The Noah Cuatro Report: Another whitewash by the Los Angeles Office of Child Protection

On July 5, the parents of four-year-old Noah Cuatro called 911, saying their son had drowned in the pool at their apartment complex. But Noah did not look like a drowning victim, and the sheriff is investigating his death. Noah’s family had been under the supervision of the Department of Children and Family Services (DCFS). The eagerly awaited report on the Noah Cuatro investigation has appeared after a long delay, and OCP in the person of Judge Michael Nash (Ret.) has exonerated DCFS from responsibility for Noah’s death. This is not surprising given the similar results of OCP’s Anthony Avalos investigation, which Child Welfare Monitor addressed in our last post.

The flaws in this latest report are so glaring that they are evident even to readers without access to Noah’s case file. The report describes a child who may have been wrongly sent back to his parents, and an agency that failed to protect him after he was sent home. But Nash limited the scope of the investigation to DCFS’s failure to carry out an order to remove Noah from his parents. “Given what is currently known, the primary issue in this case from a systemic perspective focuses on the removal order,” Nash states. He defines three questions, all of which involve the removal order. Was it appropriate? Should it have been issued? Should it have been executed? Nash concludes that the order was inappropriate, the judge was correct (nevertheless in issuing it), and the decision not to execute it was correct. End of story.

But the decision to confine his conclusions to the removal order disregards a much larger issue. Here is a family that was under DCFS supervision since the reunification of Noah and his parents in November 2018. A child under supervision by DCFS died in unexplained circumstances in the Antelope Valley of Los Angeles County. Sound familiar? Think of Gabriel Fernandez in 2013. Think of Anthony Avalos, who had been under court supervision for years but was left unprotected for over a year until he died in 2018. Had there been no removal order at all, this case would have raised serious questions.

A Story of a Troubled Family

Let us step back and look at the history, as summarized by Nash. In August 2014, shortly after Noah’s birth, he and his sister were placed in foster care with their maternal great-grandmother as a result of DCFS finding that their mother had fractured the skull of her own infant sibling, and that their father was abusing marijuana. They were returned to their parents in May 2015 based on dismissal of the allegations in the original petition for removal.

Noah and his sister were removed again in November 2016 (although his sister was returned over the objections of DCFS) due to DCFS finding that Noah had been diagnosed with “failure to thrive,” developmental delay, and congenital hypertonia, and that he was medically neglected by his parents, who failed to take him to eight scheduled appointments. Noah was originally placed in an unrelated foster home and was then placed with his maternal great grandparents in August 2017.

In November 2018, the court ordered Noah returned home to his parents over the objections of DCFS. As is common practice in Los Angeles and around the country, Noah was placed under court supervision after being reunified with his parents. The court ordered DCFS to make unannounced visits and set up a visitation schedule for Noah’s maternal great-grandparents and also ordered that Noah and his parents participate in Parent Child Interaction Therapy (PCIT) to help improve their bond. The next judicial review was scheduled for May 9.

Between Noah’s return to his parents in November 2018 and his death in July 2019 the following occurred:

The parents did not enroll in PCIT or put Noah in preschool–which would have been another set of eyes on the child. Noah had only one visit with his maternal grandmother.
On her February 28 visit the caseworker supervising the family’s case (referred to as a “CS-CSW” without clarification by Nash) described Noah as lethargic and advised his parents to take him to the doctor. They did not follow his advice, waiting for Noah’s well-child visit on March 7, where Noah was diagnosed with an ear infection and prescribed medication.
On April 17, 2019, the hotline received a call (almost certainly from Noah’s maternal great-grandmother) stating that he appeared “thinner, intimidated, and scared.” The caller alleged that Noah suffered from night terrors and said his “butt hurt” and that his father hits and curses at him. The family’s caseworker was informed of the report and went to see Noah. She noted a bruise on his back and a scab on his forearm. He denied all the allegations and agreed with his mother that he had fallen off a bunkbed. The caseworker suspected he had been coached.
On April 18, the caseworker made a report to the hotline and an investigative worker met with the family. She took Noah for a forensic exam on April 19. Noah denied any abuse and the examiner concluded that the injury could have occurred as Noah and his mother reported. On May 9, the investigator met with the family’s prior caseworker. The latter said she “always had concerns for Noah, was opposed to his return home, and felt that the parents are habitual liars who present well.” She also expressed doubts about the bonding between Noah and his parents and concerns that he was targeted by them for abuse among their other children. Nevertheless, the referral was closed on May 9 or shortly thereafter with a finding of “inconclusive.”
On May 13, the investigative worker advised the current caseworker that the allegations could not be verified, but the caseworker indicated that she was working on a petition to the court for permission to remove Noah due to concerns about the compliance and honesty of the parents. On May 15, the caseworker submitted the removal petition to the court and it was signed the same day.
On May 15, the maternal grandmother called the hotline alleging that Noah’s maternal aunt reported his father beat his mother in front of the children and sometimes threw them in the street. She also reported that Noah spent the night at an aunt’s home and woke up screaming in the middle of the night. He also told the maternal uncle that his “butt hurt” and the uncle told the aunt that Noah was being sexually abused. This referral was assigned to the same investigative worker. When the investigator saw the family on May 20, the parents and Noah denied all the allegations and Noah even denied staying over with his aunt. The mother also denied being pregnant–a fact that becomes significant later.
On May 22, a case conference including the Assistant Regional Administrator agreed not to execute the removal order while the investigation was underway. They agreed to facilitate a meeting with the family. “Unsuccessful attempts were made through July 5” to schedule this meeting, according to Nash.
On June 6, the mother, who had denied pregnancy on May 20, gave birth. At the hospital she initially denied the baby was hers, claimed she was artificially inseminated as a surrogate, but that she did not know she was pregnant. Hospital staff reported that the mother had no prenatal care and they were concerned about her mental health. Nevertheless the baby was discharged with her parents.
On June 13, the investigator, in consultation with her supervisor, decided to add Noah’s three siblings to the family’s case because of “concerns for Mother’s mental health and her ability to comply with court orders.”
On June 18, according to redacted documents that have since disappeared from the internet, an automated assessment found the risk to Noah to be “very high” and the caseworker noted “current concerns for the mother’s mental health,” as cited by the Chronicle of Social Change.
On June 19, the investigation begun on May 15 was closed. The allegation of general neglect by the mother was substantiated and the allegation of abuse by the father was found inconclusive.
On June 28 the investigative worker saw all the children and reported Noah to be in good spirits. (Note: It is unusual for an investigative worker to visit 9 days after an investigation is closed. Perhaps this is an error and the visit was by the caseworker).
On July 5, Noah was hospitalized after his parents said they found him in the pool at their apartment complex. The county sheriff stated that Noah had signs of trauma that were not consistent with drowning, and an investigation is ongoing. Noah died on July 6.

