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 ↩

Strong and Thriving Families: The Unreal World of the Children’s Bureau

NCCAN The 21st National Conference on Child abuse and Neglect (NCCAN) sponsored by the Children’s Bureau of the U.S. Department of Human Services (HHS) took place in Washington DC from April 24-26, 2019, and there could be no better window onto the child welfare zeitgeist. NCCAN’s defining spirit was perfectly embodied in the conference theme, Strong and Thriving Families. But the main takeaway for this blogger was how far the field has strayed from its central and defining mission–protecting children.

From the first words booming out of the speaker in the hotel ballroom, the conference plenary sessions focused relentlessly on a two-part message. First, the worst thing to do for abused and neglected children is to remove them from their families and we should stop doing it right now. Second, child welfare should focus on primary prevention–preventing child maltreatment before it occurs.

Removing abused and neglected children from their families is the worst thing you can do to them. That was the main message delivered by plenary speaker Amelia Franck Meyer, one of PEOPLE Magazine’s 25 Women Changing the World. Meyer made extensive use of the animal kingdom to make her points about the mother-child relationship. She started with baby ducks imprinting onto their mothers and went on to mother bears. When one of own children is not having their needs met at school, Meyer says she will stop at nothing to ensure that the little one’s needs are met. And that’s why all kids need their mother, she explained, because your mother “always has your back.”

“Mama bear” would not be the best term to describe many of the mothers I saw as a foster care social worker, or the ones whose children’s deaths I have been reviewing as part of the District of Columbia’s Child Fatality Review Committee. The moms who expose their babies to brain-damaging substances in utero, sleep through the night aided by drugs or alcohol while their infants die, can’t be bothered to bring their children to school for 30 days in a semester, leave them in the care of volatile boyfriends, or inflict bruises and cuts are hardly mama bears. And, despite what we may want to believe, some children need to be rescued from such mothers.

Meyer also told us that we should not think of children as individuals but as part of families, which sounds a bit like a return to an earlier century. And of course she did not forget to the modern trope that child welfare is not about saving children from their families but rather about helping families protect their children.

In his closing plenary session, Children’s Bureau Chief Jerry Milner urged us to stop using the term “birth parent,” “which undermines the singular parent-child relationship.” That term helps separate the idea of procreation from that of nurturing–something that Milner clearly does not want to do. We also can’t talk about “dysfunctional” families, according to Milner. If only not talking about them would make them function well!

Milner urged participants to picture a different type of child welfare system, where “families are given what they need to thrive, not just survive.” In an interview with the Chronicle of Social Change, Milner suggested that what families need to prevent maltreatment includes “parenting education and support, community-based substance abuse prevention and treatment services, ready access to needed medical and mental health services and trauma-informed services to help parents heal from their adverse experiences.”

Milner did not mention child care, housing, or increased cash assistance–services that many would argue poor families need to thrive. But that’s not surprising given that he’s a member of the Trump Administration. Even expanding access to parenting classes, drug treatment and mental health services does not sound like an administration priority–unless the funds come from reprogramming current spending, which seems to be what Milner has in mind. By his own report, he tells child welfare officials who are afraid of adding a new set of primary prevention functions to their current overwhelming mandate that they should do it instead of what they are already doing, not in addition to it! Apparently he believes that cutting funds for CPS investigations and foster care would provide ample funding for primary prevention.

So what’s wrong with all this? Isn’t primary prevention the most logical approach to any social ill? Unfortunately, there are a few problems with making it the only approach:

We don’t know much about what works to prevent child abuse and neglect. The most touted programs involve home visiting, and we don’t have a lot of evidence that they work to prevent child abuse and neglect. The California Evidence Based Clearinghouse for Child Welfare (CEBC) has rated only one home visiting program as “well-supported” by the research evidence as a means of preventing child maltreatment, and that program (Nurse Family Partnership) is limited to first-time low-income mothers. CEBC rates only one program (SafeCare) as “supported by the research evidence” as a program to prevent child maltreatment. And all of these programs have been strictly voluntary–which leaves out the families that are most dangerous to their children.
Many primary prevention programs don’t belong in the child welfare agency. Mental health and drug treatment serve a broader clientele than parents involved in child welfare and are generally provided by different agencies. And while Milner was careful not to mention housing, child care, or cash welfare, these don’t belong under the jurisdiction of child welfare agencies either.
Even if we had a better idea about what worked, we might reduce maltreatment but not eliminate it. We would need a method of investigating possible occurrences and protecting (even sometimes rescuing) the children at risk. It’s like saying we need to shut down hospitals. Of course we want to prevent gun violence, car accidents, cancer, and outbreaks of preventable infections diseases. But we certainly need to have hospitals available in case we fail.

Given NCCAN’s focus on primary prevention, it is not surprising that the Family First and Prevention Services Act received almost no mention throughout the conference, even though it is the biggest change to federal child welfare legislation in two decades and takes effect in October–and federal guidance is woefully lacking. Jerry Milner has already said that Family First is only the first step toward transforming child welfare. What he really wants is a block grant that would allow states to shift funding from CPS, foster care, and family preservation to primary prevention. And that could result in further starvation of CPS, foster care and in-home services (which need more funding, not less) in the name of a mission that should be carried out by other agencies.

