The child welfare system as a social determinant of health

Abstract

Research documents the ways that policing, incarceration, and deportation influence the health of racialized, poor families in the U.S. However, we lack empirical analysis of the ways that family policing through the child welfare system affects health. In this paper, I review the literature on intersectional harms in carceral institutions to argue that the child welfare system is a social determinant of health. First, I provide a review of the ways carceral institutions target women of color through settler‐colonial logic and the criminalization of race, poverty, and reproduction. Second, I share what is known about carceral effects on health and the mechanisms by which they function: 1. stigma, 2. maternal stressors, and 3. threat. Third, I delve into how these mechanisms manifest within the child welfare system and underscore the importance of examining their adverse health consequences. I conclude with a discussion where I call for more research on the child welfare system as a social determinant of health to understand abolitionist healthcare practices that contribute to dismantling the expanding carceral state. Collectively, these areas of literature illustrate the U.S. child welfare system's role in a broader criminalization process that detrimentally impacts the health of impoverished mothers of color.

Full text

Received: 25 February 2023
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Revised: 16 February 2024
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Accepted: 9 April 2024
DOI: 10.1111/soc4.13210
REVIEW ARTICLE
The child welfare system as a social determinant
of health
Katherine Maldonado Fabela
University of California, Santa Barbara,
California, USA
Correspondence
Katherine Maldonado Fabela.
Email: kmaldonado@ucsb.edu
Abstract
Research documents the ways that policing, incarceration,
and deportation influence the health of racialized, poor
families in the U.S. However, we lack empirical analysis of
the ways that family policing through the child welfare
system affects health. In this paper, I review the literature
on intersectional harms in carceral institutions to argue
that the child welfare system is a social determinant of
health. First, I provide a review of the ways carceral in-
stitutions target women of color through settler‐colonial
logic and the criminalization of race, poverty, and repro-
duction. Second, I share what is known about carceral ef-
fects on health and the mechanisms by which they function:
1. stigma, 2. maternal stressors, and 3. threat. Third, I delve
into how these mechanisms manifest within the child wel-
fare system and underscore the importance of examining
their adverse health consequences. I conclude with a dis-
cussion where I call for more research on the child welfare
system as a social determinant of health to understand
abolitionist healthcare practices that contribute to
dismantling the expanding carceral state. Collectively,
these areas of literature illustrate the U.S. child welfare
system's role in a broader criminalization process that
detrimentally impacts the health of impoverished mothers
of color.
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and
reproduction in any medium, provided the original work is properly cited.
© 2024 The Authors. Sociology Compass published by John Wiley & Sons Ltd.
Sociology Compass. 2024;e13210. wileyonlinelibrary.com/journal/soc4
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https://doi.org/10.1111/soc4.13210

KEYWORDS
abolition, carceral state, criminalization, family, gender, maternal
stressors, punishment and surveillance, social determinants of
health, stigma
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INTRODUCTION
A body of research has documented the ways that policing, incarceration, and deportation influence the physical
and mental health of racialized, poor families in the U.S (Garcia, 2018; Geller et al., 2014; Massoglia et al., 2019).
These carceral institutions and practices are interrelated with the surveillance and punishment that occurs in the
child welfare system. Although the psychological and social harms of child removal on poor families of color have
been documented for decades (Briggs, 2020; Edwards, 2016; Fong, 2020; Roberts, 1993,2002), scholarly attention
to the ways child welfare involvement affects health is lacking. The child welfare system (CWS) is linked to many
institutions through child protective services (CPS), such as family preservation, adoption, medicine, and social
work, that address social crises and traumas impacting the well‐being of children and youth. Like other systems
embedded within the carceral
1
apparatus of the United States, the child welfare system punishes families who
experience multiple levels of marginalization along the lines of race, class, gender, disability, motherhood status,
and other dimensions. If contemporary forms of carcerality neglect the health of racialized poor families, it is
expected that the child welfare system, as an institution of control, will have detrimental effects on the health of
entire communities in subtle and long‐term ways. In this review, I call for research on the child welfare system's
effects on the health of families by investigating child welfare as a carceral institution. Specifically, I examine family
policing as a process that allows institutions, policies, and social constructions to surveil, punish and separate
mothers from their children (Roberts, 2022). I also examine the ways these intersectional harms affect mothers'
mental health, physical health, reproductive health, and interpersonal health.
There is ongoing examination of how the legal system functions: how it fails due to being overwhelmed
(Lee, 2017), how its racial geography affects poor Black, Indigenous, and other families of color (Roberts, 2002), and
recently, how an abolitionist framework might be applied to the system (Roberts, 2022). Abolition is defined as the
re‐creation, undoing, of the social political, and economic conditions of captivity, and different forms of punishment
that fuel the logic of involuntary removal of poor children of color (Cabral, 2023; Dettlaff, 2023; Ritchie, 2023)
Abolition reimagines what well‐being means for families experiencing violence and trauma. This review does not
enlist the material and nonmaterial forms of care, strength, and safety (Dettlaff et al., 2020; Kaba, 2021; Maree
Brown, 2020) that are crucial to the well‐being of entire families affected by CPS (I name these elsewhere see
Maldonado‐Fabela, 2023). However, my theoretical visions are abolitionist. I name the harm family policing has on
the health of women of color, and highlight how we must see, hear, feel, and unravel the illnesses caused by trauma
and state‐sanctioned violence to strengthen an ongoing abolitionist movement. Building on this work, I theorize on
mechanisms by which the U.S. child welfare system becomes a social determinant of health (SDH). The SDH
framework builds on research identifying the social, economic, and political inequalities that affect health, such as
social epidemiology (Diez Roux, 2007), fundamental social causes (Link & Phelan, 1995), and racial disparities in
health (Colen, 2011; Moody et al., 2022). I use SDH broadly to focus on the health effects of the child welfare
system as a social structure, where the social position of mothers is stratified and determines differential conse-
quences and vulnerabilities to ill health (Solar O, 2010). I argue that this policing system becomes a social deter-
minant of health for poor families of color, specifically poor criminalized mothers of color, and has largely been
ignored in health disparities research and policy.