Critical Questions

This history raises serious questions aside from the question of why the removal order was not implemented, which is all that Nash addressed. This family was under supervision by the the court, with DCFS responsible for monitoring the family. The family’s caseworker was concerned enough about Noah’s safety to file a 26-page request for a removal order from court. If the agency later decided to shelve the order, what was done to ensure Noah’s safety? Between the decision not to carry out the court order on May 22 and Noah’s hospitalization on July 5, Nash does not list any visits to Noah by the caseworker who was supposed to be supervising the case. Unusually, the investigative worker was recorded as visiting them one more time on June 28, after the investigation was closed. If that was the only visit to Noah in six weeks, this is evidence of serious negligence, especially in light of the fact that the family’s caseworker thought his situation was bad enough to require a removal. Moreover, the investigator had added the other children to the case on June 13 due to concerns about the mother. Other than gross negligence, the only possible explanation for the lack of visits noted is that there were visits but Nash was not given access to the notes. That possibility is concerning; also concerning is the fact that Nash apparently did not notice the gap and ask for any missing notes.

More questions abound. Information from the hospital after the birth of the new baby was very concerning as to the mother’s lack of veracity and her mental health. Yet, this did not seem to change the outcome of the still-open investigation or result in more intensive supervision of the family. Why not? Why is there no report on the court hearing that was supposed to take place on May 9? Moreover, how could an agency make “unsuccessful attempts” to schedule a family meeting for six weeks without raising the stakes? The agency had recently had a removal order for Noah. Did they try to involve the court? Why is the family’s former caseworker now a “Human Services Aide,” which appears to be a demotion?

Perhaps Nash is right in his narrow conclusion that a removal was not warranted on May 15 when the order was granted. But it is impossible to assess this conclusion without seeing the text of the removal petition or the judge’s order. Note that DCFS was against returning Noah to his parents in the first place and was overruled by the judge in the case. Nash’s report does not provide any of the reasons why DCFS opposed the reunification. (It would be interesting to see these reasons and also learn whether they were restated in the petition requesting the removal order.) One would think that if the same team was in place when new concerns were raised, they would have been very happy to implement the removal order when they finally received it. We need to know if the team was the same and if so, why it changed.

We will have to wait for the release of the full case file to know the answers to these questions. It is not clear why Judge Nash authored such a faulty report. Perhaps it was a deliberate attempt to whitewash DCFS; perhaps DCFS administrators provided incomplete or misleading information; or maybe Judge Nash simply failed to appreciate the questions raised by the information he received. It is ironic that OCP exonerated the agency for Anthony Avilas‘s death because unlike the family of Gabriel Fernandez, Anthony’s family was not under agency supervision at the time of his death. But in addressing Noah Cuarto’s death while under agency supervision and in light of numerous red flags, OCP has exonerated DCFS, giving the agency a free pass for losing a child it was supposed to protect. It seems that the agency cannot go wrong in the eyes of Judge Nash.

Los Angeles County missed many chances to save Anthony Avalos

In July 2018, ten-year-old Anthony Avalos arrived at the Emergency Room with fatal bleeding in his brain. His emaciated and battered body succumbed the next day to years of deprivation and abuse. For four years, the Los Angeles Department of Children and Family Services (DCFS) had received 13 reports on suspected abuse of Anthony and his siblings. For part of that period, his family was actually under the supervision of DCFS.

Many commentators saw parallels between Anthony’s death and that of Gabriel Fernandez in 2013 in the same town of Palmdale, in the Antelope Valley section of Los Angeles County. Gabriel was tortured to death by his mother and stepfather after multiple reports to DCFS failed to result in his rescue from this lethal home.

But based on its review of the family’s case file, Los Angeles County’s Office of Child Protection (OCP) concluded that Anthony’s case was “very different” from Gabriel’s. OCP concluded that it could not say that Anthony might still be alive today if the agency had done things differently. In justifying this conclusion, OCP stressed that the family was not under DCFS supervision at the time of Anthony’s death and that it had been over a year since the last report was made to the child abuse hotline concerning the family.

But in his devastating article, The horrific death of Anthony Avalos and the many missed chances to save him, investigative reporter Garrett Therolf shows that DCFS had many opportunities to save Anthony. It also reveals striking connections between Anthony’s case and Gabriel’s. The same private agency counselor had worked with both boys, and had been questioned in court about Gabriel. A caseworker who had been disciplined for his errors in the Fernandez case actually supervised the social worker who managed Anthony’s case.

Garrett Therolf was kind enough to share the DCFS case file with Child Welfare Monitor. In reviewing the file, we were struck by the many red flags that DCFS ignored and the crucial points where the agency could have intensified the surveillance of the family or removed the children to safety. In this post, we highlight our own observations from the case file, complemented by key information obtained from other sources (such as interviews and grand jury transcripts) by Therolf.

The First Calls: 2013 and 2014

Anthony Avalos first came to the attention of DCFS in February 2013, when he was only four years old and reported that his grandfather sexually abused him. The agency substantiated the abuse but did not set up any ongoing monitoring, relying on his mother, Heather Barron, to keep his grandfather away from him.

