Do Anti-Poverty Programs Reduce Child Abuse?, with Dr. Hank Puls

Season 3Episode 17December 9, 2021

Could investing more in anti-poverty programs not only reduce poverty in the U.S. but also reduce child abuse and neglect?

We’re always very careful to say that poverty doesn’t cause child neglect and abuse. And we don’t want to conflate these things or have people think that we’re blaming people for being poor. Yet we do know that poverty—particularly chronic and extreme poverty—can create an environment in which neglect and child maltreatment can thrive. Given that connection, could investments in anti-poverty programs actually reduce child maltreatment?

This is a key question, especially given that rates of neglect have only seen modest reductions in the U.S. over the past 40 years. And it was what Dr. Hank Puls, professor of pediatrics at the University of Missouri-Kansas City School of Medicine, set out to research.  Are we missing an opportunity to not only reduce poverty but also the suffering that comes from child maltreatment when we don’t invest heavily enough in these programs?

Topics in this episode:

  • A pediatrician determined to reduce child abuse (1:55)
  • State anti-poverty programs (3:24)
  • Costs and benefits (11:00)
  • Advocacy, and inequities (29:01)
  • What do child advocates need? (38:04)
  • Share this episode with a friend (45:52)


Hank T. Puls, M.D., is a professor of pediatrics at the University of Missouri-Kansas City School of Medicine

State Spending on Public Benefit Programs and Child Maltreatment,” Henry T. Puls, Matthew Hall, James D. Anderst, Tami Gurley, James Perrin, Paul J. Chung. Pediatrics November 2021; 148 (5): e2021050685. 10.1542/peds.2021-050685

A Roadmap to Reducing Child Poverty, from the National Academies of Sciences, Engineering, and Medicine

For more information about National Children’s Alliance and the work of Children’s Advocacy Centers, visit our website at And join us on Facebook at One in Ten podcast.

The transcript is also available as a PDF.

[Intro music]

Teresa Huizar:
Hi, I’m Teresa Huizar, your host of One in Ten. In today’s episode, “Do Anti-Poverty Programs Reduce Child Abuse?”, I speak with Dr. Hank Puls, professor of pediatrics at the University of Missouri-Kansas City School of Medicine. Now, we all know that there is some connection between poverty and poor life outcomes for many people, and that can manifest itself in many ways: reduced educational  opportunities or unmet basic needs, poor medical and mental health care, just to name a few. And we also know that there is some correlation between poverty and neglect.


Now, we’re always very careful to say that poverty doesn’t cause neglect and abuse. And we don’t want to conflate these things or have people think that we’re blaming poor people for actually being poor. Yet we do know that poverty—particularly chronic and extreme poverty—can create an environment in which neglect and child maltreatment can thrive. What Dr. Puls asked himself and ultimately decided to research was, given this connection between poverty and neglect or child maltreatment, could investments in anti-poverty programs actually reduce child maltreatment, too?


This is a key question, especially given that rates of neglect have only seen modest reductions in the U.S. over the past 40 years. Are we missing an opportunity to not only reduce poverty but also the suffering that comes from child maltreatment when we don’t invest heavily enough in these programs? I know you’re going to be as intrigued as I am by that question. Please take a listen.



[1:55] Teresa Huizar:
Hi, Dr. Puls. Thanks so much for joining us on One in Ten today.

Hank Puls:
I’m excited to be here and chat about this stuff and just really appreciative of the opportunity. Thanks for having me.

[2:04] Teresa Huizar:
So one of the things that I want to start with is, just how did you come to this work, looking at state spending and child maltreatment? I think it’s an interesting but maybe unusual approach.

Hank Puls:
Yeah, well, I have a pretty circuitous route to this. If you would have asked me in residency, what would be the one thing you’d not be doing? It probably would have been research.

I’m in this field, I think in a unique niche where I’m not a child abuse pediatrician and I don’t work in the social services realm either. I work in the hospital taking care of kids. And so I’ve seen children abused and neglected. And when I started doing research, I kind of asked myself, where is my niche? What do I do? And I really wanted to prevent children from being abused and neglected. And I got a little overwhelmed thinking about, how do I stop a person from shaking a baby? There’s so many different contributing factors to that. And so, I’m really fortunate to work with a really nice group of researchers and in our pediatric hospital medicine group that look at social determinants of health.

And it really made me look at things from the 10,000 foot view that, how do we just lift the floor? How do we improve the living conditions of people? And through that, we can actually impact lots of different problems indirectly and hopefully kind of prevent maltreatment.

[3:24] Teresa Huizar:
I think it’s an interesting way of approaching it because you know, your listenership right now are all child abuse professionals who were dealing with cases every day. And so of course we’re concerned about the child in front of us. But we’re also concerned in the way that you are talking about in this broader sort of societal population level prevention strategies, I think as well. And I just really appreciate that you’ve taken that up.