More than 3.5 million children in the U.S. are under CWS investigation every year. Black and Native children
have the highest rates of removal from their families as a result of investigation (U.S. Department of Health and
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Human Services [HHS] 2020). CPS contact for children and youth across the U.S. does not improve child well‐being
and worsens mental health (Evangelist et al., 2023). Other negative life outcomes of contact include involvement in
the criminal justice system, unemployment, and teen motherhood (Dettlaff et al., 2020; Doyle, 2007,2008). The few
studies examining the effects of child removal and family separation for mothers describe negative outcomes, such
as trauma, PTSD, suicidality, depression, and grief (Haight et al., 2002; Hook et al., 2016; Kenny et al., 2015;
Maldonado‐Fabela, 2022). Due to the ideologies stigmatizing mothers who are not from white middle‐and upper‐
class families, CWS responses have centered on therapeutic models that attempt to fix families (Reich, 2005),
aiming to rehabilitate and “reform” under the logics of the “best interests” of children. When CPS investigations
strain parent‐child relationships through parents' emotional distress, this distress can be transferred inter-
generationally to children (Merritt, 2020a,2020b).
Mothers have custody of over 80% of children involved in CPS (HHS, 2020), and they are blamed as unfit to
parent. For this reason, this review focuses on mothers in poor families of color. As scholars argue, “the child
welfare system's emphasis on parental psychosocial functioning and parenting practices is not designed, and is
often ill‐suited, for addressing the root causes of material deprivation” (Berger & Slack, 2020; Evangelist
et al., 2023; Feely et al., 2020). Thus, by understanding the intersectional harms to the health of mothers in child
welfare, who are sometimes those same children and youth who experienced CPS (Fedock et al., 2018), we can
build resourceful futures in which the entire family is seen as both a target and possibility to transform health. We
need to better understand the ways that the child welfare system and its processes of surveillance and punishment
become a social determinant of health and find better ways to address health disparities. Broadly, I ask, how can
public health and social science researchers illuminate and explain the complex interactions of policing, surveil-
lance, and health in the child welfare system?
In this article, I first provide an overview of why social determinants of health framework can contribute to
understanding how child welfare involvement for poor mothers of color is a crucial social determinant of health in
contemporary U.S. society. Next, I provide a review of the ways carceral and policing institutions criminalize race,
poverty, and reproduction. Then, I share what is known about carceral effects on health and the mechanisms by
which they function (stigma, maternal stressors, and threat). I follow this section by reviewing how these mech-
anisms exist in child welfare and why we would expect negative health impacts based on the scholarship we have. I
conclude with a discussion where I call for more research on the child welfare system and social determinants of
health to understand healthcare practices that can help dismantle the expanding carceral state.
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WHY SOCIAL DETERMINANTS OF HEALTH?
The World Health Organization (2010) refers to social inequalities as drivers of health inequalities. Given the
multiple institutions with which the child welfare system works, social scientists and health professionals must
understand the links between the SDH and the CWS. Palmer and colleagues (2019) define social determinants of
health as the economic and political structures, social and physical environments, and access to health care that
shape health outcomes and health disparities. Researchers have documented how mechanisms, such as dysregu-
lation of physiological systems, telomere structure, and immune and inflammation response, explain how the body
responds to chronic stress created by social forces. Inequalities embedded in social structures form part of the
harm caused to the DNA of marginalized people.
Protective mechanisms of SDH include factors, such as social support, that prevent or modulate negative ef-
fects of inequalities (Santos et al., 2018). Additionally, the place where one lives and receives health care services
has been linked with morbidity and mortality (Diez, 2010). By identifying the structural determinants of CWS
(institutional context) and the intermediary determinants of health (material circumstances; psychosocial circum-
stances; behavioral and/or biological factors; and the health system) (Solar O, 2010), we can better understand how
to respond to the vulnerabilities criminalized mothers face in relation to their overall health and wellbeing.
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While SDH has been critiqued for listing conditions, such as poverty, race, and gender, without acknowledging
“the material and historical conditions that create unequal distributions of power and resources– the conditions
that spin the web of inequity such as racial supremacy, wealth concentration, neoliberal capitalism, and misogyny”
(Tsai et al., 2021, p. 3), my analysis pushes SDH to engage with the unequal power hierarchies within the child
welfare system. I do this by providing a brief history in which women of color have been criminalized and their
health has been affected, drawing parallels with the criminal legal and immigration systems, and moving away from
ideas that inherently use individual, internal, and biological justifications for health inequities. Following Garcia and
colleagues (2021), who argue that health inequalities diversions ignore in knowledge production processes the
actions of advantaged groups by focusing on individual and cultural behaviors rather than intersectional structures,
I argue that the child welfare system can be viewed as a diversion that allows health injustices to exist for poor
families of color. Because the child welfare system is a social bandage for deeply rooted social, economic, and
political inequalities, I showcase the mechanisms by which it functions, the ways in which the SDH framework
shows how and what fuels health inequities for poor families of color in the U.S., and the messiness in which this
political machine thrives in.
I utilize a broad social determinants of health perspective that draws on the health effects of carcerality. By
doing so, I extend the way that social determinants of health can be applied in ways that advance anti‐racist health
justice by naming the institutions of power that validate health inequities such as the child welfare system. I also
call for collaborative intersectional research that addresses how the social sciences and the health system
(reproductive health, aging, mental health, maternal/child health, epigenetics, health insurance etc.) can produce
more holistic responses and recreate a system that has historically reproduced racist policy to address larger social
inequalities. In my theorization, I explicitly connect ideas about criminalization, the intersectional harms of car-
cerality, and the mechanisms in which these harms perpetuate negative health effects. To capture how the child
welfare system is an empirical case of social determinants of health, I review how the social positions of crimi-
nalized groups are more likely to be targeted by carceral institutions, including the CWS.
