Feds confuse substantiation with victimization

On January 28, the Administration of Children and Families (ACF) released its annual report on child maltreatment. In its press release, the agency heralded “a decline in the number of victims who suffered maltreatment for the second consecutive year.” There are three problems with this. First, the alleged decrease in victimization between Federal Fiscal Years (FFY) 2016 and 2017 is so small as to be insignificant. Second, what declined was not child maltreatment but rather the number of children who were “substantiated” as maltreated–a decline that may reflect changing state practice rather than declining child maltreatment. Finally, ACF’s presentation appears designed to support a narrative that favors family preservation over child safety rather than to report the data in an objective manner.

The newest edition of ACF’s Child Maltreatment report is based on state data for FFY 2017, which ran from October 2016 to September 2017. The report shows that states received 4.1 million referrals (calls to child abuse hotlines) alleging maltreatment involving 7.5 million children in 2017. The number of referrals as a percentage of the number of children has increased annually since 2013. ACF does not discuss the reasons for this ongoing increase, nor does it present referral numbers by state, but such increases could stem from increased awareness of child abuse and neglect (often due to highly-publicized child deaths), public information campaigns, or other factors.

Of the 4.1 million referrals received nationwide in 2017, 2.4 million  (or 58%), were “screened in” by state or county child welfare agencies, which means they met agency criteria for receiving a response. As a result, 3.5 million children received either a traditional child maltreatment investigation or were assigned to an alternative non-investigative track, as described below. And of these 3.5 million children, an estimated 674,000 or 19% were found to be victims of abuse or neglect. This flowchart, based on data from Child Maltreatment 2017, illustrates this funneling effect from referrals to substantiation.After rounding and a calculation to account for missing data from Puerto Rico in FFY 2016, HHS estimates that the number of children found to be maltreated decreased of 3,000 (or 0.4%) from the previous year. Such a small change is hardly meaningful; it would be more accurate to say that the number was basically unchanged. This difference from one year to the next is so small that the rate of children found to be victimized was the same in 2017 as in 2016–9.1 per 1000 children. In other words, almost one percent of all children were found to be the victims of maltreatment in 2016 and 2017.

But perhaps more important than the small size of the decrease is the fact that referring to a “decline in the number of victims” or the “victimization rate”  is deceptive, which is why I have used cumbersome terms like “found to be victims of child maltreatment.” Most states use the term “substantiation” to connote that they have concluded maltreatment have occurred; some have an additional finding called “indication” that is somewhat less conclusive than substantiation. But as we all know, a finding of maltreatment is not the same as actual maltreatment. Just look back at my columns on Jordan Belliveau in Florida, Anthony Avalos in California, the Hart children in Oregon, and Adrian Jones in Kansas to find cases where horrific abuse occurred but was not substantiated until a child died.

And that is not the only problem. As ACF itself explained, changes in state policy and practice can influence the number of reports that are substantiated. Different states have different evidence thresholds to substantiate an allegation. According to the report, 37 states require a “preponderance of” evidence, 8 states require “credible” evidence, 6 states require “reasonable” evidence and one requires “probable cause.” One state changed its evidence threshold between 2016 and 2017.

In addition to different criteria for substantiation, some states treat all screened-in referrals in the same way while others have a two-track system of responding to reports. In these two-track systems (often called “differential response” or “alternative response”), some allegations receive a standard investigation, but others (usually deemed to be at lower risk of harm) receive less rigorous response, often known as a “family assessment.” The children in these cases are not determined to be victims even if they have been abused or neglected. Instead their families are offered voluntary services. About half of states reported data on children in alternative response programs. As the above flow chart shows, 639,634 children received an alternative response, almost as many as the 674,000 who were determined to be maltreated.

So a given state’s substantiation rate will be influenced by whether it has differential response in all or part of the state. And if the use of differential response in a state was expanding or contracting over a given period, this will influence the change in the number of  children who are determined to be victims of maltreatment. Specifically, if states increased their use of differential response overall, that would have reduced the number of children found to be maltreated.

And indeed, ACF reports that “states’ commentaries suggest the increased usage and implementation of alternative response programs ….may have contributed to the changes noted in the 2017 metrics.” And upon review,  the commentaries, included in an Appendix to the report, do suggest that the number of reports subject to differential response increased between FFY 2016 and 2017. Six states, including New York, and Texas (two of the four states with the highest number of children)1 were ramping up their use of differential response during FFY 2017, while Massachusetts and Oregon stopped using the two-track system in FFY 2016 and 2017 respectively.

ACF also suggests that changes to state legislation and child welfare policies and practices might influence the number of substantiated allegations. The state commentaries reveal that some states experienced such changes, although it is not clear that they trended in one direction. Some states like Pennsylvania reported an increased emphasis on safety resulting in increased substantiations and others like New Jersey reporting reduced substantiations due to new policies.

As all this discussion shows, it is almost impossible to attribute a change in the number or rate of substantiation to an actual change in the amount of child abuse and neglect. Too many other things are influencing this number and rate.

Not only did ACF inaccurately herald a decrease in maltreatment but it went on to contrast this alleged decrease with the increasing number of referrals, stating “We are experiencing increases in the number of children referred to CPS at the same time that there is a decrease in the number of children determined to be victims of abuse and neglect.” Media outlets lost no time in picking up on this alleged contrast. For example,  the Chronicle of Social Change reported that Child Victimization Declines as Reports of it Continue to Rise.

The interpretation of child welfare numbers to paint a picture of decreasing maltreatment in the face of increasing reporting is not an accident. It feeds into the narrative that is currently dominating in most states and on the federal level without regard to party. According to this narrative, almost all children are better off staying with their parents, no matter how egregious the maltreatment. Removals should be prevented at all costs. If maltreatment is decreasing and reporting is increasing, perhaps something should be done to squelch those pesky hotline callers.

The data presented in Child Maltreatment is extremely important. It is too bad ACF did not stick to reporting it accurately so that readers can understand what it means–and what it does not.


  1. Colorado, Georgia, Nebraska and Washington were the other four states that expanded the use of differential response during FY 2017. 