In May 2014 the family came to the attention of DCFS again when a caller alleged that Barron, who had four children at the time, was hitting the children with hoses and belts and locking them in their rooms for hours. An allegation of neglect (but not abuse) was substantiated. Barron agreed to the opening of a voluntary case, which was open from May 20, 2014 to December 4, 2014. A social worker named Mark Millman was assigned to manage the case.

Under DCFS Supervision: June-December 2014

In June, 2014 a PhD. psychologist who evaluated Barron concluded that she “appeared to have poor parenting skills as shown by her lack of patience towards her two children that displayed energetic behavior….At this time…. the assessor believes that her capacity to provide suitable care for her children is severely limited by her poor parenting skills, poor judgment, and denial and lack of awareness of her mental health issues.” The evaluator recommended a variety of services for Barron. She refused to participate in individual therapy–probably the most essential. But there is no indication that case manager Millman even read the report, let alone followed up to see if the services were provided or successfully completed. Barron did participate in in-home services to improve her parenting skills, which were provided by an agency called the Children’s Center of the Antelope Valley.

Once services got under way, reports from the provider were not encouraging. A July 2014 progress report from the Children’s Center indicated that Barron was “having a difficult time maintaining her composure when the children misbehave.” In its August 2014 report, the agency reported that Barron was overwhelmed. The agency case manager recommended therapy for Ms. Barron but she again refused saying she was not interested in talking about the past.

On October 9, 2014, a counselor at the Children’s Center called the hotline with concerns about the family. The counselor had tried to discuss her concerns with Millman but he seemed to “blow it off.” She reported that Barron, who had recently given birth to a fifth child, was “ very aggressive and angry and showed no nurturing to any of her children, even the infant.” She reported that she observed Barron yanking one child by the arm, yanking her daughter’s hair while brushing it, and calling the children names like “punk” and “bitch.”

The social worker assigned to investigate the new allegations was not concerned. He observed that Barron and her children were ”interacting positively” and “that mother and children had secure attachment as seen by their interaction.” Barron’s admission that she hit the children with a belt and used hot sauce to punish them for talking back did not seem to bother him. It appears that he was influenced heavily by Millman, who expressed no concern for the family. He reported that Ms. Barron “has her hands full and is doing her best….…She does cuss and yell but [is] doing all she can to provide appropriate care.”

The automated risk assessment performed as part of every investigation showed a high risk of abuse and neglect and recommended promotion to a court case. The investigator overrode this recommendation, stating that the children were already involved in a voluntary case and getting services. And somehow, despite the mother’s own admission, the investigator closed the referral as “inconclusive” for physical abuse, as well as emotional abuse and general neglect.

Another Children’s Center therapist called DCFS on November 5, 2014, alleging she overheard one child say “She’s bad because she whips our ass.” The caller said that Barron continued to get frustrated easily. She quoted Barron as telling one of the children, ‘Don’t think, because she is here, I won’t whip your ass.’” This referral was “evaluated out” with no explanation.

Case Closed: December 2014

The voluntary case was closed on December 4, 2014 with the following comments: “The mother has been compliant with services and receptive to outside resources. Although the family has received two new referrals, the allegations were assessed unfounded/ inconclusive. Mother has agreed to continuing counseling for the children.” The agency arranged for the family to receive this counseling through a new agency, Hathaway Sycamores Counseling. There was no indication that the mother had made any progress in addressing her parenting issues. Nor was there a rationale given for directing the counseling toward the children rather than the mother.

Hathaway-Sycamores was the same agency that worked with Gabriel Fernandez, as mentioned above. As Therolf reveals, Anthony was even assigned to the same counselor, Barbara Dixon, who worked with Gabriel. Dixon testified in court that she had observed extensive injuries to Gabriel but did not report them to the hotline, despite being a mandatory reporter. The fact that she still had her job is mind-boggling. According to Therolf, “her case notes show that she counseled [Gabriel] to listen to his mother more attentively and to finish his homework.”

Kareen Leiva Enters the Picture: 2015

As Therolf describes, Barron met Kareem Leiva in 2015 and began a relationship that would last several years and result in Barron’s seventh child. Within months, the father of Anthony’s two-year-old brother reported to police that Leiva was abusing his son. There was no DCFS investigation but DCFS did open a court case involving that child and his parents, resulting in regular visits to the home by a social worker, Mindy Wrasse.

On June 12, 2015, the same father went to the police again after an agency-supervised visit with his son, reporting that his son had bruises on his arm and face. The social worker observing the visit had confirmed the bruising and reported that the child repeatedly said “Mommy is mean” during the visit. The father reported that the child seemed to have bruises at every visit. Ms. Barron reported the two-year-old fell in the shower, and the toddler reportedly confirmed the report. A two-year-old’s ability to confirm this verbally–and to take a shower on his own–shows suspicious precocity for his age. Despite the other siblings giving two different accounts of the bruising, the referral was ruled unfounded on the grounds that all of the children had similar stories. Additionally, the risk of maltreatment was found to be high and the recommendation was to promote to a case. But this recommendation was overriden because there was already an open case involving the two-year-old and his mother. That case closed in October 2016, leaving no DCFS personnel in contact with the family.

The Children Beg for Help: September 2015

On September 18, 2015, the hotline received a call, revealed by Therolf to be from the principal of Anthony’s school, recounting disturbing reports by Anthony of his treatment at home. A similar call came in from a sheriff’s deputy the next day. According to Therolf’s investigation, the children were visiting their uncle, David Barron, and told him about the horrific treatment they received from Barron and her boyfriend, Karim Leiva. David Barron refused to allow his sister to pick up the children and called the police instead. Anthony and his two oldest siblings described to the deputy who responded a litany of horrific punishments by Barron and Leiva. They reported Barron made them. squat against the wall for long periods of time, a torture she called the “Captain’s Chair.” They also described beatings, food deprivation, being locked in their rooms, and Leiva’s hanging Anthony’s brother from the stairs.

When the DCFS investigator met with Anthony, he told her “Heather is my old mom. This is my new house. I am part of the Barron family now. I’m never going to see Heather again. She locks us up in our rooms and makes us starving.”

