Child maltreatment, home schooling, and an organization in need of support

The Turpin family has been in the public eye once again after NBC broadcast Diane Sawyer’s interview with two of the victims rescued from the “House of Horrors” in Perris, California on January 24, 2018. In riveting footage, Jordan Turpin describes how as a 17-year-old she escaped through a window and called the police on a de-activated cell phone which her parents did not know she had. Never having left the house by herself or spoken to a stranger, she managed to convince a sheriff’s deputy with cellphone photos of her sisters in chains. “If something happened to me, at least I died trying,” Jordan told Sawyer, stating her parents would have killed her if they had caught her. Body camera footage shows deputies walking through the trash-filled house and finding Jordan’s 12 siblings, all but the youngest stunted by malnutrition, one in chains and two others with bruised wrists from chains that had been removed and hidden while the deputies were knocking on the door. Louise and David Turpin have pleaded guilty to multiple counts of cruelty to a dependent adult abuse, false imprisonment, child abuse, and torture, and have been sentenced to 25 years in prison.

David and Louise Turpin were able to hide their extreme abuse and neglect behind the facade of a “private school” operating out of their home. Calling their home a private school is one of the options for homeschooling parents in California. These “schools” are not monitored or inspected aside from an annual fire inspection for those with six or more students, but city officials in the aftermath of the rescue could find no record that such an inspection was ever conducted on the trash-filled and hazardous Turpin home.

California is not atypical in its minimal regulation of homeschooling. As William and Mary’s James Dwyer stated at a 2021 Homeschooling Summit sponsored by Harvard Law School and described here), twelve states require nothing of homeschooling parents, not even notification to the school district; another 15 or so require notification only. The other half of states have some requirements, such as that the parent have a high school degree, that certain subjects be taught, or that students be assessed requirements, but these are generally not reviewed or enforced in a meaningful way. Moreover, no state requires that a state employee or contractor set eyes on the child once homeschooling is approved.

Clearly, the Turpins could not have gotten away with such severe abuse if the children had been in school. Teachers would have seen the extreme malnutrition of the children and the marks from chains and beatings, and the children would have been able to disclose what was happening to them. Education personnel make more child abuse reports than any other group; they made 21 percent of calls to child abuse hotlines in 2019. So it is not surprising that a disproportionate number of the horrific abuse deaths that make the news (such as the Hart children, Natalie Finn in Iowa, Matthew Tirado in Massachusetts and Adrian Jones in Kansas), involved parents who hid behind the guise of homeschooling, even though schooling rarely took place in these homes.

We have no systematic data about the association of homeschooling with child maltreatment due to data limitations. But there are some troubling reports. Child abuse pediatrician Barbara Knox studied 28 children who were victims of abuse so severe that it merits the definition of torture. In most of these cases, the children were kept out of school; about 29 percent were never enrolled in school and another 49 percent were removed from school, allegedly for homeschooling, often after a CPS report was made by education personnel. Connecticut’s Office of the Child Advocate found that of children withdrawn to be homeschooled between 2013 and 2016, 36 percent had at least one prior accepted report for suspected abuse or neglect to the Department of Children’s Services, and the majority of these families had multiple prior reports for suspected maltreatment. The Coalition for Responsible Home Education maintains a database called Homeschooling’s Invisible Children, which includes 454 cases of severe and fatal child abuse in homeschool settings in the United States since the year 1986. Since these are only the cases that made it into the media and were found by CRHE, there may be many more.

Data from the National Center for Education Statistics indicates that the percentage of Americn children who were homeschooled rose dramatically from 1.7 percent in 1999 to 3.4 percent in 2011-2012, then decreased slightly through 2019. There is some anecdotal and statistical evidence that homeschooling rose considerably during the pandemic but no definitive data as of yet; we also do not know how many children will return to school buildings when the pandemic recedes.

While abusive and neglectful parents are likely a very small minority of those who homeschool, the lobbies that represent them oppose any regulation of homeschooling, arguing that the vast majority of homeschooling parents should not be punished for the actions of a small minority. Homeschool parents who oppose regulation are represented by strong lobbies in both state capitals and at the national level. Homeschooling’s national lobby, the Home School Legal Defense Association (HSLDA) resembles the National Rifle Association in the single-minded passion of its members and its surplus of legal resources. Payment of annual dues of $130 to $144 per year buys free legal defense and representation in court for members. Adults who grew up homeschooled reported at the Harvard summit that their parents kept the organization’s telephone number on their refrigerators to be called as soon as CPS showed up at the door. HSLDA sends out email blasts to its members that can result in a barrage of phone calls that can swamp legislators’ offices and even in-person threats and harassment of state legislators, as an investigation by Pro Publica found. 

There are strong homeschool lobbies at the state level as well. In the aftermath of the Turpin case, California Assemblyman Jose Medina introduced a bill that would require a fire inspection for all private schools, including those with five or fewer students. Due to a “massive outcry” from the homeschooling community, the the inspection requirement was eliminated, leaving a bill that required nothing but identification of homeschooling families by name and address. When the eviscerated bill was scheduled for a hearing, hundreds or perhaps thousands of homeschooling families poured into the capitol building, testifying for three hours. No committee member even moved to approve the bill, and it died that day.

Playing David to HSLDA’s Goliath is a mighty little group called the Coalition for Responsible Home Education. CRHE’s mission is to “empower homeschooled children by educating the public and advocating for child-centered, evidence-based policy and practices for families and professionals.” Among its many recommendations, CRHE has several that are designed to protect homeschooled children against abuse and neglect. These include prohibiting homeschooling by parents who have committed offenses that would disqualify them from teaching school, requiring that students be assessed annually by trained mandatory reporters, and flagging certain at-risk children (such as those in families with a history of child protective services involvement) for additional protections and support.

CRHE was launched in 2013 by a group of homeschool alumni who had met through a network of blogs and Facebook groups. In the past seven years, The Coalition does more with less than any other organization I know. As described on its website, CRHE has driven media coverage of the need for homeschooling oversight; conducted extensive research; developed a set of policy recommendations, advocated for homeschooling oversight in over a dozen states and territories and helped craft successful legislation in Georgia; created a comprehensive suite of resources for homeschooling parents and students; and written a bill of rights for homeschooled children. This has all been done with unpaid staff, including its executive director, and contract workers. Now, CRHE is trying to raise funds to pay a part-time executive director next year, with the hope to grow further in the future.

In my research, I have been surprised at the paucity of organizations that advocate for better protection of children from abuse and neglect, a topic that I hope to address in a future post. While CRHE’s focus is limited to home-schooled children, this is a group that is particularly vulnerable, and evidence suggests that these children are disproportionately represented among the most egregious cases of abuse. For this reason, and in light of CHRE’s extraordinary passion and productivity, I cannot think of an organization more deserving of support by those who care about child maltreatment.

Ten common child welfare misconceptions: essential reading for child welfare commentators and policymakers

In the current rush to make child welfare more “family-friendly,” many proposals are being made for major changes, and even for the total abolition of the current system. But many of these proposals are based on misunderstandings of what we currently know about child abuse, child neglect and child welfare programs. Acting based on these misconceptions may produce policies and practices that actually harm children. A group of eminent child welfare scholars, headed by Richard Barth of the University of Maryland School of Social Work, (and also including leading child welfare scholars Jill Duerr Berrick, Antonio Garcia, Brett Drake and Melissa Jonson-Reid and Johanna Greeson) have addressed ten of the most common misconceptions in one essential article, a must-read for anyone promoting change in our child welfare system.

The article, entitled “Research to Consider While Effectively Re-Designing Child Welfare Services,” was published in the journal Research in Social Work Practice on October 18, 2021. It highlights 10 common misconceptions which the authors assert (rightly in my view) are “inconsistent with the best available contemporary evidence.” Their treatment is structured around ten questions to which a wrong answer is commonly cited and used to justify policy changes. Unfortunately, a paywall blocks access to the article for readers who do not have access to the journal from their institution, though this link provides a one-paragraph summary and the reference list. This post provides a more detailed summary of the article. Readers can contact author Richard Barth at RBarth@ssw.umaryland.edu with questions.

Are Low-Income Children Inappropriately Referred to Child Protective Services (CPS) Due to Implicit Bias?

As the authors describe, there is no doubt that low-income children are referred to CPS at a higher rate than their higher-income peers. One theory is that mandated reporters, who are often middle-class professionals, are biased against low-income parents and their parenting styles. Barth and colleagues cite studies that look at this question in several ways, all suggesting that bias is not the major reason for higher reporting of poor children. First, low-income children experience bad outcomes (in the worst case, death) at differentials consistent with or higher than the differentials in reporting rates. Second, lower-income people are much more likely to self-report maltreatment than their higher-income counterparts. And finally, low-income children who are reported to CPS are more likely to have a range of negative outcomes than their low-income peers who are not reported to CPS.

Are Families who Receive Public Social Services and Have Contact With Mandated Reporters Disproportionately Likely to be Referred to Child Protective Services?

It is often asserted that families that receive more public services (such as clinics rather than private doctors to whom they are known) and encounter more mandated reporters are more likely to be reported to CPS. But the authors show that available evidence does not support this assertion. Two studies estimated “surveillance bias” to increase CPS reporting by less than two percent. Another study found that among children in families receiving income support, those who were reported to CPS also had higher rates of delinquency, mental health problems, and hospital visits for injury. Finally, national and state data show that “as individual or community poverty increases, the proportion of mandated reporters among all reports decreases, making low-income people less likely to be reported by mandated reporters.”

Is the Racial Disproportionality of Black Children in CPS Substantially Driven by Bias?

It is a fact universally acknowledged that Black children are more likely to be involved with child welfare than their share of the population would predict. The latest federal data shows that Black children are more than twice as likely to be reported to CPS than White children. But as I’ve often written, the evidence suggests that bias is not the main reason for this disparity. Among the reasons cited by Barth and colleagues, Black children are more than three times more likely to be poor than white children. Studies suggest that when compared to children with an equal income, Black children are at the same risk or at a slightly lower risk of being reported to CPS. The authors also cite a recent study suggesting that Black substance-abused infants are actually less likely to be reported to CPS than White or Hispanic substance-abused infants. Furthermore, they cite evidence that Black-White disparities in other objective indicators of well-being, such as child mortality, are actually greater than Black-White disparities in CPS reporting. The writers therefore contend that, in order to address racial disproportionality in CPS reporting, we need to address poverty itself, as well as the factors that place Black children at higher risk of growing up in poverty.

I do differ from Barth et al in believing that factors other than poverty affect racial disparities in child abuse and neglect, and the resulting disparities in reports, substantiations, and foster care placements. The importance of factors other than poverty is illustrated by the fact that Hispanic children are less likely to end up in foster care than White children even though their poverty rates are higher, while Native American children, with similar poverty rates, are much more likely to be placed in foster care than Black children. Hundreds of years history of slavery, racial violence, and segregation have left a legacy of intergenerational trauma that has affected mental health, substance abuse, and childrearing styles. Therefore equalizing Black-White poverty rates would probably not immediately equalize their rates of placement into foster care.

Are Decisions to Substantiate or Place in Foster Care Largely Driven by Racial Bias?

Not only are Black children disproportionately more often reported to CPS; they are disproportionately more often the subject of substantiated allegations and placed in foster care.  This is clearly a concern of the authors although their analysis indicates that what is commonly asserted– that this discrepancy is largely due to a racist decision making in the child welfare system—is not supported by the evidence. The authors report that the large majority of recent studies find that “as they move through the system, socioeconomically disadvantaged Black children are generally less likely to be substantiated or removed into foster care compared to White children.” Black children do stay in foster care about 25 percent longer than White children, perhaps because they are less likely to be reunified with their parents or adopted. However, the frequently-cited idea that they are more often substantiated once economic status is taken into account has been roundly disproved, according to the paper’s authors. As I have pointed out relative to this question and the previous one, attempting to reduce disparities that are due to different levels of need might require establishing lower standards for the care of Black children by their parents, allowing them to remain in situations that would cause White children to be removed.

Is Child Neglect Synonymous With Family Poverty?

The trope that child neglect is synonymous with poverty is one of the most common myths used by advocates of child welfare reform, and I devoted part of a recent post to dismantling it. It is true, as Barth and colleagues state, that 70 percent of maltreatment reports and fatalities include neglect as a factor. And they acknowledge that there “is clear evidence establishing the relationship between poverty and child neglect.” However, this association does not mean that poverty and neglect are one and the same. Barth et al point out that studies examining the impact of both poverty and neglect have found distinct negative impacts on children for each one. They also found that studies using both officially reported and self-reported neglect found “unique constellations of risks and/or parenting behaviors” for neglect as opposed to poverty. As the authors point out, much of of the confusion between poverty and neglect is due to the fact that some states allow parents to be found neglectful when a child’s material needs are unmet, even when this deprivation was involuntary on the part of the parent. In those cases, neglect could be seen as reflecting poverty alone. But the authors point to a study showing that only a small proportion of neglect referrals (maybe one in four) is due to material needs, and that these referrals are only about a quarter as likely to be substantiated as other neglect referrals. This is not surprising, since many jurisdictions would respond in such cases by helping the family address the material need rather than substantiating an allegation of neglect by the parent.

Barth et al make an important point that “[N]arratives that conflate poverty and child neglect unfairly characterize low-income families, the majority of whom provide appropriate care for their children.” Most poor parents do not neglect their children, and eliminating poverty alone would not eliminate neglect caused by mental illness, substance abuse, or other non-material factors. Moreover, characterizing neglect as nothing more than poverty risks obscuring the harms caused by neglect, which the authors discuss in their response to the next question.

Is Child Neglect Harmful to Children?

The seriousness of child neglect is often minimized by those who say it is just a reflection of poverty. Yet, Barth and colleagues remind us that severe neglect means “the lack of the basic nurturing, care, and supervision needs of a child.” When such severe neglect is chronic or occurs at critical periods in child development, it can lead to death, hospitalization, and impaired development. The authors cite multiple studies showing the many poor outcomes that have been associated with neglect, including poor cognitive outcomes, mental illness, trauma symptoms, and substance abuse, and point out that such poor outcomes have been found even when controlling for poverty.