Yet another child abandoned by another state: Two-year-old Jordan Belliveau dead at his mother’s hands in Florida

Juliet Warren (left) with her foster child, Jordan Belliveau. The 2-year-old toddler went missing for more than two days and was then found dead late Tuesday. His 21-year-old mother, Charisse Stinson, now faces a charge of first-degree murder in the death of her child. [Photo Courtesy the Warren Family]
Jordan Belliveau, Jr. with his foster mother: Tampa Bay Times
On September 4, 2018, the body of two-year-old Jordan Belliveau was found in a wooded area in Largo, Florida. Two days before, his mother Charisse Stinson told police she was assaulted by a stranger and that her son was missing when she recovered consciousness. She later admitted that she had fabricated this account and in fact had caused the injuries that caused Jordan’s death.

Jordan had been removed from his parents in October 2016 and reunited with Stinson in May 2018. At the time of his death, Jordan was under court-ordered “protective supervision” by a nonprofit agency under subcontract with the Florida Department of Children and Families (DCF). There was also an open investigation of allegations of ongoing domestic violence between Stinson and Jordan’s father, Jordan Belliveau, Sr. DCF convened a special review team to determine why Jordan killed despite being under supervision by the system that was supposed to protect him. The team’s report was issued earlier this month.

To understand the case, one must grasp the particularly fragmented nature of child welfare in Pinellas County, Florida, in which three crucial functions usually vested in one agency are split between three different agencies. The Sheriff’s Department handles child abuse investigations, a private agency called Directions for Living manages in-home service cases under contract with Eckerd Connects, which in turn has a contract with DCF, and the State Attorney’s Office represents DCF in court.

The first call concerning Jordan and his parents came in to the child abuse hotline on October 2016, when Jordan was three months old. Jordan and his parents were living in the home of his paternal grandmother, and the caller was concerned about drugs, gang activity and firearms in the home. The allegations were verified and an emergency hearing was called. Ms. Stinson was ordered to relocate immediately and was referred to a program providing housing and support services to young mothers. However, she  refused to cooperate with the program and was rejected. A second hearing was convened on the same day (November 1, 2016) and Jordan was placed in foster care. In order to get Jordan back, the parents had to comply with a case plan which required each of them to obtain stable housing and income, comply with a “biopsychosocial assessment,” and follow the recommendations of the assessment. Ms. Stinson was also required to obtain counseling.

In January 2017, Jordan was placed with the foster family that would keep him until he was returned to his mother 16 months later. It was in this home, as his foster mother reported in a heartbreaking statement after his death, Jordan learned to roll, crawl, walk and talk and flourished in a supportive community of church members, foster families, and Coast Guard families.

While Jordan was thriving in foster care, an escalating series of violent incidents was reported between his parents. Each parent was in turn arrested for violence against the other but each case was dropped because the other parent did not press charges. Despite these incidents, Ms. Stinson was granted unsupervised visits with her son starting June 18, 2017. During the first unsupervised visit, Ms. Stinson allowed Mr. Belliveau to attend despite the fact that his visits were still required to be supervised. At this visit, which took place at a Burger King, members of a rival gang arrived and a fight ensued. Holding Jordan in her arms, Ms. Stinson struck at a woman who was fighting with Mr.Belliveau. Attempting to hit back, the woman hit Jordan in the mouth, inflicting lacerations. This incident was reported to the child abuse hotline, along with allegations that Mr. Belliveau was selling cocaine and marijuana from their home and that both parents used these drugs. Both parents refused to be tested for drugs. The investigation concluded with a finding of inadequate supervision and failure to protect Jordan by both parents.

In the next court hearing on the family case, the magistrate in charge of the case was not informed that this was a gang-related incident, that Ms. Stinson was involved, or that Jordan was injured. There was no mention of the  need to screen both parents for drug use.

According to Florida statute, DCF was required to file a petition for termination of parental rights within 60 days of November 1, 2017, when Jordan had been in foster care for 12 months. Yet no such petition was filed. At the hearing on January 8, 2018, the court found “compelling reason not to consider termination” because Ms.  Stinson was “partially compliant” with her case plan tasks because she had completed an assessment and was wrongly reported to be in counseling.

During a court hearing on April 23, 2018, Ms. Stinson’s attorney reported that she had completed the counseling mandated by her case plan, but no documentation was provided. As a matter of fact, Ms. Stinson had been terminated from counseling for the second time a week before the hearing. The Guardian ad Litem (GAL appointed to represent Jordan’s interests in court) objected to reunification because there was no documentation that Stinson was going to counseling and it appears that the case management agency objected as well. Without requiring documentation,  Magistrate Jennifer Sue Paullin ordered reunification and gave all parties 20 days to object based on new information. No objection was filed.

The court order, obtained by the Tampa Bay Times, states: “No evidence was presented to show that the circumstances that caused the out-of-home placement have not been remedied to the extent that the return of the child to the mother’s care with an in-home safety plan … will not be detrimental to the child’s safety.”.

On April 25, 2018, in anticipation of Jordan’s return to Ms. Stinson, the latter was referred to an in-home reunification program that provided twice-weekly visits from a licensed clinician. Ms. Stinson missed three or her five scheduled visits prior to reunification, which went ahead as scheduled on May 21, 2018. She missed seven of 11 visits following reunification and was unsuccessfully discharged from the program due to failure to participate

In a court hearing on June 11, 2018,  the court granted reunification to Mr. Belliveau, allowing him to join the family. Ms. Stinson had already missed several appointments with the clinician but the case management agency and government attorney reported that both parents were compliant with services.

On July 14, 2018, police responded to the parents’ residence to find Ms. Stinson bleeding and bruised and reporting that she had been punched by Belliveau. Mr. Belliveau was arrested after threatening to kill Ms. Stinson and “a lot of ….cops.” The child abuse hotline was not notified of this incident until three weeks later, on August 4. Despite the escalating violence and threats, the ensuing investigation did not find Jordan to be in danger warranting removal, but it was still open at the time of Jordan’s death.

On August 17, 2018, the agency filed an amended case plan with the court, including domestic violence services for Belliveau (as a perpetrator) and Ms. Stinson (as a victim). On August 24, Ms. Stinson refused to allow the GAL into the house. The investigator contacted the case manager for the first time on August 29, more than three weeks after the investigation began. The case manager said she normally visited once a week but admitted that he sometimes had trouble  reaching Ms. Stinson. On August 31, the case manager completed a home visit and explained to the parents that they needed to participate in services in order to retain custody of Jordan. Less than 24 hours later, Ms. Stinson reported Jordan missing.