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CRIMINALIZING RACE, POVERTY, AND REPRODUCTION
Criminalization is a process in which behaviors are rendered deviant and treated with exclusion and punishment
(Lerma, 2022; Rios, 2011). Historically, impoverished communities of color have been subject to the removal of
children as a means of controlling who gets to parent, and how the state should come into the lives of families to
“correct” the “bad” parenting. The parens patriae doctrine allowed this practice to become institutionalized
(Trivedi, 2019) where child abuse and neglect policies have been weaponized as tools to legally remove children
(Raz, 2020). Briggs (2020) argues that taking children has been a counterinsurgency tactic and an effort to “induce
hopelessness, despair, grief, and shame” (13). This settler‐colonial history is documented in the ways that Black
children were taken during slavery, Native children were taken into Indian boarding schools, Latin American
refugee and immigrant children were taken into detention centers, and children of incarcerated parents were
separated from parents through the war on drugs and mass incarceration. These incidents of child removal show
how “child separation policy is a product of racial nationalism, the genocidal impulse to annihilate the nation's
outsiders by interrupting their reproduction.” (164). Since the criminalization of reproduction has been inter-
connected with racist, anti‐colonial logic, we need to look at the ways and health effects of women of color spe-
cifically being placed in the category of “bad mother” to justify child welfare practices.
The targeting of poor, Black, Indigenous, Latina/Chicana mothers in the U.S. is a reflection of political ideologies
that social problems are driven by individuals and cultures. Roberts (1999) detailed how Black mothers, since
slavery, have been viewed under logics that justify their control, surveillance, criminalization, and violence through
maternal‐fetal conflict that holds interests in keeping Black women as workers/child bearers. An example of
maternal‐fetal conflict comes from the period of slavery: slaveholders attempted to protect the fetus, an asset as a
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future slave, from injury while disciplining the mother by beating her on her back. This conflict continues – for
example, through mainstream attacks by politicians on Black motherhood, such as Ronald Regan's “Black welfare
queen,'' or through policies that disproportionately harm Black families, such as family caps and the Hyde
amendment, that aim to keep mothers as workers and penalize motherhood. Similar logics have historically harmed
Indigenous families in the U.S. through colonial violence, such as taking children away because they are labeled
feebleminded under eugenics science (Chavez Garcia (2012)). Chavez Garcia (2012) shows how scientists racial-
ized, criminalized, and pathologized Mexican, Mexican American, and African American youth and their parents in
their justifications for building youth prisons in California. Eugenics and its associated ideologies are a common
thread of control for mothers of color in the U.S. where they are viewed as “unfit” and “bad” mothers. This has
pushed forward the justification of having to “fix” or separate families who do not fit the “ideal” norms of society.
The settler colonial, anti‐black logic around maternal‐fetal conflict, eugenics, and child abuse definitions have
allowed laws to perpetuate health inequities (Taylor, 2019). Roberts (1999;2002) discusses how policies
attempting to control the bodies of Black women affect women's navigation of motherhood, affecting not only their
reproductive choices but also their children. Similarly, Goodwin (2020) argues that the war on poor women's
reproduction not only leads to surveillance and criminalization of pregnancy, negatively affecting women's health,
but also compromises the physician‐patient relationship. Bridges (2011) similarly shows how pregnant women
seeking prenatal care in a hospital known as a “legend in American medicine” experience surveillance through racist
logic in the social imaginary of racial minorities, suggesting that “non‐white persons serve an important function in
enacting contemporary forms of medical disenfranchisement as well as reiterating and reproducing racial dis-
courses” (248).
Davis (2019) captures how these compromised relationships are influenced by medical racism and facilitate the
reproductive vulnerabilities of premature birth, low birth weight, and other birth outcomes Black women experi-
ence. Additionally, medical legal violence for undocumented Latina mothers reflects how anti‐immigrant laws have
detrimental effects on the health care of Latinx communities (Van Natta, 2023). This body of research shows how
the criminalization of mothers of color negatively affects their health and highlights the importance of linking
studies of criminalization with health.
Women of color continue to experience the effects of settler‐colonial, anti‐black logic in their daily lives.
Intersectional statuses showcase how these logics work to impact health. I do not attempt to provide an exhaustive
list, but rather to show how many groups of mothers are subject to state‐sanctioned violence which ultimately
affects the health of entire groups across the U.S. For instance, immigrant mothers who must hide under punitive
labor exploitations that harm health is of crucial concern for immigration scholars (Abrego and Menjivar, 2012).
Reproductive justice movements have noted the challenges for teenage mothers that come through poverty and
larger constructions around who is fit to parent (California Latinas for Reproductive Justice). For instance,
Silver (2015) highlights how young parents involved in child welfare are navigating the fragmentation of multiple
systems alongside resistance practices by youth who are labeled and treated within an “ethos of blame” (19). Queer
mothers, especially queer mothers of color, also find themselves stigmatized due to their sexual orientation which
increases reports to child protective services by healthcare providers (Kuri, 2020). Research on formerly incar-
cerated mothers who attempt to reconcile mother identities through PTSD and reentry processes shows the
connections between the criminal legal and child welfare systems (Gurusami, 2019) and the sexual violence‐to‐
prison pipeline (Michalsen, 2019) impacts on women's mental health during probation or parole (Fedock
et al., 2018). Similar observations are made in research on gang‐affiliated mothers. These women are viewed as
dangerous, sexually promiscuous, unfit, and, in turn, prone to investigations by the child welfare system (Hunt
et al., 2011; Maldonado, 2018; Maldonado‐Fabela, 2022). Criminalization, thus, is a mechanism by which mothers
are viewed, treated, and punished under logics that mirror a so‐called therapeutic state of punishing people and
families rather than addressing structural issues.