On Monday, conference participants returned to the real world, where media outlets in Illinois and nationwide were reporting on five-year-old AJ Freund, who was beaten to death on April 15. His parents, who reported his disappearance three days later and tearfully attended a vigil shortly thereafter, have been charged with his murder. As the Chicago Tribune put it,

Witnesses in all corners of AJ’s life saw signs of abuse or neglect. A doctor, neighbors, police and others knew or suspected that much was amiss over the years. Many of them sounded alarms that were recorded by the courts and the Illinois Department of Children and Family Services, which once again finds itself struggling to explain why a child on its watch is now dead….Yet AJ, who was born with opioids in his system, was left to live in a filthy house of horrors where it appears he was hurt again and again.

And if Jerry Milner and Amelia Franck Meyer have their way, many more AJ’s will suffer and die without anyone to rescue them. Because they believe that child welfare agencies should not be in the business of rescuing children.

Reducing Congregate Care Placements: not so easy, not always good for kids

Most child welfare experts and policymakers at all levels seem to agree that our nation needs to reduce the use of group homes and other non-family placements (often called “congregate care”) for foster youth. Yet signs from around the country suggest that the drive to move foster youth quickly out of congregate care is facing some obstacles–and may be resulting in more damage to foster youth.

The child welfare establishment–including the federal Administration for Children and Families, agency leaders at the state and local level, prominent think-tanks, scholars, and foundations–is in agreement that “every kid needs a family.” These leaders acknowledge that some foster youth need a group placement to address behavioral issues that may prevent success in foster care, but such youth should be moved out of the group setting as soon as these issues are addressed.

In 2015, the California Legislature took the lead in implementing this new focus by enacting the Continuum Care Reform (CCR), which required all foster youth to be placed in families except those requiring intensive supervision and treatment for a temporary period. Such youth must be placed in Short-Term Residential Treatment Programs (SRTP’s), which must be accredited and meet rigorous standards.

Congress followed in 2018 by adopting the Family First Prevention Services Act (FFPSA, (Title VII of the Bipartisan Budget Act of 2018), which imposed similar changes on the federal level, with a temporary congregate therapeutic option called Quality Residential Treatment Programs (QRTP’s) instead of SRTP’s. To receive reimbursement for a QRTP placement, a “qualified professional” must determines within 30 days of the placement that the child needs to be placed in such a setting rather than a relative or foster family home. The decision must be approved by a court within 60 days and reviewed at subsequent hearings (usually every three to six months). Moreover, a child cannot remain in a QRTP for more than 12 consecutive months (or 6 months for a child under 13) without written approval from the head of the agency.

California, where CCR took effect in 2017, has been widely viewed as a harbinger of what might happen after FFPSA takes effect next October. But Golden State policymakers have been “shocked shocked” to learn that children have not been moving out of congregate care settings as fast as anticipated. The reform was expected to pay for itself due to savings from moving children from pricier congregate care settings to cheaper family homes. However, this has not happened. The Office of the Legislative Analyst has found higher than projected state spending for one main reason: instead of moving from group homes into family foster homes, children are moving into “STRTPS,” the new congregate option offered by CCR.

Although the Legislative Analyst did not speculate about reasons for the slow transition, one does not have to look far for clues. A report from San Joaquin County indicates that the county is unable to find homes for the teens with the greatest needs, who remain in group homes. Efforts to recruit foster parents willing to take on these challenging youths have so far failed.

Another jurisdiction that started eliminating group homes long before the Family First Act was New York City. The city’s Administration for Children and Families (ACF) is reeling from an alarming report about the intake center where children are taken after being removed from their families. Workers described an atmosphere of chaos, violence, weapons in plain sight, feces-smeared walls, overcrowding and “a dangerous mix of babies and young children with special needs living alongside troubled teens and even adults straight out of jail.” This intake center was was meant as a place for children to wait for a few hours until a placement could be arranged. But staff report young people with behavioral problems or medical needs living in the shelter for months because foster families cannot be found for them. One disabled teenager lived there for a year. The president of the union representing ACF workers blamed these long stays on management decisions made years ago to close group homes, based on the belief that family homes were better for children. Unfortunately, the agency has not been able to find families to take in many children with behavioral problems, mental disabilities, and histories of trauma and abuse.

In Georgia, there are more children in foster care than ever before and not enough homes for them. Wanting to address this problem, long-time foster and adoptive parents John and Kelly DeGarmo started the Never Too Late (NTL) foster home for boys. But when they applied for a license to accept youth from the foster care system, they found it was too late. Due to the Family First Act, Georgia was not going to license any new residential group homes. State administrators instead asked NTL to serve as a Transitional Living Program, (TLP), for youth ages 16-21 as the boys transition from foster care to independent living. These programs are also needed, but one can’t help but wonder about Georgia’s plan for meeting the needs of the many children who cannot find foster homes and could have thrived in atmosphere of loving care at Never Too Late.

In my own jurisdiction, the District of Columbia, the Child and Family Services Agency is proud of the low percentage of foster youth that are in group homes, attributing it to “the agency’s success in supporting children and youth with higher needs in traditional foster homes.” Yet, advocates are declaring a foster care placement crisis. There is a lack of appropriate foster homes for many children, particularly older teens and those with behavioral problems. As a result, according to the Children’s Law Center, foster youth experience multiple placement disruptions, with devastating consequences to their mental health. CLC also blames the placement crisis for delayed removals of children from unsafe homes, youths remaining in poorly matched placement, and youths leaving their official placements for unofficial community settings. Yet, there is no voice advocating for more therapeutic group homes, the most appropriate setting for many such youths.