Charisse Stinson has been charged with first degree murder for hitting Jordan, causing him to hit his head and have a seizure. Police report she did not seek medical treatment immediately and Jordan died. She then allegedly dumped his body in a wooded area and lied to police about a stranger kidnapping him, resulting in an Amber Alert and days of searching before Jordan’s body was found.

The special review team made six findings about the system’s  failures to save Jordan:.

  1. The decision to reunify Jordan with his parents was apparently driven by the parents’ perceived compliance to case plan tasks rather than behavioral change. Case decisions were solely based on addressing the reasons Jordan came into care. which related to gang and drug activity in the home where he was living. Although other concerns came to light during the life of the case, like substance abuse, domestic violence and mental health issues among the parents, these factors were not added to the case plan or considered in the decision to reunify Jordan with his parents. Ms. Stinson herself requested anger management training during a meeting in 2016 but this was never included in her case plan or provided. Moreover the court was kept in the dark about many of these concerns. “On multiple occasions, Ms. Stinson provided false information to the court,” which the case management agency and government attorney did not correct.
  2. Following Jordan’s reunification with his parents, staff failed to follow policy and procedures to ensure child well-being, such as making weekly visits. Moreover, they did not notify the court or take any action based on the mother’s lack of compliance with post-reunification services.
  3. When a new report was made to CPS, the investigator “failed to identify the active …threats occurring within the household that were significant, immediate, and clearly observable.” These included: ongoing and escalating violence between the parents, the father’s threat to kill the mother, and his gang membership and access to weapons, among others. In a major understatement, the Special Review Team opined that “Given the circumstances, a modification of Justin’s placement should have been considered.”
  4. There was a “noted lack of communication and collaboration” between investigative staff located in the Sheriff’s Department and case management staff during the August 2018 child abuse investigation. The investigator did not talk to the case manager for over three weeks after opening the investigation.
  5. There was a failure of communication and collaboration between all of the different entities involved in the case. There was a “lack of diligence in conducting multidisciplinary staffings at critical junctures of the case.” Neither the case management agency nor the state attorney provided accurate information to counter the false information provided by the mother to the court. Unbelievably, the case manager attended court hearings with no information about the mother’s participation in counseling, which was provided by the same agency.
  6. Assessments of both parents failed to consider the history and information provided by the parents and resulted in treatment plans that were ineffective to address behavioral change.

The review team did a good job of isolating the specific system failures that occurred in Jordan’s case but was not as successful identifying the systemic problems behind these failures. In this writer’s opinion, three major systemic factors contributed to the failure to protect Jordan:

  1. Lack of coordination and communication between agencies. This was the factor emphasized by the review team, which suggested that this issue was limited to Pinellas County. State Senator Lauren Book castigated the team for for this implication, arguing in a statement that the issue of “siloed communication” goes beyond the county and even beyond child welfare itself, citing the errors that predated the shooting at Marjorie Stoneman Douglas High School.
  2. Inadequate funding of child welfare services, leading to high caseloads and staff turnover.  The review team gave an offhand mention to the difficulty caused by high caseloads and turnover, both of which can be traced to inadequate funding but treated it as a given, rather than a problem to be rectified.
  3. The overemphasis on family reunification. In Florida and around the country, family reunification has been emphasized to the degree that children are often placed at risk. The Tampa Bay Times highlighted this  problem in its editorial entitled, Another child dead, another state failure. The death of a child following reunification is not a new story in Florida or around the country. If Florida law had been followed, Jordan’s parents’ rights should have been terminated before he was ever returned to them. A case manager who left Directions for Living shortly before Justin’s death told Florida’s News Channel 8 that the system “puts far too much weight on reuniting kids with unfit parents and makes it nearly impossible for caseworkers to terminate parental rights.” When asked why workers did not remove Jordan, she replied, “We are on quotas and we are told, ‘If there is any way to keep this kid in home do it.”

What is to be done to prevent future deaths like Jordan’s? It must begin, as the Tampa Bay Times editorial board asserts, with holding those involved accountable. This applies particularly to the magistrate on the case, who should have given the child rather than the parents the benefit of the doubt and held up reunification until she heard from the mother’s counselor. Second, child welfare must be funded adequately so that its staff are well-qualified and able to devote the time to handle cases correctly. Third, the silos must be broken down through improved policies and procedures that mandate data sharing and collaboration, but only adequate funding to enable reasonable caseloads will allow this to happen.

Finally, Florida and other states must rectify the balance between a child’s safety and the value of family reunification. Agencies must recognize that some parents who are suffering from the consequences of intergenerational trauma and dysfunction cannot change–at least within a timeline that is appropriate for a developing child.  This decision must be made early, with the input of qualified staff, high-quality evaluations, and laws and policies that put the child first.

As Justin’s foster parents put it, “Ultimately, we hope that our painful loss will result (in) a fundamental re-examination of the entire system, of how foster care works, of the reunification process. Jordan deserves that, and the other children in the system deserve that.”

Charisse Stinson is awaiting trial on charges of first degree murder and lying to police. She gave birth to another child in December and Belliveau has been determined to be the father. Both parents have filed court documents requesting the child be handed over to Belliveau, who has been arrested twice since Jordan’s death.

 

 

 

 

Race, Tribe and Child Welfare: How Identity Policy Trumps Children’s Needs

rainbow children
Image: nataliekuna.com

Our country has a terrible history with regard to our African-American and Native American citizens. Centuries of racism have led to consequences that last until today, and racism continues to be a fact of life affecting minorities around the nation. But attempts to address historical wrongs can end up further victimizing the very people we are trying to help. A case in point is the Indian Child Welfare Act. While the recognition of these unintended consequences is spreading, some activists are trying to replicate the same harmful “protections” for African American children.

“The removal of Indian children from their natural homes and tribal setting has been and continues to be a national crisis,” according to a report issued in 1976. And indeed, it was estimated that 25% to 35% of Native American children had been removed from their homes and placed in foster homes, adoptive homes, or institutions. About 90% were being raised by non-Indians.

To put an end to “the wholesale separation of Indian children from their families” Congress passed the Indian Child Welfare Act (ICWA) in 1978. ICWA recognized tribal sovereignty over custodial decisions about Native American children, required that child welfare agencies make “active efforts” (defined as greater than the “reasonable efforts” required for other children) to keep Native American children with their families, and established a hierarchy of preferred placements, with family or tribe members as the preferred placements.