But sadly, the agency that was responsible for Anthony’s safety did not allow him to stay in his safe “new home.” The investigator spoke with three staff members of Hathaway-Sycamores, the agency providing home-based services to the mother. The three reported that they were “constantly in the home” and that the mother did not hit the children. They said the children did not seem frightened, never talked of abuse, and there were no locks on the doors. The contrast with the reports of the Children’s Center a year earlier is striking. Given what came out after Anthony’s death, it is clear that the providers from the Children’s Center were much more discerning. Or perhaps Hathaway-Sycamores was in the grips of an ideology that values family preservation over child safety–a belief system that has led to many other children being abandoned to a horrible fate. In any case, it is incredible that DCFS was still using this agency after its role in Gabriel’s death.

Heartbreakingly, Ms. Barron was allowed to take the children home from her brother’s house. Not surprisingly, they recanted all the allegations once deprived of the protection of their aunt and uncle. Instead, they said their aunt and uncle told them to make these allegations. The wholesale retraction is suspicious because of the similarity and unusual nature of the allegations and the young age of the children, as well as the number of previous reports of abuse. It doesn’t take a genius to realize that the children may have been frightened into recanting their allegations. But the investigator decided that the aunt and uncle were manipulating the children and had instigated the allegations. (Therolf reports that she was new to the job and testified in court that she was unaware that survivors of abuse often retract their accounts.). The allegations were found to be “inconclusive “and the referral was closed with a disposition of “situation stabilized.”

One last chance of rescue missed: April 2016

On April 28, 2016, DCFS received another report, which Therolf learned came from a domestic violence center staffer who was working with Barron. Two of Anthony’s brothers had bruises on their faces. Barron said they had been in a fight, but the boys told the reporter that Karim Leiva made them fight each other. They also reported being locked in their rooms and deprived of food for long periods of time. Barron stated that Leiva had not been in the home since the previous September. In interviews with the investigator, Anthony, his sister, and the five year-old brother all denied the allegations. Anthony and his sister denied that Leiva was in the house or even that they knew him–a denial which should have raised serious concerns to the investigator. Wrasse, the social worker who was monitoring the open case involving Anthony’s brother, said the children definitely knew who Leiva was–and she thought he was coming regularly to the house. The investigator of the previous report also declared definitely that the children knew Leiva.

Despite all these inconsistencies, the allegations were all judged “unfounded” or “inconclusive,” and the disposition was “situation stabilized.” The risk assessment showed a high risk of abuse or neglect and a recommendation to “promote” the case. But the recommendation was disregarded because there was already a social worker on the scene–the same worker who was sure Leiva was coming into the home regularly. Her involvement ended in October 16, and then the children were totally on their own.

There were no more allegations until it was too late for Anthony. At some point, Ms. Barron cut ties with her brother and sister-in–law and moved Anthony to a school that did not know his history. Nobody was left to protect him. It is nevertheless surprising that no reports came from the children’s schools–a fact that deserves further investigation. According to Therolf, Anthony’s teacher noticed that he was “often nervous about something.” Such nervousness is not normal and should have triggered a response. But that is an issue for another post.

June 2018: Anthony’s suffering ends

Anthony’s fate was sealed when he told his his mother that he liked boys and girls. Leiva overheard this conversation. The following night, his siblings later reported, Leiva picked up Anthony by his feet and slammed his head on the floor repeatedly. The next morning, Barron called 911, saying Anthony had fallen. He was taken to the hospital and died the next day.

Anthony’s siblings initially denied any abuse, but as soon as they were questioned by an expert forensic interviewer, they revealed all the horrors that were occurring in the home. As punishment for minor transgressions, they were made to kneel on rice with weights in their hands, were kept awake all night (with water thrown into their faces by Barron or Leiva if they fell asleep), and were whipped with a belt or extension cord on the buttocks or soles of their feet. Anthony was singled out of special punishment. Leiva would pick him up by the feet and slam him on the floor head-first, as he did the night before Anthony died. By dying, Anthony saved his siblings from this nightmare home. They were removed from the home Barron and Leiva , who have been charged with first-degree murder for Anthony’s death.

DCFS had many chances to save Anthony but it wasted them all. This gifted, sensitive, and loving child was condemned to years of suffering ending only with his death. OCP was set up to protect children in the wake of Gabriel Fernandez’s death. It’s sad that this office ended up basically whitewashing Anthony’s. Now we are waiting for their report on why four-year-old Noah Cuatro was killed when DCFS disregarded an order to remove him from his home. Based on the Avalos report, the chances of a thorough investigation by OCP are slim.

Who’s watching the children? Abuse more likely when child is with male caregiver

kevin-daniel-jackson_1566691813763_7614840_ver1.0_1280_720 — Kevin Daniel Jackson, 28, accused of killing his girlfriend’s son: WDIO.com

When a child is found to be seriously or fatally abused, the perpetrator is often found to be a male caregiver. But a new study using data from pediatric emergency rooms provides powerful evidence of the correlation between caregiver characteristics and the likelihood of abuse.

The new study is the first to compare caregiver features among children with injuries due to abuse to those with accidental injuries. The article was published in the Journal of Pediatrics, and a summary is available online on the Science Daily website. The authors used data on 1615 children under four who were brought to a pediatric emergency department. Overall, 75% of the injuries were classified as accidents, 24% as abuse and 2% as indeterminate.

The differences between the likelihood of abuse versus accident among different groups of caregivers are striking. Abuse was determined to be the cause of injury to only 10% of the children for whom a female was the only caregiver at the time of injury and fully 58% of children who were with a male caregiver when injured. There was a big difference between fathers and boyfriends however; an “alarmingly high” 94% of the children who were alone with the mother’s boyfriend at the time of injury were determined to be abused, as compared to “only” 49% of injured children who were with their fathers at the time of injury.

Analysis of the 83 cases of severe injury (including fatalities) provided even stronger evidence of the connection between male caregivers and abuse. The authors found that “nearly all cases of severe injury in which fathers and boyfriends were present involved abuse, and for fatalities, the fathers and boyfriends were most commonly present as lone caregivers. Mothers were rarely present alone when severe abusive injuries occurred.”