The state of Washington has about 100 youths in out-of-state facilities due to a lack of in-state beds. A scathing report recently described abusive restraint practices and other problems at an Iowa facility where Washington was sending some of its foster youth. In a letter to the legislature, Ross Hunter, director of the Department of Children Youth and Families, acknowledged that the agency has an insufficient array of therapeutic group homes and residential facilities for children with severe behavioral problems that make it impossible to maintain them in foster homes. Among the consequences of this shortage, Hunter cites the following: (1) children being repeatedly placed in homes that can’t handle them, resulting in damage to the children and loss of foster parents to the system; (2) over 2000 office and hotel stays for children last year; and (3) use of expensive one-night placements “at extraordinary cost and detriment to the child,” in addition to the out-of-state placements. Hunter proposes to bring all of Washington’s children home and eliminate office and hotel stays by expanding the number of therapeutic group home beds, as well as increasing the quality of existing congregate placements.

Oregon is also reeling from reports of abusive out-of-state placements. After being sued for housing foster kids in hotels, it stopped that practice but sent more high-needs children out of state. Reports of a nine-year-old being injected with Benadryl to control her behavior have led to a public outcry that over 80 Oregon foster kids are in out-of-state facilities, many of them troubled for-profits, because the state lacks residential programs to provide the treatment they need.

Washington and Oregon are among the states with the highest proportions of foster children placed in families, according to federal data cited in a recent report from the Annie E. Casey Foundation that drew extensive press coverage. The report provided state-by-state numbers, generating media coverage (but not in Washington and Oregon) that praised those jurisdictions with lower group home percentages and chastising those with higher rates. But nowhere did the authors mention the fact that eliminating too many congregate placements may lead to foster youth staying in offices, hotels, emergency placements, and abusive out-of-state facilities.

We are not taking this opportunity to argue that many group homes (especially those using the house parent model) are more family-like than many foster homes–which we have argued elsewhere. Even if we accept the premise that no young person should be in a group home one minute longer than necessary once ready to function well in a foster home, there are several problems with implementing this premise in the real world.

We don’t have a diagnostic instrument capable of determining in advance who “needs” a congregate placement and who does not. As of now, it is a subjective determination, making it difficult to project a specific decline in congregate care placement. There is concern that the FFA may make it too difficult for children to gain access to the therapeutic placements they need.
Whether a child is “ready” for family life depends upon the families available. Some very gifted, well trained and dedicated foster parents can nurture high-needs youth who would not thrive in the average foster home. But when such a parent is not available, a child might be better off in a high-quality therapeutic group placement.
Often a family simply cannot be found that is willing to accept a teen with troubling behaviors or a history of residential treatment or delinquency. The most ridiculous sentence in FFPSA is this one: “A shortage or lack of foster family homes shall not be an acceptable reason for determining that the needs of the child cannot be met in a foster family home. ” What should be done then with a child that has no place to go?
A year (or six months for a preteen) may not be enough time for a troubled child to become “family-ready.”. Many children and teens in foster care have suffered years of trauma in their homes, and perhaps multiple placements in foster care. The time required is more likely measured in years than in months.
It may be difficult for smaller, high quality group homes to meet the criteria for QRTP’s.

There is no doubt that many congregate care facilities are of poor quality–witness the horrors suffered by Washington and Oregon youths who were shipped out of state. The framers of FFPSA were right in wanting to ensure that these facilities entrusted with our most fragile youth are up to the task, although they adopted a blunt instrument for doing this. Let’s hope that other states follow Washington’s plan and respond to FFPSA by ensuring that therapeutic group homes are adequate in quality and quantity rather than eliminating them.

Placing children with the parent that abused them: The problematic theory of parental alienation

MayaTsimhoni — Maya Tsimhoni: *Detroit Free Press*

An unproven–and mostly discredited–theory is encouraging family court judges to award custody–against children’s wishes–to the parent that has been accused of harming them. Moreover, this theory of “parental alienation” has “spawned a cottage industry of so-called family reunification camps that are making big profits from broken families.” That’s the message of a stunning report by the Center for Investigative Journalism aired on public radio’s Reveal program.

The Reveal broadcast focused on two custody cases in which the judge ordered children placed against their will with the parent that they claimed was abusive. In one case, the judge sent a teenage boy to juvenile detention because he was not making sufficient efforts to get along with his mother. He and his sister were then sent to live with their father and allowed no contact with their mother for a period of three years. In the other case, a fourteen-year old girl who said her mother was emotionally abuse and wanted to live with her father was sent to a “reunification camp” for ten months at her parents’ expense. Her mother was given full custody and the teen was separated from her father father for four years. The judges in both cases based their decisions on a theory called “parental alienation.”

“Parental alienation,” originally “Parental alienation syndrome (PAS),” was the brainchild of Richard Gardner, a child psychiatrist who developed it to help fathers fight abuse claims in custody disputes. In its current iteration, parental alienation describes a parent’s attempt to turn the children against another parent in a custody dispute. A charge of parental alienation is often deployed by a parent who has been accused of abuse, allowing that parent to turn the tables and accuses the other parent of brainwashing the children. The theory encourages judges to remove children from the parent with whom they are bonded because that parent is believed to have alienated them against the other parent.