Unfortunately, ICWA in practice has had unintended consequences, depriving Native American children of the rights given to other children and putting the wishes of the tribe above the interests of the child, as I described in a recent post.  Because of ICWA, 26-month Lauryn Whiteshield and her twin sister were removed from a non-Indian foster family with whom they had spent more than a year and placed with her grandfather and his wife, despite her long history of child neglect and the fact that there were five other children in the household. But Lauryn never reached her third birthday. Her step-grandmother threw her down an embankment and killed her.

Ironically, a law designed to prevent family separations has turned into a vehicle that separates children from the only family they have known. Two-year-old Andy had lived with his foster parents for almost his entire life. But when they filed to adopt him, tribal officials intervened because of his Navajo and Cherokee ancestry. They wanted to send him to New Mexico to live with strangers and a Texas judge agreed, even though Andy’s birth parents approved of the adoption.

Andy’s foster parents appealed successfully, and eventually the tribe changed its mind. But Texas, Louisiana and Indiana filed a lawsuit along with the foster parents of Andy and two other children, to ensure that no more children would be threatened with removal from their families because of their race. On October 4, 2018, a federal judge in Texas agreed,  ruling that ICWA’s requirement of differential treatment based on race violated Native American children’s right to equal protection under the law. (See analyses by the Chronicle of Social Change and the Goldwater Institute.) The decision has been appealed and the appeals court has issued a stay of the Texas judge’s ruling.

Like Native American children, African-American children have been overrepresented in foster care, adoption, and involvement in child welfare systems. According to federal data, black children were 13.8 percent of the total child population in the United States in 2014. Yet, they constituted 22.6 percent of those identified as victims of maltreatment, and 24.3 percent of the children in foster care.

In order to address the racial disparity in child welfare, agencies around the country have adopted strategies like family group decision making, workforce retraining for “cultural competence,” and attempts to recruit a more diverse workforce. It is not clear that any of these approaches have been successful, in part because disproportional representation in child welfare may be due more to the historical effects of past racism than to a racist child welfare system, as I described in an earlier post.

There is no direct evidence that any of these policies have been harmful, although analysts have certainly expressed concern that artificially trying to equalize the proportion of black and white children removed from their homes could result in less protection for black children. However, things could get a lot worse. Black children could suffer similar consequences as Native American children are suffering if states decide to implement ICWA-like “protections” for them.

And indeed, two Minnesota legislators have proposed the Minnesota African American Preservation Act (MAAPA). Based on ICWA, MAAPA would set a higher bar for removing African American children from their homes than white children. Instead of requiring “reasonable efforts” to prevent removal and to reunify family as current law requires, MAAPA would require “active efforts,” the same term used in ICWA. MAAPA specifically defines these efforts  and states that they must be greater than the reasonable efforts required for other children.

MAAPA would create a new bureaucracy paid for by taxpayers to oversee the new requirements. An “African American Child Well-being Department” within the Department of Human Services would receive notification of all cases involving African-American children and “directly  oversee, review, and consult on case plans and services” offered to these children. The law would also create an African American Child Welfare Oversight Council “to help formulate policies and procedures relating to African
American child welfare services, to ensure that African American families are provided with all possible services and opportunities to care for their children in their homes.” MAAPA would also authorize a set of grants to fund services specifically for African-American families.

So what would the consequences be for African-American children? Like ICWA for Indian children, MAAPA would establish a substandard set of protections for African-American children.   The higher bar for child removal and the lower bar for family reunification could well result in more children being left in, or returned to, homes where they are in danger.

The creation of new bureaucracies based on race would create a fragmented child welfare system based upon the belief that black children and families are fundamentally different from others. Moreover, it might divert funding away from desperately needed uses like adequate staffing and pay for child welfare social workers.

There has been a lot of talk about identity politics and its effect on recent elections and party preferences. ICWA and MAAPA are examples of what might be called “identity policy,” in which people are treated differently based on their genetic ancestry. This is not the right direction for our country.

ICWA is under attack because it sets up a separate–and inferior–set of protections for Indian children. MAAPA would do the same thing for African American children. By all means, let us do what we can to eliminate discrimination by child protective services. But denying these children the right to equal protection under law is exactly the wrong way to help them.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

at causes children to be separated from they only family they recognize. Two sisters, aged 14 and 15, are fighting to stay in the home where they have lived since 2010, while the tribe (in which they were only enrolled in 2012 by their mother) is fighting for their removal. https://www.record-eagle.com/news/local_news/foster-children-face-uncertain-future/article_5813c8b6-838c-5eb6-b07b-e87ac7819b5c.html

https://www.gofundme.com/foster-kids-civil-rights-lawsuit?viewupdates=1&rcid=r01-153876288175-a63810f367b240b2&utm_source=internal&utm_medium=email&utm_content=cta_button&utm_campaign=upd_n

Since I wrote that post, a judge has agreed that…

Yet, ICWA has become Some ICWA supporters argue that it is not being implemented fully, which is why Indian children continue to be removed from their homes at a higher rate than white children. A similar movement has taken place among the child welfare establishment, The movement to erase the “disproportionality” in the representation of black and white children in child welfare systems has many similarities to what motivated passage of ICWA.

Sadly, these so-called advocates have failed to understand the fact that….

They seem to want equal representation, even if it means that more black children will suffer and die from abuse and neglect.

The misuse of data and research in child welfare: home visiting and infant removals in New York State

Healthy Families New YorkData and research have tremendous potential to inform policymaking, allowing us to identify population trends and to assess the effectiveness of programs. Unfortunately the increasing importance placed on these tools has resulted in their frequent misuse. One recent article in the Chronicle of Social Change, a major online child welfare publication, exemplifies typical errors often made by public officials and accepted uncritically by the media.

The article is called The Program New York Says Helped Cut Newborn Removals to Foster CareIn it, Ahmed Jallow reports that the number of infants removed into foster care in New York State has “plummeted” while the same indicator has been increasing in the majority of states. Jallow quotes unnamed “state officials” that a home visiting program called Healthy Families New York (HFNY) is “the primary reason for this reduction in infant removals” and devotes most of the article to explaining and supporting this assertion. Unfortunately, the officials Jallow quotes simply don’t have the evidence to substantiate their claims. Rather than make this clear, Jallow reports these unbacked claims without qualifications and even adds additional misleading information to bolster them. These issues can be grouped into several categories.