Are Research-Supported Practices Effective for Families of Color?

With the passage of the Family First Prevention Services Act allowing Title IV-E funding to be used to pay for “evidence-based practices” to keep families together, some advocates are asserting that programs deemed evidence-based are not actually shown to be effective for people of color. Barth and colleagues cite a study showing that four of popular programs in the California Evidence-Based Clearinghouse for Child Welfare – Parent Child Interaction Therapy, Trauma-Focused Cognitive Behavioral Therapy, Level Four Triple P and Multi-Systemic Therapy – have been found to be well-supported in studies with samples that include at least 40 percent children and families of color. Moreover, Cognitive Behavioral Therapy, the basis of many interventions, has been shown to be broadly effective across populations. Nevertheless, it is clear that the overwhelming majority of the interventions in the clearinghouse have not included many people of color. I am more persuaded by the authors’ suggestion that just because an intervention study did not include people of color does not mean it would not be effective for them with modifications to make them more relevant to families of color. However, I do feel compelled to report on my skepticism about many of these programs that have been found to be “evidence-based,” regardless of the nature of the families served. In the enthusiasm to replace foster care with family preservation, at least one popular program (Homebuilders) has been approved for Family First funding even though the evidence does not strongly support its effectiveness for any families, as I have discussed previously.

Do Children Grow up in Foster Care?

It is very common to read about children “growing up” in foster care, but as Barth et al point out, that is a rare occurrence today. While long-term foster care was common in the past, today’s emphasis on permanency has made stays much shorter. Barth et al cite “overwhelming” evidence that fewer than one percent of infants and ten percent of children 13 and under who enter foster care grow up in care. Infants entering care spend only about 10% of their time between 0 and 18 in care; children who are older when they enter care spend less time in care. Children who “age out” of care are mostly those who entered as teenagers, and many of them were admitted to foster care because of behavioral problems. As the authors point out, talking about children who “grow up” in foster care overemphasize the importance of the foster care experience as part of the life trajectory for most children and understate the importance of foster care as a temporary, last-resort option.

Does Foster Care Cause Poor Outcomes for Children and Youth?

There is no doubt that studies of young adults who have spent time in foster care show that they have worse outcomes than those who have not. Sadly, some commentators use this research to argue that being in foster care leads to worse outcomes than remaining at home. But as Barth and his colleagues had already explained in a previous section of their paper, child maltreatment has been shown to have many negative outcomes, which should not be confounded with the effects of foster care. Another review by Barth and others of “dozens of methodologically rigorous studies” examining outcomes in multiple domains suggests that it is unlikely that foster care worsens outcomes, and it improves them in some areas like child safety–as one would hope. Barth et al attribute the widespread misstatements about the role of foster care in adult outcomes to the strong impact of anecdotes from some foster care alumni about their bad experiences. This is despite the fact that studies reviewed by the authors show that most young people reported satisfaction with their foster care experiences.Majorities of young people in multiple studies reported that they had positive relationships with their caregivers, received quality care, felt safer in their foster homes than in their original homes, and felt that their removal was justified by the circumstances. Another reason for inaccurate conclusions about foster care, according to the authors, may be an over-reliance on studies of youth who aged out of care. This is a group that tends to have more issues even before entering care than other youth. In summary, as the authors state, “an evidence-informed understanding of the role of foster care in the lives of maltreated children indicates that the average experience of care is more favorable than conditions in the birth home at the time of removal.”

Is Adoption Breakdown Common for Former Foster Children?

The final misconception addressed by Barth and his colleagues is that a large fraction of adoptions end in breakdown. They mention commentators who have expressed concerns that the push to permanency may result in some adoptions being finalized too quickly, resulting in later dissolution. Instead, Barth et al show that research suggests adoption dissolution rates typically fall below five percent across a range of studies. Instead of the embracing the misconception that adoptions are likely to dissolve, Barth and his colleagues suggests that advocates for children in foster care should think of adoption as “a stable permanency alternative for children who otherwise cannot be reunified.” As they rightly state, “reform efforts that seek to curtail the opportunity for adoption among children who cannot be reunified would deny… children the lifetime of permanency that our laws seek to promote.”

Policy based on wrong assumptions is likely to be bad policy. Yet, the daily child welfare news is full of reports of child welfare leaders spouting these misconceptions–and worse, making policy and passing legislation based on them. In just one recent example, the New York City Council recently passed legislation requiring the Administration on Children’s Services “to report on various demographic information including race, ethnicity, gender, community district, and primary language of parents and children at every step of the child welfare system and to create a plan to address any disparities identified as a result of such reporting.” Perhaps those voting for this legislation had no idea that anything besides bias could contribute to these disparities, nor that “creating a plan to address them” could mean imposing a lower standard of parental care for children who come from over-represented groups–leaving aside the waste of time and money that could be better spent in helping children.

The misconceptions highlighted by Barth and his colleagues are already affecting child welfare policy and practice around the county in ways that are likely to put abused and neglected children at risk of further harm. This magisterial review, with its more than 140 references, is essential reading for anyone who prescribes or develops child welfare policy or practice. Let us hope it receives the attention it deserves.

No Way to Treat a Child: a needed corrective to the dominant narrative

No Way to Treat a Child: How the Foster Care System, Family Courts, and Racial Activists Are Wrecking Young Lives

These days, It is a bit difficult to be a left-leaning liberal while also being an advocate for abused and neglected children. I would never have expected that a Senior Fellow at the American Enterprise Institute (AEI), Naomi Schaefer Riley, would be one of my closest allies in child advocacy. Or that my proudest achievement since starting this blog would be my service on a child welfare innovation working group that she organized out of AEI, or that, with a few quibbles over details, I would agree with the main points of her new book. But that is the case in these strange times, in which many of my fellow liberals appear effectively indifferent to the fate of children whose parents they view as victims of a racist “family policing system.”

Naomi Schaefer Riley is a journalist, a former editor for the Wall Street Journal, and the author of five previous books. In her new book, No Way to Treat a Child: How the Foster Care System, Family Courts, and Racial Activists Are Wrecking Young Lives, uses examples, data and quotes from experts to show in heartbreaking detail how policymakers from the left and the right have converged in creating a child welfare system that puts adults first. Much of this occurs because in deciding how to treat abused or neglected children, the people who create and carry out child welfare law and policy “consider factors that are completely unrelated to and often at odds with a child’s best interests,” as Riley puts it.

Take family preservation and reunification, for example. Instead of placing the safety of the child as the highest priority, Riley illustrates that child welfare agencies leave many children in dangerous homes long past the time they should have been removed, with sometimes fatal results. They give parents more and more chances to get their children back, long after the law says that parental rights should be terminated. The book is full of stories of children ripped away from loving foster parents (often the only parents they have ever known) only to be returned to biological parents without evidence of meaningful changes in the behaviors that led to the children being removed.

Not only do today’s advocates of “family first” wrest children away from loving families to return home, but Riley describes how they send other hapless children to join distant relatives that they never knew, on the grounds that family is always best even if the relative does not appear until as much as two years after an infant has been placed in foster care. The fact that a relative may display the same dysfunction that the parent showed may be ignored. I would add, based on personal experience, that in my foster care work I often met grandmothers who seemed to have gained wisdom (and finally, for example, gave up drugs) with age, as well as aunts and uncles who avoided the family dysfunction and went on to lead productive lives, making their homes available to the children of their less well-adjusted siblings. But Riley is right to say we should consider not just blood, but also fitness and bonding before removing a child from a good pre-adoptive home to live with a relative.

As Riley describes, one of the primary factors that is now taking precedence over a child’s best interest is that of race or ethnicity. Riley explains how data on the overrepresentation of Black and Native American children in foster care in relation to their size is being attributed to racism in child protective services, as I have explained elsewhere, ignoring the evidence that the underlying disparities in abuse and neglect are largely responsible for these differences in foster care placement. And they don’t seem to have a problem with holding Black parents to a lower standard of parenting than White children to equalize the ratios. Moreover, many of these “racial activists” are recommending eliminating child welfare systems entirely along with abolishing the police. As Riley states, Native children are the canaries in the coal mine, “for what happens when you hold some parents to a lower standard, as we have done with the Indian Child Welfare Act with devastating effects for Native children.

Another way we subordinate the interests of children is by minimizing their parents’ responsibility for their treatment by saying it is simply due to poverty. Riley addresses the common trope that “neglect,” the reason that 63 percent of children children were removed from their families in 2019, is “just a code word for poverty,” a myth that I have addressed as well. I’d venture that anyone who has worked with families in child welfare knows there is often much more going on in these families than poverty alone, including substance abuse, mental illness, and domestic violence. Riley puts her finger on an important issue when she suggests that part of the problem may be that we use a general category called “neglect” as the reason behind many removals. However, I don’t agree with her recommendation to discard neglect as a reason for removal. As I explain in a recent post, we need to distinguish between the over-arching categories of “abuse” and “neglect” and the specific subcategories of neglect such as lack of supervision, educational neglect, and medical neglect. Contrary to Riley’s suggestion that they are types of neglect, substance abuse and mental illness are factors that contribute to it. This important information should be included in the record but should not be confounded with types of neglect.

Another way that policymakers disregard the best interests of the child is by deciding that foster homes are better than institutions for almost all children instead of recognizing that some children need a more intensive level of care for a limited time, or that others can thrive in group homes that simulate a family setting but provide more intensive attention than a typical foster home can provide. The Family First Prevention Services Act (FFPSA), which went into effect for all states on October 1, does allow for children to be placed temporarily in therapeutic institutions, although it sets some unreasonable limits on these institutions and on placement of children in them. But it does not provide any funding for placement in highly-regarded family-like group settings such as the Florida Sheriff’s Youth Ranches. (I’m not sure why Riley says in later in the book that FFPSA “is looking like another piece of federal legislation that will be largely ignored by states, many of which have already been granted waivers from it.” Those waivers were temporary and there is no way states can ignore the restrictions on congregate care).

In her chapter entitled “Searching for Justice in Family Court, Riley describes the catastrophic state of our family courts, which she attributes to a shortage of judges, their lack of training in child development and child welfare, and their leniency with attorneys and parents who do not show up in court. As a model for reform, Riley cites a family drug court in Ohio that meets weekly, hears from service providers working with parents, and imposes real consequences (like jail time) on parents who don’t follow orders. But this type of intensive court experience is much more expensive. These programs are small, and expanding this service to everyone would require a vast infusion of resources.

I appreciated Riley’s chapter on why CPS investigators are underqualified and undertrained.” Having graduated from a Master in Social Work (MSW) program as a midcareer student in 2009, I could not agree with her more when she states that the “capture of schools of social work and child welfare generally by a social-justice ideology has produced the kind of thinking that guides social welfare policy.” I’d add that some students are ill-prepared for their studies and may not get what they need while in school to exercise the best judgment, critical thinking, effective data analysis, and other important hard and soft skills. Riley suggests that the function of a CPS worker is really more akin to the police function than to the type of traditional social work function performed by other social workers in child welfare–those who manage in-home and foster care cases. As a matter of fact, Riley quotes my post suggesting that CPS Investigation should be either a separate specialty in MSW programs or could be folded into the growing field of Forensic Social Work.

Riley’s chapter on the promise of using predictive analytics in child welfare shows how concerns that using algorithms in child welfare would exacerbate current discrimination are not borne out by history or real-world results. Use of an algorithm to inform hotline screening decisions in Allegheny County Pennsylvania actually reduced the disparities in the opening of cases between Black and White children. As Riley states, this should not surprise anyone because data has often served to reduce the impact of bias by those who are making decisions. As she puts it, “if you are concerned about the presence of bias among child-welfare workers and the system at large, you should be more interested in using data, not less.”

Perhaps not surprisingly, it is Riley’s two chapters on the role of faith-based organizations in child welfare that made me uncomfortable. Riley describes the growing role of these groups, especially large evangelical organizations, in recruiting, training, and supporting foster and adoptive parents.” Like it or not,” she states, “most foster families in this country take in needy children at least in part because their religious beliefs demand such an action.” But the Christian Alliance for Orphans, an organization often quoted by Riley, was one of the groups behind the “orphan fever” that took hold among mainstream evangelical churches in the first decade of this century. Many families were not prepared for the behaviors of their new children and some turned to a book by a fundamentalist homeschooling guru named Michael Pearl that advocated physical discipline starting when children are less than a year old. Many of the adoptions were failures, some children were illegally sent back to their own countries, some children were abused, and at least two died of the abuse. But Riley’s narrative suggests that many evangelical churches working with foster youth are using a trauma-focused parenting model (Trust-Based Relational Intervention) that is diametrically opposed to the Pearl approach. Nevertheless, the association of evangelical Christianity with a “spare the rod” parenting philosophy as well as the possibility that saving souls is part of the motivation for fostering or adoption, make me a bit queasy about over-reliance on evangelical families as foster parents, and I would have liked to see Riley address this issue.

In her esteem for religious communities and their role in child welfare, Riley is worried that some jurisdictions will bar all organizations with whom they work from discriminating on the basis of sexual orientation or gender identity, driving religions institutions out of business. Since the book was written, however, the Supreme Court has ruled that the City of Philadelphia violated the First Amendment when it stopped referring children to Catholic Social Services for foster care and adoption because the agency would not certify same-sex foster parents. So this threat may be dwindling for the time being. In general, unlike many liberals, I agree with Riley that, as long as there is an agency to work with any potential foster parent, we should “let a thousand flowers bloom” rather than insisting that every agency accept every potential parent.

Riley ends the book with a list of recommendations for making the system more responsive to the needs of children rather than adults. She agrees with liberals that we need an influx of financial resources as well as “better stewardship of the money we already spend.” We need both a massive reform of our child welfare agencies and a family court overhaul, she argues. She wants recruitment of more qualified candidates for child welfare agencies and better training for them. She urges the child welfare system to move away from “bloodlines and skin color” and allow a child to form new family bonds when the family of origin cannot love and protect that child. I certainly hope that policymakers on both sides of the aisle read and learn from this important book.