According to Joan Meier, a leading researcher in the field of domestic violence and custody cases, there is little evidence to support the idea that “parental alienation” due to manipulation by one parent is a common occurrence. However, invoking parental alienation allows an abusive parent to portray a protective parent as a vengeful liar who is manipulating the children by implanting false memories of abuse. The theory creates a “paradoxically disastrous dynamic“: if an abuser can convince a court that the children’s attitudes reflect parental alienation, he can actually benefit from his abuse.

The Reveal story was misleading in one respect. While acknowledging that the charge of alienation is overwhelmingly used by fathers against mothers, the story focused on two families in which the mothers used the charge to take custody from the fathers. Much more common are stories like the following:

In August 2018, six-year-old twin boys were ordered removed from the sole custody of their mother (with whom they had lived for five years) and placed with their father, who was alleged to have physically and sexually abused them for years. The father, an Air Force colonel with a traumatic brain injury, had acknowledged problems with controlling his anger and sexual impulses. Yet a family court judge in Montgomery County, Maryland gave sole custody to the father, voicing the belief that the boys’ mother had manipulated them into making five allegations of abuse–even though such fabricated abuse allegations from young children are rare.
The divorce case of Omer Tsimhoni and his ex-wife, Maya Eibschitz-Tsimhoni of Bloomfield Hills, Michigan, drew international attention in 2015 when the judged locked up their three children, ages 9, 11, and 14, because they refused to have lunch with their father. The children spent more than two weeks in juvenile detention before the judge released them after public outcry. The mother had claimed the children were estranged from their father because he physically and verbally abused them, and the father accused her of alienating the children. Later, the father was given temporary custody and the children did not see their mother for almost nine months. The mother was finally given primary custody by a new judge in June 2016.

How do judges make these decisions, which often seem cruel and contrary to common sense? According to Meier, many lack understanding of domestic violence and child abuse. Moreover, they often rely on neutral evaluators who also also lack “meaningful knowledge or expertise in domestic violence and abuse. Adding to this ignorance is the emphasis in family courts and mental health training on the importance of children retaining relationships with noncustodial parents after divorce and a consequent emphasis on “co-parenting,” which often reinforces the parental alienation hypothesis.

Unfortunately, there is no data to indicate how often parental alienation plays a part in child custody decisions. But according to Joan Meier, “parental alienation remains a dominant issue in many, if not most, custody cases in which a mother has alleged that a father was abusive.”

Claiming parental alienation has proven quite successful for abusers. In the first study of its kind, Meier and Sean Dickson reviewed 238 published opinions from around the country. The results were startling. When courts believed a father’s claim of alienation, fathers won almost every time, regardless of whether or not the mother reported abuse. Mostly stunningly, even when the court believed that abuse occurred, the alienation claim trumped the abuse claim. In the seven cases where the court believed the abuse claims (five involving domestic violence, one physical abuse, and one both), the father won custody in every case.

According to Meier, the increasing use of parental alienation theory is part of a broader “trend toward reversal of custody from protective mothers to allegedly abusive fathers…” Moreover, studies have identified “a trend toward favoring fathers, in contrast to widespread assumptions that mothers are favored in custody litigation.”

Thankfully, it appears that due to media coverage and the work of scholars and activists, awareness about the use of parental alienation theory is growing among the public, child advocates, and policymakers. After eight years of advocacy, the House passed a Concurrent Resolution last fall that states that “child safety is the first priority of custody and parenting adjudications, and courts should resolve safety risks and claims of family violence before assessing other best interest factors.” The resolution also calls for higher standards for evidence and for the “experts” who testify in court and calls on Congress to schedule hearings on family court practices with regard to children’s safety and civil rights. According to Joan Meier, this resolution is “the perfect springboard” for local activists to take to their legislators and ask for similar changes at the local level, where the family courts actually operate.

DV LEAP, an advocacy organization founded by Joan Meier, and other organizations are also fighting for the rights of protective parents and abused children in court. On March 22, DV LEAP and many other organizations filed a groundbreaking brief with the New York State Court of Appeals that is the first documented collaboration between domestic violence and child maltreatment professionals on parental alienation theory. According to Meier, this brief has the potential to be a catalyst for national change.

This post is a departure for Child Welfare Monitor. We have not touched on many issues outside the arena of public child welfare. But parental alienation theory is yet another example of powerful adults ignoring the best interests and expressed wishes of children, and putting them at risk due to ignorance or mistaken beliefs. Those of us who care about abused and neglected children need to expand our awareness and activity to include all children whom our institutions fail to protect from maltreatment.

Inspector General: Child safety and well-being no longer priorities for Illinois Department of Child and Family Services

DCFS has lost focus on ensuring the safety and well-being of children as a priority. This is evidenced by several recent cases and the clear lack of attention to assuring children and families receive adequate, thorough, and timely responses and needed services. Investigators, caseworkers and supervisors are unmanaged, and unsupported. Children are dying, children are being left lingering in care, children are being left in in psychiatric hospitals beyond medical necessity causing them to lose hope. This is not just unacceptable it is HARMFUL

That startling statement was made by the Acting Inspector General (IG) for Illinois Department of Children and Families to News Channel 20 about its most recent annual report. During FY 2018, the Office of Inspector General (OIG) reviewed 97 deaths and one serious injury of children whose families were involved in the child welfare system within the preceding 12 months. Of the 98 families involved, at least 52 were the subject of of a completed child abuse or neglect investigation during the previous 12 months; fully 37 of these investigations failed to find any abuse or neglect and were closed without any action to protect the child. Twelve of the 98 families were the subject of an open investigation when the child died, eight were involved in an open family service case, and three had had a family case closed within a year of the death. (See the full count of deaths by case status at the bottom of this article.)