You recently published an article that, really it’s why we’re having this conversation today. It’s a study really looking at state spending on benefits for individuals in poverty or near poverty and how that intersects with child maltreatment. As someone who—as you say, you’re not a child abuse pediatrician—what hypotheses did you have going into doing the study to begin with?

Hank Puls:
Well, I certainly hypothesized that if we reduced childhood poverty … there’s a lot of literature out there that poverty substantially contributes to risk for maltreatment. And there’s a whole body of evidence that—it’s not my forte, but—understanding those pathways.

But sorry, Teresa, I like to tell stories. So I will take a step back and say—

Teresa Huizar:
Please do!

Hank Puls:
I came up with the idea for this project while listening to a presentation at the Pediatric Academic Societies meeting, one of our key academic annual events, and Dr. Bernard Dreyer, one of the prior presidents of the American Academy of Pediatrics, was presenting with his colleagues from the National Academies of Sciences in the U.S. Congress had charged the National Academies with detailing the literature on the causal impacts of poverty on adverse child outcomes and adverse child health and educational outcomes and everything.

And of course they found that poverty leads to bad outcomes and when you use these anti-poverty programs it actually helps outcomes. And the second thing they asked them to do, which is something that Canada and the United Kingdom have by some metrics been successful with, which is cutting child poverty in half. So they wanted to cut child poverty in half within 10 years.

And I was kind of blown away by that because it just didn’t seem feasible to me. But it also got me thinking. If we cut child poverty in half, what would be the impacts for child maltreatment and our overburdened system? And so I started looking at the types of programs that they were looking at exploring and expanding.

And I decided, let’s just try to look at how much money goes into these programs and what would be the potential impacts on child maltreatment. And you mentioned states. We chose to look at states for a very specific reason. Because, one is, the amount of money states spend on these programs is actually quite substantial and almost comparable to how much the feds are spending as well.

And as child advocates, it’s hard for us to go to D.C. and lobby and make federal national changes. It’s a little bit more tangible to be able to go to our state, county, and lobby there and make incremental changes within each state. So we really did look at the spending on these anti-poverty programs and how much states contribute to those, and how much it might cut down on child maltreatment.

[6:34] Teresa Huizar:
And for people who may not be as versed as you are in what some of these programs are, can you just give some examples of the types of public benefit programs that you looked at?

Hank Puls:
Sure. So, we looked at a number of programs, and we lumped them into five categories. The first one was cash, housing, and in-kind assistance. And what that means is programs that just physically give families money or they give them material goods that they otherwise were lacking, or they provide financial assistance for housing. And then the second was housing infrastructure. How much states spent on actually building public housing.

The third was not the federal but the state’s own refundable, earned income tax credit. So, the federal earned income tax credit itself is estimated to really reduce child poverty in the United States. But states—only about 23 states during our study period actually had their own income tax credit.

So about half the states out there were providing no additional benefit for their populace compared to the federal benefit. So we looked at whether states spend money on that.

How much states contributed to programs that subsidized childcare for low-income families was a fourth category.

And the last one is medical assistance programs. And that includes CHIP [Children’s Health Insurance Program], which is the program for low-income children, and then also Medicaid, which is for low-income children and lower-income adults.

[8:01] Teresa Huizar:
So those are the broad categories that you looked at. And I want to delve into those a little more in a minute, but one of the things that I want to preview for people who haven’t read your article is—just in a nutshell, what were your findings, ultimately?

Hank Puls:
Yeah, so, the bottom line is that we’ve found that when states spent money, those programs all just lumped together, it’s substantially reduced child maltreatment. And I guess I’ll take a step back. You know, we can’t prove cause/effect with our study model, our study design. So it really just shows association.

And I will say that this study also was built on the backbone of a lot of other people who’ve done some hard work that actually used past child welfare reforms and studied kind of in live experiment. And so our results do kind of support that. But if states spend more money on these programs, it was associated with reductions in child abuse and neglect.

And we looked at those individual programs and those individual categories of spending as well and found for the most part, most of them pretty consistently reduced poverty. So it didn’t really matter which way you gave families economic relief. They all kind of were associated with it.

[9:14] Teresa Huizar:
It was the economic relief itself that seemed to be making the difference. Is that what you would say generally?

Hank Puls:
I’m actually really glad you asked that because they’re all different, right? So if we provide people with cash or clothing or food, that’s kind of different than providing them with health insurance.

Teresa Huizar:

Hank Puls:
And so I think that each one of these categories of programs has a very different path to potentially preventing child maltreatment.