Among female caregivers, one group was more likely associated with injuries and that was babysitters. Fully 34% of the children left alone with babysitters were found to be victims of abuse

The researchers point to several policy implications of their study. First, they highlight the importance of asking who was caring for the child at the time of injury as part of the investigation to determine whether an injury is the result of abuse. Second, they call for abuse-prevention strategies to focus on male caregivers and female babysitters. (Currently, such programs, like shaken baby education, often focus on mothers.)

But the authors do not mention another policy implication that is equally important. Ensuring that all low-income children have access to high-quality early care and education (ECE) is a logical implication of the study.

As I have written in an earlier post, there are many pathways by which ECE can prevent maltreatment. Free, high quality ECE would provide mothers with an alternative to leaving their children with caregivers who are unsuitable to the task–be it boyfriends, fathers, or babysitters. ECE has other child welfare benefits as well. Staff who are trained as mandatory reporters ensures that more adults will be seeing the child and able to report on any warning signs of maltreatment. Quality ECE programs that involve the parents can also improve child safety by teaching parents about child development, appropriate expectations, and good disciplinary practices. They may also connect parents with needed supports and resources in the community and help them feel less isolated and stressed.

Of course the benefits of ECE extend far beyond child welfare in the narrow sense. We are worried about school readiness for low-income children and we know that much of brain development occurs between the ages of 0 and 3. That’s why quality ECE has been such a priority for the early childhood community. But child welfare policymakers have not yet caught onto the importance of ECE as a means of preventing child maltreatment.

An excellent issue brief from the Administration on Children and Families recommends improving access to ECE for families that are already involved with child welfare. That is a great proposal, but the child welfare field is beginning to focus on prevention rather than only treatment. We must explore ways to provide access to ECE among children who are at risk of child abuse and neglect. Expanding access to subsidized child care among lower-income families, because income is so highly correlated with child maltreatment, would be a good beginning.

Prevention is the word of the day in child welfare. A key part of prevention is making sure children spend their time with caregivers who will not harm them.

When will they ever learn? Another little boy dead on DCFS’ watch in Antelope Valley

Another little boy is dead in Los Angeles County after being left in the hands of his abusers by the Los Angeles County Department of Child and Family Services (DCFS). This time, the victim was four-year-old Noah Cuatro. Noah’s family had been the subject of at least 13 calls to the county’s child abuse hotline. He had been removed from his abusive parents for two years but was returned to him less than two months before he was killed.

Noah’s death is the third since 2013 of child who had been the subject of multiple reports and investigations by child welfare authorities in the remote Antelope Valley of Los Angeles County. In June, 2018, Anthony Avilas was tortured to death by his mother and her boyfriend, who are facing capital murder charges. In 2013, eight-year-old Gabriel Fernandez suffered the same fate. His mother is serving a life sentence and her boyfriend is on death row.

At least 13 calls had been made to the county’s child abuse hotline alleging that Noah’s parents were abusing their children, according to a devastating article in the Los Angeles Times.

Although the case file has not been released, sources revealed some of the contents to the Times reporters. In 2014, DCFS substantiated an allegation that Noah’s mother had fractured the skull of another child. In 2016, Noah was removed from his home and remained in foster care for two years. He was ultimately placed with his great-grandmother, who states that she often told DCPS social workers about concerning behavior her granddaughter displayed at her visits with Noah. She also claims that Noah begged her not to let him go.

Once Noah returned home, reports of abuse continued to be phoned in in February, March, April and May 2019. One report alleged that Noah was brought to the hospital with bruises on his back. A report on May 13 alleged that his father had a drinking problem, was seen kicking his wife and children in public, and sometimes when drinking voiced his doubt that Noah was his child.

At least one DCFS social worker took these reports seriously. On May 14, sources told the Times, she filed a 26-page report to the court requesting an order to remove Noah from his parents. And the judge granted that report the next day. But weeks went by–and the order was not implemented, even after new allegations came in that Noah had been sodomized and had injuries to his rectum. Noah died on July 6, more than seven weeks after the order was granted.

We do not know why Noah was not removed, because state law requires that the agency conduct its own investigation before the case file can be released in child fatality cases. We do know from another Los Angeles Times article that DCFS has already changed its policy on court removal orders to say that such a delay should be an “extreme exception” and must be brought to the director of the agency and approved by his Senior Executive Team.

Why so many tragedies in the Antelope Valley? Given its small population, Antelope Valley has a disproportionate number of deaths caused by a parent or caregiver of children already known to DCFS. according to calculations by the Chronicle of Social Change. Nobody knows if this higher death rate is due to cultural or economic features of the area or to challenges in staffing DCFS. Difficulties in attracting and retaining staff in this remote part of the county have been described in numerous reports, most recently an audit of DCFS and a report on the death of Anthony Avalos.

On July 23, the Los Angeles County Board of Supervisors unanimously approved a motion requiring DCFS to work with other agencies and educational institutions to develop a staffing plan to alleviate staff shortages and turnover in the Antelope Valley. I It also directs DCFS to immediately develop a Continuous Quality Improvement Section and fill approximately 20 positions which will allow for increased case reviews, initially focused on the Antelope Valley section.

These are good steps that are surely needed, given the staffing problems in Antelope Valley. However, until we know the reason the court order requiring Noah’s removal from the home was disregarded, we don’t know if these steps will address the proximate cause of Noah’s death–the failure to remove him from his home when a social worker clearly recognized the need for it. It appears that this removal order was overriden by someone above the social worker – but we need to know why and by whom. This crucial decision may have little to do with staffing problems and more to do with other factors–such as an ideological preference for parents’ rights or a reluctance to remove children.