Attributing causality without evidence. The centerpiece of the article is the claim by  New York State officials that the HFNY home visiting program is the primary reason for the reduction in infant removals in New York City. HFNY is New York’s version of one of the most popular home visiting models, which is called Healthy Families America (HFA). The difficulty of proving causality is well-known by social scientists, and journalists who write about policy should know enough to caution against accepting such blanket statements. To reduce child removals, a home visiting program would first have to reduce child maltreatment, and that reduction would have to be translated into a reduced removal rate. There are many factors that could more directly affect the number of infant removals, such as a shift in policy to prioritize keeping families together while accepting higher risks to children. And indeed, in New York City, by far the largest jurisdiction in the state, the Commissioner of the Administration on Human Services has attributed the decline in its foster care rolls to his agency’s “focus on keeping families together wherever we can.”

Making factual errors. Jallow states that “evaluations of HFNY show a significant impact in preventing further maltreatment incidents for parents involved with child protective services.” Actually, evaluations do not show a significant impact of the HFA model on child maltreatment. As a matter of fact, the respected California Evidence based Clearinghouse on Child Welfare (CEBC)  gave HFA a rating of “4” for prevention of child abuse and neglect, which means that studies have failed to find that it has any effect on child maltreatment. (The only worse rating is 5, which indicates that a program may be harmful to participants.) The only evaluation that Jallow cites is an interim report from an ongoing evaluation of HFNY suggesting that the program might reduce subsequent reports among women who had a previous substantiation for abuse or neglect. However, this study was never published in a peer-reviewed journal and therefore was not included in CEBC’s review.

Misusing evidence-based practice compilations. The CEBC and other clearinghouses of evidence-based practices can be very helpful to lay audiences by digesting and translating the results of methodologically complex studies and rating programs by the strength of their evidence. But users must be careful to read and understand the reports they are using.  Jallow states that the HFA home visiting  model (of which HFNY is an example) “has the highest rating of effectiveness on the California Evidence-Based Clearinghouse.” But he was reading the wrong report. As mentioned above, CEBC found that HFA failed to demonstrate any effect on child abuse and neglect. It is in a separate report on home visiting programs for child well-being that HFA CEBC gave HFA its top rating (“well supported by research evidence”) because of its impact on outcomes other than child abuse and neglect.

Overgeneralization: “In terms of documented proof, home visiting is the one that we know absolutely works,” Timothy Hathaway, executive director of Prevent Child Abuse New York, told Mr. Jallow. Unfortunately, Mr. Hathaway was overgeneralizing. There are many different home visiting programs which vary based on the nature of the provider, the content of the program, the goals of the program, and other factors. The effects of most home visiting programs on child abuse and neglect have been disappointing. The only program that has been found to have well-supported evidence of an impact on child abuse and neglect from CEBC is the Nurse Family Partnership program, which is very expensive and difficult to implement, and can only be used for certain populations–like first-time mothers. It is not surprising that many jurisdictions have opted to implement HFA instead.

Disregarding recent data. In addition to all the problems cited above, Jallow and his New York State informants chose to disregard the most recent data on foster care entries in New York. Jalloh reports, accurately, that the decline in infant foster care placement between 2012 and 2016 was part of an overall decline in the number of New York children entering foster care. And as Jallow states, this decline occurred while entries into foster care increased on the national level. But the pattern was reversed in 2017: nationally, foster care entries decreased slightly, while New York’s foster care entries increased. We don’t yet have the 2017 data for infants, but it seems likely that the trend in infant removals also reversed. Could it be that New York is starting to see the same kind of increase in removals that occurred earlier in many other states? Perhaps a growing opioid crisis in western New York is contributing to this, or perhaps the increase in child removals stems from concern that the focus on family preservation is endangering children.  And indeed an increase in child removals in New York City over the past 18 months has been attributed to an increase in hotline reports and a more aggressive response to these reports by investigative staff in the wake of  the highly-publicized child abuse deaths of two children who were known to the system but not removed. Disregarding the most recent year of data certainly makes for a clearer picture, but but it may be a less accurate one.

Jallow’s article illustrates how a flawed understanding of research and data can lead to faulty conclusions. A grandiose claim that one program is responsible for large changes in an indicator like child removals  deserves initial skepticism and rigorous vetting. Uncritical acceptance of such claims can lead to misguided policy decisions, like a decision to direct more funding to a program that is unproven. The press should scrutinize such claims assiduously, rather than accepting them credulously, presenting them without qualifications, or adding  flawed arguments in favor of these claims.

 

Why America needs an Interstate Child Abuse and Neglect Registry

HeavenWatkinsOn May 18, 2018, a little girl named Heaven Watkins was found brutally beaten to death in her  home in Norfolk Virginia. Three months earlier, Heaven was hospitalized with third-degree burns that kept her in the hospital for six days and required skin grafts. Child Protective Services in Norfolk was reportedly called but they decided not to intervene to protect Heaven.

Investigations from KARE 11 in Minneapolis and 13News Now in Norfolk revealed that Heaven  was removed from her parents four years before in Minnesota due to concerns about physical punishment, sexual abuse, drug sales and guns in the home. Virginia DSS has refused to tell reporters whether its workers knew of the family’s history in Minnesota. The haunting question is whether Virginia would have done more to protect Heaven had they known of her history in Minnesota.

Heaven was not the only child in the care of a parent who was known to Child Protective Services in another state. A 2012 report by The Oregonian  discussed several other children who died of abuse after investigation that did not unearth their family history in other states. Heaven’s story has triggered renewed calls for an interstate registry of child abuse and neglect. Had a registry existed, Virginia would have known the troubled history of this family and might have opted at least to provide supervision if not to remove the children.

The establishment of an interstate registry of child abuse and neglect was actually mandated more than a decade ago by the same legislation that mandated the national registry of sex offenders. Section 633 of the Adam Walsh Child Safety and Protection Act of 2006 required the Secretary of Health and Human Services to create a national registry of substantiated cases of child abuse and neglect. Yet this registry was never created.

Congress never appropriated funds to establish the registry but it did designate funds for a feasibility study that was also mandated under the act. A Research Report on the feasibility study and a report to Congress based on the results were published in 2012–six years after passage of the Act. The conclusions of the report were somewhat discouraging as to the potential benefits of a national registry. But interestingly, the underlying research reports had a much more positive view of the feasibility and potential benefits of the registry.