You know, for Medicaid, for example, Medicaid has been shown to reduce poverty more than all other benefit programs combined.

Teresa Huizar:

Hank Puls:
And there’s been a couple studies that show that families that have gained Medicaid coverage have fewer medical out-of-pocket expenses and also have had less—when they’ve been measured it—less parental stress.

So it’s pretty easy to see that Medicaid, you know, your child gets hospitalized. You don’t have Medicaid. You’re actually kind of in financial ruin with medical debt, let alone out-of-pocket expenses that you’ve just accrued with time for our lower-income families.

So it can reduce poverty. It could also help parents—who are the perpetrators often in child abuse and neglect—gain access to physical or, you know, health care to improve their physical well-being, but also potentially mental health care that can improve their mental well-being. So I think there’s a lot of ways—

Teresa Huizar:
Substance abuse treatments, lots of things. Yeah.

Hank Puls:
—that these programs can help prevent child maltreatment.

The big thing is none of these programs are actually intended to prevent child maltreatment. They’re all intended to support families, or provide health care, or something else. Preventing child maltreatment is just one really nice side effect of the program.

[11:00] Teresa Huizar:
You know, one of the things that I was sort of struck by when I read this study is, when you look on it at on a per-person basis, the investment is not immense.

You know, I think sometimes when you hear people talk about public benefit programs, they make it sound like these are on a per-person basis, wildly expensive. But if you looked at it—if I’m remembering your median expenditure per person, it seemed like it was 7,000 or so dollars, maybe, on average among the states.

And I was thinking to myself—I mean, it’s not nothing, but it’s a fairly small investment to make a big difference, potentially, especially if even a modest increase in that could make a substantive difference. And I want to talk a little bit about this modest increase, because one of the things that you found, it seemed to me is that—and I don’t want to misquote your study. So, you know, you correct me at any moment—that it seemed like if there was a 13% increase in spending that this garnered some of the substantial drops in child maltreatment, you were talking about. I mean, you preview your own results here, so you correct me.

Hank Puls:
I like to give credit where credit’s due. You know, some other people have done some important work on this, and they’ve actually been able to study: Individual families get this amount of money, and how much maltreatment? And your comment of modest investments or modest increases in families’ income have been shown to decrease maltreatment.

You know, one little subtlety of our study is that the data weren’t available for us to understand exactly: This amount of money went to this family or this amount of funding went to this family.

Teresa Huizar:
Oh sure. Oh of course.

Hank Puls:
So it’s actually—our study is at the population level where a state spends X millions or billions of dollars on these benefit programs.

And you just put that money out into the total population. How does it potentially reduce maltreatment at the population level? So, I would caution—our study doesn’t say that if you give this family $1,000, it should reduce the risk of maltreatment this amount. But our study suggests if you do put the money out there in the way that these programs did during 2010 to 2017, it suggests that maltreatment should be reduced.

And I think some of—to highlight some of the subtleties—some of these programs like TANA, for Temporary Assistance for Needy Families, provide assistance to families in deep poverty, you know, like below the 50 percentile of the federal poverty level, where some of the programs like Medicaid are directed towards families above the federal poverty limit, often—some states up to 300% of the federal poverty limit. These programs are not providing assistance to just quote unquote impoverished families by the federal poverty limit. It’s low income impoverished, low income, lower income families.

And some of them, like the earned income tax, it’s dependent on families actually working to be able to tap into the earned income tax credit. So yeah, so if states spend about $1,000 per impoverished person in their state—and clearly we had to use some kind of denominator because a lot of money’s being spent in California because there’s a lot of people compared to, say, Delaware.

Teresa Huizar:

Hank Puls:
And also states in theory should be spending more if there’s more impoverished persons. So if you spend $1,000 per impoverished person in their state, we estimated that child maltreatment would be reduced by about 4%.

And that’s the reporting of child maltreatment to child protective services [CPS}. And then that same amount of money was also associated with about 4% reduction in children being identified as victims or substantiated as victims and a 2% decrease in foster care placement, and a 7% to 8% decrease in child abuse related fatalities.

When we took those associations and we kind of said, “Okay, let’s extrapolate this to the population. What does this really, you know, what is a 4% reduction?” I think most states would be happy to reduce the number of reports they’re receiving by 4%. But is that a good investment? Because I think it’s a good investment just from a humanist, but we have to convince our lawmakers that it’s a good investment.

And so if you spent that money, in one year of spending, that would extrapolate to about 181,000 fewer children coming in contact with CPS in a year; about 28,000 to 29,000 fewer children being deemed victims; 4,100 fewer children being placed in foster care; and about 130 fewer children dying each year.

So, when we put it in absolute terms, it seems like a lot of burden and a lot of trauma that potentially is avoidable.