Sadly, there is no provision in California or LA County requiring an in-depth case review to be released to the public. This never happened in the cases of Anthony Avalos or Gabriel Fernandez. In order to get to the bottom of these horrendous deaths, Los Angeles County’s Board of Supervisors should pass legislation requiring such a review. Washington’s state’s statute requires a review (by experts with no prior involvement in the case) when the death or near-fatality of a child was suspected to be caused by child abuse or neglect, and the child had any history with the Children’s Administration at the time of death or in the year prior. These reviews must be completed within 180 days and posted on the agency’s website. Florida has a similar requirement, as I have described in an earlier post.

The father and siblings of Anthony Avalos filed a $50 million suit against DCFS and one of its contractors only a few weeks after Noah’s death. They allege that the department “was complicit in the abuse and neglect of Anthony and his half-siblings.” The same attorney is now representing Noah’s grandmother, and a lawsuit is sure to follow. How many more deaths will it take before the county can be relied on to protect its vulnerable children from suffering and death inflicted by their parents?

Illinois’ Intact Family Services: What happens when family preservation trumps child safety?

ChapinHall Illinois’ child welfare services to families that are allowed to keep their children have major systemic flaws that put children at risk. Most importantly, there is extreme reluctance to remove children from their homes and place them in foster care. Those are the findings of a review from Chapin Hall at the University of Chicago that was commissioned by the Governor in the wake of several deaths of children whose families were being supervised by the state.

This report follows an earlier one, discussed in a previous post, by the Inspector General (OIG) for the Illinois Department of Children and Family Services (DCFS) stating that child safety and well-being are no longer priorities for the agency. One problem area identified in that report was Intact Family Services, which are the services provided to families in order to prevent further abuse or neglect without removing the child. OIG’s 2018 annual report included an eight-year retrospective on the deaths of children in Intact Family Services cases, which concluded that in many of these cases the children remained in danger during the life of the case due to violence in their homes, when DCFS should have either removed the children or at least sought court involvement to enforce participation in services,

Increasingly, child welfare systems around the country have been relying on services to intact families (often called in-home or intact family services) in order to avoid placing children into foster care. In 2017, according to federal data, only 15% of children who received services after an investigation or assessment were placed in foster care; the other 85% were provided with services in their homes. These services may become even more predominant with implementation of the Family First Prevention Services Act, which allows federal Title IV-E funds to reimburse jurisdictions for the cost of such services.

It is important for child welfare agencies to be able to work with families that remain intact. This allows the agency to monitor the children’s safety and avoid the trauma of placement in foster care while working to ameliorate the conditions that might lead to a foster care placement. But agencies must be cognizant that not every family can be helped this way, keep a close watch what is going on in the home, and be ready to remove children when necessary to ensure their safety. The deaths of children who have received Intact Family Services in Illinois have raised questions about whether the agency is accomplishing these tasks.

In Illinois, Intact Family Services (referred to below as “Intact”) are provided mostly by private agencies under contract with DCFS. The Chapin Hall report found systemic issues that create barriers to effectively serving intact families.

Avoiding foster care placement: Perhaps the most important issue observed by the researchers was the high priority that Illinois places on avoiding placement of children in foster care. As a result of many years of such efforts, Illinois now has the lowest rate of child removal in the country. Intact staff expressed the belief that “recommendations to remove children based on case complexity, severity, or chronicity will not be heard by the Division of Child Protection (DCP) or the Court.” As a result, Intact supervisors are reluctant to reject referrals of families even when they believe a family cannot be served safely in the home. They are also reluctant to elevate cases for supervisory review when they have not been able to engage a high risk family.

Supervisory Misalignment: In the past, negotiations between DCP and Intact over the appropriateness of a referral occurred on a supervisor-to-supervisor level, allowing Intact to push back against unsuitable referrals. An administrative realignment that placed investigators and Intact under different administrations eliminated this ability of Intact to contest inappropriate referrals. According to the researchers, this resulted in the opening of Intact cases for families with “extensive histories of physical abuse” that Intact staff believed they could not serve effectively.

High Risk Case Closures: Intact service agencies are expected to work with a family for six months and then close the case with no further involvement by DCFS. The researchers learned that there was no clear pathway for intact staff to express concerns when they been unable to engage a family. As a result, some providers told the researcher that they may simply close the case when a family will not engage.

Staffing Issues: Caseload, capacity and turnover. The researchers found that DCP investigators are overwhelmed with their high caseloads and are desperate to make referrals to Intact to get families off their caseload as soon as possible. The prescribed caseload limit of 15 cases per worker is very hard to manage, and some workers carry even more cases. Moreover, DCP workers tend to stop managing safety plans and assessments as soon as a referral is made to Intact, which leaves children in limbo until services begin. For their part, Intact workers’ caseloads are often over the prescribed limits and are not adjusted for travel time or case complexity. Moreover, the difficulty of their clientele makes the current caseload of 10:1 difficult to manage. High turnover among Intact workers, investigators and other staff can also contribute to the information gaps and knowledge deficits mentioned below.

Role Confusion: DCP workers and Intact workers seem to have different views of the role of the DCP worker, according to the researchers. DCP workers view their role as making and justifying the decisions about whether to substantiate the referral and remove the child. However, the Intact Family Services policy calls upon them to engage the family and transmit all necessary information to the Intact staff. Cultural differences between the two sets of workers compound the problems.

Information Gaps: Because of the role ambiguity mentioned above, investigators often fail to pass on crucial information to Intact workers. Yet, these workers often cannot access investigators notes or key features of the case history. Moreover Chapin Hall’s reviews of the two recent deaths of toddlers in intact cases found that much of the family’s history was inaccessible because cases were expunged or purged. DCFS expunges most unsubstantiated reports and shreds investigators files and appears to be more aggressive about such expungements than most other states, according to a previous DCFS Director, George Sheldon.

Service Gaps: The researchers also mentioned gaps in service availability, especially long waiting lists for substance abuse prevention, which make it very difficult to engage families as well as providers.