In summary, much research documents how the criminalization of race, poverty, and reproduction affect the
life chances and well‐being of marginalized groups in the United States. However, less research documents how the
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child welfare system impacts women's health. Social science and public health researchers can address this gap by
examining how criminalization by the child welfare system contributes to health inequities. More specifically, so-
ciologists studying health inequities can investigate how the child welfare system is a social determinant of health in
the U.S. and has fundamental consequences for racial/ethnic and gender health disparities. Below, I review existing
literature that documents the intersectional harms of carceral institutions, under which the child welfare system
falls.
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INTERSECTIONAL HARMS OF CARCERAL INSTITUTIONS
The health consequences of family policing via the child welfare system are not as fully explored as they are for
crime policing via the carceral system and immigration policing through the immigration system. To highlight the
implications of child welfare as a social determinant of health, I turn to research on immigration and criminal
statuses. My goal is not to review the extensive literature on these areas, but rather show how immigration and
criminal statuses operate as political machinery that influences the health of racialized groups. Research identifies
how the intersection of stigmatized statuses places groups at a greater risk for poor health, partially because of
their disproportionate exposure to social stressors, including discrimination (Grollman, 2014). These intersectional
harms are mediated through racialized, classed, and gendered discourses, where, for example, Latino and Black
men's dehumanization enables mass incarceration and mass deportation in the United States. The targeting that
occurs for men of color in the U.S. has been identified as a mechanism of criminalization (Rios, 2011) and the politics
of fear created through the racialized discourse have implications for the racialized legal status of immigration. Due
to the stigmatization and gender and racial stereotypes of men of color as criminals, incarceration has been
justified, and punitive state policies contribute to the justification of mass deportation through discourses of im-
migrants as dangerous. Both (il)logics fuel an agenda of state repression against communities of color, as well as
negatively influence the health of entire groups. A similar practice has been analyzed for family policing (Lee, 2017;
Roberts, 2022); yet, it is not clear how the child welfare system itself is a determinant of health even though CPS
contact creates categories of racialized legal status.
Criminal status and immigration status have been investigated as racialized legal statuses that influence
health. The concept of racialized legal status shows how the law becomes a mechanism to govern and control
different groups and produces racial/ethnic health disparities (Asad & Clair, 2017). Whether racial and ethnic
minorities have a legal status or not, modes of exclusion are produced through this process that target racialized
groups and impact their health. Studies on policing, incarceration, and the criminal legal system show how criminal
status, contact with police, and legal outcomes have consequences for individual and community health. For
example, Lopez‐Aguado (2018) shows how punitive institutions enforce a carceral social order, where those
practices and labels affect entire communities in and out of jails and prisons. The racial segregation that occurs
during incarceration shows how institutions inform these socialization experiences and how racial sorting has
collateral consequences for the families of those incarcerated given the “criminal” label. This form of racial sorting
is a determinant of mental health, where segregation and allostatic load are linked (Bellatore et al., 2011; Mas-
sey, 2004; Yang et al., 2020). Similarly, Comfort (2008) shows the consequences of men's incarceration on women
and children and how visitation processes create secondary prisonization for families. This secondary prisonization
negatively affects the mental health of families – for example, causing depression and anxiety for mothers
(Maldonado‐Fabela, 2022). Other studies show how the application of the “criminal” label effects health, including
mental health (Hatzenbuehler et al., 2015), cardiometabolic and lung health (Topel et al., 2018), asthma (Frank
et al., 2013), and sexual health. Together, the evidence indicates that criminalization creates a racialized legal
status and affects the health of individuals, families, and communities.
Literature on immigration as a social determinant of health shows how the behavioral framework focuses on
individual behaviors, the cultural framework focuses on group traits, shared beliefs, and values that shape choices
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and health‐related behaviors, and the structural framework shows how access to healthcare and immigration status
impact on health (Castañeda et al., 2015). Viruell‐Fuentes and colleagues (2012) argue that immigrant health re-
searchers need to move away from behavioral and cultural frameworks and employ a structural framework which
acknowledges how individual experiences connect to larger structures of inequality. Scholars employing a struc-
tural framework have documented the health impacts of deportation threats and anti‐immigrant policies and the
mental health impacts of exclusionary immigration policies across the U.S (Hatzenbuehler et al., 2017). For instance,
Garcia (2018) argues that for Mexican immigrant women, the threat of deportation is an anticipatory stressor
that can become a chronic stressor, ultimately impacting their economic stability and family well‐being.
Lauderdale (2006) documented how the stress induced by anti‐Arab discrimination negatively affected the birth
outcomes of Arab women after 11 September 2001. Torche and Sirois (2019) documented that after the passage of
SB1070, undocumented women in Arizona birthed lower birthweight children. Several other studies link immi-
gration enforcement and captivity to mothers' health in detention (Ellman, 2019), fear of accessing medical in-
stitutions (Cervantes & Menjívar, 2020), and separation, across borders, from children (MacKenzie et al., 2017).
Finally, other research shows that the negative health effects are multigenerational (Rabin, 2018).
The research reviewing the health impacts of incarceration, policing, and surveillance for immigrant and
incarcerated groups shows how the carceral state influences health and wellbeing. While these intersectional
harms are documented (Paik, 2021), more analysis is needed to understand the role of family policing, specifically,
within and outside of criminal legal and immigration involvement. To understand, how carcerality functions to
affect health, I review the specific mechanisms that fuel and oftentimes justify the deterioration of health for
marginalized groups.
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MECHANISMS OF CARCERALITY THAT AFFECT HEALTH
5.1
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Stigma
Sociologists argue that stigma requires power hierarchies that impact on status loss, discrimination, stereotyping,
and separation which, in turn, affect life chances (Link and Phelan, 2001). Such power situations exist for mothers in
the child welfare system because multiple social categories lead women to be stigmatized and have CPS contact.