[15:59] Teresa Huizar:
You know, one of the things that we’ve been working on a while has been around child abuse fatalities, and I was most struck by the reduction percentage-wise there because, you know, if you really look at those numbers, they’ve been pretty intractable in the U.S. for a while.

So while we’ve seen drops in physical abuse and sexual abuse, you really haven’t seen the numbers budge around child abuse fatalities, in—I don’t know—20 years probably. I mean, they go up a point or two here or there, you know, a few kids here or there, but there’s been no real gain. And I feel like it would make a huge difference, you know, not just in the suffering and lives lost, but in building some momentum towards stopping kids from being killed in the first place and feeling like there are some solutions available instead of, I think the sort of resigned attitude that you hear a lot of, which is sort of like, “Well, some kids are always going to be killed. You know, that’s just a sort of side effect of child abuse and bad things that parents do.”

And I think that maybe we’re underestimating the degree to which the stressors in the environment really contribute to that. So I personally found that as an interesting element to all of this. This is an interesting journal article to child abuse professionals, but it seems to me that you’re also hoping that policy makers take the time to really educate themselves as to the findings.

What are you hoping that state policy makers in particular take away from this?

Hank Puls:
And that is the point of doing the study, right? You know, the last thing I want to do is do a research study and have it gather academic dust. Right? And it’s easy to see where some of my pediatric colleagues might do a study on asthma. It doesn’t need to get any attention in the press or amongst our policy makers to have a positive effect, improving children’s lives. We can look at that literature, assimilate it, make practice changes kind of within our walls. But for this public policy work, we have to get it in front of our policy makers.

And so I think our study can show a few things that this money could potentially be well-spent. And I think that we live in times where we’re pretty politically divided. And I think there’s a narrative around some of these programs that is quite negative and undersells the potential societal gains of some of these programs.

One of the aims of doing the study was to show an outcome that is important for me to make an impact on but might actually be more politically feasible to move the needle a little bit. It’s easier for some folks to lobby to say, “Look at the Medicaid expansion; it can actually potentially reduce child fatalities by X percent.” And that might get more traction than saying health care is a universal right. Because hopefully there is not an argument that there’s an acceptable number of child fatalities, right? That it’s a preventable count, and a heartbreaking count, unfortunately.

[19:08] Teresa Huizar:
You know, when I was reading your article, I was also thinking about the barriers that you described to getting policy makers to take these issues up in the way that you’d like them to and hope they will. And that we hope that they will. And one of them had to do with how, you know, the costs essentially accrue versus when the benefit shows up. And so can you talk a little bit about that? Because I think it’s something we should think about as we’re making arguments to policy makers.

Hank Puls:
So, I think it is important to mention that preventing child abuse and neglect is in and of itself a good enough reason to invest in these programs.

But we included those cost estimates or the cost effectiveness ratios of spending in these programs because we wanted this to gain traction with policy makers. And when we take these arguments, it’s not enough to say, “Hey, this prevents child abuse and neglect.” State policy makers and legislatures need to balance their budget and they need to hear: How is this economically feasible? Where does the money come from? And I can’t answer the question where the money comes from, but we can kind of answer: What does the money get you? What is the return on the investment? So when we talked about spending $1,000 per person in poverty, that’s about a 13% increase.

Doesn’t sound like a lot. You said again, you said “modest increase.” Nationally that accumulates up to $46.5 billion across all 50 states and D.C. So, to you and I, it’s a lot of money. To governments, especially our federal government, it is probably not that much money. You know, what that gets us is, when you spend that and we look at how much maltreatment’s prevented, the cost-effectiveness ratios from a government standpoint, don’t look very good in our study. But again, I’ll fall back on what I mentioned earlier: Preventing child abuse and neglect is not the primary aim of these programs.

So this is just icing on the cake for what the programs are already doing. And this is additional economic returns on the investments. When we used our studies results and then combine that with some other people’s prior work where they had estimated the economic burdens associated with child maltreatment, and they looked at short-term and long-term burdens.

So this would be short and long-term health care costs, criminal justice costs, child welfare costs, foster care. All of it. And they also placed value using kind of economic measures valuing individual lost life and future lost productivity. And when we use their information and combined it with ours? We found that if you spend $46.5 billion, that over the life of those children—because we know that child maltreatment can have downstream effects for the life course of children. If you spend $46.5 billion dollars in the life of those children, you potentially are going to turn $25.8 billion of it. So we’re roughly half.

But if we also count all the children just reported—so I think that a lot of people would be familiar with the idea that children reported often have similar outcomes, both personally and economically, to children substantiated—we potentially would return $3 to your $1 invested. So potentially return $153 billion. So that to me shows that this is money well spent.