Not all of the deaths or serious injuries can be attributed to DCFS failure to protect a child. Twenty-seven deaths were ruled natural; most of the children involved had serious medical issues. Some of the deaths (including most the 16 youths in foster care)¹ were sadly due to violence, car accidents, drug abuse by older youths and other circumstances not under the Department’s control. Heartbreakingly, two older teens in foster care died of abuse that was inflicted on them as infants and left them medically compromised.

However, many of the case reviews suggest DCFS missed danger signs and opportunities to save vulnerable children. Thirteen children were killed by a parent, step parent, parent’s paramour, another relative or unknown perpetrator within a year of an open investigation or service case. These children were beaten, starved, stabbed, and shot to death. The cause of 23 deaths of children in families that recently interacted with DCFS is still undetermined; many are currently being investigated. Most of these children were infants; many of the deaths appeared to be linked to unsafe sleep practices and at least four raised concerns of abuse. The deaths of 24 children with an open or recently open case were classified as accidental. Fourteen of these deaths were attributed to asphyxia, suffocation, or sleep related causes; there were also two accidental drownings, an accidental hanging, and an accidental shooting of a three-year-old by an 11-year-old, as described below.

The OIG completed “full investigations” of four cases that have drawn extensive media attention:

Seventeen-month-old Semaj Crosby was found dead under a couch in her home 30 hours after being reported missing. There was both an open in-home case and a pending child protection investigation of the family at the time Semaj was reported missing. The family had been the subject of 11 investigations during the two years before her death. The mother received SSI for cognitive delays but was never assessed to determine her ability to keep her children safe. Semaj’s seven-year-old brother was psychiatrically hospitalized three times for threatening to kill himself during the time the family’s case was open. A family service caseworker visited the home the day before the toddler was reported missing, and a child protection investigator had been to the house the day the report was made. No immediate safety concerns were reported by this investigator, even though the health department deemed the apartment uninhabitable after the body was found. Criminal and child neglect investigations are pending.
Four-year-old Manual Aguilar was killed, apparently starved to death, and his body was burned post-mortem. Four years before his death, Manual and his three siblings were removed from their mother’s custody after she left the three older children in a car overnight at temperatures hovering around freezing, while Manual was left in a stranger’s care. The children were returned home a year before Manual’s death despite the mother’s failure to progress in therapy and an unfounded investigation stemming from bruises to one child that his older siblings reported were inflicted by the mother during an overnight visit. Five months before Manual’s death, the two older siblings texted to their former foster parent that their mother was beating them, but the investigation was unfounded when they recanted. The mother has been charged with murder.
A daycare center reported that a two-and-a-half-year-old appeared to have cigarette burns on both hands. The reporter also said the child’s face had been swollen on two prior occasions, and an unknown male accompanying the mother was seen to hit the child across the face a week before. The investigator closed the case without investigating adequately either the child’s burns or the family’s allegation that they occurred at the daycare. Two days following the investigation’s closure, the child experienced cardiac arrest and died four days later. The autopsy concluded that the manner of death was undetermined and suspicious, but a child protection investigation did not find evidence to find anyone responsible for the death.
An eleven-year-old girl accidentally shot her three-year-old brother in the head while playing at home. This child survived and and this appears to be the only non-fatal case reviewed. The parents had left four of their children, of which the eleven-year-old was the oldest, at home alone. The father had eight drug convictions and had been arrested multiple times for physically assaulting the mother. The investigation of the shooting was the eleventh investigation of this family since 2008. One investigation had occurred when the father barricaded himself in the home with the mother, who was eight months pregnant, and the screaming and crying children. The children’s eight-year-old sibling was in residential care in the custody of DCFS at the time of the shooting and the agency was required to monitor the at-home siblings as well. Nevertheless no visits by case managers to the home were documented in the 45 months before the shooting with one exception. A case manager attempted to visit the home 21 days before the shooting but was not allowed in. .

The acting Inspector General told a reporter that understaffing may have contributed to the state’s inability to prevent child deaths. Following the death of Semaj Crosby, the OIG investigated a media report that child protection workers in the local office were offered incentives for early case closure. The IG found that while Semaj’s family was involved with DCFS, the entire region was understaffed (at times as low as 66% of staff needed), resulting in excessive caseloads for investigators. In December 2016, the field office administrator offered a $100 gift card to the investigator who could close the most cases in January. The IG found similar incentive programs for early case closure around the state.

The OIG also found that “a large contributing factor to the caseload problem was that the previous director had several management initiatives that seemed to take priority” over any attempt to redistribute caseloads. One of these initiatives, Rapid Safety Feedback, received some media attention last year. DCFS awarded a multimillion-dollar contract to two out-of-state firms using a “propriety algorithm to identify cases most likely to result in death or serious injury.” There were concerns that this contract was one of several no-bid contracts given to a circle of former associates of the previous director, as described by the Chicago Tribune. The contract was terminated after 25 to 50 percent of cases were flagged as having a a greater than 90% probability of death or serious injury in the next two years, alarming and overwhelming social workers. At the same time, the algorithm failed to predict the death of Semaj Crosby and other children who were killed while under supervision by DCFS.

The OIG report identified two areas of “chronic misfeasance,” or conduct that is lawful but inappropriate or incorrect. One of these areas is “intact family services,” which is DCFS-speak for the services provided to families 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. The OIG 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.