Stigma has negative health consequences and is an essential organizing concept of research on the social
determinants of health which are a “central driver of morbidity and mortality at a population level” (Hatzenbuehler
et al., 2013). Stigma within the carceral state has direct effects on the health of racialized communities. For
example, the stigma associated with gang member policing has been shown to have negative mental health impacts,
including anxiety and paranoia (Flores, 2021), and the stigma of intrusive policing of men of color in urban com-
munities is associated with higher levels of anxiety and trauma (Geller et al., 2014).
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Maternal stressors
Racism‐related, immigration‐related, and poverty‐related stressors impact the health of criminalized mothers.
Maternal stressor landscapes are theorized at the intersection of race, class, and gender that affect pregnancy,
birth outcomes, and mothers' health (Koning & Ehrenthal, 2019). The link between maternal stressors and birth
outcomes in biomedical and population‐based studies points to the importance of social environments and life
events that contribute to health. However, measuring and conceptualizing the intersection of these stressors and
examining mechanisms related to psychosocial stressors along with race, class, and gender differences remains
unclear (Koning & Ehrenthal, 2019). Additionally, how systems like child welfare are included in this intersection of
social stressors for mothers is understudied.
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5.2.1
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Racism‐related maternal stressors
Research on racism‐related stress shows how Black mothers' experiences of their own and their children's crim-
inalization due to racism have influenced not only their health but also their parenting (Elliot & Reid, 2019).
Vicarious experiences of discrimination also impact the mental health of Black women (Moody et al., 2022). The
criminalization of youth of color has been documented (Chavez Garcia, 2012; Rios, 2011), and it amplifies family
criminalization, where Black mothers of teenage children collectively experience surveillance and punishment
(Elliot & Reid, 2019).
5.2.2
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Immigration‐related maternal stressors
Immigration‐related stressors for Latinx families are well documented (Ayón et al., 2020). Illegality has been
conceptualized as a social determinant of health and research in this area shows how health policy and health
practitioners largely play a role in shaping immigrant health disparities (Garcia, 2018). The legal vulnerabilities
experienced by immigrant families highlight the connection between maternal stressors and legal violence, showing
how the law forms a foundation of inequality in the lives of legally vulnerable mothers.
5.3
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Threat of family separation
Research shows how surveilled mothers use avoidance strategies to prevent state interaction that can cause harm
(Gurusami, 2019). For undocumented people, the deportation threat produces fear and chronic stress, and in turn,
mothers are forced to avoid formal support systems, such as health care and social services (Abrego &
Menjivar, 2011, p. 16). Garcia (2018) shows how the deportation threat serves as an anticipatory stressor for
Mexican‐origin mothers, and mother's immigration fear‐related avoidance of public assistance prevents adequate
medical care for children (Toomey et al., 2014). These maternal stressors are explained in the social determinants of
health research that shows how stressors, because of social conditions, drive health inequality. Other studies detail
the violence and poor healthcare inside immigration detention centers where mothers receive “inadequate medical
and mental health care, threats, sexual abuse, retribution for hunger strikes, over‐vaccination of children (with
adult hepatitis), spoiled and inedible food, inadequate clothing during cold weather, prohibitions against infant
crawling, and lengthy periods of detention” (Gomez Cervantes et al., 2017, p. 280). This research not only shows the
detrimental effects of detention but also the ways state violence consciously continues to negatively impact the
health of criminalized mothers and their children. Similar practices occur with children under the care of the state
while mothers attempt to regain custody.
Based on this evidence, it is expected that women involved in the child welfare system will experience similar
negative impacts on their health. I apply these mechanisms of carcerality to child welfare below, and review studies
that document how they have shaped the health and well‐being of mothers. Although many of the reviewed studies
focus on broader processes of surveillance, stigma, punishment, and child abuse and neglect, rather than health,
they collectively make the case for additional research on how these mechanisms impact health and specifically,
how the child welfare system operates as a social determinant of health.
5.4
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Carceral mechanisms in the child welfare system
Despite ample evidence suggesting parallels between child welfare and carceral institutions, child welfare and
health researchers have not clearly articulated how carceral mechanisms work within child welfare and how they
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directly affect the experiences of mothers. The consequences of carcerality are not unique to incarcerated in-
dividuals and their families. Parents under child welfare surveillance also get punished in ways that have social and
familial consequences (Edwards, 2019; Roberts, 2012), and mothers with no contact with the criminal justice or
immigration systems still experience health consequences when child welfare surveillance itself becomes a social
determinant of health. For example, mothers may lose employment opportunities in teaching or childcare, lose jobs,
and or go homeless after the separation of children. Formerly incarcerated mothers are forced to struggle through
mental health needs due to the fears of losing custody and having to use hypervigilant motherwork to navigate
parole/probation and CPS (Gurusami, 2019). This body of research shows how non‐incarcerated people and family
members live through the health consequences of incarceration. Child welfare‐involved mothers who are not
incarcerated may have parallel experiences through family policing.
Another dimension worthy of research is the link between legal statuses attained in the child welfare system
and health disparities. Lopez Espino (2021) argues that the treatment of Latinx parents in the child welfare courts is
shaped by racialized views of parents as nonnormative, with deficient cultural practices of parenthood. This shows
how street bureaucrats in the child welfare system (attorneys, judges, social workers, mandated reporters)
contribute to a family policing system whose practices affect the health of racialized groups. Beardall and
Edwards (2021) further demonstrate how native children and parents continue to be targets of child removal
through a settler colonial carceral state. The Indian Child Welfare Act of 1978 aimed to end the abuse and removal
of native children; yet, the application of this law has been inconsistent. Thus, American Indian and Alaskan Native
children are more likely to be placed in foster care (Beardall & Edwards, 2021). Between 1978 and 2016, the Native
foster care population grew tremendously; many state caseloads more than doubled (Beardall & Edwards, 2021,
p. 551). Thus, even with policies and laws aimed at ending abuse of children of color, stigma, and racialized legal
status via the CWS still determine if and how parents of color and their children will be vulnerable to negative
health outcomes.