The argument from state legislatures might be, “Well that’s life course. We have to balance our budget every year.” So, that number doesn’t really ring true for me. We looked at just what the short-term returns were, and they are more modest. For $46.5 billion, you might return $1.5 billion, which is rather small, or up to $9.3 billion if we include children reported as well.

[22:48] Teresa Huizar:
It’s really just looking at the benefit in one year and the cost and a specific time period as well, right? So that’s what you mean by short term, that if you’re lining up and saying we’re balancing our books in the same fiscal year—but we also know that child abuse isn’t ameliorated in a year. Right? I mean—oh, that it was—you know, when people experienced adversity for a year from having been maltreated. But that’s an interesting point and one that I had not really spent—you know, it’s not that it never occurred to me, but I never really spent some time thinking about the way in which state governments may—because they’re not looking in a longer term timeframe. They’re simply looking at how are we balancing the budget right now—that really sort of plays into their interest in these cost/benefit analyses that various folks have done and that you’ve contributed to as well.

One of the things that I was also interested in is you really talked about sort of scoring, you know, how we score programs. And here, you know, we’re in Washington, D.C. And so we’re used to the CBO’s [Congressional Budget Office’s] scoring of bills and how important that is to their passage or failure in Congress. And, you know, if they say that something is going to cause enormous debt in the future, then often those things are dead in the water.

And one of the things that the paper talks about is really looking, at a way, in the scoring of budget bills and these programs to look at incorporating some of those long-term cost recovery. Do you know if anybody’s sort of exploring that work or interested in it? Because I certainly wasn’t. I was like, that is interesting. And that might be a way into this argument with policy makers around this.

Hank Puls:
So, Teresa, you mean, like the CBO and looking at some of these policies or programs, the long-term impacts. Is that what you’re saying?

[24:39] Teresa Huizar:
Yeah. How do we incorporate that kind of in the financial scoring of these bills so that they look more attractive to begin with?

So if they’re having a budget bill that says, “Oh yes, let’s build in 13% more funding for anti-poverty programs or state benefit programs,” you know, how are we also in the scoring process? Making sure that it’s looking at offsets as well and not simply looking at just costs, the sort of expense side of that balance sheet.

Hank Puls:
I feel like that’s a hard question for me to answer. You know—

[25:32] Teresa Huizar:
[Laughing.] You’re like, “Further exploration needed.”

Hank Puls:
I mean, I’m not sure that that’s a scientific question. I think that’s more of getting people to care about the longitudinal well-being of our next generation. Do you not think that?

[25:32] Teresa Huizar:
I think we’re in trouble if that’s all it is. [Laughing.] I really do think people generally, you know, I have—I want to speak up on the behalf of policy makers. Because we work with them every day, and I think they genuinely care about child abuse. I’ve never met one that I felt didn’t, and that’s on both sides of the aisle. I felt like it’s a non-partisan, bi-partisan issue anytime we’ve been on the Hill. So I feel very grateful for that.

That said. There are, you know, financial hawks and people who are much more non-spending oriented or who are just moved by spending arguments more than they are arguments around suffering. In part because, I think, there’s a certain fatalism about suffering that exists—not just in the part of policy makers but on the part of just human beings in general. You know, it’s like, “The poor are always going to be with us.” That kind of idea that there’s something that’s not shiftable in this. And I think that, you know, overcoming that is something we’re all interested in doing, but I think that is really changing that cultural mindset and that sort of resignation to suffering I think is something that we’re all going to be working on, you know.

Hank Puls:
I mean … child abuse and neglect do occur outside the context of poverty. And so we can—

Teresa Huizar:
Oh, certainly.

Hank Puls:
—and I think that I don’t know if I have an existential or philosophical belief of whether we’ll ever be able to fully do away with abuse and neglect. But I do think that a healthy dose of appreciation that we could completely do away with poverty, and we’re still going to have other human problems that might lead to child abuse and neglect.

I do think for those economic hawks that you speak of, I think there are good solid arguments to come back on, on how reducing abuse and neglect can create a nice feedback loop of cost savings. So, you know, I talked about an advocating for Medicaid. It reduces poverty, a great deal. It improves people’s well-being. Outside of the results of our study. I firmly believe that’s a great path towards preventing child abuse and neglect. But for your economic hawks, you know, other people have already studied this as well. Like about 10% of money spent in Medicaid for children is associated with the burdens of abuse and neglect.

Child’s abused or neglected. They incur extra health care costs, extra prescriptions. Extra downstream mental and physical adverse outcomes. And still you can say, well, not only will spending on Medicaid improve health outcomes, long-term but cut down about 10% of your expenditures within the program.