What can happen when “Family First” goes too far: a Wisconsin story

On October 1, 2021, the Family First Prevention Services Act (FFPSA) took effect for all states that had not yet implemented it. But many jurisdictions had already been realigning their systems in line with the family preservation emphasis of FFPSA before that time – many with great fervor. An article about one Wisconsin county piqued our curiosity, and further investigation suggests the state may be encouraging a disproportionate emphasis on keeping families together at the expense of child safety. Wisconsin is certainly not unique; the focus on keeping families together at almost all costs has been increasingly prevalent in state and county child welfare systems since long before the passage of FFPSA in 2018.

On August 13, the local Gazette published an article reporting that that foster parents and others in Rock County Wisconsin were asking for an investigation into worker turnover and leadership in the county’s child welfare system. Rock County is a county in southern Wisconsin with a population of 163,354 in 2018 and home of the city of Beloit. The article reported that at a recent meeting of the county board, local foster parents complained about employee turnover and a change in philosophy in the County’s child welfare system since the passage of the Family First Act by Congress in 2018. The foster parents alleged that changes in the child welfare system “have led to a mass exodus of longtime county CPS staff.” According to the speakers, the exodus in turn has resulted in a curtailing of investigations and delays in finding services and permanent homes for foster children.

County reports obtained by the Gazette showed that turnover among Child Protective Services (CPS) investigative and ongoing support workers increased from 57 percent in 2016 to 88 percent since that time. The Gazette found that 56 workers had left these jobs since 2016, leaving only three workers still in place who had been there in 2016. In open letters to the board, CPS workers expressed fear that they would “be fired, demoted or marginalized if they voice[d] ideas that run contrary to the county’s shifts in the foster system.” (The county’s Human Services chief later challenged the information about turnover, telling the Gazette that it had been 70 percent since 2016.)

The Gazette also reported dramatic growth in the backlog of completed investigations. According to data from the state Department of Children and Families (DCF) dashboard, the county had a 94% rate of timely completion of initial child screenings (child maltreatment investigations) in 2016, placing it close to the top of all counties in Wisconsin. But by this year as of September 28, 2021, Rock County had completed only 44.7 percent of initial screenings on time, placing it near the bottom of all counties.

Current trends in child welfare suggest that the change in philosophy to which parents and workers were referring was the increased focus on family preservation incorporated in the Family First Act, which had already been taking hold in many states before they actually implemented it. Information available on the website of Wisconsin’s Department of Children and Families supports that assumption. According to a page titled Child Welfare Strategic Transformation in Wisconsin, [s]ince 2018, Wisconsin has been progressively working toward transitioning the child welfare system to become more in-home, family-focused, and collaborative.” The website also indicates that DCF had “partnered with” a company called Root Inc. (a “change management consulting firm”) “to understand how Wisconsin counties were progressing toward achieving the 4 strategic priorities listed above.” A slide presentation from DCF and Root Inc. indicates that the purpose of the partnership is to “dramatically increase the number of children/families served in home.”

In the first phase of the partnership, according to the slides, Root’s ethnographic researchers studied 13 counties (including Rock County) through interviews, focus groups, and observations and came up with “a set of 17 behaviors that differentiated counties along a continuum of change and transformation.” In choosing the counties for the study, the researchers identified counties that they characterized as “on the way” or “advanced” based on the decline in the rate of their foster care populations, the ratio of entries to exits, and the percentage of calls that lead to removals of children from their families. (They left out counties on the bottom of the continuum of change). The authors of the slides did not provide the classification for each county, but Rock County’s inclusion means it was classified as advanced or at least “on the way.”

The first set of findings about “advanced” counties refers to “Mindsets and Decision-Making.” In these counties, one slide indicates that the “culture prioritizes and reinforces the importance of keeping families in home.” There are six bullets under that heading, which are displayed below. Two are of particular interest. “Decisions to remove are met with critical questioning and even pushback. And in “observation, individuals apologize to their peers when pushing for a [court] petition [for removal of a child].”

Source: Wisconsin Department of Children and Families. Child Welfare Transformation. Available from https://dcf.wisconsin.gov/files/press/2021/wi-dcf-root-insights-03-12-county-detailed.pdf

This language raises some serious concerns. Obviously it is best to keep children at home when it is possible to do it safely. But some children cannot be kept safe at home. And to say a worker should receive pushback, or even apologize, for trying to save a child’s life or prevent injury seems excessive, to say the least

In terms of worker-family relationship, the slides state that advanced counties are “[n]on-judgmental towards actions and optimistic in the belief that families can change.” Specific behaviors cited include that “[w]orkers discuss severe forms of maltreatment with a desire to understand the root causes without passing judgment.” Workers in advanced counties are also said to “easily identify strengths of a family.” In fact, teams in advanced counties “hold each other accountable for negative or pessimistic views of families and work hard to avoid anything that could be perceived as disparaging of a given family.” Moreover, “even with complex cases,” workers in advanced counties “approach a new case with optimism, staying open-minded about the severity of safety concerns and/or the possibility of being able to address challenges.”

It may be good practice for social workers to be optimistic and see family strengths, but unrealistic optimism coupled with blindness to danger signals can leave children vulnerable to severe harm. In Los Angeles County. a belief that social workers should focus exclusively on a family’s strengths led a CPS worker and upper management to disregard glaring evidence that four-year-old Noah Cuatro was being targeted for abuse by his parents. The fact that workers are expected to be “open-minded” even in the face of “severe” safety concerns raises some alarm in a system established to protect children. And asking teams to hold each other accountable to take a rosy view of all the families they serve may be problematic.

To be fair to the authors of the slides, they included in the traits of workers in “advanced” counties some attributes that are important for good child protective services workers, such as knowing “how to probe when kids are being coached,” so they clearly understand that families and children cannot always be believed when they deny that maltreatment has taken place. “Regularly assessing danger threats” is another trait the authors ascribe to workers in “advanced” counties. But the presentation makes a questionable distinction, stating that workers in advanced counties are “laser-focused on identifying and isolating safety threats (as opposed to risk) and desire to expand their skills with respect to isolating and controlling safety.” (The italics are ours). Child welfare systems around the country draw this distinction between safety and risk, defining “safety” as the absence of imminent danger while “risk is defined as danger to the child in some unspecified future. But this distinction is hard to draw and can have the paradoxical result of a child being found “safe” but “at high risk of future harm.”

The idea that child welfare systems may have begun overemphasizing family preservation in the years leading up to and following passage of the Family First Act is not a new one for this blog. We have reported that this reluctance to find fault with parents, remove their children, or terminate parental rights allowed the deaths of children known to child welfare systems around the country, including Zymere Perkins in New York, Adrian Jones and Evan Brewer in Kansas, Gabriel Fernandez in California, and Jordan Belliveau in Florida. Reports have found an extreme reluctance to remove children in Illinois, after the deaths of several children while their families were under supervision by the state. In a case mentioned earlier, the Los Angeles Times‘ found that a core practice model focusing exclusively on family strengths and disregarding obvious red flags resulted in the failure of the agency to implement a court order that would have saved the life of four-year-old Noah Cuatro. We have also discussed how this extreme reluctance to remove a child is related to the current “racial reckoning” and consequent desire to reduce racial disparity in foster care placement.

Returning to Rock County, it may not be surprising that workers who came to child welfare to protect children would leave when confronted with a demand to apologize for requesting to remove a child. On the other hand, all the other counties in Wisconsin are being subjected to the same pressures. Whether the family preservation emphasis is the only cause of Rock County’s loss of veteran staff, or whether there are other factors behind it, Child Welfare Monitor cannot say. However, we can suggest that wholesale departure of a child welfare workforce may be one additional consequence of a system realignment that went too far.

The misuse of data to support preferred programs: the case of family resource centers

Family resource centers, also called family support centers or family success centers, are becoming the prevention program of choice for child welfare agencies around the country. These neighborhood-based centers are being touted as America’s best hope for preventing child maltreatment before it occurs. But the proponents of these centers have been a little too eager in their claims that these programs are supported by research. Two studies recently released to great fanfare do not stand up to close examination. The sites chosen appear to have been chosen for their potential to support the desired conclusion, the evaluations do not convincingly adjust for confounding factors (a major misstatement was made in one of the studies regarding the implementation date of a possibly confounding policy), and the studies are rife with methodological problems related to the measure of success and the attribution of outcomes to the programs.

According to the Child Welfare Information Gateway, family resource centers are “community-based or school-based, flexible, family-focused, and culturally sensitive hubs of support and resources that provide programs and targeted services based on the needs and interests of families.” These centers are known by different names around the country, including Family Centers, Family Success Centers, Family Support Centers, and Parent Child Centers. Services provided often include parenting support, access to resources, child development activities, and parent leadership development.

Family resource centers (FRC’s) are being heavily promoted by child welfare agency leaders, as well as influential private actors such as Casey Family Programs as “less punitive, more open-ended, flexible and voluntary venues where vulnerable families can connect to services, particularly in the communities sending the most children to foster care,” as a recent article in The Imprint put it. FRC’s are gaining increased support around the country. New York City recently announced that it would expand from three to thirty Family Enrichment Centers. In October 2021, the District of Columbia opened ten new Family Success Centers in 2021, under its “Families First DC” initiative. Texas has recently announced that it is investing $1 million to create an unspecified number of Family Resource Centers, and has announced the first five grantees. Many other jurisdictions, such as New Jersey, Vermont, and Allegheny County Pennsylvania, have been operating FRC’s for years. A national membership organization called the National Family Support Network (NFSN) represents and promotes these centers.

Two recent studies have drawn press attention with reports that two family resource centers have been very successful preventing child maltreatment and as a result are saving money for taxpayers. The studies were carried out by a Denver nonprofit called the OMNI Institute, “in partnership with” the NFSN and Casey Family Programs. The researchers report that they identified the two programs by contacting NFSN members and reviewing existing evaluations of FRCs “to identify potential opportunities that could serve as return on investment case studies.”

One of the two programs studied was the Community Partnership Family Resource Center (CPFRP) in Teller County, Colorado, a rural county in central Colorado with a population of approximately 25,000 that is almost all White. As described in their report, the researchers wanted to explore the impact of two new programs that the center implemented in 2014 and 2016, that they hypothesized might have the effect of preventing child abuse and neglect in the county. One of these programs was Colorado Community Response, a voluntary program for parents who were reported for abuse or neglect but were either screened out at the hotline level or investigated but received no child welfare services. A second program, Family Development Services, was a voluntary primary prevention program helping struggling families set goals and connect to resources. The researchers claim that the creation of Colorado Community Response and increased funding for Family Development Services offered “a potential opportunity to examine the Return on Investment for CPFRC to the child welfare system, by comparing child maltreatment outcomes prior to and after the establishment of these new practices.” They decided to use the number of maltreatment allegations that were “substantiated” (or found to be true upon investigation) as their outcome of interest.

In designing their study, the researchers sought to identify other changes that might also affect levels of child maltreatment in order to avoid confounding effects. They learned that Colorado had implemented a “differential response” model in 2013, which was a two-track model for addressing allegations of abuse or neglect. Allegations that are viewed as less serious are assigned to the alternative response track and usually do not receive a substantiation, or finding of abuse or neglect. Obviously, the change to differential response might dramatically affect the number of substantiations. The researchers identified several other policy changes and events that might have affected substantiations, such as the establishment of a statewide child abuse hotline and the inception of the COVID-19 pandemic. According to the report, they decided to use 2015 is the baseline year because “neither Colorado Community Response nor Family Development Services programming were available to the whole CPFRC population, but the statewide child abuse hotline and differential response models were in place.” They chose 2018 as the comparison year because it was the only year that both Colorado Community Response (CCR) and Family Development Services were fully implemented with no other major system-wide changes in place, and before a change in CCR eligibility requirements and the onset of the COVID-19 pandemic.

Using data provided by the state on its online dashboard, the OMNI researchers found that there were 82 substantiated assessments in 2015 and only 30 in 2018. To adjust for population changes they divided each number by the number of children in the County at the time, producing what they called an “outcome weight” for 2015 and a “deadweight rate” for 2018, as described in the first graphic below. Subtracting the deadweight rate from the outcome weight and multiplying by the child population in 2018, the researchers came up with a reduction of 51 fewer substantiated assessments in 2018, as illustrated in the second graphic. (The adjustment made little difference; simply subtracting the 30 from 82 resulted in a reduction of 52 substantiated assessments.) This impressive drop in substantiated cases translates to a “62.84 percent reduction in substantiated assessments from 2015 to 2018.”

Source:
Source: Sara Bayless, Melissa Richmond, Elaine Maskus, and Julia Ricotta, Return on Investment of a
Family Resource Center to the Child Welfare System
. Available from https://childwelfarewatchblog.files.wordpress.com/2021/09/8b78c-communitypartnershipfamilyresourcecenterchildwelfarereturnoninvestmenttechnicalappendix.pdf.

The researchers used the estimated number of children served by CPFRC during 2018 (1,444) relative to the estimated number of children at risk for maltreatment based on income-to-needs (ITN) ratio (1,479)* and age (1,272), to decide how much of the change in substantiations to attribute to the program. The result was an “attribution estimate of 98 percent based on the ITN ratio and 114 percent based on age. Combining these estimates, the researchers decided to attribute the entire reduction in substantiated cases to CPFRC.

Finally, the researchers calculated a return on investment using total child welfare expenditures in 2018 divided by the number of substantiated assessments in that year, resulting in a total cost of $49,026 per substantiated investment. Multiplying that figure by 51, they concluded that the reduction of 51 substantiated assessments, (of which 100 percent were attributed to the program) saved the Teller County child welfare system $2,500,326 in 2018 compared to 2015. Dividing this total by $856,194, they came up with a “Return on Investment” of $2.92 for every dollar spent on the program.