Building on work that conceptualizes how structural stigma impacts the health of marginalized populations
(Hatzenbuehler, 2017), child welfare and family researchers can analyze the mediators and mechanisms (i.e. stress
mechanisms, psychosocial mechanisms) and structural forces (policies and cultural norms) that influence health.
Involvement in the child welfare system has not heretofore been conceptualized as a stigmatized status. As this
discussion has shown, a body of empirical evidence suggests that mothers and their families in the system are
stigmatized. In this next section, I highlight the mechanisms in child welfare: stigma, maternal stressors, and threats
and responses to family separation.
(1) Stigma in Child Welfare Cases
5.4.1
|
Stigma of poverty
Stigmatized statuses contribute to health inequality. The literature on child welfare shows that stigmatized statuses
are drivers of punishment and criminalization. The stigmatization of perceived unfit motherhood often results in
mothers becoming entangled with the Child Welfare System, which can adversely affect their health. Child welfare
involvement for mothers is related to stigma in multiple ways: (1) race, class, gender, and immigration status; (2)
mental illness and or disability; (3) interpersonal violence; and (4) substance use. Stigma impacts the everyday lives
of marginalized groups (Link and Phelan, 2014; Morey, 2018), but little is known about how the stigma of child
welfare involvement operates as part of broader processes that impact the health of CWS‐involved families,
especially families of color. For example, parents are punished through formal and informal discretionary practices
and definitions of neglect. Most cases in CPS are cases of neglect (Lee, 2017), and about 75% of cases are related to
poverty and its impact on housing, food, education, and basic needs (HHS, 2018). A study in New York City shows
how stratified reproduction is reproduced in ways that stigmatize poor mothers by race, class, and gender and
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influence power dynamics and stereotypes in CPS cases, outcomes, and fears. As such, documenting how stigma
and poverty are interconnected through the logic of poverty governance that attempts to manage families, is of
crucial importance given the categorization of unfit motherhood.
5.4.2
|
Stigma of substance use
Scholars have analyzed how the stigma of substance‐using mothers in the child welfare system affects the re-
sources they receive. Individual‐level stigma creates fear and mistrust, making harm reduction and access to
services difficult for mothers and creating internalized stigma due to the stigma of “unfit” parenting (Wolfosn
et al., 2020). Interpersonal experiences of stigma related to family, partners' substance use, and lack of support are
barriers for pregnant women and mothers attempting to obtain services. In addition, there exists institutional‐level
stigma in health and social services and population‐level stigma due to discriminatory policies, laws, and mass
media (Wolfson et al., 2020). This body of research highlights how multiple levels of stigma influence the services
accessed in child welfare for substance‐using mothers. However, while stigma exists in multiple dimensions of
interactions with the child welfare system, an analysis of how the system becomes a social determinant of health is
missing.
Institutionally orchestrated stigma isolates and marginalizes women and ignores the trauma and emotions of
stigmatized mothers while privileging other groups of people (Kenny et al., 2015; Scheper‐Hughes, 1992). The
social suffering experienced by mothers who lose custody due to using drugs reveals how power and stigma are
inevitably involved in the stereotypical construction of “unfit” mothers in the child welfare system. Further, it has
ramifications for mothers' health. Othering and blaming parents reflect neoliberal logics that construct stigmatizing
statuses (Kenny & Barrington, 2018). For example, one mother in Kenny and Barrington's (2018) study shared:
“We were just being really hard on ourselves and it was really painful cause people accept grieving if
your child dies, right, but not if it was taken away. If […] they were taken away, you're automatically
evil and you fucked up and you're an abusive piece of shit. So it's like you have no support other than
each other and you're both broken. So we're drinking and broken, and don't know where to turn
under all the stress. And so we started having physical altercations which started from verbal.”
(Kenny & Barrington, 2018; p 212).
This quote shows how the state‐produced stigma affects social relationships, access to social support, and in
turn, health. Despite the need for social support, including from other CPS‐involved mothers, women's loss and pain
are delegitimized through stigma, which cuts mothers off from social support and contributes to worse health. The
social determinants of health framework can explain how the child welfare system's harm to criminalized mothers
of color affects health and access to health care.
5.4.3
|
Stigma of interpersonal violence
The child welfare system is routinely involved in cases of interpersonal violence. This violence is linked to negative
health outcomes, such as psychological distress (Romito et al., 2005). Women who experience interpersonal
violence and in turn, a CPS case experience grief and loss, and their identity as mothers is harmed (Nixon
et al., 2013). Furthermore, they have poor health and substance use. Additionally, mothers who experience control
by partners face further complications. Their partners and the system frame them as inadequate. In addition, CPS
often ignores the threat of exacerbated violence by partners.
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Studies in England, Canada, Australia, and the U.S. collectively document the stigma against mothers who both
experience domestic violence and lose custody of their children. Society deems women responsible for exposing
their children to their partners' violence. The child welfare system operates like an additional abusive partner,
accusing women of being “bad mothers” and, by blaming them, justifying the system's control of them
(Lapierre, 2010). While responsibility does not neatly fall into a binary (perpetrator vs. victim), stigma against
mothers who experience partner violence is a tool to fuel a racist, capitalist, patriarchal child welfare system that
has long‐term effects on the lives of criminalized women. Neoliberal paternalism operates via race and gender
structures within the system (Woodward, 2021). Additionally, research on coercive violence, which results from
increased vulnerability to violence via the extension of state surveillance into women's intimate relationships
(Monterrosa & Hattery, 2022), suggests how stigma in a romantic relationship may expose women to an investi-
gation that can have consequences of losing custody. This form of violence reveals how health is affected when
violence and surveillance are intertwined.
