The economic burden of child maltreatment in the United States and implications for prevention ☆ ☆☆
- a National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
- b RTI International, Public Health Economics Program, Research Triangle Park, NC, USA
- Received 28 April 2011, Revised 30 September 2011, Accepted 12 October 2011, Available online 31 January 2012
Abstract
Objectives
To present new estimates of the average lifetime costs per child maltreatment victim and aggregate lifetime costs for all new child maltreatment cases incurred in 2008 using an incidence-based approach.
Methods
This study used the best available secondary data to develop cost per case estimates. For each cost category, the paper used attributable costs whenever possible. For those categories that attributable cost data were not available, costs were estimated as the product of incremental effect of child maltreatment on a specific outcome multiplied by the estimated cost associated with that outcome. The estimate of the aggregate lifetime cost of child maltreatment in 2008 was obtained by multiplying per-victim lifetime cost estimates by the estimated cases of new child maltreatment in 2008.
Results
The estimated average lifetime cost per victim of nonfatal child maltreatment is $210,012 in 2010 dollars, including $32,648 in childhood health care costs; $10,530 in adult medical costs; $144,360 in productivity losses; $7,728 in child welfare costs; $6,747 in criminal justice costs; and $7,999 in special education costs. The estimated average lifetime cost per death is $1,272,900, including $14,100 in medical costs and $1,258,800 in productivity losses. The total lifetime economic burden resulting from new cases of fatal and nonfatal child maltreatment in the United States in 2008 is approximately $124 billion. In sensitivity analysis, the total burden is estimated to be as large as $585 billion.
Conclusions
Compared with other health problems, the burden of child maltreatment is substantial, indicating the importance of prevention efforts to address the high prevalence of child maltreatment.
Keywords
- Child maltreatment;
- Economic burden;
- Lifelong consequences
Introduction
Child maltreatment (CM) is a serious and prevalent public health problem in the United States, responsible for substantial morbidity and mortality. The 4 major types of CM are physical abuse, sexual abuse, psychological abuse, and neglect (Leeb et al., 2007). In fiscal year 2008, US state and local child protective services (CPS) received 3.3 million reports of children being abused or neglected and an estimated 772,000 children were classified by CPS authorities as being maltreated (USDHHS, 2010). The number of confirmed cases has decreased over the past several years (USDHHS, 2010), but researchers argue that CPS data grossly underestimate the total incidence of CM (Haugaard and Emery, 1989, Hussey et al., 2006, Swahn et al., 2006 and Waldfogel, 1998). A nationally representative study of children aged 0–17 reported that 10.2% of US children experienced some form of maltreatment in 2008 (Finkelhor, Turner, Ormrod, & Hamby, 2009).
CM has been shown to have lifelong adverse health, social, and economic consequences for survivors, including behavioral problems (Felitti et al., 1998 and Repetti et al., 2002); mental health conditions such as posttraumatic stress disorder (Browne and Finkelhor, 1986, Holmes and Sammel, 2005 and Moeller et al., 1993); increased risk for delinquency, adult criminality, and violent behavior (Fang and Corso, 2007 and Widom and Maxfield, 2001); increased risk of chronic diseases (Browne and Finkelhor, 1986 and Felitti et al., 1998); lasting impacts or disability from physical injury (Dominguez, Chalom, & Costarino, 2001); reduced health-related quality of life (Corso, Edwards, Fang, & Mercy, 2008); and lower levels of adult economic well-being (Currie & Widom, 2010). Given the high prevalence of CM and the many negative short- and long-term consequences of CM, the economic costs of CM may be substantial. Estimating the economic burden of CM is important for several reasons. Economic estimates can help to increase awareness of the current severity of CM, place the problem in the context of other public health concerns, and may be used in economic evaluation of interventions to reduce or prevent CM.
Several studies have drawn attention to the problem of CM by producing estimates of the national economic burden of CM (Conrad, 2006, Daro, 1988, Fromm, 2001, Miller et al., 1996 and Wang and Holton, 2007). These studies made important contributions and advanced awareness, but shortcomings have been identified (Corso & Fertig, 2010), which should be addressed if burden estimates are to be used for health policy analysis. Problems include the “(1) lack of transparency in inputs used in the estimation procedure, (2) calculation mistakes, and (3) methodological errors” (p. 297) (Corso & Fertig, 2010). Correcting for these flaws is crucial to producing higher quality future estimates of the economic burden of CM. Furthermore, since the last estimate of the economic burden of CM conducted in 2007 (Wang & Holton, 2007), researchers have found additional quantified evidence regarding the health care costs associated with CM during childhood and adulthood (Bonomi et al., 2008 and Florence et al., 2012) and the long-term consequence of CM on adult earnings (Currie & Widom, 2010). Including these latest study results should improve understanding of the economic burden of CM.
Economic burden estimates generally take 1 of 2 perspectives to quantifying a health problem: a prevalence-based approach or an incidence-based approach. Both are relevant to CM. Prevalence-based economic burden provides an estimate of the direct and indirect costs incurred in a period (most often 1 year) as a result of the prevalence of CM during this same period (or this given year), regardless of the onset of CM. Thus, in a prevalence-based study of the economic burden of CM with a time frame of, say, 1 year, costs associated with all cases of CM (including cases with the onset in or at any time before the base year) would be included; however, only costs incurred during the 1-year period would be counted (Haddix, Teutsch, & Corso, 2003).
In contrast, incidence-based economic burden represents the total lifetime costs resulting from new cases of CM that occur within a set time period (most often 1 year) (Haddix, Teutsch, & Corso, 2003). Incidence-based costs are more difficult to estimate because they require data on short- and long-term costs and consequences of CM, such as its chronic sequelae on health, employment, and earnings over the lifetime of an individual. However, incidence-based costs are more useful for the economic evaluation of CM prevention/intervention activities (Haddix, Teutsch, & Corso, 2003). For example, the lifetime costs avoided could be compared with the costs of preventing 1 case of CM in a benefit-cost analysis of prevention. Both direct and indirect costs are included in an incidence-based costing perspective.
All of the previous estimates of the economic burden of CM that we are aware of are not estimated on a cost-per-case basis, except for the Conrad (2006) study. Similar to other studies, Conrad's study has a number of methodological shortcomings. For example, for the effect of CM on juvenile delinquency, Conrad uses the raw number of how many abused children become juvenile offenders as reported in a study by Widom and Maxfield (2001). This number does not take into account how many of these children would have been offenders if they had not been abused and therefore overestimates the effect of CM on juvenile delinquency. Widom and Maxfield (2001) report that about 27% of abused and neglected children have had a juvenile arrest, compared with 17% of non-abused children. This 10% marginal (or incremental) effect would have provided a more accurate estimate of the effect of CM on delinquency. There are similar problems with the estimates of effect of CM on adult criminality and lifetime productivity. In addition, for some of the cost estimates (such as the use of health care and mental health services), annual costs (prevalence-based estimates) of CM were calculated. Because the study was designed to estimate the incidence-based lifetime health care costs, the stream of incremental health care costs associated with CM over the lifetime should be used, discounted, and summed to net present value in the base year of analysis (Haddix, Teutsch, & Corso, 2003).
In this paper, we present new estimates of the average lifetime cost per CM victim and aggregate lifetime costs for all new cases of CM incurred in 2008 using an incidence-based approach. This study extends previous research in this area by correcting methodological flaws of previous studies; incorporating more recent and comprehensive studies of the epidemiology, consequences, and costs of CM; and providing a framework for using the findings in the literature to estimate the incidence-based economic burden of CM.