A second area of “chronic misfeasance” identified in the 2019 report which has also drawn media coverage is the practice of leaving foster children in psychiatric hospitals “beyond medical necessity,” or after they are stable enough to be cared for outside that setting because there is no appropriate placement. OIG reported that the number of such episodes increased from 273 in FY 2017 to 329 in 2018. “The availability of community-based services and resources for youth with significant mental and behavioral needs continues to be at crisis levels.”

The OIG’s overall conclusion–that child safety and well-being are no longer priorities for DCFS–is sobering. But even more alarming is the fact that this description could be applied to many or even most other states. Although we don’t have numbers for most states, every year brings stories from around the country of children killed after long histories of contact with child welfare authorities. Twenty-seven percent of the fatality cases analyzed by the Administration on Children and Families for its Child Maltreatment report had at least one Child Protective Services contact within the past three years. State child welfare agencies tend to hide behind strict privacy protections in order to avoid releasing information on child protection failures, even though the case information could be released without including the names of the families involved. As a member of the District of Columbia’s Child Fatality Review Commission, I hear at almost every monthly meeting about one or more children who died after the family was called to the attention of CPS multiple times. And yet, I am not allowed to share any information about these cases with anyone, including legislators.

At least in Illinois, thanks to the DCFS Inspector General, the public and its elected representatives are given the opportunity to learn about failures to protect children while in the custody of their parents as well as those the custody of DCFS. This information helps make the case for change. The OIG report was the subject of a hearing in Springfield. The Governor has already requested an increase of more than $70 million for 126 new staff and technology upgrades.

Unfortunately, most states do not have an independent agency like the Illinois OIG to look out for children who are served by the agency both at home and in care. In a report issued on April 4, 2018, the National Council of State Legislators found that only 11 states have “an independent and autonomous agencies with oversight specific to child welfare,” although they seem to have missed Illinois. All states need such an autonomous agency. Somebody needs to reveal the truth about how we fail our most vulnerable children–and what it would take to do better.

Number of Child Deaths by Case Status from OIG Report

Case Status* Number of deaths or serious injuries

Pending Investigation at time of child’s death………………………………………………………12

Unfounded Investigation** within a year of child’s death……………………………………37

“Indicated” Investigation*** within a year of child’s death…………………………………..15

Youth in care………………………………………………………………………………………………………………16

Open Placement/Split custody****……………………………………………………………………………..3

Open Intact Case*****………………………………………………………………………………………………….8

Closed Intact Case within a year of child’s death……………………………………………………….3

Child of Youth in Care……………………………………………………………………………………………………1

Child Welfare Services Referral (no allegation of abuse or neglect)………………………….2

Preventive services to assist family but not as result of indicated investigation………1

Total……………………………………………………………………………………………………………………………….98

*When more than one reason existed for the OIG investigation, the death was categorized based on “primary reason.”

**An investigation in which the agency was unable to verify that abuse or neglect occurred.

***An investigation in which abuse or neglect by the parent was found to have occurred.

****Child was in home with siblings in foster care

****A case in which the family was receiving services while the child remained in the home.

Of the 16 children who died while in foster care, a 14-year-old and an 18-year-old died of gunshots by unrelated perpetrators, two died as a consequence of abuse by their parents in infancy, three were infants in care of relatives and cause of death was undetermined for two and suffocation for one, two died of methadone or opioid intoxication, one 18-year-old died in a car accident and five died of natural causes. ↩

Therapeutic Group Homes: Needed Programs in Danger from Family First Act

It is a fact universally acknowledged that some children cannot thrive in foster care. This includes children whose behaviors are so challenging that most foster parents will be unable to cope. These children often go through many foster homes before they are finally placed in a more appropriate placement, usually a therapeutic group home or residential treatment program.

One of the goals of the Family First and Prevention Services Act (FFPSA), passed last year as part of the Bipartisan Budget Act of 2018), was to reduce the use of placements other than relative homes and traditional foster care. However, FFPSA recognized that some children and youth cannot thrive in foster care and allowed for placements to meet their needs. Unfortunately, the many restrictions imposed by the Act mean that many of these young people may not able to access these facilities or will be prematurely removed from them.

Many youth who are placed in foster care have serious emotional and behavioral issues. Many have endured years of trauma, including physical and sexual abuse, severe neglect, and living in dangerous and chaotic conditions. Some have cognitive or neurological issues caused by drug exposure in utero or severe neglect. Some have violent outbursts, many are verbally aggressive, and many have difficulty in making attachments. As a result of these problems, many of these hard-to-place young people have been placed in ten or more foster homes.

High-quality therapeutic group homes are more able than foster families to work with challenging youth for a number of reasons described in an excellent video from the Sonoma County Juvenile Justice Commission. Their staff are trained in working with behaviorally challenging youth and often operate from a trauma-informed perspective. These facilities often have therapists and psychiatrists and other mental health personnel on staff. Good therapeutic group homes create a homelike environment, with young people living in cottages with a total of six or eight youths. Staff are dedicated and passionate about what they do. Unlike foster parents, these staff usually work shifts and thereby avoid burnout. Residents also draw strength from peers with similar issues, especially older peers who have improved and can serve as role models.

Some hard-to-place youth could thrive in the right kind of foster homes, those with training, time, and willingness to work with young people whose behavior is challenging. But many foster parents refuse to take teens or any or children with behavioral or mental health problems. Some states are trying to increase the availability of therapeutic foster homes, but funding and supply constraints mean that such efforts will be far too small to replace therapeutic group homes.