So there’s a lot of opportunities I think, to kind of appeal to the economic hawks. And then, like you said, child abuse and neglect is something that both sides of the aisle can get behind. And again, that’s one of the reasons—it wasn’t my prime reason for doing the study. I wanted to truly try to understand what are the ways, in an equitable fashion, to try to provide primary prevention of child abuse and neglect.

And my hope is that, the fact that if you frame the argument for expanding some of these programs or increasing spending in some of these programs as a path towards preventing child abuse and neglect, cutting down a foster care expenses for a state, that suddenly becomes a little bit more appealing to both people in the aisle.

[29:01] Teresa Huizar:
How are you finding—I mean, the study was just published, so it’s not like it’s been out in the public domain long—but I’m wondering how you have found the response to the study and whether you’ve had opportunity to have any feedback from any policy makers? Or is it too early for that, And we’re hoping for that to come?

Hank Puls:
I’m a little blown away by their response. You know, in my young research career, that this is a new for me. There has been an outpouring of interest. And that makes me really happy for the outlook for some of these programs and for child advocates, arming themselves with information to take to our government and legislature to try to move the needle on some of these things.

And we’ve had opportunities to kind of put stuff out in the press, and we’re going to be meeting with some leaders and various national organizations to try to understand how we can move the needle with this. And I’ll be honest, some of this attention is probably due to the timeliness of the study, with the American Rescue Plan under COVID and the potential Build Back Better Plan. And so some of this is current events. And our study, I think, is touching on some things that people are right there right now, out in the ethos talking about.

[30:13] Teresa Huizar:
Yeah, I think that’s true. And also, I mean, I just—you mentioned the American Recovery Act Plan and other related things, and I think that that’s its own natural experiment. And you know, how this will impact kids and families, all the various components that have to do with direct payments and other kinds of things. So I’m interested in that.

What are you hoping that, you know, child advocates like us take away from this and do with this information? You’ve put it out in the public domain, but I’m sure aside from just the policy makers themselves, which you hope take it up, what is it that we can do to help sort of catalyze and galvanize that conversation?

Hank Puls:
That’s a great question. And I think the intent by doing the analysis at the state level had that exact question. Because these results are for the states. This is how states choose to invest. So, for you in D.C., D.C. was included. But for somebody in Ohio, that’s working at a Child Advocacy Center [CAC] or, you know, somebody in Delaware or in my home state of Kansas, you can take these results and say, “This applies to us. This is us.”

And, you know, in Kansas, we have not expanded Medicaid. So this is a substantial, you know, opportunity to move the needle on these topics. That you need not rely on your federal partners to do it. You can make local impacts and advocating for these changes.

I’ve never worked at a Child Advocacy Center and it’s not in the scope of my practice. But I imagine that you guys are overburdened with volume and at times limited in the resources you have to offer families. And so I also believe that a lot of great programs that we have—home visiting and others—if we have additional resources to offer families, and we just think about Maslow’s Hierarchy of Needs.

You can only do so much education and support of families, but if you can’t materially or economically change the living conditions for families, how are we supposed to prevent child abuse and neglect if they’re just left in certain conditions? So I think that our results hopefully can empower people to go talk with—you know, spider web out and talk with lots of other people.

And honestly, I will consider it a success if our results can get just a couple legislatures to vote for Medicaid expansion in one state and successfully expand Medicaid in one state, I think that that would substantially improve children’s lives in that state.

[32:43] Teresa Huizar:
Well, you’re talking to a listenership of true advocates around prevention and intervention. So I feel like maybe we can do better than that.

So CAC folks, you know, get right on it. You’re always up at your state legislatures advocating for something. So add this to the mix, because I think it is critical prevention work and primary prevention, which is where we really want to be in terms of reducing suffering over the lifespan.

Where are your research interests taking you next? Is it something that’s a follow-up to this or is it something else entirely?

Hank Puls:
Yeah, I remain highly interested in public policies that can serve as primary prevention of child abuse and neglect. And I think this is one step towards advocacy, but also understanding.

So I think our study raises new questions that need to be answered. So one is that, how does each one of these programs actually lead to reductions in poverty? And if we understand those mechanisms better, is cash in hand truly effective? Is Medicaid effective? And is it effective because it improves the mental and physical being of the parents? Or is it effective because it reduces poverty?

If we understand those pathways better, we can then go back and try to inform and structure the actual policy and the implication of these programs in such a way that they could maybe be even more effective at preventing child abuse.

The other question is one of equity. Our study examined the spending as it was distributed by the programs by the states. And so there’s going to be a lot of different ways that states did or didn’t implement these programs. And states come up with creative ways of sometimes making it challenging for families to access resources and benefits.