The authors made a number of recommendations for addressing these problems they identified. These include:

Work with courts and State’s attorneys to refine the criteria for child removal in complex and chronic family cases;
Develop and refine protocol for closing Intact cases;
Direct attention to cases at greatest risk for severe harm; revisit the use of predictive models which should be transparent, based on broad input and be supported by ethical safeguards’
Clarify goals and expectations across staff roles;
Utilize evidence-based approaches to preventive case work;
Improve the quality of supervision;
Adjust the preventive services offered through Intact to meet the needs of the population;
Restructure Intact Services to address the supervisory mismatch with DCP; and
Redesign the assessment and intake process to reduce redundant information, improve accuracy or assessments to support decision-making and improve communication across child serving systems.

We would have liked to see a recommendation to modify Illinois’ policy of expunging and purging all unsubstantiated investigations. At a hearing in May, 2017, the DCFS Director, George Sheldon, expressed his support for allowing DCFS to keep records of all investigations, even if they are unsubstantiated. Research suggests that it is very difficult to make accurate decisions about whether maltreatment has occurred; moreover, unsubstantiated reports are as good as substantiated ones in predicting future maltreatment. Examples of children killed after families have had multiple unsubstantiated reports have been observed all over the country.

This report should be a must-read for all child welfare agencies. Children in many states have died of abuse or neglect after intact cases have been opened for their families. (Think about Zymere Perkins in New York or Anthony Avalos and Gabriel Fernandez in Los Angeles.) Many of the issues identified by the Chapin-Hall report may have contributed to these deaths as well, particularly the extreme avoidance of child removals that has condemned so many innocent children to death ever since the widespread push to reduce the foster care rolls, supported by a coalition of wealthy and powerful foundations and advocacy groups.

The foster care crisis in Massachusetts: common sense solutions, not ideology, are needed

An investigation by the Boston Globe’s Kay Lazar has drawn public attention to the foster care placement crisis in Massachusetts. The opioid epidemic has led to a spike in the demand for foster homes, but the Department of Children and Family Services (DCF) has been unable to recruit and retain enough foster parents. Therefore, children newly removed from their homes often have no place to spend the night, sometimes spending it in a car with a social worker awaiting a call to say a bed is available up to 100 miles away.

And the trouble doesn’t end with the first overnight placement. One third of foster children in Massachusetts were moved at least three times during their first year in the system. According to one social worker quoted, relatively healthy children come out of care with behavioral problems and attachment issues due to their devastating experiences in foster care.

Lazar and her paper are to be commended for making the public aware of these unacceptable flaws in the Commonwealth’s treatment of its most vulnerable citizens. But by interviewing only a small group of child welfare experts with similar perspectives, Lazar missed some of the obvious common sense solutions to these problems.

Take the lack of emergency foster homes, which results in many children spending their first night in foster care in a car waiting for a bed. There is an obvious solution, and that is to establish temporary regional shelters so that every child can find a warm bed and a welcoming hug on what may be the most traumatic night of their lives.

So why was this solution not mentioned? Many states have seen their emergency shelters become warehouses for children for whom a placement cannot be found. As a result, some states have closed these facilities–instead of improving them. But these closures don’t solve the problem that homes are not available.

Smarter jurisdictions, often working with nonprofits, use emergency shelters for children newly removed from their homes. A nonprofit called Amara operates temporary shelters for children who have just been removed from their homes in Seattle and Tacoma, Washington. The shelters are a haven for traumatized children where they receive loving care from staff and volunteers. And they offer social workers a much needed three to five days to find a foster home that is the best match available–not just the first to answer the phone.

There is a no obvious solution to the overall shortage of foster home beyond the first few nights of a placement. Lazar rightly draws attention to the bad treatment that foster parents receive from an agency that fails to provide information about the children who are placed with them, does not provide the therapy and services the children need, pays them too little to support the kids, doesn’t train them in caring for traumatized children, and requires them to adhere to conflicting and outdated regulations. By all means these problems must be fixed–for the sake of the children as well as the foster parents. But it is unlikely that they will rectify the shortfall of foster homes. More creative and courageous solutions are necessary.

Providing free housing and/or salaries for foster parents might help increase the supply of foster homes. An Oklahoma nonprofit is building larger homes where foster families can live rent-free in exchange for taking in larger sibling groups. SOS Children’s Villages Illinois operates several foster care communities in which full-time professional foster parents care for large sibling groups of up to six children. Child welfare agencies should work in partnership with local nonprofits to develop such programs.

But Massachusetts needs to face the facts. There will never be enough high-quality foster homes for all the children who need them. As Stan Rosenberg, former President of the Massachusetts Senate and a former foster youth, wrote in the Globe, many foster parents are loving and caring but others are in it for the stipend and the children placed with them will suffer the consequences. A high-quality group home or residential facility can be much more nurturing and family-like than a low-quality foster home. More such facilities (often known as “congregate care”) are needed in order to prevent our abused and neglected children and youth being re-traumatized by repeated moves between foster homes.

Children who have trouble finding permanent placements tend to be older and/or have more severe behavioral, neurological and cognitive problems which stem from many years of trauma, deprivation, and often in utero substance abuse. Some of these children cannot thrive in traditional foster homes, which are not trained to deal with their difficult behaviors. There are many high-quality group homes around the country where dedicated staff devote their lives to changing the trajectories of these wounded children.

But the political climate has been opposed to such facilities for a long time, as Child Welfare Monitor has often discussed. Congregate care facilities have been closing for years as states have deprived them of funding and stopped sending children there–even if they have to be left in dangerous homes, placed in barely-adequate foster homes, or bounced from home to home. The percentage of children in Massachusetts placed in congregate care facilities decreased from 22% in 2007 to 17% in 2017.

The bias against congregate care has been enshrined in the Family First and Prevention Services Act, (FFPSA) passed as Title VII of the Bipartisan Budget Act of 2018. Under FFPSA, states will no longer be able to draw upon federal funds for congregate care except for children who have been judged too disturbed to thrive in a foster home by a “qualified professional.” These facilities must meet new criteria for licensure, and congregate care placement will be reviewed at every court hearing. Moreover, a child cannot remain in one of these placements for more than 12 consecutive months (or 6 months for a child under 13) without written approval from the head of the child welfare agency.