Unfortunately, the restrictions imposed by FFPSA may make it difficult to for many needed therapeutic group homes to continue operating. FFPSA allows the federal government to share the costs of treatment-based congregate care only at facilities that qualify as Qualified Residential Treatment Programs (QRTP). These programs must meet several criteria, including accreditation, a trauma-informed model, medical staff on call, and an aftercare program, among others. Accreditation especially is a long and arduous process that generally takes 12 to 18 months and some homes may not be able to accomplish it by the time the Act takes effect on October 1, 2019 (unless the state chooses to delay implementation for two years). Accreditation is a difficult and costly requirement for a smaller facility. It is important to ensure that only high-quality group homes retain state contracts, but accreditation may not be the best way to ensure quality for smaller programs.

Even more concerning are the limits on which children can be placed at these facilities and for how long. A child’s initial placement in a QRTP will not be reimbursed unless a “qualified professional” determines within 30 days of placement that the child needs to be placed in such a setting rather than a relative or foster family home. This assessment must use an approved tool and be conducted by “a trained professional or licensed clinician who is not an employee of the State agency and who is not connected to, or affiliated with, any placement setting in which children are placed by the State.” The decision must be approved by a court within 60 days and must be reviewed at subsequent status hearings. Moreover, a child cannot remain in a QRTP for more than 12 consecutive months (or 6 months for a child under 13) without written approval from the head of the agency.

There are several problems with these restrictions. It is not clear that agencies can find enough qualified professionals who are not employed by the agency or connected to any placement setting used by the state. More concerning are the time limits. Many therapeutic group home professionals believe that most children with emotional and behavioral problems cannot be in and out of therapeutic residential settings in six months. Many will need to stay a year or even longer.

Without needed therapeutic group homes, many children will experience a string of failed foster home placements, with each one leading to further damage to the child, who may end up on the streets or in jail. As a director of a facility that closed in North Dakota put it, new policies mean that “You are only going to refer kids to (residential child care facility) levels of care after you have exhausted all the other less restrictive options of care. That means putting them with their families, in foster care and repeating failed foster care placements several times before a referral to this level of care would be entertained.”

Group homes have already been closing around the country as states have adopted policies against congregate care (and also due to failure to provide adequate funding) and some states are already seen bad consequences from these closures. In Baltimore, the number of children sleeping in offices shot up from less than five per six month period in 2015 to 130 in the first half of 2018 due to a shortage of foster homes and a dramatic reduction in group home capacity. In Hillsborough County, Florida, hard-to-place foster youths have been spending the night in cars for lack of appropriate placements. In the state of Washington, group homes have been shutting down for years due the state’s failure to keep up with the increasing costs of care. This has contributed to a crisis in care for older, harder-to-serve youth, who are being put up in hotels, offices and $600-per night emergency foster homes and being sent out of state for care. In Illinois, hundreds of foster youths were being kept unnecessarily in psychiatric hospitals as of last August because of a decline in licensed residential facilities.

The attempt to close congregate care facilities without providing an alternative is eerily reminiscent of the closure of institutions for the mentally ill in the 1960s. These hospitals were supposed to be replaced with community health services that were never funded. We are still reaping the consequences with the abundance of mentally ill people sleeping on the streets of America’s cities.

As I mentioned in last week’s post, FFPSA’s group home restrictions were not based on ideology alone. The cost savings from reducing federal reimbursement for group homes were necessary to offset the increased cost of funding services to prevent children’s placement in foster care. But penny-wise is often pound-foolish and the future costs of eliminating therapeutic residential options for foster youth may be much greater than the present savings.

It is not too late for Congress to amend the Family First Act to reduce restrictions on therapeutic group care. Until we have an abundance of qualified therapeutic foster parents willing and able to take the hardest to place youth, cutting down on therapeutic group homes is irresponsible, short-sighted, and a recipe for possible disaster.

Supporting homelike residential settings: a needed correction to the Family First Act

Crossnore With the passage of the Family First Prevention Services Act as part of the Bipartisan Budget Act of 2018, much attention has been paid to Part I, which allows jurisdictions to use federal foster care money to pay for services to a family to to prevent a child’s entry into foster care. Part IV of the Act, which drastically restricts federal reimbursement for placements other than relative homes and traditional foster care, has received less coverage.

Placements that are not in the homes of relatives or foster families are often described as “congregate care.” The term is generally used to include group homes, residential treatment, maternity homes, and other placements that are not a family home. As these placements have fallen out of favor, this label has taken on a pejorative tone.

The Administration on Children and Families stated in 2015, that

Although there is an appropriate role for congregate care placements in the continuum of foster care settings, there is consensus across multiple stakeholders that most children and youth, but especially young children, are best served in a family setting. Congregate care should be a temporary placement for young people with behavioral or mental health issues who need therapeutic services in order to become stable enough to return to a family setting.

FFPSA enshrines this view by denying federal funding for placement in congregate care settings beyond two weeks, unless the setting meets criteria for a Qualified Residential Treatment Program (QRTP) as defined by the Act. These include accreditation, a trauma-informed model, medical staff on call, and an aftercare program, among others.