There are many serious problems with this analysis. The choice of substantiations as an indicator of victimization is problematic because of the large body of literature illustrating the difficulty of determining if a child has been maltreated and the absence of differences in future outcomes between children with substantiated vs. unsubstantiated allegations. Allegations (or referrals) seem to be a more meaningful measure of abuse or neglect. Using data from two years without looking at the numbers for the years in-between is also problematic, as the researchers themselves admit. In their discussion of the weaknesses of the study, they acknowledge that using only two years, without the years in between, is not ideal because it provides a less robust understanding of changes in child maltreatment as well as making its estimates more susceptible to influence by other system-level factors.

But there is a much worse –indeed fatal–problem with the two years chosen. The researchers claim that they chose 2015 because Differential Response was already in effect in in that year, having been implemented in 2013. But going to Colorado’s “Community Performance Center” (data dashboard) as helpfully directed by a footnote, one quickly learns that no children were assigned to Family Assessment Response (the option that does not result in substantiation) in Teller County in 2015, as shown in Table One below. In 2018, 82 children, or 44.3 percent of all children assessed, were assigned to Family Assessment Response. So an unknown part of the decrease in the number of children substantiated could have been due to the rollout of Differential Response.

Table One

Source: CDHS Community Performance Center, Number of Children Assessed in Child Welfare, available from https://rom.socwel.ku.edu/CO_Public/AllViews.aspx?RVID=647

If there was any doubt that the advent of Differential Response may be related to the drop in substantiated assessments, one only has to look at Figure One below. It is hard to figure out how the researchers missed this graphic, which is prominently displayed on the relevant page of the data dashboard, and shows how substantiations fell between 2016 and 2018 as the number of children assessed through FAR increased. This is a bizarre error, considering that the researchers specifically cited the prior rollout of differential response as a reason for choosing 2015 as the baseline year for the study.

Source: CDHS Community Performance Center, Number of Children Assessed in Child Welfare, available from https://rom.socwel.ku.edu/CO_Public/AllViews.aspx?RVID=647

Another problem is the method the researchers used to attribute all of the “reduction” in cases to the program. First, the authors provide no explanation of the estimate that 1,444 children received services at CPFRC. We assume this includes every child who ever walked into the center, but we just do not know, since the researchers do not define it. We have no idea of the quantity of services received by each child. We don’t even know if this is an unduplicated count. Moreover, this conclusion simply violates common sense. On the face of it, how could one assume that one family support center caused the entire reduction in child maltreatment substantiations in a county? It just beggars belief.

The second study by OMNI focused on the Westminster Family Resource Center (WFRC), which serves a mostly-Latino population in Orange County, California. WFRC provides a variety of services, including information and referral, family support, case management, counseling, after school programs, domestic violence support, parenting classes, and “family reunification family fun activities.” WFRC belongs to a network of 15 Family Resource Centers known as Families and Communities Together (FaCT). The researchers report that In conducting the study OMNI took advantage of a pre-existing evaluation of all the centers in the FaCT network, which was conducted by Casey Family Programs, Orange County Social Services Agency, another nonprofit and a consulting firm. OMNI reports that “After consultation with the evaluation team and a review of the demographic profile of the areas served by FRCs within Orange County as a whole, OMNI identified Westminster Family Resource Center (WFRC) as a strong option for this project.” (The larger study is listed as “forthcoming” from Casey Family Programs in the references to the OMNI report.)

Unlike the Teller County report, the Orange County report compares outcomes across geographic areas rather than two time periods. The researchers defined WFRC’s service area as the census tracts where at least one percent of the population was served by WFRC. They matched 12 census tracts in Los Angeles County to the area served by WFRP based on ten “community level indicators related to child maltreatment,” such as the percentage of families in poverty and the unemployment rate; the other indicators were not listed.

Using data from the pre-existing evaluation, the researchers subtracted the substantiation rate (number of substantiated children per 1000) in the WFRC areas from the substantiation rate in the matched areas for 2016 and 2017, the most recent years for which data were available, and then multiplied the difference by the number of children in the WFRC service area. The calculation is shown in the attached graphic, which incorrectly divides the number of children in the service area by 1,000. This calculation produced an estimate of 35 fewer substantiated assessments in 2016 and 56 fewer substantiated assessments in 2017. Unlike with the Teller County study, a reader cannot check the underlying data because it comes from an as yet unpublished study. Admitting that there are no guidelines for attributing results to a program in a “quasi-experimental evaluation” using community-level indicators, the researchers rather randomly decided to attribute 50 percent of the difference in substantiated assessments to the program.

Source: Sara Bayless, Melissa Richmond, Elaine Maskus, and Julia Ricotta, Return on Investment of a
Family Resource Center to theChild Welfare System, Westminster Family Resource Center, Orange
County, CA. Available from https://childwelfarewatchblog.files.wordpress.com/2021/09/7845f-westminsterfamilyresourcecenterchildwelfarereturnoninvestmenttechnicalappendix.pdf
Note that the the equations are incorrect. The number of children in the service area was not divided by 1,000.

As in the Teller County study, the researchers went on to calculate a return on investment for WFRC. Although they did not explain their methodology for doing so, it appears they used the same approach of dividing child welfare costs for each year by the number of substantiated assessments for that year to come up with an estimated cost per substantiated assessment in California, adjusting for inflation, and finally subtracting the estimated costs of WFRC. By this method, they arrived at a return on investment of $2.80 in 2016 and $4.51 in 2017, which they averaged to get a total return on investment of $3.65 per dollar spent on the program.

The use of substantiation rates as an indicator of success is as problematic as in the Teller County study. As I have mentioned, substantiation does not equal victimization but instead reflects the agency’s performance in determining whether maltreatment really happened. Using substantiation as an indicator of maltreatment could introduce bias if one of these counties substantiated allegations at a higher proportion of cases than the other, as discussed below.

While there is no mistake as glaring as the Teller County team’s erroneous assumption that differential response had already been implemented in the study’s baseline year, the possibility of significant confounding effects does exist–in this case between places rather than times. California has a county-run child welfare system and the writers do not discuss any policy or practice differences that may exist between Los Angeles County and Orange County and how they might affect the differences in substantiation rate between the two counties. And indeed, data from the Child Welfare Indicators Project at Berkeley shows that Los Angeles County does substantiate a higher proportion of allegations than does Orange County. Of all the children with allegations in 2016 and 2017, 15.7 and 14.7 percent had substantiations in Orange County, versus about 18 percent in Los Angeles County both years. In addition, the fact that the reduction in substantiated assessments, and therefore the estimated cost savings due to the program, varied so much between 2016 and 2017 is already concerning and suggest that the impact found depends upon the year, and could be vastly different if another year were chosen.

The attribution of 50 percent of the difference in substantiations between the two counties to the WFRP has no basis in fact or social science. The researchers did not attempt the kind of calculation reported for Teller County (however problematic) in which they compared the number of children served to the number of children who might be at risk of maltreatment. They indicate that WFP served 1.77 percent of households in its service area as defined by the researchers, and we have no idea how that compares to the number of households where children are at risk of maltreatment.

Looking at the Teller County and Orange County studies together, the choice of these two specific programs out of all the over 3,000 FRC’s represented by NFSN (and the choice of only one out of 15 programs evaluated in Orange County) raises the possibility that the researchers cherry-picked programs to achieve the desired results. In fact, the researchers report that that is exactly what they did! One of the criteria they reported using to select their ultimate sites was that “there were available data demonstrating a plausible connection between FRC services and child welfare system outcomes;” another was that “[t]here were available quantitative data demonstrating that the child welfare system has benefited (e.g., through reductions in the incidence of child abuse/neglect).” The researchers also claim that they were looking for sites representing “demographically different communities,” and I suppose they achieved that with their two sites with mostly White and Latino clientele; but they seem to have been unable to find a suitably promising site with a predominantly Black clientele.

Clearly it is not easy to evaluate programs without random assignment to a treatment and control group, or at least a comparison group that is matched individually to a group of participants. It is also difficult to evaluate a program where each participant gets a different package of services, with some receiving as little as one visit to the center. There is ample reason to doubt that Family Resource Centers will have a large impact on the most serious cases of child abuse and neglect because the parents who use these centers tend to be those who are already open to seeking help, learning new parenting tools, and working toward change. It seems likely that the parents of the most vulnerable children are often the ones who are not willing to seek the kind of help that Family Resource Centers provide. Chronically neglectful parents may lack energy and motivation to go to a Family Resource Center; chronically abusive families are likely to want to avoid letting other adults set eyes on their children. That is why jurisdictions that are really serious about prevention have chosen to adopt more targeted strategies. For example, Allegheny County Pennsylvania, which has a network of 27 Family Resource Centers and was a pioneer in this effort, knew they had to do more for families with more intense needs. They created a three-tier model called Hello Baby, in which families are placed into tiers based on their needs. They are reaching out to all families, and they are referring those in the middle tier to county’s FRC’s. For the families with the greatest needs, a more intensive option is being offered.

A recurrent theme of this blog has been the use of flawed research to promote the programs that the promoters want to support, most recently in my post about race-blind removals. Using flawed research to support programs results in misperceptions by the public and its representatives and in turn to bad policy decisions. One does not have to look beyond Teller County for an example “Child abuse reports have declined dramatically locally due to a partnership between a key Teller government agency and a nonprofit organization,” trumpeted a local paper based on the press release from OMNI. In the article, the DHS Director Kim Mauthe was reported as saying that “the findings of the report are good news for the county. “It’s exciting because the calls we did receive through our child abuse hotline show that we had a decrease of child abuse by 57 percent, which is huge….” It is not clear what would be more disturbing: that Mauthe really believed this program had reduced child maltreatment (not “abuse” as she described it) by 57 percent, knowing that the study period included her county’s adoption of differential response, or that she was cynically misrepresenting the study results to the media. The report was presented at a meeting of county commissioners, who applauded Ms. Mauthe. They now presumably think that child maltreatment is on its way to disappearing, and if anything more is needed it would be to add more funding to the Family Resource Center–not necessarily the best approach if they want to reach the families with the most intense needs.

It is not surprising that this flawed research was funded and promoted by Casey Family Programs, a wealthy and powerful non-profit that has played an outsized role in child welfare in recent decades, funding advocacy-oriented research, providing free consultation to states, and even helping the government hire people who support its views. One of CFP’s goals is to “safely reduce the need for foster care in the United States by 50 percent,” a goal that is incidentally meaningless without a beginning and ending date. Most recently, CFP has publicized the faulty data on race-blind removals that I discussed in a recent post.

Family resource centers can be a great addition to a neighborhood, providing connections to needed programs and services for needy families. But two recent studies that claim to show that these centers reduce child maltreatment and thereby save money to taxpayers are too flawed to provide any meaningful evidence that they indeed have this effect. Any continuing publicity these studies receive may lead unsuspecting public officials to invest in family resource centers at the expense of other programs that may be more promising in preventing child maltreatment.

When ideology can kill: the death of Noah Cuatro

Image: KTLA.com

As many of my regular readers know, I have been fearful that the current climate emphasizing family preservation and racial and ethnic disparities in the child welfare involvement might end up inadvertently harming children. Well, it has happened in California, where a child is dead after the Department of Child and Family Services (DCFS) disregarded a court order to remove a child from a lethal home, motivated in part by hypersensitivity to concerns of possible bias and an exaggerated focus on family strengths that blinded agency staff to glaring problems.

On July 5, 2019, the parents of four-year-old Noah Cuatro called 911, saying their son had drowned in the pool at their apartment complex. But Noah did not look like a drowning victim. He had signs of strangulation, old and new rib fractures, and bruises across his chest, arms, and legs, and a large mark on his forehead. The cause of death was ruled as suffocation. His parents are facing trial for murdering and torturing him.

In August 2019, the Los Angeles Office of Child Protection (OCP) issued a flawed report that exonerated the Department of Child and Family Services of any responsibility for Noah’s death. Fortunately, the Los Angeles Times and the Investigative Reporting Program at UC Berkeley went to court to gain access to documents that would tell them what really happened. They reviewed juvenile court files, emails, and testimony from a grand jury proceeding that led to the indictment of Noah’s parents. In a harrowing article describing the results of their investigation, the journalists document the role of errors, misjudgments, bureaucratic conflict, bias accusations, and a flawed practice model that together “blocked multiple opportunities to protect Noah.” My account is based in part on the Times article as well as the OCP report, which contains some dates and other details that help flesh out the timeline of this tragic case.

Noah Cuatro was first removed from his parents in August 2014 when he left the hospital after birth, after his mother, Ursula Juarez, was alleged to have abused an infant half-sister, causing skull fractures. He ended up in the home of his great-grandmother, Eva Hernandez. At the age of nine months, he was returned to his parents when the agency was unable to prove the allegations against Juarez. But the Times-UC Berkeley investigation found that Noah’s parents always felt that DCFS had robbed them of the first nine months with their newborn. And Hernandez felt that perhaps because they missed his first nine months, they never bonded with Noah and therefore targeted him for abuse.

In November 2016 Kaiser Permanente called the child abuse hotline to report that Noah had missed eight doctor’s appointments over the spring and summer of 2016. An investigation found that Noah had gained only a few ounces between February 2015 and October 2016. His muscles were deteriorating, and he was unable to walk at the age of 27 months. Once again, Noah was removed from his parents and placed first in a facility for medically fragile children and then back with Hernandez.

Two years later, on November 9, 2018 Noah was returned to his parents by a court over the objections of DCFS. Noah had thrived with Hernandez, reaching the appropriate weight and height for his age. He screamed and wet the bed before and after visits with his parents and begged to stay with his great grandmother. Moreover, his parents had not complied with court orders to participate in therapy and visitation with Noah. But the Juvenile Court commissioner, Steven Ipson, saw “substantial progress” by the parents and sent Noah home, requiring that his parents arrange for a visitation schedule with Hernandez, participate in Parent Child Interaction Therapy with Noah, and send him to preschool.

