Child Maltreatment and the Ecosystem of Socioeconomic Inequities and Inequalities

In 2020, approximately 3.9 million child abuse and neglect reports were filed to Child Protective Services (CPS) in the US.¹ Approximately 17% of these reports were substantiated, with 618 000 documented instances of child maltreatment, mainly neglect (76%), and more than 124 000 children receiving foster care services. Rates of child maltreatment were highest among American Indian or Alaska Native children (15.5 per 1000 children in the population of the same race or ethnicity) and African American children (13.2 per 1000 children).

In a quantitative policy analysis, Johnson-Motoyama and colleagues² examine the association of state policies governing the Supplemental Nutrition Assistance Program (SNAP) with CPS involvement and foster care placement in the US. Their econometric analysis shows that states with more income generosity policies related to SNAP observed decreases in reported child maltreatment and neglect, substantiated cases, and intake into foster care. The findings suggest that ensuring child and family food security may be instrumental in preventing child maltreatment and foster care referral. The availability of discretionary family funding, such as generous SNAP benefits, may indeed reduce CPS reporting and prevent recidivism.³

No matter how rigorous in conceptualization and execution, there are inherent risks to association analyses formalized in regression models of multivariable inputs but a singular univariable output—a common econometric approach. The first risk concerns the interpretation of the directionality embedded in an econometric model; here, that the X variable of greater access to SNAP (as a proxy for food security) translates into the Y variable of less child maltreatment. The step to implying causality is just a small one. The step to inferring singularity of the presumed cause may be even smaller.

The second risk is decontextualization. The determinants of child maltreatment, subsequent CPS involvement, and protective actions are contextual, complex, and multidimensional,³ with food insecurity being only 1 factor. However related they may be, food insecurity and child maltreatment are both cause and consequence of distal social-ecological dynamics that affect the health and well-being of children, families, and communities, as Belsky⁴ argued so convincingly in his classical 1980 article on the ecology of child maltreatment. Expanding Bronfenbrenner’s ecological systems theory, Belsky reported that child maltreatment is “multiply determined by forces at work in the individual (ontogenic development) and the family (the microsystem), as well as the community (the exosystem), and the culture (the macrosystem) in which both the individual and family are embedded.” Johnson-Motoyama et al² add empirical evidence that macrosystem policies such as SNAP prevent child maltreatment and the need for foster care, especially the more generous these policies are. This evidence must be contextualized within the larger contemporary body of research on associations between child maltreatment and individual, family, and neighborhood poverty; housing instability; food insecurity; structural racism and injustice; and socioeconomic inequities and inequalities.⁵

The concept of poverty is nuanced, and its pathways to child maltreatment and CPS involvement are multifaceted.³ Poverty plays out in many forms at the individual, family, and community levels. Although low family material wealth is associated with child maltreatment and CPS involvement, unemployment may not be.³ Yet, while poverty alone may not explain the processes that lead to CPS reports, families involved in CPS are likely to experience socioeconomic disparities.⁶ Concentrated neighborhood poverty, insufficient physical and social neighborhood resources and capabilities, and, more generally, neighborhood inequality have been linked to higher rates of surveillance, reporting, and investigations of child maltreatment.³ Relatedly, low-income parents who live in non-impoverished neighborhoods are less likely to engage in child maltreatment than those in communities with concentrated poverty.³ In contrast, child maltreatment reports are commonly initiated from schools, social institutions, and health care facilities. Low-income families who live in more affluent neighborhoods may be scrutinized more, leading to disproportionate reporting to and investigations by child welfare institutions.

The US has a detailed history, both historical and recent, of discriminatory and structural oppressive systems that linger within social institutions. The remnants of these systems increase inequities in surveillance of children and families that identify as minority race.⁵ Evidence on the effects of implicit bias in investigating a child maltreatment report and the removal of children to foster care has been equivocal. In contrast, phenomenologic accounts from parents detail racial discrimination in how CPS staff interact with and decide whether to investigate low-income minority families.⁵ Child Protective Services reporting rates for American Indian/Alaskan Native, Black, and Latinx children are disproportionately higher than those for White children.⁵ Sociologists have argued that responses to child maltreatment tend to focus on individual parents rather than on the socioeconomic inequities and the structural social inequalities that cause the individual, family, and community pressures that eventually may lead to child maltreatment, CPS involvement, and foster care placement.^5,6

