Anti-Poverty Interventions and Their Importance in Childhood Abuse Prevention

The impact of child abuse on the life course can be devastating and have intergenerational, multifaceted consequences that limit life potential. In this issue of Pediatrics, the article by Domond et al¹  affirms the far-reaching impact of child abuse, demonstrating that it is associated with poor economic outcomes in adulthood. By linking government administrative databases in their prospective study, Domond et al¹  showed that even when adjusting for socioeconomic background (parental ages at childbirth, parental education, income, and mother’s employment status during the child’s preschool years); concurrent parental mental health problems; and/or child IQ or disruptive behaviors, abuse is linked to a 2- to 3-fold increase in social welfare receipt from early-to-mid adulthood (23–37 years). This effect is most pronounced when participants reported both childhood abuse and intimate partner violence, leading Domond et al¹  to conclude there is a dose-dependent response of abuse on economic outcomes. As such, the authors call for an increased emphasis on screening for abuse to implement early prevention intervention services.¹ 

Although the Domond et al article shows poor economic outcomes independent of socioeconomic backgrounds, participants who experienced abuse were more likely to come from disadvantaged backgrounds, suggesting a vicious, cyclic interplay between abuse and economic outcomes.¹  Once abuse has occurred, intervening at an early stage is a laudable goal, but the Domond et al¹  article provides evidence that even that may be insufficient to change the economic trajectory. As such, the conversation must shift from the dose-dependent effect of abuse to the dose-dependent protection of primary prevention.

Poverty is a potent risk factor for child maltreatment and should be a primary focus of prevention efforts. The Earned Income Tax Credit (EITC) and the Child Tax Credit (CTC) are among some of the most powerful antipoverty programs in the United States, providing a partially or fully refundable tax credit to families that equate to a once-a-year, lump-sum cash transfer worth up to 45% of a family’s annual earnings.^2,3  In 2021, tax credits moved 9.6 million people out of poverty, approximately half of whom are children.⁴  A study examining the relationship between tax credits and child maltreatment reports found that for each additional $1000 in per-child EITC and CTC tax refunds, state-level rates of reported child maltreatment declined in the week of and 4 weeks following refund payments by an overall estimated 5.0%.⁵  The temporal relationship between tax credit disbursements and child maltreatment reports suggests the abuse is not only the outcome of chronic economic stress, but acute income availability to purchase necessities. This pattern holds true even when substantiated cases of abuse are evaluated. For example, 1 study found that the introduction of a refundable EITC was associated with a 13% decrease in state-level rates of hospital admissions for pediatric abusive head trauma.⁶  Another found EITC associated with a reduction in supervisional child neglect.⁷  Additionally, refundable EITC has been associated with an 11% decrease in foster care entries.⁸  And the protective effect of antipoverty policies is in no way limited to tax credits. For example, expanded Medicaid has also been linked to a statistically significant decrease in substantiated reports of neglect when compared with states that did not expand their Affordable Care Act Medicaid eligibility.⁹ 

The impact of shelter-in-place and prolonged closures of educational and health systems on child maltreatment and its detection during the COVID-19 pandemic is yet to be fully realized. However, it is notable that the previously mentioned studies do not consider the pandemic-era expanded CTC or stimulus checks; the former, which helped lower child poverty by more than 40% between 2020 and 2021, reaching a record low of 5.2%.¹⁰  One can only extrapolate that these lump-sum payments were likely protective in preventing further child abuse and neglect during a historic social, economic, and health disruption.

In the 2016 policy, “Poverty and Child Health in the United States,” the American Academy of Pediatrics made a commitment to reduce and ultimately eliminate child poverty with the goal of improving physical, mental, and developmental health.¹¹  Very simply, but critically, antipoverty policies will also keep kids safer. Borrowing from the oncologic Knudson hypothesis, also known as the 2-hit hypothesis, poverty can be thought of as the first hit placing children at risk for poor physical, mental, and economic well-being, with abuse providing the second hit that cinches the transgenerational nature of these poor outcomes.¹²  Therefore, by neglecting the potential for childhood abuse prevention, the medical community and society at large are doing too little, too late. The emerging evidence of the prevention benefits of expanded CTC should serve as a call to action for pediatricians to double-down on advocacy efforts for antipoverty programs, such as childcare subsidies, tax credits, cash transfer programs, low-income housing infrastructure, and expanded Medicaid assistance, which will bolster the economic resources of families and reduce the risk of maltreatment across the life course.

CTC

Child Tax Credit

EITC

Earned Income Tax Credit