Sadly, ideology is reinforced by the reluctance of public officials to ask their taxpayers to find room in their hearts to fund high-quality facilities to these neediest of all children. Such facilities are much more expensive than foster homes and many have been starved out of existence around the country.

Instead of discussing the need for more congregate placements, Lazar quotes advocates who state that more children could be maintained in their own homes if adequate services could be provided to their parents. Yet, as she herself states, about 80% of the children in DCF’s caseload are living at home while the agency attempts to help their families avoid foster care. A spate of deaths of children in DCF-supervised homes since 2014 has distracted the agency from any attempt to reform foster care. Do we really want to put more children at risk to avoid spending money to nurture and house our most vulnerable children?

Primary prevention of child maltreatment should include family planning

Primary prevention is the phrase of the day in child welfare. As Jerry Milner, Associate Commissioner of the Children’s Bureau of the Department of Health and Human Services put it in a letter attached to the program for the recent NCCAN conference, “Right now, our child welfare system typically responds only after families have lost much of their protective capacity and children have been harmed. We need to create environments where families get the support they need before harm occurs. This calls for an intensified focus on primary prevention and a reconceptualization of the mission and functioning of child welfare systems.”

Primary prevention refers to the prevention of abuse and neglect before it occurs through universal approaches. This is distinguished from secondary prevention, which focus on those at risk for a problem like child maltreatment, or tertiary prevention, which focuses no preventing on recurrence of a problem that has already occurred. (The much touted Family First Act allows funds to be used only for tertiary prevention, which is perhaps why it was not mentioned at the conference and why the Children’s Bureau has been dragging its feet on issuing guidance to states and counties.)

Yet, discussions of primary prevention (including those at NCCAN) often leave out the most primary of all–encouraging people to delay childbearing until they are ready to be parents, to wait at least 18 months between pregnancies, and to curb the overall number of children they have.

The connection between teen pregnancy and child maltreatment is well-known, but adolescence is lasting longer than ever, and even mothers aged 20 to 25 are more likely to abuse or neglect their children than older mothers. California researchers Emily Putnam-Hornstein and Barbara Needell found that babies born to mothers who were under 20 were twice as likely to be reported to child protective services (CPS) by the child’s fifth birthday as those born to mothers 30 or older. Among children referred to CPS by age five, almost 18 percent were born to a teenage mother and 50 percent were born to a mother younger than 25. Among children with no CPS contact, only 8 percent were teen births and 30 percent were born to a mother under 25.

Less well-known or discussed is the consistent evidence that larger family size and closer child spacing are correlated with child maltreatment. The Fourth National Incidence Study of Child Abuse and Neglect found that households with four or more children had a maltreatment rate of 21.2 per thousand, compared with 11.9 per thousand for families with two children. Putnam-Hornstein and Needell found that children who fell third or higher in the birth order were more than twice as likely to be the subject of a maltreatment report as first children.

Not surprisingly, research suggest that the interaction between birth order and maternal age creates the highest risk for a child maltreatment fatality. A study using linked birth and death certificates for all births in the U.S. between 1983 and 1991 found that the most important risk factors for infant homicide were a second or subsequent infant born to a mother less than 17 years old. These infants had 11 times the risk of being killed compared with a first infant born to a mother 25 years old or older. A second or subsequent infant born to 17 to 19-year-old mother had nine times the homicide risk of the first infant born to the older mother.

And setting the research aside for a moment, anyone who has worked for or with CPS, or in foster care, knows the prevalence of larger families with closely-spaced children in the system, often with a mother that started childbearing as a teen. This blogger has observed the same pattern as a member of the District of Columbia’s Child Fatality Review Committee, and it has been observed in other jurisdictions as well.¹

If it is not the lack of research, why do supporters of child maltreatment prevention fail to include family planning and contraception in their suggestions? Judging from the reactions this blogger has received when raising this issue, it is our country’s shameful history of attempting to restrict childbearing by women of color through means including forced sterilization and the promotion of birth control methods like Norplant.

But advocates for children of color should not allow this racist history to prevent thinking clearly about what is best going forward. There are few if any policies that could be more helpful to the future of black children and the elimination of racial disproportionality in foster care placement than ensuring that black women have access to the most effective methods of contraception so that they can determine their own futures.

Family planning and contraception need to be included in the discussion about child maltreatment prevention. Research suggests that media messaging, better information, and use of more effective contraceptive methods contributed to the drastic decline in the teen birth rate from 61.8 per thousand in 1991 to 18.8 per thousand in 2017. However, it is still high among certain populations, including Black (27.5 per thousand) and Hispanic (28.9 per thousand) teens.

We now have safe, effective long-lasting reversible methods of contraception. Known as LARC’s, for “Long Lasting Reversible Contraceptives, these methods provide long-lasting contraception without requiring action by the user. They include IUD’s and contraceptive implants. But LARC’s are not universally available, and even when available, women desiring these methods may have to return for a second appointment. Moreover, health care professionals are often not trained to address myths and misconceptions concerning longer-lasting contraception. The Colorado Family Planning Initiative improved access to LARC’s by training public health providers, supporting family planning clinics, and removing financial barriers. As a result of this initiative, the state’s teen birth rate was cut in half in just five years.

The Colorado initiative could be adopted nationwide, combined with a mass media campaign to explain the benefits to both children and parents of planning and spacing of pregnancies and births. We know that such campaigns can change people’s health-related behavior, as in the case of smoking cessation and HIV prevention.

The omission of pregnancy prevention from the primary prevention toolkit is particularly upsetting because very few programs have been shown to be effective in preventing abuse or neglect after a baby is born. Jerry Milner and other proponents of primary prevention in child welfare argue that we should help families before they maltreat their children. How much more efficient and humane it would be to postpone the birth of children who are likely to be maltreated and help troubled adults address their problems before they have a first or subsequent child rather than afterwards?

Testimony of Dr. Angela Diaz, CECANF, August 6-7, 2015), https://slideblast.com/cecanf-nyc-meeting-transcriptfinal_59767e8e1723ddc0e0eedc5d.html ↩