And so there is a lot of potential that the money, when I was talking about it’s injected out into the populous, there’s a lot of reasons to be concerned that some of that money was not equitably distributed. And, you know, whether it be that the benefit is contingent on employment and there’s structural racism factors that inhibit certain populations from gaining employment—

Teresa Huizar:

Hank Puls:
—or some of the benefits and, you know, access to certain benefits, either geography wise or health literacy wise are not as accessible to some populations.

So there’s concern that this money may not have been distributed equally, but also our population of children don’t bear the burden of poverty equally. Some populations are disproportionately in poverty, in deep poverty, in concentrated poverty, and experience chronic poverty. And in those populations of persons who are living in concentrated deep poverty, it might take more money to lift them out of poverty—

Teresa Huizar:

Hank Puls:
—but also more money would be required to change the pathways or the things that lead to child maltreatment.

So we’re really interested in doing another line of inquiry, either with this data or other data to examine how these benefit programs, either equitably reduce child maltreatment—and I’m sure that your listeners are highly aware that trauma treatment burden is not shared by children equally either.

Teresa Huizar:
Yes. Right.

Hank Puls:
And so if we’re looking for equity, we would like to see this money disproportionately reduce child maltreatment and, you know, just decrease those disparities in child maltreatment outcomes. But I think that there’s cause for concern that they might exacerbate them. And I think that if, depending on what we can work on and find that really has implications, I think, for how we structure the program.

Should we put more money in the earned income tax credit that requires employment? Or should more money go into a child tax credit that’s just given to all families? We need to ask ourselves how these primary prevention programs, how—are they equitable? And if they’re not, how do we fix it?

[36:47] Teresa Huizar:
I think that’s such a critical question because we already know that there’s disproportionality in the child welfare system. So simply baking in more of that is about the last thing that we want to do, or sort of creating structures that just reinforce that constantly. And so I think that you’re raising a good point about the thoughtfulness of where we make those increased investments and really sort of interrogating the structure of those programs and how people access them and, and those kinds of things will be critical in this.

It seems to me that you have a lot of work ahead, these research interests that you have are important ones. And I think also ones that, you know, are going to keep you deeply engaged in research for quite some time.

Hank Puls:
Well, unfortunately, you know, I would love it if we would do away with childhood poverty in the United States and do away with child maltreatment. Unfortunately, they’re going to continue. And as long as they continue, I think we need to kind of understand how to prevent it. And each one of these, as you kind of mentioned earlier, American Rescue Plan and potentially the Build Back Better Plan or natural experiments. But we also have a natural experiment of COVID and how that may or may not have impacted child maltreatment rates.

Teresa Huizar:

Hank Puls:
It’s just a very convoluted question. And, yeah, there’s a lot of work to do to provide support for families and prevent trauma.

[38:04] Teresa Huizar:
Absolutely. Well, is there any question that I didn’t ask you that I should have or anything else that you’d like our listeners to know?

Hank Puls:
You know, one question is, for those that are working with children who have already suffered trauma, you know, what are the resources that are lacking that the people providing some important care for children that they need? You know, what policies do we need to work for?

I mean, certainly I think it doesn’t matter if you’ve already been traumatized or you’re at risk for trauma—you know, having adequate food, medical care, and everything’s important. But are there any kind of additional resources that you think that frontline child advocates and people working with traumatized children need more of?

[38:49] Teresa Huizar:
Oh yes. [Laughter.] But I think that one thing that we’re missing in this country, and that is so very strange to me really thinking about it is: In this country, child victims don’t have an inherent right to heal. So we sort of rely on this patchwork of nonprofit organizations and networks of them, and community mental health care centers, and other kinds of things who are all doing great work. It’s not that they’re not.

But it’s that if you are victimized and you’ve experienced trauma, there’s nothing that guarantees you access to mental health care and trauma treatment. And so you might get it. You might not get it. You might get poor quality care or some that’s not trauma-focused or not evidence-based.

And I think if you really think about, you know, child trauma as a failing of our society, which I do, then it’s maddening, honestly, the kids aren’t guaranteed access to the medical and mental health care services they need to heal. And I think that if we sort of shift this to thinking of it in the same way that there were crime victims’ rights—if we think about children as having this right, well, first of all, to a safe childhood, but beyond that, when they have had trauma in their lives, whether it’s from child maltreatment or something else, having this inherent right to medical and mental health care, I think it’s just a mental shift we haven’t made as a culture. And I think it’s fundamental then, the way that plays out into lack of adequate funding for programs.