In the report to Congress, HHS  emphasized the barriers to developing a functional registry. These include the Adam Walsh Act’s prohibition on including any information other than the perpetrator’s name, the need for stronger due process requirements in some states if the database were to be used for employment checks (which is not the purpose envisioned by the statute), the need to provide funding or other incentives for states to participate, and the need for legislative changes in many or most states. These are serious barriers indeed but could be addressed, albeit with new legislation and funding that would not be trivial to obtain.

Unlike HHS, the authors of the feasibility study addressed the barriers but gave first billing to the conditions that allow for the development of a registry. In the final paragraph of the research report states that “The foundations for a national registry already exist in the child protective services field given that nearly all States maintain the necessary data on child abuse and neglect perpetrators. The technical capacity of the States also supports the feasibility of a national registry.” The authors go on to discuss the barriers, but give first billing to the conditions that support the registry.

In its report to Congress, HHS concluded that even if the barriers to an interstate registry could be resolved, the registry would provided limited information “beyond what is already available from existing single state registries” and therefore “the added safety benefit of a national registry of child maltreatment perpetrators would be quite limited.” HHS concluded that a decision on whether to implement the registry should “consider whether this or alternative child safety investments would be most effective in promoting the well-being of vulnerable children.” The clear implication was that alternative investments would be advisable.

HHS drew its conclusion about the limited safety benefit of a registry from the prevalence study mentioned above. The researchers used the numbers of perpetrators with incidents in more than one state to estimate how many interstate perpetrators would be identified by a registry.  Using information from 22 states with about 54% of the U.S. population, the researchers estimated that 7,852 perpetrators of child maltreatment in 2009 (or 1.5% of all substantiated perpetrators) had any substantiated maltreatment incidents in another state within the preceding five years.

HHS  described 7,852 as a small number, and therefore concluded that there was  “no evidence of a widespread phenomenon of child maltreatment perpetrators who offend in multiple states.” Moreover, HHS added that most of these perpetrators had “a single additional substantiation for child neglect (rather than for physical or sexual abuse) in a single additional state.” Moreover,  just half of one percent of child maltreatment deaths in states participating in the study was attributed to a perpetrator who had a substantiated maltreatment report in another state (4 in total).”

HHS’ interpretations suggest a low valuation of children’s lives and freedom from suffering. Almost 8,000 interstate perpetrators in a year could be considered a large number, even if most of them were substantiated for neglect and not abuse. The downplaying of neglect is a common trope among critics of CPS intervention. but neglect can be equally dangerous and often coexists with abuse that may not be substantiated.  “Just” four deaths in one year is a hard description to stomach while wondering if even one of these deaths could have been prevented with an interstate registry. Moreover, each death implies an unknown but larger number of injuries, and even more children living in pain and fear.

While dismissing the prevalence study’s estimates as “small,” HHS failed to mention the conclusion in a separate report on the prevalence study that the number of positive matches from states’ use of a fully functioning national registry would be much larger than the estimates above would indicate. That’s because the registry would be most commonly used during an investigation before a substantiation decision has been made, and the investigators would be  looking for a substantiation in just one state. Therefore, the researchers concluded that the registry would likely yield “several times the number of matches” that the study found for interstate predators.

HHS also downplayed the benefits found by the Key Informants Survey–the other part of the feasibility study. Of the 36 states participating in the Key Informants Survey, 25 states said participating in a national registry would save time, and 22 states thought it would “provide more timely knowledge that would be useful in assessing child safety.”  The authors of the research report concluded that “There appears to be significant interest in a national registry, primarily because States already have to inquire about possible prior perpetrator status from multiple States.” In the report to Congress, on the other hand, HHS did not report that there was significant interest by states’ in a registry. Instead, the agency reported that survey results indicated that the primary benefit of the registry would be to save time, and then cautioned that this time-saving benefit might not occur.

Similar to the key respondents, the authors of the feasibility study concluded that an interstate registry might be most useful in saving staff time and resources “resulting from the speed and efficiency of making all interstate inquiries, the vast majority of which will not find a match.” The authors added that this could enhance child safety due to faster processing of maltreatment cases. This conclusion was not included in the report to Congress.

Of course an interstate registry could not be produced quickly or on the cheap. Creating and activating it would be a multiyear effort that would have to begin with the amending of the authorizing legislation to include at least sex and date of birth in addition to perpetrator’s name. Many states would need to change their legislation as well in order to eliminate statutory barriers to participation. As the authors of the feasibility study indicated, convincing a “critical mass of states” to participate quickly might require incentives, such as funds to offset costs for initiating a registry. Clearly, an infusion of federal funds for this purpose would be a necessary incentive.  Perhaps Congress could make participation in the registry mandatory in order to receive federal child welfare funds under CAPTA or better still the Social Security Act.

It is concerning that HHS under the last Administration produced such a distorted view of the Congressionally-mandated feasibility study of an interstate child abuse and neglect registry.  It is my hope that this issue can be revived in the current Congress, perhaps as part of the reauthorization of CAPTA. Our children deserve no less.

 

 

Caring about Children Isn’t Racist

Well, it happened. After a lifetime of service to poor and maltreated children, I’ve been accused of racism. I knew it would happen eventually. I couldn’t keep saying with impunity that children shouldn’t be collateral damage in an attempt to avoid “punishing” parents who happen to be members of a minority group.

It was a prominent critic of government intervention to protect children who noticed an op-ed that I wrote for the Chronicle of Social Change in August 2017 and demanded a retraction.

In the offending piece, I critiqued an article in the New York Times entitled Foster Care as Punishment: The New Reality of Jane Crow. In my rebuttal, entitled Foster Care as Punishment? A Case of Biased Reporting by the New York Times, I attempted to highlight the naivete of the reporters, who accepted the statement of a birth mother that she splurged on brand-name diapers for her baby as an indicator of her fitness as a mother.

As the authors put it, “Maisha Joefield thought she was getting by pretty well as a young single mother in Brooklyn, splurging on her daughter, Deja, even though money was tight. When Deja was a baby, she bought her Luvs instead of generic diapers when she could.” The authors went on to describe the night when an exhausted Ms. Joefeld put Deja to bed and “plopped into the bath with earphones on.” Ms. Joefeld was indeed tired. Deja was placed in foster care after she was found wandering the streets of Queens at midnight after trying and failing to rouse her mother.