The red flags appeared almost as soon as Noah returned to his parents. On her visits to the family, Susan Johnson, the social worker assigned to the case, learned that Noah’s parents were ignoring the court orders for therapy, preschool and regular visits with his great-grandmother. In April 2019, an aunt made a call to the child abuse hotline, reporting that Noah was losing weight and had thinning hair. Worse, he had changed from an exuberant boy to a scared one. Another relative had told her that during an overnight stay Noah had night terrors and complained of pain in his “butt.”

Johnson went to the home and found Noah with marks on his right arm and neck, a big bruise on his left arm, and lotion covering his back, which his mother attributed to eczema. When Johnson asked what happened when he did something wrong, Noah said “I get hit,” but he quickly retracted. She tried the same question again, and got the same affirmation and quick retraction–characteristic of a scared, abused child. Back at the office, Johnson met with her supervisor and a senior administrator, who told her to file a petition for removal.

But it was not Johnson’s job to assess the truth of the allegations. She was a “Continuing Services Children’s Social Worker” (CS-CSW) in DCFS lingo, whose job was to monitor and assist the families in their journey toward a safe home and case closure. The duty of investigating the allegations fell to an “Emergency Response Children’s Social Worker (ER-CSW often known as a Child Protective Services or CPS worker in other states) named Maggie Vasquez Ducos. When Vasquez Ducos visited the family, Juarez told her that Noah got his injuries by falling off a bunk bed. She also told her, in tears, that Johnson and DCFS had been persecuting her. Noah denied abuse, and a medical exam found that his injuries could have been caused by falling from a bunk bed.

Vasquez Ducos consulted with the social worker who worked with the family before Johnson, Lizbeth Hernandez Aviles. Hernandez Aviles reported that “she had always had concerns for Noah, was opposed to his return home, and felt that the parents are habitual liars who present well,” according to the OCP report. She expressed concern about the existence of bonding between Noah and parents and believed he was the child in the family targeted for abuse.

Nevertheless Vasquez Ducos made a finding of “inconclusive” on the new allegation, meaning that there was insufficient evidence to determine that child abuse had occurred, on May 9, 2019. There is no indication in the records reviewed by the Times and UC Berkeley that Vasquez Ducos reached any of Noah’s relatives, an essential component of any serious child abuse investigation. The police investigation after Noah’s death found text messages between relatives revealing their rising concern during the same time period about the parents’ treatment of Noah.

While Vasquez Ducos was investigating, Johnson was writing and submitting her petition for the removal of Noah and on May 15 it was granted by the court, along with the requirement that Noah be taken for a medical exam. On the same day, a new referral came in alleging domestic violence in the home and sexual abuse of Noah. Assigned to investigate the new referral, Vasquez Ducos learned of the removal order and immediately began to question the need for it. Parroting the words of Noah’s parents, she told her supervisor that Johnson was “harassing them.” She argued that Johnson was biased against the parents and overly influenced by great-grandmother Hernandez.

Investigating the new allegations, Vasquez Ducos visited the family on May 20, 2019, accompanied by the previous social worker, Hernandez Aviles, who had voluntarily taken a demotion to be a Human Services Aide due in part to the stress of managing Noah’s case, according to the Times-UC Berkeley investigation. They found Noah with an injury to his cheek, for which three explanations were given, along with plenty of coaching by Mom for Noah to endorse her explanation. During the visit, Hernandez Aviles reported that Noah “randomly” ran up to her stating ““They feed me a lot,” “They take good care of me,” and “They love me.” It’s hard to imagine better evidence of coaching, and indeed Hernandez Aviles noted that many of Noah’s responses appeared coached.

But Vasquez Ducos was unmoved. In a May 22 meeting with higher management, she argued against the removal order and the top administrator in the room took her side, telling Johnson not to execute the order.* It was agreed that DCFS would facilitate a “child and family team meeting” with the family. Johnson testified that when she tried to state her case, a supervisor elbowed her to be quiet. But she was heard to state, “that she didn’t want a dead kid on her watch,” according to an email quoted in the Times article. Ironically, the new allegation was cited as a reason not to remove Noah until the investigation could be completed. To make matters worse, Johnson, Noah’s main advocate, was removed from the case. It appears that the top administrator who made the decision not to enforce the court order also wanted a Spanish-speaking case manager, although such a person was never appointed and the job of managing the case for the rest of Noah’s life was left to Vasquez-Ducos, who was an investigator, not a case manager.

On June 6, Juarez, who had repeatedly denied being pregnant, gave birth to a baby boy. She had received no prenatal care and initially claimed to be a surrogate, despite lacking any paperwork, and tried to “sneak out of the hospital.” A Kaiser social worker informed DCF about the birth. She also told Vasquez Ducos that Kaiser’s psychiatric exam showed that Juarez had traits of a sociopath and indicated that she was worried about Juarez’ contradictory accounts of her pregnancy. Nevertheless. Vasquez Ducos and her supervisor decided to let Juarez go home with her newborn.

During the month of June, the family seemed to turn against Vasquez Ducos as well, apparently obstructing all her attempts to visit him before the end of the month. Her last visit with Noah was on June 28, 2018. According to the OCP report, Noah was described as “in good spirits and reported that he was doing well.” Vasquez Ducos reported that Noah’s father dismissed her attempt to schedule the long-delayed meeting with DCFS that was agreed at the May 22 meeting, saying they wanted no further involvement with the agency–a strange thing for a social worker to accept as the prompt scheduling of the meeting should have been a condition for keeping Noah at home.

In the final week of Noah’s life, Vasquez Ducos (perhaps sensing impending disaster and seeking justification) set her sights on the people who tried to protect Noah, stating in emails that Johnson was biased towards Noah’s family, that great-grandmother Hernandez (the only person who treated Noah like a mother) was at fault for biasing Johnson, and that Noah’s parents were victims of DCFS. “I feel like as a Department we have been picking on this family,” she wrote on July 3. Three days later Noah was dead.

A close reading of the Times-UC Berkeley article and the OCP report shows that DCFS disregarded numerous red flags that should have been obvious to any competent social worker with a modicum of training: the parents’ repeated failure to comply with the terms of their custody order; the admissions of abuse and subsequent retractions by Noah; his unsolicited comment that his parents treated and fed him well and other obvious signs of coaching; the assessment indicating that the mother had traits of a sociopath; and the comments by the previous social worker, among many others. There were multiple failures in case practice including the ignored removal order, the disregarded court order for a medical exam, the lack of response to the parents’ repeated failure to comply with the terms of their custody (a reason in itself for removal of the child); and the failure to schedule a family meeting which was an essential component of the plan to leave Noah at home.

But what makes this more than yet another story of missed red flags and bad case practice is the explicit evidence of the impact of two factors—bias accusations and “strength-based practice–in the death of Noah Cuatro.

Bias accusations

From the beginning of her involvement, Vasquez Ducos seemed to be convinced by Noah’s parents that Susan Johnson was biased against Noah’s parents. The charge of bias took place in the context of a state and national reckoning with racial and cultural bias against people of color. As I’ve written, there is a growing focus on the disparities in child welfare involvement between different racial and ethnic groups. These disparities are evident as they relate to Black and Native American children, who are much more likely to be reported to CPS, found to be abused or neglected, and placed in foster care, than White children. But this is not the case for Latinos like Noah, who actually are underrepresented in foster care nationally, constituting 25.4 percent of the child population but only 20.8 percent of those in foster care. In California, Latino children enter foster care at the same rate as all children–5.3 per thousand in the population, and in Los Angeles County they enter foster care at a slightly lower rate. Yet, “people of color” who are said to be over-represented in foster care and child welfare services are often assumed to include Latinos.

The extent to which Vasquez Ducos and her supervisors believed that Johnson (a Black woman) was biased against Latino families is unclear. The previous social worker, who had argued for removal, was Latina. The great-grandmother, who Vasquez-Ducos accused of influencing Jackson against Juarez, was also Latina. Yet, the Times reported that the administrator who quashed the removal order also wanted Johnson replaced with a Spanish-speaking social worker, even though the entire family was fluent in English except for one person in the extended family. Whatever the cause, the facile use of the bias label seemed to blind Vasquez Ducos to the evidence that should have been apparent to any minimally-trained investigative social worker.

The reporters found something very telling in Vasquez Ducos’ notes. She quoted Juarez as saying “Why would we hurt our baby when we just got him back? I have had this case open for four years, and I have been told I’m good enough to only have my two kids but not Noah. How does that make sense?” Apparently Vasquez Ducos agreed. She must have never learned about the well-known phenomenon of one child in a family being targeted for abuse, as well as the attachment problems that can ensue when an infant is apart from its mother from birth, information that one hopes is included in training for child protective services workers everywhere.

Strength-based practice

Perhaps even more important than the bias issue is the role that a “signature” DCFS policy played in Noah’s death. In telling testimony reported by the Times, Vasquez Ducos’ supervisor reported that “DCFS management wanted to follow the core “practice model” that requires workers to remain focused on the positive, taking a better look at a family’s strengths and less at its weaknesses.” Similarly, Hernandez Aviles told the grand jury that colleagues decided not to remove Noah in line with the agency’s “strength based approach.”

According to Los Angeles DCFS website, its social workers use a “Core Practice Model that prioritizes child safety while emphasizing strengths over deficits, addressing underlying needs over behaviors, and instilling empowerment over helplessness.” This Core Practice Model is an example of what is generally called “strength-based practice,” a theory of social work practice that emphasizes clients’ self-determination and strengths.

I am familiar with this approach because I was trained in a similar model by the District of Columbia’s Child and Family Services Agency. We learned that in the past, child welfare practice was characterized by an emphasis on deficits, telling parents what is wrong with them and what they must fix. This approach, we were told, created hopelessness among parents and interfered with the development of good relationships with social workers. We were told that strength-based practice empowers families to make positive self-directed change.

It makes sense find a family’s strengths, emphasize them to the family and build on them. I certainly tried to do this when I worked with families that were trying to get their children back from foster care. But to disregard problems that could lead to harm to a child in no way “prioritizes child safety” as DCF claims to do. Noah’s case shows how disregarding family problems despite numerous red flags can lead to tragedy.

But strength-based practice is in line with a national movement focusing on parents’ rights and stressing the importance of keeping families together, with removals eliminated or drastically restricted. This movement has been reinforced by the current racial reckoning, which has produce arguments that child protective services is nothing more than a “family policing system.” Noah’s case shows what can go wrong when this philosophy goes unchecked.

Bobby Cagle, the Director of DCFS, told the reporters that he saw no problems with his agency’s policies or its handling of Noah’s case. He refused to say if any employee was disciplined as a result. Firing people is not a solution to such unnecessary deaths as that of Noah. However, it seems likely that one or more people in the Lancaster office of DSS are so unsuited to their jobs that they pose a danger to children. Keeping them on the job is unacceptable on child protection grounds, not to mention the need for accountability.

The death of Noah Cuatro was a tragedy. The fear and suffering that he endured starting from the time he was returned to his parents at the age of four was also a tragedy. We cannot know many children are suffering at this very moment because social workers or their bosses miss the most obvious red flags due to ignorance, overwork or because their ideology or training does not allow them to see the glaring faults of their parents. DCFS’ Office of Child Protection tried to cover up this horrendous failure that cost the life of a child. The Los Angeles Times and UC Berkeley deserve kudos for providing the answers that OCP tried to cover up.

*According to OCP, a removal order authorizes, but does not require removal of a child. However the court must be notified within ten days if the child is not removed. Nobody notified the court that the removal order obtained by Johnson was not carried out until the hearing on June 25, more than 45 days after the order was approved. The ordered medical exam had never been carried out.

Report of Maltreatment: a major risk factor for child mortality

When I joined the District of Columbia’s Child Fatality Review Committee, I was expecting to review many deaths of children due to child abuse and neglect. Thankfully, that was not the case–or at least there were few cases that were clearly due to maltreatment. But over time I learned that the relationship between child maltreatment and child fatalities was more complicated. I was shocked to discover how many children who died of of natural causes, accident, homicide, or suicide came from families that had previously reported to Child Protective Services (CPS). There has been a spate of new research demonstrating that children who have been the subject of a child abuse or neglect report are more likely to die from many major causes than other children, even when confounding factors are controlled. This increasing body of evidence has major policy implications, including the need to intervene with high-risk infants at or before birth.

Many of the new studies come from California, where researchers linked prior CPS reports with birth and death records. The size of California, with its more than 10 million children, allowed the researchers to obtain statistically significant results despite the relative rarity of child fatalities. Moreover, the researchers could adjust for sociodemographic factors including birth payment method (public vs. private insurance), maternal age, maternal education, race and paternity establishment, birth order, child gender, and child health risk indicators (low birth weight and birth abnormalities). The researchers chose to focus on children with any maltreatment allegation, rather than only substantiated ones, because of the literature suggesting the difficulty of making an accurate finding of past maltreatment, as well as the absence of differences in subsequent outcomes between children with substantiated and unsubstantiated allegations.

In the first study using this approach, Emily Putnam-Hornstein of the University of California Berkeley sought to establish whether children reported for maltreatment were at higher risk of death by intentional and unintentional injury during their first five years of life. She linked CPS, birth and death records for over 4.3 million children born in California between 1999 and 2006. And what she found was striking: after adjusting for socioeconomic and other risk factors at birth, children with a prior report to CPS died of intentional injuries at a rate that was 5.9 times greater than children who were not reported. More surprisingly perhaps, these children died of unintentional injuries at a rate that was twice as high as that for unreported children. In total, children with a prior allegation of child abuse or neglect were fatally injured at a rate 2.5 times higher than children without a prior allegation. Putnam-Hornstein found that a prior report to CPS was the strongest independent risk factor for injury mortality in the first five years of life out of all the risk factors studied. The existence of more unintentional injuries among children with prior CPS reports may reflect the lack of age-appropriate supervision by parents, as Putnam-Hornstein suggests, given that these parents have already been the subject of CPS reports. But she also notes the probability that some of the injuries classified as unintentional may have actually been intentional injuries that were misclassified on death certificates.*

Putnam-Hornstein and colleagues, using the same dataset, also studied how the risk of fatal injury varies by the type of maltreatment allegation, adjusting for baseline risk factors. They found that children with a previous allegation of physical abuse died from injuries at a rate 1.7 times higher than children referred from neglect. Moreover, these children died from intentional injuries at a rate five times higher than children with an allegation of neglect. Yet, these children had a significantly lower risk of unintentional injuries than children with an allegation of neglect. They point out that these findings are consistent with the general conceptual understanding that abuse is an act of commission, while neglect is an act of omission.