The fact that programs that are good and are funded are never funded at scale. So you know, home visiting programs are funded—and they’ve had some recent significant increases—but they’re still not funded at scale. Um, or the kinds of investments you’ve been talking about still aren’t funded at scale. Or, you know, the sort of treatment available through Children’s Advocacy Centers, it’s still not funded at scale. And I think, you know, if we decide to take this seriously from a public policy perspective, we’re going to have to stop thinking of it as a gift we bestow on children and really think about it as their inherent right to have, and that driving investments differently.

So I know that there are people—some cynics maybe listening to this who are like, “Yeah, good luck with that, lady.” But I really do feel very strongly about that, that if we want to make proper investment, it has to come from a place of believing that kids not only deserve it but have a right to it.

Hank Puls:
Yeah, I really appreciate those thoughts. I think of a commentary I read at one point that—and I think the title is something akin to “Has CPS Outlived Its Usefulness?”—and that the point was that in examining children pre- and post-CPS intervention, their economic, psychosocial factors were unchanged.

And that’s because we’re not equipping our people with the tools they need to actually substantively improve these conditions in these people’s lives. You know, you’re talking about the idea that children are not guaranteed the necessary care. I think it brings up the idea that we can talk about poverty limits and we can talk about uninsured rates, but that sometimes that does miss the point that it’s not about necessarily uninsured. It’s underinsured.

It’s not a binary thing.

Teresa Huizar:
That’s so true.

Hank Puls:
We need to provide the actual amount of support. So the uninsured rate of children in the U.S. is actually pretty low. But—and it continues to be threatened however—it’s pretty low, but that doesn’t mean kids actually get the care that they need.

[42:22] Teresa Huizar:
No. I think most people would be very shocked, given that child abuse has a clear physical impact on kids, how few kids get medical evaluations, for example, for child abuse. And that should shock us, that it’s probably nationally on average maybe 10% of kids who have been substantiated for child abuse of some kind who are actually getting, I mean, good medical care.

So not just like, before you go into foster care, you get your little exam. But even of child sexual abuse victims, because they’re not guaranteed that care, you know. If they’re connected with the CAC, they’ll get a medical exam, but if they’re not, good luck in terms of getting a medical evaluation.

And I think that, you know, this is really criminal if we think about what that means for their long-term physical health and mental health.

And I also think, if you were asking me about places to make investments, it’s in substance abuse treatment and mental health care for parents. If we’re missing those things, we’re missing critical things that will make a difference in neglect rates, because a lot of what gets captured as neglect is some combination of substance abuse and—untreated substance abuse, untreated mental health issues, and domestic violence. So I think that, you know, when you mix all that in a cocktail with poverty, you’re bound to have child maltreatment in many cases. And I just think that we’ve been talking about all these things that are interconnected in places where public policy can really make a true difference because the investment can make a difference.

Hank Puls:
You mentioned neglect. And you mentioned that sexual abuse or physical abuse have substantially decreased in the decades. Neglect has not.

Teresa Huizar:

Hank Puls:
And I think that our study and others previous have shown a pretty consistent finding that neglect is more sensitive to poverty. Other priors worked out, you know, as poverty rates go up, the slope of neglect going up is much steeper than physical abuse, sexual abuse.

Teresa Huizar:

Hank Puls:
And our study shows that if you spend money on the programs that cut down on poverty, the projected decreases in neglect are steeper than physical abuse or sexual abuse. I think that makes sense. And if we look at our system, that’s overburdened, you know, cutting down on volume—and I never want to, I don’t want to, I hope that my comments aren’t minimizing the impacts on individual children.

Teresa Huizar:
No, not at all.

Hank Puls:
But if we talk about numbers in the system, if we cut down the volume of neglect, I think we just equip our overburdened system a little bit better to be able to attend to, you know, individual children’s needs. I’m hopeful on the momentum towards, and the movement towards, primary prevention, but simultaneously realizing that providers at Children’s Advocacy Centers, our child abuse pediatricians, are kind of keeping fingers and toes in the holes in the dam—

Teresa Huizar:
That’s so true.

Hank Puls:
—to try to hold this off. And so I want to be cautious about not diverting funds from tertiary prevention, but, you know, I think that upstream efforts, the benefits might be delayed somewhat. But I think the upstream efforts are an important aspect to trying to solve this.

[45:19] Teresa Huizar:
I think these things are so complimentary, and I appreciate you talking about them in that way and that, you know, our dearest love would be to all work ourselves out of a job. But until that day comes, you know, we want to work in partnership in terms of reducing the numbers of families who ever have to encounter all of our systems. That’s what we’re all working toward.

[Outro music]

Well, thank you so much. I just really appreciate the conversation today. And when your next study is done on this subject, you come right back. Because we’d love to talk to you about your findings about that too. Thank you so much.

Hank Puls: It’s been a pleasure. Thanks for having me.


Teresa Huizar:
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