Child Maltreatment and Policy in the United States
The etiology of child maltreatment is profoundly influenced by families’ well-being and by a complex network of social, community, and societal supports and policies. Racism embedded in these systems has led to large inequities in wealth and advantage, which in turn are widely believed to drive racial and ethnic disproportionalities in the child welfare system (ie, 1 group’s representation in child welfare being out of proportion with their representation in the general population). It has been recognized that a public health, multisectoral, and multifaceted approach is needed to substantially reduce child maltreatment in the United States.1 Yet, we too often look to the child welfare system to respond to these problems when it is neither positioned nor adequately funded to comprehensively address root causes of maltreatment and inequities.
The policy focus for child maltreatment in the United States has historically been more reactive than proactive or prevention-based. In 1971, the Comprehensive Child Development Act was passed by Congress but vetoed by the President. This bipartisan legislation would have created a multibillion-dollar national child care system with the intent of supporting early child development and parental workforce participation. Three years later, in 1974, the Child Abuse Prevention and Treatment Act (CAPTA) was first passed, setting standards for receiving and responding to allegations of child abuse and neglect. CAPTA was and remains important and necessary policy. However, the early 1970s could be understood as a decision point when the collective emphasis for the approach to child maltreatment in the United States was set as investigative and surveillance-based, rather than prevention-focused.
Child Care in the United States
State and federal funding for child care and early education in the United States have failed to meet the societal need. In 2017, the United States ranked 35th among 37 countries tracked by the Organization for Economic Cooperation and Development in government spending on early childhood education and care.2 Because of low levels of funding, only 15% of 12.8 million eligible children in 2018 received child care subsidies through the state-federal Child Care and Development Fund block grant, the largest federal program subsidizing child care for low-income families.3 Families living in poverty spend on average 30% of their income on child care, and inequities in the geographic availability of quality child care options correlate with socioeconomic status and race.4 Limited supply and access, lack of affordability, and low levels of governmental funding leave child care unattainable for far too many Americans.
Build Back Better Offers Solutions for Child Care and Maltreatment
The Build Back Better (BBB) plan offers an opportunity to invest in the upstream primary prevention of child maltreatment. Many of the policies contained in the BBB framework have an evidence base to support their capacity to prevent child maltreatment, including child care subsidies,5 tax credits,5,6 housing assistance,5,7 and expansions in affordable health care.5,8 Even modest improvements in families’ economic well-being, whether it be through economic and concrete supports or reductions in out-of-pocket expenses, have been shown to decrease rates of child maltreatment and have the endorsement of the Centers for Disease Control and Prevention as a prevention strategy for child maltreatment.9–11 There are numerous reasons why the aforementioned policies are good for the well-being of children and families, and evidence suggests that the prevention of child maltreatment should be among them. However, with the lapse of the Child Tax Credit and the fate of BBB being in doubt (as of Spring 2022), advocates must look for progress where it might be most attainable.
The BBB plan proposes to make the largest investment in child care in US history, something that we as a nation failed to do in 1971. The BBB plan would invest $273 billion in child care for children up to 5 years of age and $109 billion to fund free universal preschool for children 3 and 4 years of age, both over the next 6 years.12 This would be a seismic change for the landscape of child care and early education in the United States, offering numerous benefits for families’ economic stability, parental workforce participation,13 children’s developmental and educational outcomes,14 and would constitute a promising step toward addressing inequities.4
Universal child care and early education could also have considerable implications for the prevention of child maltreatment by decreasing families’ out-of-pocket expenses and increasing income through higher workforce participation, particularly among mothers.13 Better access to quality child care might also reduce family stress, supervisory neglect, and families’ need to use inappropriate alternative caregivers, who may perpetrate physical or sexual abuse. Greater spending on child care for lower-income families has been associated with lower rates of maltreatment, foster care placements, and maltreatment-related fatalities.5 And policies making child care subsidies more available to families already involved with the child welfare system have been associated with less need for foster care.15
Using estimates from Puls et al for the associations between spending on public benefit programs, including child care, Medicaid, and cash, housing, and in-kind assistance,5 and data from the Children’s Bureau’s annual Maltreatment Reports,16 we estimate here that the investments in the BBB plan for child care alone might reduce investigations for suspected maltreatment by 6.4%, victimization by 6.0%, foster care by 3.1%, and maltreatment-related fatalities by 11.6%. Application of these estimates to 2014 to 2019, mirroring the 6-year funding period proposed in BBB, yields a striking number of potentially safer children: 1.3 million fewer children investigated, 244 000 fewer children substantiated as victims, 39 000 fewer children entering foster care, and 1198 fewer deaths. Given that 1 year’s incidence of investigated child maltreatment costs the United States economy an estimated $2 trillion,17 investments in child care and early education must be weighed against the maltreatment that they may prevent.
We must broaden our discourse on economic and concrete supports for families, and child care subsidies and universal early education specifically. Universal child care and early education have the potential to provide economic support for families, increase parental workforce participation, create living-wage jobs, improve children’s development and kindergarten readiness, begin to address some dimensions of inequities, and lastly prevent child maltreatment. Substantively increasing funding for child care and early education would provide a down-payment on the long-term health and development of our next generation of Americans.
Recommendations for Pediatricians and other Advocates
Pediatricians are in a unique position to facilitate change in these areas and should:
Recognize the growing body of evidence indicating that programs providing economic and concrete supports to families, including child care and early education, have the capacity to reduce child maltreatment, and treat them accordingly in both clinical and policy contexts.
Become familiar with existing child care and early education resources in their area, paying particular attention to geographic inequities in access, availability, and quality (https://www.childcareaware.org/resources/map/).
Ask families about their resource needs, including child care needs, perceived options, and arrangements, and connect them to resources. (Child Care Aware, local referral agencies dedicated to connecting families to quality, affordable child care [https://www.childcareaware.org/resources/ccrr-search/]).
Advocate with policy-makers at the local and state levels on the importance of accessible, affordable, and quality child care and early education for child and family well-being, either directly or through their local AAP Chapter (https://www.aap.org/en/community/chapter-websites/).
Familiarize themselves with how their state invests in the Child Care and Development Fund relative to their eligible population (Fig 1), how their state may limit access through restrictive policies,18 and advocate for further investments (https://ccdf.urban.org/search-database).
Advocate with federal decision-makers for passage of BBB or its elements, particularly child care subsidies and universal early education (AAP Committee on Federal Government Affairs; https://www.aap.org/en/community/aap-committees/ committee-on-federal- government-affairs/).
We thank both Gretchen Cusick, PhD, and Zach Laris, MPH, for their review of this article.
Dr Puls was the primary author of the manuscript; Dr Chung and Ms Anderson provided critical input and revision of the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest relevant to this article to disclose.