In the next California birth cohort study to be published, Putnam-Hornstein and her colleagues sought to establish whether infants previously reported for maltreatment face a heightened risk of Sudden Unexpected Infant Death (SUID), a term that refers to children who die in the first 12 months of life with no immediately identifiable cause or explanation.** They started with the same dataset of all children born in California between 1999 and 2006 with corresponding CPS and death records through each child’s first birthday. Adjusting for risk factors at birth (including low birth weight and late or absent prenatal care), they found the rate of SUID was more than three times greater among infants who had been previously reported for past maltreatment than among infants who had not been reported. The authors suggest several possible explanations for this finding. The existence of a previous CPS report may indicate the presence of risk factors the researchers were not able to measure, such as maternal substance abuse, which has been found to be associated with SUID. In addition, families reported to CPS may be less likely to adhere to safe sleeping guidelines due to the stressors they face and the fact that they have not yet been reached or convinced by public health messaging around safe sleep practices.

To complement the first two studies, which focused on injury deaths and unexplained non-injury deaths, Schneiderman, Prindle and Putnam-Hornstein looked at non-injury, medically-caused deaths of infants in the first year of life. In this study, the researchers used records for the more than 3.4 million children born in California between 2010 and 2016. They found that after adjusting for baseline risk factors (including low birth-weight and preterm birth), infants with one CPS report were almost twice as likely to die of medical causes than infants with no CPS reports; infants with more than one CPS report were more than three times more likely to die of medical causes than those without a CPS report. The researchers also found that among infants reported for maltreatment, periods of foster care placement reduced the risk of death from medical causes by roughly half. The authors speculate that the higher risk of death from medical causes among infants in families with CPS reports is related to these families’ challenges around mental health, substance abuse, and extreme poverty, as well as their lack of social support. Medical neglect may also be more likely in these families given their CPS history. And unfortunately, as described by child welfare analyst Dee Wilson, there is a strong correlation between medical fragility and parental incapacity to care for a child, as parents with little or no prenatal care and those who abuse drugs are most likely to have babies with low birth weight and birth abnormalities. The protective effect of foster care suggests that many foster parents are better equipped to meet the medical needs of fragile infants than the families from which they have been removed.

But it is not just infants and young children previously reported to CPS who are more likely to die of non-maltreatment causes than their non-reported peers. In a newly published article, Palmer, Prindle and Putnam-Hornstein report on their study of CPS history and risk of suicide. Using linked birth, death and CPS records, they followed all children born in California in 1999 and 2000 and all death records through 2017. Using a “case-control design,” they matched each suicide case to four living controls based on demographic characteristics including sex, year of birth, maternal race and ethnicity, maternal age at birth, maternal education, and insurance type at birth. They found that over half (56.5 percent) of children who died by suicide had a history of past allegations of abuse or neglect, as compared to 30.4 percent of the control youth. Children with any CPS history were three times as likely to end their own lives than children without such a history. In a second study, they compared suicide victims with CPS involvement to a matched group of living adolescents with CPS involvement to determine if the nature of the allegation or the child welfare response affected suicide risk. In that study, they found that teens with one or more substantiated allegations were no more likely to die of suicide than teens with allegations that were not substantiated. Moreover, they found no difference in suicide risk between teens who were placed in foster care and those who were never removed from home. They did find increased odds of suicide among teens with more recent CPS reports, allegations of physical abuse, and allegations of sexual abuse.

As I stated in the top of this column, I have observed that many victims of homicide cases reviewed by the District of Columbia’s Child Fatality Review Committee had a history of CPS reports. Their families had long histories of calls to CPS alleging both abuse and neglect, with school absenteeism being one of the most frequent allegations. Eventually, these young people became involved in violent and illegal activities, ultimately leading to their deaths. There is some relevant evidence from an older study of Washington State children born between 1973 and 1986 who were reported to the state child abuse registry. Matching each reported child to three other children of the same sex, county of birth, and year of birth, the researchers found that children reported to the registry were almost 20 times more likely than the comparison population to die from homicide. These researchers were not able to to control for other variables that might affect homicide risk, including poverty and maternal education, so the differences may be exaggerated but are likely real.

The studies reviewed here show that children who are reported as possible victims of abuse and neglect are at risk for more than “just” further abuse and neglect, but for other bad outcomes, including a sudden infant death and for deaths due to injuries (intentional or unintentional), medical causes, suicide, and homicide. While different factors may come into play for different causes and manners of death, maltreatment allegations generally suggest parents who, even if not actually abusive or neglectful, are not well equipped to protect and nurture their children. As Putnam-Hornstein puts it in her article about injury deaths, these data confirm that “children reported for maltreatment have a truly distinctive risk profile defined by much more than just birth into poverty.”

The research described above suggests that youths who previously reported for abuse or neglect are more likely to die due to their own self-harming behaviors, not just directly through acts of commission or omission by their parents. This is not surprising, as a large body of research links child maltreatment and wide variety of adverse outcomes, including, diminished cognitive and executive function, poor mental and emotional health, attachment and social difficulties, post-traumatic stress, juvenile delinquency, and substance abuse. In a recent commentary, Dee Wilson describes specific pathways by which childhood abuse and neglect lead to early-onset mental health conditions, which in turn result in higher rates of suicide, substance abuse and lethal violence in adolescence and young adulthood.

The growing body of research linking child abuse reports with mortality from causes other than child maltreatment itself has important implications for policy. More intensive supports should be put in place for all children remaining at home after a CPS report, especially infants and young children, who are most vulnerable and whose development is most affected by maltreatment. Such intensive approaches could include supportive housing, residential drug treatment programs where children can stay with their mothers, and high-quality early care and education programs. Older children who are the subject of a report should receive a mental health assessment and access to activities and services that provide them with nurturing relationships and opportunities to develop talents and skills, as Dee Wilson describes in his commentary.

But while one can argue for more intensive services for children with substantiated allegations, the idea of mandating services when allegations are not substantiated is a non-starter at a time when the conversation is about restricting the role of CPS, not expanding it. But the research described above also lends support to the growing chorus of voices that is calling for putting more resources into programs that prevent the occurrence of child abuse and neglect, rather than responding to its occurrence. There is a growing interest in “targeted universal prevention programs,” like Hello Baby in Allegheny County Pennsylvania and Family Connects in North Carolina and Oregon, which reach out to all families but provide a more intensive intervention to the families of children who are most at risk of being abused or neglected. Family Connects has already shown some promising results, reducing CPS referrals and emergency room visits among infants receiving the intervention.

It is important to note that mortality is not the only outcome that matters. Because the definition of death is unambiguous, and death data are collected everywhere, death rates are a good way to calculate risk differentials between groups. But for every child who dies as a direct or indirect consequence of abuse or neglect, there are many more who are seriously disabled or injured or suffering from the kinds of adverse outcomes mentioned above, including poor mental and emotional health, juvenile delinquency, and substance abuse. We need a stronger response to reports of child maltreatment, whether or not they are substantiated or the child is placed in foster care. And we must intervene as early as possible to protect high-risk children, rather than waiting for them to be the subject of a child maltreatment report.

*It should be noted that evidence cited by Putnam-Hornstein shows that death certificates “severely” undercount the number of deaths due to child maltreatment and inflicted injuries, and it is likely that over half of fatalities due to maltreatment may be incorrectly classified as due to accidents, natural causes, or undetermined.

**Ultimately about half of these deaths are classified as caused by sudden infant death syndrome (SIDS), a term which connotes a death that remains unexplained following an in-depth investigation.

***Emily Putnam-Hornstein and colleagues found that in California, 82 percent of infants remained at home following their first CPS report. Of these infants remaining at home, only one in ten of their parents received services through an open case, and 60.7 percent were re-reported within five years. Those who did not receive services through an in-home case may have received community-based services but that information is not available.

Lethal reunifications: two children dead in New York and Florida

Their names were Rashid Bryant and Julissia Battles). She was seven years old and he had lived for only 22 months. He lived in Opa-Locka, Florida, and she lived in the Bronx. They were both taken into state care at birth. Julissia had a life of safety and love with her grandmother, occasionally punctuated by disturbing visits with her mother, until the age of six, when she was dropped off for a visit that ended in her death. Rashid knew 14 months of safety and care starting at birth, before the months of torture began. An inexplicable drive to reunify families, regardless of the lack of change in the parent’ ability to care for their children, is behind both of these tragic stories.

The 694 days of Rashid Bryant

By the time Rashid Bryant was born, on December 13, 2018, his parents were already known to the Florida Department of Children and Families, according to Carol Miller of the Miami Herald, whose articles from May 10 and July 8 are the basis of this account. Rashid’s parents, Jabora Deris and Christopher Bryant of Opa-Locka, had first come to the attention of the Florida Department of Children and Families (DCF) in 2013 and were reported at least 16 times to DCF. The allegations included parental drug abuse, physical injury, domestic violence, and inadequate supervision of their many children. The reports alleged that Deris smoked marijuana with her older children, that most of her children did not to school, that her home had no running water and that the children were hungry and losing weight. An allegation that Bryant had thrown one of his children into a car when escaping from police finally resulted in court-ordered in-home supervision of this family by DCF. When Deris and her newest child tested positive for marijuana, all of the children were removed but were soon returned to the family in August 2018.

By that time, Deris and Bryant had eight children including two younger than two and a hotline report said that the couple were leaving a 15-year-old in charge of several younger siblings, including a two-year-old who was seen outside naked. In October and November 2018, DCF received seven new reports, including drug abuse, inadequate supervision and “environmental hazards.” The couple’s children were taken into custody around Nov. 22, 2018 and were placed with relatives and foster parents. Less than a month later, their ninth child, Rashid, was born and was immediately taken into state care.

The 14 months from his birth in December 13, 2018 until his return “home” on February 2 may have been the only time that Rashid received the love and care he deserved. But the system had reunification on its mind. By August 2019 the parents were given unsupervised visitation, which was revoked after they suddenly moved without notifying the court, but was restarted again in January 2020. That same month, a supervisor with a private case management agency handling the case for the state of Florida stated that conditions for the children’s return had been met. But records reviewed by the Herald show that DCF did not agree, stating that “This determination was not supported, given that the reason for removal had not been remedied.”

On February 28, 2020 14-month-old Rashid and three brothers were returned to their mother by the court, despite the fact that DCF had asked the judge to return the children gradually, starting with one older child. According to agency records reviewed by the Herald, the children were sent home without supportive services to assist the mother with her four young children. As if that were not enough, the judge also saw fit to give “liberal, unsupervised visitation” to Deris with her other five children.

About a month later, Deris’ tenth child was born, to the “complete surprise” of caseworkers, who reported that she had denied in court that she was pregnant. Three weeks after the birth of her tenth child, the judge saw fit to return her remaining four children, leaving the new mother with the custody of ten children including five that were younger than five years old. Oversight of Rashid and the three brothers sent home with him ended in August of 2020, and all monitoring of the family end by October of that year at the judge’s order.

We don’t know when Rashid’s suffering began. We do know that he injured his leg around June 2020, but his mother waited two days to seek medical help, leaving the hospital with Rashid after refusing to allow an X-Rray. It appears Rashid spent the last five months of his life mostly in bed. At a June 22 pool party at the house of an aunt, Rashid and his father never left the car, according to the aunt. When she tried to pick him up from his car seat, she reported that Rashid began to cry. She never saw him again. Rashid’s maternal grandfather, who frequently visited the home, reported not seeing Rashid for about two months. (Why these family members did nothing in view of these red flags is another question.) Rashid’s brother, then 16, told police that he noticed something wrong with Rashid’s leg two months before he died because the little boy cringed and cried when it was touched. The teen described another incident where Rashid vomited all over his bed and then lay still and shaking with his legs up in the air. The teen could not remember if his mother sought medical attention after either of these incidents. After that incident, reported the teen, Rashid could not move his right arm. Four days before he died, a sister saw Rashid vomit after eating. She reported that the right side of his body appeared limp and his eyes were moving in different directions.

On November 6, 2020, two weeks after DCF closed the case on the family by court order, Rashid was dead. He had lived 694 days. The arrest warrant said that Rashid had suffered two seizures in the month before his death but his mother had never bothered to take him to a pediatrician. On the morning of Rashid fatal seizure, Deris called her sister saying he was unresponsive and “foaming from his nose and mouth.” Her sister told her to take him to the hospital. Deris did call for an ambulance–83 minutes later.

The Medical Examiner reported that in the months before his death Rashid had suffered two cracks to his skull — one healing, the other fresh. He also had a healing rib fracture and a recently broken leg. The cause of Rashid’s death was “complications of acute and chronic blunt force injuries.” The contributory cause was “parental neglect.” Deris and Bryant were arrested within a week of Rashid’s death and are awaiting trial on manslaughter and aggravated child abuse.

But somehow, DCF has not decided whether Rashid died of abuse or neglect–so they refuse to release the case files that they are required to release by law when a child dies of abuse or neglect by a caregiver . That requirement is in a state law that was passed requiring such revelations in the wake of the Miami Herald’s publication in 2014 of, Innocents Lost, detailing the deaths of about 500 children after DCF involvement. The Herald has filed suit against DCF and has been joined in the suit by a dozen media companies and advocacy groups.

