and improving healthy eating among SNAP recipients.

States typically provide a combination of free in- person classes and online or hard copy resources that address issues such as budgeting, shopping guidance, and healthy food preparation. Because these resources tend to be directed towards the general population, it is important to makeadaptations to accommodate different audiences, such as families and people with disabilities, including people with IDD.

Overall, this study highlights that the negative effects of poverty include an increased risk of food insecurity for young adults with IDD. Poverty is a complex and overarching issue that pervades the lives of many people with disabilities and is associated with poor economic, education, health, and social outcomes (Gershoff, Aber, Raver, & Lennon, 2007; Halfon, Larson, Lu, Tullis, & Russ, 2014; Holzer, Whitmore Schanzenbach, Duncan, & Ludwig, 2008; McDonough, Sacker, & Wiggins, 2005). In considering new interventions and polices to address food insecurity, a better understanding about the intersection of food insecurity and these life domains is critical in order to parse out the effects of other variables.

Limitations of this research include the use of cross-sectional data that do not allow for any establishment of causality. With regards to Table 5 Past Month SNAP Participation Among Young Adults Age 18–25 Who Live in Households With Incomes Less Than 125% of Poverty Line, 2011–2014 National Health Interview Survey OR s.e. Sig.95% CI, LL95% CI, UL IDD1.25 0.44 NS 0.63 2.48 Other limitation2.08 0.46 ** 1.35 3.20 (Reference group: No limitation) Food insecure 1.70 0.15 *** 1.43 2.03 Male 0.88 0.06 NS 0.77 1.01 Age 1.04 0.02 * 1.01 1.08 White 0.70 0.08 ** 0.56 0.89 Non-Hispanic 1.44 0.15 ** 1.17 1.78 Multiple adults, no kids 9.43 1.96 *** 6.27 14.22 One adult, 1þkids 43.90 9.10 *** 17.82 39.52 Multiple adults, 1þkids 26.54 5.36 *** 17.83 39.52 (Reference group: One adult, no kids) High school education or more 0.67 0.06 *** 0.56 0.80 Worked last week 0.68 0.05 *** 0.59 0.79 Food insecure * IDD 1.71 0.94 NS 0.58 5.05 Food insecure * Other limitation 0.94 0.31 NS 0.49 1.81 (Reference group: Food insecure * No limitation) Constant 0.02 0.01 *** 0.01 0.04 Obs¼5,831 F(14, 286)¼49.07p¼.0000 Note. SNAP¼Supplemental Nutrition Assistance Program. IDD¼intellectual and developmental disabilities. NS¼Not significant.

*p,.05; **p,.01; ***p,.001.

D. L. Brucker and D. Nord 529 AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES AAIDD 2016, Vol. 121, No. 6, 520–532 DOI: 10.1352/1944-7558-121.6.520 SNAP, selection bias and underreporting remain concerns with interpreting the current analysis.

Omittedvariablesbiasisalsoaconcern.The income measures available in the public-use NHIS files are broad in nature, reducing the ability to examine differences in income in fine detail. Similarly, the IDD variable groups togeth- er people with diverse conditions. As a result, it is impossible to determine the exact level of an individual’s impairment and how the impairment affects the outcome. In addition, the construc- tion of the past month SNAP receipt variable likely underestimates the true number of people who participated in SNAP during the past month. Future research can address these con- cerns. Research that examines food insecurity over time for people with IDD, from childhood through adulthood, could better identify oppor- tunities for policy improvements. Conclusion Food insecurity is a concern for nearly one-third of young adults with IDD. Advocates and policy- makers must, therefore, continue to keep this issue at the forefront of new policy innovations as broader initiatives that seek to improve overall economic stability are implemented. References Academy of Nutrition and Dietetics. (2015).

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Received 2/4/2016, accepted 2/26/2016.

The authors would like to thank two anonymous reviewers for their comments. This project was funded by the U.S. Department of Agriculture, Economic Research Service Agreement #58-5000-4-0026 and by Cooperative Agreement #H133B080005 from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR), U.S.

Department of Health and Human Services. The findings and conclusions are those of the authors and do not represent the policy of either the U.S. Department of Agriculture or the U.S. Department of Health and Human Services. The authors retain sole responsibility for any errors or omissions.

Authors:

Debra L. Brucker,University of New Hampshire, Institute on Disability; andDerek Nord, University of Minnesota, Institute on Community Integration, Research and Training Center on Community Living. Derek Nord is now at the University of Indiana, Indiana Institute on Disability and Community.

Correspondence concerning this article should be addressed to Debra L. Brucker, University of New Hampshire, Institute on Disability, 10 West Edge Drive, Suite 101, Durham, NH 03824, USA (e- mail: [email protected]).

532Food Insecurity AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES AAIDD 2016, Vol. 121, No. 6, 520–532 DOI: 10.1352/1944-7558-121.6.520