Studies have noted the deficiencies in child welfare departments when dealing with abused women and child
removal (Douglas & Walsh, 2010), and how mandated (child abuse) reporting laws may undermine help‐seeking for
survivors of partner violence (Lee, 2015; Lippy et al., 2020). Due to these laws, women are less likely to seek help
and in turn, more likely to experience child removal (Ogbonnaya & Pohle, 2013). The stigma against mothers of
color who are surviving violence but are held responsible for the abuse (Goodman et al., 2019) reveals how in-
tersections of interpersonal and state violence harm health. Not only do these laws impact the health of women,
making situations worse, but they are also further complicated by intersectional statuses where survivors fear
involvement with the criminal legal system, homelessness, and deportation (Earner, 2010; Lippy et al., 2020).
Despite this body of literature showing the connections between law, violence, and the child welfare system, we
still lack an analysis of how this fuels health disparities for families of color.
5.4.4
|
Stigma of mental illness
Stigmatized statuses that affect the health of criminalized mothers may co‐occur – for example, mothers who are
partner violence survivors may also have a mental illness. Women's situations may also be complicated by race,
class, gender, and immigration status. For this reason, disabled mothers and mothers with mental illness face
challenges that need to be addressed by researchers studying stigma and child welfare system involvement. So-
ciologists have shown the relationship between stigma and mental illness and the way it fuels public conceptions,
stereotypes, and rejections (Link and Phelan, 2014).
Mothers with mental illness are three times more likely than mothers without serious mental illness to lose
custody of their children or come in contact with CPS (Park et al., 2006). They are eight times more likely than
parents without a serious mental illness to encounter CPS and 26 times more likely to have changes in living ar-
rangements (Kaplan et al., 2019). Mothers with mental illness face unique challenges related to educational
attainment, socioeconomic status, and parenting. Ackerson (2003) shows how parents with serious and persistent
mental illness face challenges when raising children due to the stigma of diagnosis – that is, the way that child
welfare workers use diagnosis in court processes. Also, some parents in the child welfare system are misdiagnosed,
showing the critical importance that healthcare professionals have in child welfare proceedings. A participant in one
study noted:
“I’ve been diagnosed everything… One said I was a paranoid schizophrenic and the other one said no, I
wasn’t… You know, when you get a different doctor, they see what they think they see, and do the
best they can, you know …and some of them want to medicate you to death, and, you know, not deal
with your problems and not talk to you. I had one doctor …he gave me too much shock and I was in a
coma for 3 weeks.” (Ackerson, 2003, p 112).
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This participant shares how critical it is for healthcare professionals and child welfare service providers to be
equipped with tools that do not further harm parents' health, their child custody status, and overall well‐being. By
further analyzing how the stigma of mental illness and child welfare involvement fuels health disparities, we can
expand on the healthcare responses to not only support the health of parents in crisis, but also their parenting and
children's health.
Despite ample evidence describing how mothering in the context of child welfare system involvement is
stigmatized at individual, community, and macro levels, research has not documented how this process is related to
the exacerbation of health disparities for families of color across the U.S. A social determinants of health framework
can expand this line of research by showing how stigma is embedded within larger social structures that shape
inequality for specific groups of mothers, in this case poor, criminalized and stigmatized mothers of color.
(2) Maternal Stressors and Health Impacts
While much research has not documented the specific stressors and impacts on health when having child
welfare cases, we have broader evidence suggesting that racism, family separation, and child removal have con-
sequences on the health of mothers (see studies above). Few research documents how CPS contact and child
removal affect mental health. Maldonado‐Fabela (2022) documents how gang‐affiliated mothers with CPS contact
experience detrimental effects on their long‐term health, such as depression and anxiety. She connects the
intersectional harms that exist for women involved in child welfare and shares how they affect the health of
mothers. The following is an excerpt from an interview with one of Maldonado's participants:
“As Mayra reflects on the coping that occurs when her health begins to deteriorate, she also shares in
detail how basic needs of her body are impacted due to larger structural issues related to housing.
The stressors that accumulate for Mayra are something she has learned to trace and identify, and also
events she stays ready for, as life transitions, back and forth, like a pendulum—from crisis, to
transformative life events… The health impacts she shares (anxiety, loss of appetite) form part of
multi‐institutional violent processes that “show up” in the body” (17).
Maldonado‐Fabela (2022) identifies the ways that maternal stressors of child welfare involvement are not
isolated instances, but a result of mothers' multiple marginalizations. Fedock et al. (2018) document intersectional
harms with women on probation and parole. They document the relations between childhood abuse, intimate
partner violence, child welfare system involvement, and mental health and argue that women with dual involve-
ment in criminal justice and child welfare as well as multigenerational involvement in child welfare experience
increased levels of anxiety and depression. These two studies showcase the ways that maternal stressors result
from the logic of criminalization and continued adversity through structural and interpersonal violence. Re-
searchers need to examine these interconnections closely and understand the ways that criminalized mothers of
color experience cumulative disadvantages and an accumulation of stressors across the life course that processes
differently in the bodies of poor, women of color. Moreover, more research is needed to understand the specific
ways that CPS contact evokes these stressors, and the ways these stressors impact the health of mothers and their
families.
(3) Threat and Responses
CPS operates as a “threatening institution” by fostering a pervasive sense of uncertainty and insecurity through
investigations, and by generating widespread precarity (Fong, 2023, p. 15; Merritt, 2020a,2020b). Fong (2019)
shows how “CPS concerns – even if only an imagined threat – also inform how poor mothers mobilize institutional
resources for their families. Mothers want and need to connect their children with doctors, schools, and other
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services, yet must do so in ways that do not expose them to CPS intervention, prompting a selective or reluctant
participation” (28). Fong explains how this influences the way mothers navigate these concerns with their own
agency. Access to social services is important for the life chances of these mothers, but surveillance research shows
how parenting is threatened and otherwise influenced through fear.
In interactions with pediatricians, mothers in Fong's study reported:
“I feel little interest or pleasure in doing things. I feel too stressed to enjoy my child. I get more
frustrated than I want with my child’s behavior.” It’s like a trap. If you say yeah, I get more frustrated
with my child’s behavior, that means you’re gonna hit em or something, they probably think… So I just
circle “sometimes.” Why do you need to know about what I do?”