Julissia Batties: from home to hell

On August 10, police and medics were summoned to the 10th-floor Bronx apartment where Julissia Batties lived with her mother, Navasia Jones, her 17-year-old half-brother, and one-year-old brother, as reported by the New York Times and many other media. Her mother gave inconsistent accounts to the police but it appears that after finding Julissia “vomiting and urinating on herself” at 5am, she waited three hours, and went to the store and the bank, before she called for emergency services shortly after 8:00 AM. Julissia was pronounced dead shortly after 9am. Julissia’s 17-year-old half-brother later told police that he had punched Julissia in the face eight times that morning because he thought she had taken some snacks. But those were not the injuries that killed Julissia. The medical examiner found injuries all over her body. On Friday her death was ruled a homicide caused by blunt force trauma to the abdomen. There have been no arrests so far.

Records show that Julissia’s mother had a long history of involvement with ACS and police. In 2013, the year before Julissia was born, Jones lost custody of her four older children. When Julissia was born in April 2014, she was immediately removed from her mother’s custody and placed with her paternal grandmother, Yolanda Davis. A family court judge initially granted Jones’ motion for custody of the new baby, but ACS appealed, and the appeals court stayed enforcement of the custody transfer pending their decision on the appeal. In 2015, the appellate court agreed with ACS, stating that “the mother had failed to address or acknowledge the circumstances that led to the removal of the child.” The court stated that although the mother complied with the services required by her case plan, “she was still prone to unpredictable emotional outbursts, even during visits with the children, and she was easily provoked and agitated. Indeed, the case planner testified that she had not seen any improvement in the mother’s conduct even after the mother participated in the mandated services.” The court concluded that “until the mother is able to successfully address and acknowledge the circumstances that led to the removal of the other children, we cannot agree that the return of the subject child to the mother’s custody, even with the safeguards imposed by the Family Court, would not present an imminent risk to the subject child’s life or health.” Wise words indeed. Julissia remained with her grandmother, Yolanda Davis, until being returned to her mother on March 2020, when she was almost six years old.

It appears that the COVID-19 pandemic had some role in the transformation of a weekend visit into a custody change that resulted in a child’s death. Davis told a local TV station, PIX-11, that a caseworker told her the visit had been extended due to the pandemic, and the extension never ended. Sources told the New York Post that the mother was officially granted custody in June 2021, though the circumstances are unclear. The decision to return Julissia to her mother appears to have been made at the recommendation of SCO Family of Services, a foster care nonprofit that was managing the case for ACS. After the first month or so, Julissia was not even granted visits with her grandmother, which would have been a much-needed respite and could have saved her, had the grandmother seen or reported injuries or other concerns. The New York Daily News reported that in May 2020, Davis was denied visits with Julissia because she had allowed the child to see her own father, Davis’ son. The motivation behind denying a child visits with the only parent she had known for six years are truly hard to understand.

There were many indications that all was not well in Navasia Jones’ household in the months before Julissia’s death. A neighbor told the Times that “there was always a lot of commotion, always yelling, always screaming” in the apartment. As recently as August 6, his girlfriend had called authorities to report that Julissia had a black eye. The neighbor told the Times that he had spoken to police and ACS staff about the family several times. Police reported to the Times that officers had filed at least nine domestic abuse reports on the family and responded to five reports of a person needing medical attention.

The decision to send Julissia home with her mother after six years apart is particularly strange because the Adoption and Safe Families Act of 1997 (ASFA) requires that a state must file for termination of parental rights after a child has spent 15 of the last 22 months in foster care. The requirement was written into law because children were languishing for years in foster care without a plan for permanency. It was recognized that children need permanency and stability and it is hard to understand why ACS and its contractor would want to move a thriving child from the grandmother who had parented her from birth to age six.

Much needs to be clarified to understand how this child was returned to the family that would kill her. ACS and SCO have declined to comment on the case, citing confidentiality. ACS did issue a statement that “its top priority is protecting the safety and wellbeing of all children in New York City.” But it is clear that other priorities took a front seat in Julissia’s case.

Factors Contributing to lethal reunifications

What explains the adamant determination on the part of some agency personnel and judges to return children to biological parents who have shown no sign of changing the behaviors that caused the system to remove them in the first place? To some extent, it reflects an ideology–one that is becoming increasingly dominant in the nation– that is committed to family preservation and family reunification at almost any cost. Child welfare is known for pendulum shifts in the emphasis on child safety as opposed to family preservation and reunification, but the latter is clearly in the ascendant right now. Extreme deference to this ideology can blind agency employees and judges to what is right in front of their faces: the failure of a parent to change the behaviors and attitudes that resulted in the initial removal of a child.

The obsession with family reunification at all costs can be encoded into social worker evaluations. In Tennessee, a recent survey of social workers suggests that they are being judged by whether they close cases in a timely manner, regardless of child safety. As one worker put it, “Children are returned home or exiting custody to relatives quickly to lower the number of cases without regard to whether the children will be truly safe and the parents ready to parent again.”

The current emphasis on family preservation and reunification is often justified as a way to ratify racial imbalances in child welfare involvement. A growing movement urges drastically scaling down or eliminating current child welfare services on the grounds that the overrepresentation of Black children in care compared to White children is a consequence of racism. Supporters call for elimination of the “disproportionality” between removals of Black and White children from their parents, while disregarding higher rates of poverty and historical trauma that result in more child maltreatment among Black families. To say that Black children need to stay with, or return to, abusive parents in order to equalize the percentages of White and Black children in care is to devalue children and reduce them to nothing more than their race, a strange position for an anti-racist movement to take. As described in a document entitled How we endUP: A Future without Family Policing, parts of this movement are fighting for repeal of ASFA, which would eliminate timelines and encourage jurisdictions to reunify children with their birth parents years after they had established parental bonds with other caregivers, such as grandmothers or former foster parents.

Racial considerations are not the only factor driving systems to support reunification at all calls. Lethal reunifications occur in states like Maine, where 88 percent of the children in foster care are White. Maine’s Office of the Child Advocate recently reported that the state’s child welfare system continues to struggle to make good decisions around two critical points–the initial safety assessment of a child and the finding that it is safe to reunify the child with her parents. In its review of seven cases closed through reunification, the OCA found multiple incidents where children were sent home with insufficient evidence that they would be safe. In one case, the parents had not been visited for a year-and-a-half despite the fact that home conditions were a reason for the original removal. In another case, providers were not contacted or given the information they needed to treat the issues that had resulted in the removal. In another case, the parent “failed to understand or agree to the reasons the children entered custody, but this was not considered significant.” In yet another case, the trial home placement started too soon and the parent never completed required substance abuse treatment. The child was sent home two months after the parent had a positive toxicology screen.

In responding to the criticisms of Maine’s OCA, OCFS admitted that “staff have been challenged with the current workload based on the increase in the number of calls, assessments, and children in care.” It is clear that insufficient of resources lead to excessive caseloads around the country, endangering children. In Tennesseee, for example, while caseloads are not allowed to exceed an average of 20 (a very high number in the experience of this former social worker) data obtained by the Tennessee Lookout, indicated that 30% of caseworkers had caseloads of more than 20, and that many had 30, 40 or even 50 cases. Insufficient funding often means low pay and a difficulty in attracting people with the education and critical thinking skills required for the job. High caseloads and poor pay lead to high turnover, resulting in a loss of institutional memory about specific cases that may drag on for years, such as those discussed here. In turn, high turnover leads to high caseloads as social workers have to pick up cases from those who leave. Such factors may or may not have contributed to the deaths of Rashid and Julissia; they have certainly contributed to other child deaths around the country. Most taxpayers don’t want to think about these systems or fund them; it is easy to avoid reading about the consequences when they occur.

And cost considerations drive reunifications in another way as well. Reunifications save money for cash-strapped child welfare systems. Once a child is sent home and the case is closed, the jurisdiction incurs no more expenditures for foster care. If the child is instead placed in guardianship or adoption with a relative or foster parent, the jurisdiction may end up paying a monthly stipend to the caregiver until the child turns 21. Of course, many relatives who step up to the plate like Julissia’s grandmother are not paid, due to the same budget concerns. giving rise to the current outcry and debate around hidden foster care.

Family court problems contribute to lethal reunifications as well. Rashid’s death appears to be primarily due to a judge who insisted against agency protests on the return of nine children in the space of two months, during which the mother also gave birth to a tenth child. The information available suggests that Florida DCF staff proposed a much slower reunification process. We don’t know what influenced the judge’s decision, but we do know that family courts are overwhelmed and in crisis, resulting too often in the deaths of children in both custody and child protection cases. These courts are inundated with cases, judges often lack the training they need, delays are all too frequent and were worsened by the pandemic. Judges rarely see consequences for decisions that lead to an innocent child’s death, and I have never heard of a judge being removed for the death of a child that was placed in a lethal home against all the evidence. The judge who sent Rashid to his death probably continues to endanger other children daily. This judge must be named, punished, removed and never again allowed to send children to their deaths.

The degree to which the pandemic contributed to Julissia’s and Rashid’s deaths is impossible to estimate. Julissia’s irregular reunification was justified to her grandmother on the grounds of the pandemic. Both Rashid and Julissia should have been visited regularly at least monthly once they were placed with their original families, depending on state regulations. Visits to Rashid should have occurred until the judge terminated them in August, well after the leg injury that left him bedridden, and he should have also been seen in the visits to his siblings that terminated in October. Even if the case managers were visiting (virtually or in real life) only the four children whose cases had not been closed, they should have had the curiosity to ask about little Rashid. For Julissia, there should have been visits throughout her 16 months in hell. Were these visits conducted at all, virtually, or in person? What information was gathered at these visits? This information that must be revealed.

This is not my first post about a lethal reunification in Florida. In January 2019, I wrote about Jordan Belliveau, who was murdered by his mother eight months after being reunified with her, even while a agency in Pinellas County was still monitoring the family. A caseworker for the agency and later resigned told News Channel Eight 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.” It does not appear that the state learned from Jordan’s death.

I could have written about other lethal reunifications in New Mexico, Ohio, and elsewhere. But I often resist writing about the deaths of a specific child or children known to the system that was supposed to protect them. There are so many reports of such cases, and they are only the tip of the iceberg. Why choose one and not another? I cried for Rashid but I did not write about him until I read about Julissia. Then I knew that I had to write about both, because they represent so many others whose names we will never know. Some of these children’s names may never be known to the general public because there was no outraged grandmother to speak out, no determination of the cause of death, no charges by police, or no alert reporter to reads a crime report and ask questions. But others are unknown because they are suffering in silence and darkness. Because death is not the worst thing that can happen to a child whose life is one of unremitting pain.

Congress must take steps to ensure availability of therapeutic residential care

Around the country, there is a lack of appropriate placements for the most traumatized and hard-to-place foster youth–a shortage that has reached crisis proportions in many states, including Texas, Washington, and Illinois. These children are spending days, weeks or even months in offices and hotels or languishing in inpatient psychiatric units where there is no semblance of normal life. These young people have been damaged by our negligence and now deteriorate daily without the treatment they need and deserve.  Unfortunately, recent federal legislation is likely to worsen the crisis by withdrawing federal funding for children placed in some of the best therapeutic residential settings.

An unforeseen consequence of the much-heralded Family First Prevention Services Act (FFPSA) of 2018 may exacerbate the shortage of therapeutic placements in many states. FFPSA had twin goals: to shift resources from foster care to family preservation, and within foster care, to shift resources from congregate care settings (anything other than a foster home) to foster homes.  However, the framers of the act did recognize that some children need more intensive care than a foster home can provide, and for them FFPSA defined a new category of placement called a Quality Residential Treatment Program (QRTP). QRTP’s must have a trauma-informed treatment model, involve families, be accredited by an approved organization, and provide at least six months of aftercare. A child can be placed in a QRTP only if a qualified professional determines that the child’s needs cannot be met in a foster home, and the placement must be approved by a judge. Other than specialized settings for teen parents, children who have been sex-trafficked, and supervised independent living settings for foster youths aged 18 and older, QRTP’s are the only non-family placements that can be funded under FFPSA.

Unfortunately, in creating QRTP’s, Congress unintentionally created a conflict with a provision of the Medicaid law that may sharply limit the number of children who can benefit from this new category of therapeutic placement. The problem is that federal Title IV-E foster care funding pays for room and board, but not the costs of medical, dental, behavioral and mental health care for children in foster care. States generally extend Medicaid to all foster youths, allowing the program to cover those costs. But the “IMD exclusion,” a provision included in the original 1965 legislation creating the Medicaid program, prohibits federal Medicaid dollars to be used to pay for any care or services to anyone under 65 who is a patient in an “institution for mental diseases” except for in-patient psychiatric services provided to children under 21. An Institution for Mental Diseases (IMD), as defined by Section 1905(i) of the Social Security Act, is a “hospital, nursing facility, or other institution of more than 16 beds, that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases including medical attention, nursing care, and related services.” (For more on the IMD exclusion, see Fact Sheets by the Legal Action Center and the Training and Advocacy Support Center.)

This “IMD exclusion” reflects the sentiment at the time of Medicaid’s creation in 1965 against the large public institutions where the mentally ill were warehoused at the time. The provision was a driving force behind the transformation of public mental health care from an inpatient to an outpatient model, often known as “deinstitutionalization.” But now, many high-quality therapeutic residential programs have more than 16 beds distributed between separate units or cottages on one campus, and in many states these are exactly the facilities that qualify to be licensed as QRTP’s. Without a legislative fix, QRTP’s of over 16 beds may be considered IMD’s and children placed there will not be eligible for federal Medicaid funding for any of their care, including medical, dental, behavioral and mental health services, whether delivered inside or outside the residential program.  States will then have to pay the entire costs of all care for foster children placed in these settings.

Decisions as to whether a facility is an IMD are made on a facility by facility basis based on federal law, regulations and guidance. But the definitions of IMD’s and QRTP’s, as well as the guidance provided by the Center for Medicare and Medicaid Services (CMS) in the State Medicaid Manual section 4390 on how to determine if a facility is an IMD, suggests that QRTP’s are likely to be considered IMD’s. When California wrote to CMS arguing that its “short-term residential treatment programs” (which they were hoping to designate as QRTP’s) should not be considered IMD’s, CMS responded that it was  “unable to provide California the blanket assurance requested that STRTPs are not IMDs.” While a state Medicaid agency can elect not to consider a facility to be an IMD, CMS can essentially overrule these decisions by requiring a state to review the status of these facilities based on its guidance.