These structural inequalities reach well beyond the social welfare system. In their reporting of suspected child maltreatment, health care organizations and clinicians may perpetuate the same inequities and inequalities seen on the social welfare side. Drawing on Bibbins-Domingo,⁷ the health and well-being of children and families fundamentally depend on “nonmedical factors such as housing, food, and transportation,” and few clinicians will argue to the contrary. In reality, lacking any of these resources may trigger clinicians’ implicit bias, lead them to equate socioeconomic and racial inequity with a heightened propensity to neglect or abuse children, and guide them to file a CPS report. Here too, we see the complex interactions between social amenities, nutrition support, structural discrimination, and CPS involvement.

Structural inequalities also play out at the individual citizen level. Even as enlightened as we want to believe we are, we each define inequity and inequality on our own terms. Thus, we see the causes of child maltreatment through the shaded lens of our explicit and implicit biases; to wit, when we refer to the children who experience maltreatment in duality as “these poor children.”

Adults may be the perpetrators of actions of child abuse and neglect. The causes, however, lie in the ecologic characteristics of behavioral ontogenesis (becoming an abuser or neglecter), the microsystem of family (household and beyond), the exosystem of community (from neighborhood to home to shelter to street), and the macrosystem of culture (who we accept and who we reject).⁴ Improving the development, health, and well-being of children by preventing maltreatment requires incisive action that, per its Latin etymology, cuts into the ecosystem of socioeconomic inequities and social inequalities. Ensuring food security through generous SNAP policies is a critical step—yet only one of many.

Published: July 13, 2022. doi:10.1001/jamanetworkopen.2022.21516

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Okechukwu A et al. JAMA Network Open.

Corresponding Author: Ivo Abraham, PhD, Center for Health Outcomes and PharmacoEconomic Research, R. Ken Coit College of Pharmacy, University of Arizona, 1295 N Martin, Tucson, AZ 85721 (abraham@pharmacy.arizona.edu).

Conflict of Interest Disclosures: Dr Abraham reported receiving grants from the National Health Institutes National Heart, Lung, and Blood Institute; Saudi Arabian Cultural Mission; Arizona Department of Health Services; and the Centers for Disease Control and Prevention to the University of Arizona; grants and fees from Janssen/J&J for research, consulting, and publication; fees from GSK for consulting and serving on the advisory board; grants from Sanofi for research, consulting, and publication; fees from G1 Therapeutics for consulting; grants from Sandoz/Novartis for research, consulting, and publication; grants from Rockwell Medical for research; grants from Celgene/BMS for research; fees from Eversana for consulting; grants from Coherus Biosciences for research and publication; fees from University of Hyogo for lecturing; fees from University of Basel for lecturing; grants from Mylan/Viatris for research and publication; fees from EUSA Pharma for consulting; grants from Morphosys for research, consulting, and publication; fees from the Association of Community Cancer Centers for consulting; grants from Alcon for research; fees from the CMR Institute for editorial; fees from the European Commission for consulting; grants from Novartis for research and publication; fees from Omnicuris Healthcare for consulting and lecturing; fees from Taylor & Francis for editorial; and fees from West Virginia University for lecturing and consulting to Matrix45 LLC. Dr Abraham is Deputy Editor-in-Chief of the Journal of Medical Economics, which is an uncompensated editorship but for which he receives an annual allotment of submissions free of publication charges, and is Quantitative Methods Editor of JAMA Dermatology, which is a compensated editorship contracted to Matrix45. Dr Abraham holds equity in Matrix45, LLC, which provides scientific and consulting services to biopharmaceutical, diagnostics, and medical device companies on a non-exclusivity basis; government and international agencies; and academic or health care institutions. By company policy, owners and employees are prohibited from holding equity in client and sponsor organizations (except through mutual funds or other independently administered collective investment instruments), contracting independently with client and sponsor organizations, or receiving compensation independently from such organizations. Any compensation related to the provision of services to government and international agencies, academic institutions, and healthcare institutions by equity owners is collected by Matrix45. Dr Abraham does not receive compensation from Matrix45. No other disclosures were reported.