Moreover, a child’s initial placement in a QRTP will not be reimbursed unless a qualified professional determines within 30 days of placement that the child needs to be placed in such a setting rather than a relative or foster family home. This assessment must use an “age–appropriate, evidence-based, validated, functional assessment tool approved by the Secretary” and the conclusion must be approved by a court within 60 days and must be reviewed at subsequent status hearings. A child cannot remain in such a setting for more than 12 consecutive months (or 6 months for a child under 13) without written approval from the head of the agency.

Keeping all but the most troubled children out of congregate care would make sense in a world with enough great foster homes to accommodate all children, including large sibling groups. But we are far from having such a world. In most states there are not enough foster homes, even including bad and indifferent ones, to accommodate all the children in need. And that means some children staying in congregate care, some in hotels, and others bouncing from one unsuitable home to another.

The shortage of foster homes is no secret, which is why foster home recruitment has been such a big topic in child welfare circles. Unfortunately, there is no sign that any of the highly-touted and often-expensive new efforts taking place around the country will make a dent in the gap between demand and supply. Society is changing in many ways, including the influx of women into the workforce, and there are simply not enough people who are willing and able to provide foster care in the same areas where it is needed.

Yet there is another model of foster care that has not drawn sufficient attention and is in great danger from the implementation of FFPSA. These are residential homes and boarding schools providing “residential (home-like) non-treatment related services to children living away from their families,” according to the Coalition of Residential Excellence (CORE), which represents such programs. These programs often consist of one or more cottage-style homes with live-in cottage parents, with or without an onsite school. Some of the well-known examples are the Crossnore School and Children’s Home in North Carolina, the Connie Maxwell Children’s Home in South Carolina, the San Pascual Academy in San Diego, A Kid’s Place in Tampa Bay and the Florida Sheriff’s Youth Ranches.

Like QRTP’s, these residential programs are generally accredited, seek to involve families, and provide aftercare services, and they often have a trauma-informed model of care. But because these programs are not designed for children with severe behavioral problems who could not flourish in foster care, they cannot receive reimbursement under FFPSA.

So what is the problem? Couldn’t the children in these programs do equally well in traditional foster care? There are numerous reasons why that may not be the case.

There are simply not enough foster homes. If cottage-based residential facilities can no longer take children, that will worsen the situation and will lead to more stays in hotels, offices, sibling separations, and foster homes that are not well-matched to children’s needs. Unfortunately, FFPSA specifically says that “a shortage…of foster family homes shall not be an acceptable reason for determining that the needs of the child cannot be met in a foster family home.”
Due to the scarcity of foster families, few jurisdictions can afford to be choosy enough about whom they accept and retain. And that is why we never stop hearing stories of abusive foster homes that were not closed despite numerous complaints. And that is why every foster care social worker (and former workers like myself) can tell you multiple stories about foster parents who simply don’t care. They may not be abusive or neglectful, but they won’t lift a finger to take the doctor, visit their schools, or drive them to and from extracurricular activities. Of course there are many great foster parents, who treat their charges as their own children but these are a minority. Many foster homes are only slightly less deprived or chaotic than the homes from which the children were removed. When you contrast these homes to the enriched environments of a place like Crossnore (with its house pets, rope-based adventure playground, on-site school, medical care, and 19 kinds of therapy (including equine assisted therapy), it is hard to imagine anyone preferring an indifferent foster home.
Many children must be separated from their siblings because most foster homes cannot take larger sibling groups. Many residential cottage-based programs like Crossnore, the Florida Sheriff’s Youth Ranches, and A Kid’s Place in Florida pride themselves on taking large sibling groups.
Even the best foster parents can have trouble making sure the children’s needs are met in school and coordinating the wide variety of educational, mental health and medical services the child may need. Many of these residential facilities, benefiting from private donations, provide high-quality mental health services and extracurricular activities on site. Those that have schools provide a seamless integration of home and school and education tailored to children’s needs and saving transportation time and funds.

Richard McKenzie, a professor of economics who grew up in an orphanage in the 1950’s, responded to the contention that children always do best in loving and responsible families as follows: “Well, duh! Clearly, families are the bedrock of all societies. The basic problem in child welfare is that many parents, biological and foster, are far from loving and responsible. Indeed, many are derelict in their duties.” (His article, The Success Story of Orphanages, is well worth a read.)

So why is Congress, along with other federal and state policymakers, so oblivious to the benefits of family-like residential settings? It is clear that the high cost of residential care contributed to Congress’ eagerness to restrict it. Savings from Part IV of FFPSA were needed to offset the cost of adding services under Part I. But cost comparisons are often deceptive and short-sighted. Residential home-like programs provide therapists, case managers, after-school activities, and more. Moreover, they bring in substantial private funding in addition to state support. And the future savings that come from providing high-quality, trauma-informed care and education will doubtless reduce future expenditures caused by dropout, crime, and drug abuse.

CORE supports amending FFPSA to treat residential programs that use a house parent model as foster homes for the purpose of federal reimbursement. It is essential that Congress make this improvement this year before the provisions of FFPSA take effect in October. (A state can delay implementation for two years, which means it foregoes receipt of TItle IV-E funds for in-home services for the same period).

Cutbacks on residential programs have already resulted in sibling separations in states like California. From 2006 to 2015, Sonoma County Children’s Village was a haven for 24 foster children who lived in four homes, with surrogate grandparents living on campus. But after California began to limit group home placements to children requiring high levels of care, the village had to close. Sixteen children, including a group of seven siblings, had to leave. Let us hope that Congress will have the compassion to prevent such senseless actions from taking place on a national scale.