Even before the current crisis over QRTP’s, the IMD exclusion had resulted in the loss of Medicaid coverage for foster children living in therapeutic residential facilities in at least two states. For years, Minnesota was using residential programs that would have met the definition of QRTP’s as an alternative to, or a step down from psychiatric hospitalization. But, as reported by the Star-Tribune, after a review ordered by federal officials, 11 treatment centers with a total of 580 beds lost about $4.5 million in federal Medicaid funding–a cost that had to be picked up by counties. Utah went through an “IMD sweep” in 2010, which resulted in its replacing most of its residential treatment centers serving children in foster care with facilities having less than 16 beds.

The Association of Children’s Residential and Community Services (ACRC) has been contacting states to find out how they are dealing with the IMD/QRTP issue. They found that states fall into several groups:

  • Some states are not concerned about the IMD problem because they are not planning to implement QRTP’s. Some already rely on facilities that are exempt from the IMD exclusion (Psychiatric Residential Treatment Facilities or facilities with fewer than 16 beds) or will use state funds to pay for children placed in residential care.
  • Some states are proceeding on the hope that their QRTP’s will not be declared to be IMD’s even if they have more than 16 beds. This includes six states where all of the programs that have been approved as QRTP’s have more than 16 beds.
  • Some states are discussing whether to limit the size of their QRTP’s but have not yet decided whether to do so. In many of these states, the majority of the potential QRTP’s have more than 16 beds–or the majority of the QRTP beds are in facilities with more than 16 beds.
  • Some states are trying workarounds to avoid the IMD designation. Two states have decided to separately license cottages that are on the same campus, which enables them to use the bed count for the individual cottage rather than the entire facility, thus potentially avoiding an IMD designation. Another state has classified all residential facilities as serving youth at risk of sex trafficking, one of the allowable uses of congregate care. Whether these workarounds will be accepted by CMS or the Administration for Children and Families (in the case of the latter state) remains to be seen.

Colorado has decided to limit its QRTP’s to 16 beds or less, and a FAQ document from the Colorado Department of Human Services provides an interesting case study in how one state has tried to address the QRTP issue. Hoping to find a way to license its existing residential facilities as QRTP’s, Colorado’s Medicaid and child welfare agencies worked together to analyze the federal IMD criteria and its application to QRTP’s. These agencies “explored every possible argument that would allow Colorado to confidently move forward with QRTPs without risking an IMD designation.” But ultimately they agreed that the only way to avoid the designation was to reimburse only QRTP’s with 16 beds or less. Currently almost all of Colorado’s residential facilities that could have been designated as QRTP’s have more than 16 beds. Instead of creating smaller programs, the state is planning to serve fewer children in residential facilities. The question is whether they will have appropriate options for those children who have been determined to need therapeutic residential care. There is considerable concern that they will not.

Without legislation exempting QRTP’s from the IMD exclusion, states will be faced with the choice of paying the full costs of care for children in therapeutic residential care or scrapping their current facilities and starting from scratch. Vulnerable children may end up in greater numbers in hotels, offices, and hospital beds or bouncing between foster homes that are not equipped to care for them.

According to ACRC, there is no evidence that residential programs with 16 beds or less produce better outcomes than programs with a higher capacity. As a matter of fact, there are reasons to think that a larger campus would be able to offer more services (like therapeutic riding or other specialized therapeutic modalities) that would not be possible to offer on a smaller campus. It is also possible that the IMD/QRTP conflict might result in more foster youth receiving a higher level of care through Psychiatric Residential Treatment Facilities (PRTF’s). These are facilities that deliver an inpatient level of care outside a hospital and they are not considered IMD’s. They are exempted from the IMD exclusion and Medicaid can pay all costs for these facilities, including room and board. So FFPSA might have the perverse result of having more children in a more restrictive, less homelike setting.

On July 23, ACRC sent a letter to the House and Senate leadership asking them to pass legislation by October 1, 2021, exempting Qualified Residential Treatment Programs (QRTPs) from the Institution for Mental Diseases (IMD) exclusion. In the letter, ACRC argues that that “without the exemption for QRTPs, thousands of children in foster care who are vulnerable will be pushed into more restrictive placements, non-therapeutic shelters, unlicensed or unstable settings, or they will bounce from placement to placement without addressing their true needs – which is opposite the intent of the FFPSA.” So far, about 540 organizations have signed onto the letter, and more signatures are coming in daily.

Many groups concerned with the mentally ill have long been advocating for an end to the IMD exclusion altogether, arguing that it is behind the nationwide shortage of psychiatric beds. Rep. Grace Napolitano, Democrat from California, has introduced a bill (H.R. 2611) to eliminate it. CMS and ACF during the Trump Administration also proposed eliminating the exclusion specifically for QRTP’s in its budget for 2021. There are strong arguments for eliminating this exclusion, but the urgency of the QRTP problem requires immediate action, rather than waiting to change a policy that has lasted 50 years.

Unfortunately, there is opposition to lifting the IMD restriction among powerful and wealthy advocates whose ideology appears to blind them to the reality facing our most vulnerable children. William Bell of Casey Family Programs, the nation’s most influential child welfare funder and a leading force behind the Family First Act, urged Congress in testimony to “stand firm” in resisting modifications to the IMD rule. In the real world, where staff work face-to-face with wounded children, the picture looks very different.

The IMD exclusion for QRTP’s threatens to eliminate one of the most promising avenues to address the desperate shortage of therapeutic residential placements for foster youth that already exists in many states. On the state level, legislators must open their hearts and their minds to the pleas of those who are on the front lines caring for our most troubled children. They must increase funding for the therapeutic residential programs the most vulnerable foster youth so desperately need. Congress must help by exempting QRTP’s from the IMD exclusion, enabling the federal government to ensure access to therapeutic residential care–and ensure that the legislation they authored and passed can actually be implemented by states. 

The power of wishful thinking: the case of “race-blind removals” in child welfare

Wishful thinking is a very human pattern of thought that can even be functional at times. Thanks to wishful thinking, a placebo can actually cure an illness. Great ideas can gain support even if we don’t know they will succeed. But when wishful thinking is used to distort available data to support a given theory or policy, it becomes a problem. Such is the case with “race-blind” removals. The story of how this simple concept became viewed as a solution to the disproportional share of Black children in foster care, in relationship to their share of the general population, is a case study in the misuse of data to promote a particular viewpoint.

As reported in The Imprint and the Los Angeles Times, the Los Angeles Board of Supervisors has voted to support a project testing “race-blind removal” or “blind removal” of children into foster care. Blind removal was pioneered in Nassau County, New York in 2011 and “discovered” (as they describe it) by a team of researchers headed by Jessica Pryce of Florida State University, who were investigating the practices of two counties that were credited by New York’s Office of Child and Family Services (OCFS) with reducing racial disparities. Before the inception of blind removal, county investigative workers were presenting cases to a committee made up of supervisors, managers, and an attorney before a child could be removed and placed in foster care. Under blind removals, the members of this committee were no longer given information that might give a clue as to the race of the child and family. According to an email from a county official, the information that is withheld includes race, ethnicity, first and last names, addresses, the location of the reporter if that reflects the community where the child lives, and any other information (such as socioeconomic status or receipt of government benefits) that is not deemed to affect safety or risk.

Nassau County adopted the blind removal policy as a way to address its high rate of racial disproportionality in foster care, with Black children being much more likely to be removed and placed in foster care than White children. According to data provided by New York State, Black children were over 14 times more likely than White children to be placed in foster care in Nassau County in 2010. The blind removals policy is based on the belief that implicit racial biases affect the decision to remove a child and that removing this information from the process will remove the bias.

Unless there is strong evidence in support of such a program, one might worry about a practice that relies on people who know so little about a family. One might wonder if such a meeting is the best use of time for overburdened social workers and supervisors. Perhaps it would be better to make sure investigators have enough time to interview everyone who might be able to give them information about the family under consideration rather than burden them with another meeting. And what about emergency situations, where a child cannot be safely left in the home? An article in Children’s Bureau Express documents concerns from social workers who fear that blind removals would make it harder to do their jobs for these and other reasons. Another concern is whether race-blind removals might provide more of an opportunity for investigative workers to express any racial bias they have, since they control the information that is presented to the committee.

But if blind removal truly does cause a significant reduction in racial disparities, perhaps it is worth implementing despite the costs. And if one can believe a TED Talk by Jessica Pryce that has been viewed 1.3 million times, the practice has been spectacularly successful. According to Pryce, “In 2011 57 percent of the kids going into foster care were black, but after five years of blind removals, that is down to 21 percent.”  (At which point the audience broke into applause). Such a simple idea and such a huge impact! Casey Family Programs, the nation’s most influential child welfare funder, highlighted this program in an article on its website, stating without providing numbers that “within five years, the number of Black children removed from their families was reduced considerably, representing the most significant decrease in racial disproportionality within the county system ever.” New York State was so excited that it required all counties to develop a blind removal process effective October 14, 2020, offering a strikingly vague and yet broad description of what information must be kept from the committee: “all demographic and identifiable information (race, gender, language needs, zip code, etc. sic)).” Several other jurisdictions have expressed interest, including Los Angeles County, which is proceeding with its pilot.

Such a great result should be documented and the data made available to the public and researchers, preferably online, so it is surprising that Pryce was unwilling or unable to provide the source of the percentages at the heart of her popular talk. Instead, she referred me to the data team at Nassau County, who did not respond, nor did did the Commissioner’s Office. Nor was Casey Family Programs able or willing to provide the document referenced in their footnote to their statement about the program’s stellar results. Happily, I was able to obtain data from the New York State Office of Child and Family Services showing the percentage of children removed into foster care who were Black every year from 2009 to 2020. Those percentages are shown in Chart One.

Chart One

Source: Data provided by New York State Office of Children and Family Services

The first fact that emerges from the New York data is that Jessica Pryce’s percentages were not accurate. The 57 percent (56.7 percent) that she cites as the percentage of Black children removed in 2011 was actually the percentage of Black children removed in 2010. As for the 2016 data (the endpoint of the five-year-period cited by Pryce), 37.1 percent of the children removed in 2016 were Black, rather than 21 percent cited by Pryce–rather a large difference. There was a sharp increase in the Black share of children removed, from 45.2 percent in 2009 to 56.7 percent in 2010, the year before the program was implemented. With the implementation of blind removals, the percentage of children removed who were Black declined for two years to 45.5 percent in 2012, then rose for two years to 57.4 percent in 2014, fell to its all-time low of 37.1 percent in 2016, then rose to 49.7 percent in 2018, dipping slightly back to 45.1 percent in 2019, then popping back up to 49.5 percent in 2020–higher than it was in 2009 before the program was implemented. With such large fluctuations from year to year, as well as changes in direction, it is hard to imagine drawing any conclusions from the difference between any particular two years.

It is also important to note that the total number of children placed in foster care in Nassau County dropped precipitously from 429 in 2009 to 91 in 2020, as shown in Chart 2. This drastic drop in removals of Black and other children means that there was a lot more going on than the effort to make removals race-blind; cutting removals by three-quarters requires major changes in policy and/or practice. So it is hard to attribute any change with confidence to the race-blind policy. It also means that the numbers of children removed became smaller and smaller, resulting in a larger margin of error.

Chart Two

Source: Data provided by New York State Office of Children and Family Services

OCFS also provided data on Nassau County’s “Black Admissions Disparity Rate.” This rate, which New York State collects for all its counties, is defined as the “ratio of unique Black children admitted to foster care per 1000 Black children under 18 relative to comparable rate for White children.” According to OCFS, the disparity rate for foster care admissions went down from 14.30 (meaning Black children were 14 times more likely to be removed than White children) in 2010 to 12.60 in 2020. But it fluctuated to a surprising degree (between 24.4 and 6.16 between 2011 and 2019) that is not consistent with the percentages shown above and casts doubt on the correctness of the ratios provided. Assuming the 2020 ratio is correct, Nassau County currently has the highest disparity in foster care placement for Black children in the entire state. According to its ranking of counties based on this ratio, Nassau County was at the bottom in 2020 of all counties listed* with its disparity rate of 12.6, compared with 3.34 for the state as a whole. Hardly a role model for New York or the nation! Now this doesn’t mean we should blame Nassau County’s child welfare system for its abysmal disparity ranking. Other factors are probably behind that large disparity compared to other counties, such as the socioeconomic status of the Black and White populations in a given county. Which raises the question, how much can we expect blind removals to change racial disparities in foster care?

New York State recognizes the weaknesses of its data but focuses on the positive overall trend between 2010 and 2020. As John Craig of OCFS put it in his email to Child Welfare Monitor, “While Nassau County has seen fluctuations in the rate of Black children entering care over the past 10 years, overall, the trend has been very positive. OCFS commends Nassau County for recognizing the disproportionality of children of color in the child welfare system and implementing this innovative approach.” 

Despite OCFS’ valiant attempt to portray Nassau County’s data as “very positive,” the data do not provide a strong justification for expanding the program. While the Black percentage of children taken into foster care in 2020 was 49 percent compared to 57 percent in 2019, there were changes in both directions in the years between those two dates, and the 49 percent was actually higher than the Black percentage in 2009, two years before program implementation. There is reason to wonder whether New York, Los Angeles and others were really concerned about what the data showed. Instead, they may have proceeded in part based on the inherent logic of the approach, which addresses racial disparities directly in a way that is appealing to those who seek a relatively simple solution. Most importantly, they wanted it to work, so they decided that it did, regardless of the highly equivocal findings.

It would be wonderful if we had easy solutions to racial disparities in child welfare, but evidence suggests that higher reporting, investigation and removal rates among Black children stem from their greater needs, rather than bias among social workers. LA County would be better off studying how to make CPS decisions more accurate rather than imposing a cumbersome and unproven hurdle on social workers trying to protect endangered children.

* Certain counties were excluded because of very small number of Black children or Black children taken into foster care.