Often, criminalized mothers experience a pendulum of risk and threat. In the context of criminalization, Black
and low‐income mothers develop protective parenting strategies to raise children safely. Fong (2019) shows how
mothers who fear having their kids taken away by CPS develop strategies that are protective and selective to
strategically participate in institutions in ways that do not heighten the risk of state supervision. Mothers also
develop motherwork strategies to create safety and healing in system‐impacted families (Maldonado, 2019). More
research is needed to understand how CPS threats are functioning under carceral commitments of surveillance and
punishment and how this affects health.
6
|
CONCLUSION: FUTURE RESEARCH AND ACCOUNTABILITY
Public health and social science researchers can respond to the complex interactions of policing, surveillance, and
health in the child welfare system by examining the mechanisms that create intersectional harm in the lives of poor
families, and investigating how healthcare practices can help dismantle the expanding carceral state we live in. By
enhancing their comprehension of healthcare as both a continuation of surveillance and a means to counteract
health disparities, researchers and practitioners can do more than merely identify the foundational injustices of the
child welfare system. They can also confront and transform therapeutic practices that unjustly penalize families—
particularly targeting mothers of color—thereby fostering a more equitable healthcare landscape. Amid the
expansion of the carceral state and the pervasive influence of social determinants of health, I strongly urge re-
searchers to recognize and address the intertwined systems that perpetuate punishment and affect health. This
includes challenging the criminalization of race, poverty, and reproduction which further entrenches punitive
treatment of poor families. In doing so, we link social determinants of health, like the child welfare system, to a
deeper exploration of the biopsychosocial factors eroding family well‐being. This approach enables us to more
effectively confront and heal the historical traumas impacting the daily health of communities of color, offering a
more comprehensive understanding and solution to these entrenched issues. Social scientists aiming to bridge
sociological research with biomedical sciences have a unique role in this line of work, especially for those working
with low‐income communities of color, where criminalized families of color most often live and experience
surveillance.
In this article, I highlighted (1) how the child welfare system is a social determinant of health through the
criminalization of race, poverty, and reproduction (2) the intersectional harms of carcerality (3) the mechanisms of
carcerality that impact on health, and (4) carceral mechanisms existing in the CWS (i.e., stigma, maternal stressors,
and threat). This discussion directs our attention to the intersections of legal vulnerability, criminalization, and
health disparities for poor families of color involved in the child welfare system. Health policy and research should
not only employ intersectional analysis across multiple dimensions but also advocate for practices that protect
families by decriminalizing parents, preventing family separation, and actively supporting children and youth facing
crises. This approach aims to foster systemic change that uplifts and safeguards vulnerable populations. The call to
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abolish the child welfare system has been made (Beardall & Edwards, 2021; Dettlaff et al., 2020; Roberts, 2022;
Sangoi, 2020) and needs urgent attention. What role do health researchers and practitioners have in creating a new
system of care and safety for marginalized families?
Recent studies have begun to explore health disparities through intersectional perspectives (Homan
et al., 2021) but there is a pressing need for further research aimed at dissecting, quantifying, and overhauling the
structural biases within child welfare agencies that perpetuate health inequities and contribute to the expansion of
the carceral state. The overrepresentation of low‐income families of color in the child welfare system underscores
its role in exacerbating health disparities, highlighting the necessity to broaden the social determinants of health
framework to encompass the impact of family policing through the child welfare system. In light of the current
public health crisis, this analysis seeks to transcend the traditional Western perspective on health and medicine,
aiming instead to illuminate the processes through which negative health outcomes are experienced, addressed,
and identified. To shift away from the paradigm that diagnoses and stigmatizes mothers, it's critical to hold health
systems accountable for their contribution to perpetuating racism, affecting health, and influencing the life op-
portunities of marginalized communities across generations. I encourage researchers to delve into the intersec-
tional factors that detrimentally impact the health of entire communities and advocate for increased scrutiny of the
child welfare system and its associated entities for their contribution to adverse health outcomes. This necessitates
a broader scope of research that not only identifies but also holds these systems accountable for their role in
exacerbating illness among vulnerable populations. The child welfare system is one case within the larger spectrum
of carceral institutions negatively impacting health, but we need to address child welfare because its omnipresence
continues to show how surveillance and health will transform the future of marginalized families entangled with
multiple institutions.
ACKNOWLEDGMENTS
Thank you to the reviewers, Center for Engaged Scholarship colleagues and discussants, and Dr. Tanya Nieri for all
their feedback on this paper.
CONFLICT OF INTEREST STATEMENT
No conflict of interest.
ORCID
Katherine Maldonado Fabela https://orcid.org/0009-0009-1196-0772
ENDNOTE
1
I use carceral state and carcerality interchangeably to highlight the intersecting agencies and institutions that create a
state of and place that is not only. “Outside and apart from our everyday lives, but [is] instead [one that] shape[s] and
deform[s] our identities, communities, and modes of social interaction” (Rodriguez, 2010, p. 9).
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AUTHOR BIOGRAPHY
Katherine Maldonado Fabela is a Chicana mother and activist from South Central Los Angeles and a Ph.D.
candidate at the University of California, Santa Barbara. She is an incoming Assistant Professor at the Uni-
versity of Utah in the Department of Sociology. Her research areas include socio‐legal studies, medical soci-
ology, inequalities, and visual and feminist methodologies. She investigates the mental health impacts of child
welfare system involvement for criminalized Chicana/Latina mothers and their families across the life course.
Katherine focuses on examining mechanisms of intergenerational healing that contribute to health and well‐
being.
How to cite this article: Maldonado Fabela, K. (2024). The child welfare system as a social determinant of
health. Sociology Compass, e13210. https://doi.org/10.1111/soc4.13210
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