I thought the authors’ concept of good mothering seemed to be a little backwards, as it prioritized spending on brand names over being available to respond to a small child at any time of the day or night. So I wrote, “It is odd to me that the authors seem to consider splurging on brand-name diapers, sneakers, or apparel to be an indicator of good motherhood.”

Little did I know the firestorm I was launching. The authors had said nothing about sneakers or apparel, but I grouped them with diapers, because I was making a general point about some parents’ undue preoccupation with brand names. And those words were a trigger to to those advocates of family preservation under all circumstances who are always looking for a chance to cry racism.

In an email I received 15 months after publication of my op-ed, the Publisher of the Chronicle of Social Change told me that the Chronicle would be publishing a publisher’s note concerning my use of “racially charged language” and asked me whether I wanted to submit a statement that he would consider including.

What the Chronicle eventually published was called An Apology for a Regrettable Chronicle Op-Ed. In it the publisher and Editor state that “the trope of a low-income mom buying children designer clothes, at the expense of spending on more critical family needs, does exist as a crude and often racial stereotype.” They apologize for their “poor judgement” in allowing “a callous dismissal of a young single mother’s very human efforts to do right by her daughter” to stand.  They deleted my piece from their website. And they did not publish my statement that I had sent to the publisher at his request. Here is what I said:

This statement [about brand-named diapers, clothing and shoes] was based not on racism but on my experience as a social worker in foster care. It was not unusual for birth parents to complain when foster parents dressed their kids in clothes that were not stylish or (God forbid) handed down. It was also not uncommon for them to splurge on high-end apparel or athletic shoes, or talk about splurging on them, in visits to their children. All of these behaviors together made a big impression on me. That some parents who had subjected their children to abuse or neglect seemed to care passionately about the brand of diapers, clothing or shoes their child wore seemed contradictory and illustrated a fundamental problem with their parenting.

I expressed my feelings most clearly in an adoption hearing that I will never forget. One of my favorite foster parents, an African-American woman I will call “Ms. Brown,” had petitioned to adopt “Ronald,” a little boy whom she had loved and cared for as her own for several years. “Ronald’s” father, a drug user who often showed up to visits with his son high or exploded with rage during visits, often requiring a police presence, was fighting the adoption tooth and nail with the help of his very aggressive lawyer. Through the lawyer, the father raised the issue that “Ronald” was often dressed in what seemed to be hand me downs or cheap clothes. The Judge asked for my opinion and I gave it to her. I told her how this father resembled many other birth parents, who are more concerned with the newness and style of their children’s clothes than with the safety, security and most importantly love provided by the foster parent. For me, the father’s question illustrated his inability to understand what matters to a child (love and security) and what doesn’t (brand names.)  The judge cut me off, admonishing me sharply for my editorial comments. But I hope she understood. She eventually approved the adoption. I recently saw “Ronald,” and he is thriving with “Ms. Brown.”

Because I worked in the District of Columbia, most of my clients (parents and children) were African-American. If I had worked in Maine or Indiana, I have no doubt that I would have seen some of the same patterns among white parents. Perhaps it is an issue of class [to some extent]. But I think most of all it reflects parents who have not grown up sufficiently themselves to understand that their children are not dolls to be dressed up in a way that reflects well on parents and that they need love, not brand-name diapers or fancy clothes. No, my words were not racist. They were about what matters for children, and what doesn’t. Children should be at the heart of this debate, not racial groups.

Readers who have worked with abusive and neglectful parents as social workers, therapists, or in other capacities will recognize the phenomenon I describe here. The fact that neither the New York Times journalists nor the publisher of the Chronicle (who was clearly puzzled by where my reference came from if not racism) understood this shows their distance from the people they are writing about. Nor do they understand that many healthy and mature parents of all races, such as the foster parent I called “Ms. Brown,” are completely unconcerned with brand names.

I have written before, and will write again, about what has been called “the liberal dilemma of child welfare reform.” Many of my fellow liberals seem to be reluctant to “punish” parents whose problems in parenting stem from poverty and racism by taking away their children or even monitoring and offering services to these families. The whole idea of “punishing” parents, which was used in the title of the Times article, reveals the emphasis on parents’ rights over child safety. But if we succumb to this attitude, we may be condemning poor and minority children to years of suffering and even death. Is that really the anti-racist position?

Some of these who advocate family preservation at any cost are eager to describe any criticism of an African-American parent as racist. They use the fear of being called racist to suppress expressions of alternative viewpoints. As a child of Holocaust survivors, I am well aware of what can happen when fear paralyzes free speech. I was sad to see the Chronicle respond so pusillanimously the demand that I be silenced.

 

 

 

Why No One Saved Gabriel Fernandez

Gabriel Fernandez
Image: LATimes.com

On September 13, 2018, a Los Angeles County judge denied a motion to dismiss felony child abuse and falsification of records charges against four former child welfare caseworkers in the 2013 death of ten-year-old Gabriel Fernandez.  The charges, filed in 2016, marked the first time Los Angeles caseworkers were criminally charged for misconduct connected with their work, and is one of only a few similar cases nationwide.

If Gabriel’s case is one of the few child deaths to result in prosecution of state workers, the egregious nature of the state’s failure explains why. A brilliant article by investigative reporter Garret Therolf shows that for seventh months, evidence of Gabriel’s abuse steadily accumulated. Yet again and again, the Los Angeles Department of Child and Family Services (DCFS) failed to intervene. Some of the worst errors are listed below.

