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August/September 2020Vol. 21, No. 6Child Well-Being Belongs to All of Us: Creating a Legacy of Family Prosperity

Written by Ann Flagg, senior director for policy and practice, American Public Human Services Association; and Mary Ann Cooney, chief program officer, Health Equity and ASTHO Challenge, Association of State Territorial Health Officials (ASTHO)

"There comes a point where we need to stop just pulling people out of the river. We need to go upstream and find out why they're falling in."—Desmond Tutu

States, counties, and communities across the country are meeting the impacts of the public health emergency and related economic shocks with innovation, rapid adjustment to service models, and a renewed sense of urgency in aligning programs and funding to better support children and families. At the intersection of the public health emergency, economic crisis, and spotlight on structural inequities, we have an opportunity to reimagine a health and human service delivery system that invests in children, families, and communities; focuses on health and prevention services; and eradicates the structural inequities that have led to untenable disparities among communities of color and families with low income. Swift action to advance a collective vision that shifts to a preventative child welfare model—driven by communities and enacted by state and federal policy and investments—is a critical joint opportunity to dramatically enhance our public health and human services partnerships.

Based on the most recent data, more than 400,000 children are in foster care (Children's Bureau, 2019). Between 2011 and 2018, more children entered foster care than exited care nationally (Children's Bureau, 2019). Of the cases referred to child protection agencies nationally (an estimated 4,327,000 referrals in 2018), the vast majority are referred for neglect, and only 19 percent of all investigated cases are substantiated on average (Children's Bureau, 2019). Children in poverty experience more abuse and neglect (Forston et al., 2016). Rates of child abuse and neglect are five times higher for children and families with low socioeconomic status compared with children in families with higher socioeconomic status (Forston et al., 2016). In addition, although the overall child mortality rate has been decreasing, the number of child abuse and neglect fatalities, of which more than 80 percent are children under the age of 5, has been increasing for over a decade (Children's Bureau, 2019). Up to 88 percent of all child deaths are NOT known to child protection, and many were seen by other professionals (e.g., health care), highlighting the importance of coordinated and multisystem efforts (Commission to Eliminate Child Abuse and Neglect Fatalities, 2016).

When comparing maltreatment rates across race and ethnicity in 2018, American Indian/Alaska Native and African-American children have the highest rates of being in foster care at 16.0 per 1,000 for American Indian/Alaska Native children and 9.1 per 1,000 for African-American children versus 5.3 per 1,000 for White children (Children's Bureau, 2019). Research indicates that these disparities are driven by environmental and systemic risk factors and not race alone (Child Welfare Information Gateway, 2016). However, it is incumbent upon the health and human services sector to recognize that further investment in the infrastructure of communities that address the social determinants of health and build protective factors and resilience in families and communities is an imperative to reducing disparities in the child welfare system. 

It is critical that we outwardly and honestly acknowledge our need to entrench family- and community-based solutions within a prevention framework and commit to a new legacy of child well-being. This requires intentionality in all we do. We must prioritize community investment, address social determinants of health through a life-course model approach, and maximize cross-collaborative, boundary-spanning strategies and systems.

States and localities are making real-time, frontline decisions regarding where to direct resources. The lifetime economic burden of new child maltreatment cases in the United States is $428 billion per year, factoring in tangible costs, such as medical care, special education, and criminal justice involvement, and intangible costs, such as pain and suffering of the child and broader community (Casey Family Programs, 2019). What if we reimagined a system where maternal and public health, economic assistance, mental health, and housing systems aligned to invest in the prevention of incidents of maltreatment occurring in the first place? What if we stopped pulling kids from the river and prevented them from falling in? 

The reactive model embedded in our day-to-day systems was built on how we address familial challenges and adversity rather than on pillars of change in how we prevent neglect coupled with universal investments that allow all families to thrive. The importance of embedding evidence-based, psychosocial support systems and programs such as Moms Helping Moms, the parent partner programs, home visiting models, and others is paramount.

Leaders from multiple sectors are already poised to take action at local, state, and national levels to leverage public health and human services systems to make this paradigm shift. Together, we can put the following in place:

  • Models that link universal population health models with effective family-led models (current best practices on child development, including adverse childhood experiences, neuroscience, family-to-family engagement, maternal and paternal health, and population health approaches)
  • Aligned and linked funding streams across public health, child welfare, and broader human and social services
  • Measurements that focus on improved well-being of families, generationally, across the social determinants of health and throughout the life course
  • Commitment to continuous quality improvement that embraces new breakthroughs and evidence without penalizing systems and families
  • Efforts to capture shifting social norms and those actions needed to provide that change

The American Public Human Services Association and the Association of State and Territorial Health Officials are partnering to support states and counties in seizing this monumental opportunity to shift the paradigm through changing mental models so that child and family well-being becomes a core priority of all health and human services agencies. The window of opportunity toward shifting the public discourse and understanding to a collective vision rests on building a foundational family well-being roadmap based on known protective factors, strength-based approaches, and necessary universal supports for all families. Should we seize the opportunity, the promise of successful transformative reform will fulfill a legacy of family and child well-being.


Casey Family Programs. (2019). Transforming child welfare systems: What is a population-based approach to child welfare? 

Children's Bureau. (2019). The AFCARS report: Preliminary FY 2018 estimates as of August 22, 2019 (No. 26). U.S. Department of Health and Human Services, Administration for Children and Families. 

Child Welfare Information Gateway. (2016). Racial disproportionality and disparity in child welfare. U.S. Department of Health and Human Services, Administration for Children and Families, Children's Bureau.  

Commission to Eliminate Child Abuse and Neglect Fatalities. (2016). Within our reach: A national strategy to eliminate child abuse and neglect fatalities.

Forston, B. L., Klevens, J., Merrick, M. T., Gilbert, L. K., & Alexander, S. P. (2016). Preventing child abuse and neglect: A technical package for policy, norm, and programmatic activities. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.