  • Gabriel’s mother had been the subject of at least four calls to the child abuse hotline, had abandoned one child, and had lost custody of a son a year older than Gabriel. Yet, this record was never reviewed by workers investigating multiple reports of suspicious injuries to Gabriel.
  • Each time investigators came to the home, they interviewed Gabriel and his siblings with his mother in the room, against agency policy and common sense. And each time they did so, he recanted his previous statements. Even after he came to school with his face full of bruises from being shot by his mother with a BB gun, he recanted and told the investigator the injuries were from playing tag with his siblings. In the face of visible evidence, the investigators repeatedly chose to believe the repeated recantations
  • Investigators never spoke with neighbors or school personnel (other than the teacher who reported the abuse) but according to Therolf the abuse was known widely among school staff.
  • A computer program had found Gabriel to be at “very high risk” of abuse, requiring that the case be “promoted,” usually involving asking a court to require services or foster care. But the investigator, backed up by her supervisor, referred Gabriel’s mother to voluntary family services. Gabriel’s mother Pearl Fernandez withdrew from these services after three visits.
  • During the brief period of voluntary services, Gabriel wrote several notes saying he wanted to kill himself. Gabriel’s therapist informed the caseworker and supervisor, but they took no action.
  • The therapist had grown concerned that Gabriel was being abused, but her supervisor told her not to call the hotline so as not to jeopardize the mother’s participation in the voluntary case.
  • After three visits, Pearl Fernandez asked for her voluntary case to be closed. The caseworker accepted her decision, stating that there were no safety or risk factors for the children. Contrary to policy, her supervisor signed off on the case closure without reading the file.
  • After the case was closed, a security guard at the welfare office saw Gabriel covered with cigarette burns and other marks and being yelled at by his mother. The called DCFS twice and got lost in the automated system. The 911 operator gave him the non emergency line, which he called. He was later told that a sheriff’s deputy had gone to the home and seen nothing wrong.
  • Gabriel’s teacher, who had lost hope of any rescue from DCFS, called the DCFS investigator one more time late in April when Gabriel showed up looking worse than she had ever seen him. One eye was blood-red, skin was peeling off his forehead, and other marks were on his face, neck and ear. Her call was never returned. Gabriel had only about a month left to live.

Investigators later learned that during the weeks before his death, Gabriel  was spending days and nights locked in a cabinet with a sock in his mouth, hands tied, a bandanna over his face, and handcuffs on his ankles. His solitude was interrupted by vicious beatings and torture sessions in which his siblings were required to participate. On May 22, Pearl and Aguirre tortured Gabriel a final time with a BB gun, pepper spray, coat hangers and a baseball bat. When they finally called 911, paramedics found two skull fractures, broken ribs, several teeth knocked out, BB gun pellet marks, cigarette burns on his feet and genitals, a skinned neck, and cat feces in his throat.

Therolf poses a key question regarding Gabriel’s death: “Was [the] failure …to protect Gabriel an isolated one—the fault of four employees so careless and neglectful that they allowed a child to suffer despite a series of glaring warning signs? Or was it a systemic one, the result of a department so ill-equipped to safeguard children that tragedies were bound to happen?”

While Therolf does not actually answer the question, his report offers a number of key findings and insights that point strongly in the direction of systemic factors as the prime contributors to the failure to protect Gabriel. Therolf found that many of the errors made by investigators, such as failure to interview children alone or to speak with witnesses outside the family, were prevalent in Los Angeles County. Sadly, many of the same failures were evident in the very recent case of Anthony Avalos, also in Los Angeles. And we also see similar failures , and in cases around the country, including Kansas, New York, and Oregon.

The systemic factors that cause these failures fall into two major categories–resource constraints and ideological factors.

Resource Constraints

Child welfare involves a balancing act between too much intervention  or “erring on the side of child safety” as Therolf puts it and too little or “erring on the side of family preservation.”  Striking this critical balance requires a combination of  knowledge, skill, and time. In other words, as Therolf puts it, “it requires a highly trained workforce with the resources to carry out a thorough investigation in every case.” Therolf rightly contends that most agencies don’t have these resources. One has only to read the constant stream of news reports of overwhelming caseloads and poor training of child welfare workers around the country. All of this reflects the unwillingness of taxpayers and legislatures to provide what is needed to protect children. Inadequate funds mean caseloads are too high and salaries are too low, both resulting in low standards for caseworkers.

More funding and could buy both lower caseloads and higher salaries, which are necessary to obtain more qualified investigative workers. After reading so many similar stories, and recalling my own rudimentary training as a Child Protective Services (CPS) worker I am beginning to think that ultimately CPS Investigation should be a specialty in Masters in Social Work Programs. Students would learn advanced interviewing skills and how to assess the truthfulness of children and adults rather than, for example, believing children when they recant allegations with their parents in the room.  Alternatively, CPS Investigations could be folded into the growing field of Forensic Social Work. In any case, a Masters-level specialization could be required in order to be a CPS worker, also adding a needed level of prestige to an important, difficult and hard-to-fill  job.

Ideological Constraints

Inadequate resources might result in a random distribution of agency errors between those that involve too much intervention and those that involve too little. But the dominance of a particular ideology may skew the errors in one direction or another. And Garrett Therolf alludes to the rise of an ideology prioritizing family preservation nationwide and particularly in California during the years preceding Gabriel’s death. This ideology contributed to the decline in foster care numbers around the nation and particularly in Los Angeles, where Therolf reports the number of children in foster care fell from about 50,000 in 1998 to 19,000 in 2013. Much of this decline occurred during the tenure of DCFS administrator David Sanders, who later went on to lead Casey Family Programs, a foundation worth over two billion that has played an outsize role in national child welfare policy. The same year that Sanders took over at Casey, it declared a new goal to reduce the number of children in foster care by half by 2020.

Therolf was right to point a finger at Casey Family Programs. In my post about the death of two children by child abuse in Kansas, I wrote about how Casey leverages its massive wealth to affect policy directly, bypassing the voting public. It provides financial and technical assistance to state and local agencies, conducts research, develops publications, and provides testimony to promote its views to public officials around the country. Through its wealth in an underfunded field, Casey has been able to directly influence policy at the federal, state, and local levels.

Therolf points out that opinions on child welfare often cut across traditional political groupings. While Casey tends to support progressive causes, its emphasis on family preservation is often shared by conservatives who desire to reduce the government’s incursions on parental authority and at the same time to reduce spending. Working together, Casey and the George W.  Bush administration created a waiver policy that allowed child welfare agencies to direct unused foster care funds toward family preservation services–a policy change which created an incentive to reduce the use of foster care. Therolf links this incentive to the drastic decline in the Los Angeles County foster care rolls between 1998 and 2013, stating that “When Gabriel came to the attention of DCFS, the chances of an abused child being placed in foster care were “lower than they’d been in many years.”

Perhaps all of the factors that led up to Gabriel’s death can be summed up by a striking statement by the supervisor on Gabriel’s case, who is currently standing trial in Gabriel’s death. He told Therolf that he had  “concluded long ago that some of the children who depended on the department would inevitably be injured, if not killed.” He expressed frustration that administration and the public expected him to prevent all such deaths. This is not an acceptable attitude. It is true that a child welfare agency cannot prevent deaths among children who are unknown to the agency. But to expect that children will die under the agency’s watch–that is a low expectation indeed. We must do better by our most vulnerable children.