Targeted Universalism in child maltreatment prevention: the promise and the challenge

Image: Family Connects Durham

A growing chorus of voices is calling for a shift of resources away from responding to child abuse and neglect toward preventing its occurrence. Interest is coalescing around a newer idea that would combine universal reach with a response that is targeted based on a family’s risk, sometimes called targeted universalism. Several jurisdictions are already implementing initiatives based on this approach. Governments interested in adopting such a system need to resolve a number of questions concerning the system’s entry point, goals, lead agency, program content, and how to attract and retain the families that are most at risk. But the idea of targeted universalism is worth pursuing as it combines the advantages of both approaches.

The new focus on prevention should not be confused with the changes made by the Family First “Prevention” Services Act of 2018, which allows funds under Title IV-E of the Social Security Act to be be diverted from foster care to services to help keep children with their families. Despite its name, Family First funds can be used only for services to families in which abuse or neglect has already occurred. Such services are generally considered treatment, not prevention, although public health specialists refer to them as “tertiary prevention,” which mean preventing the recurrence of a problem. But this is not the meaning of prevention to the layperson, and the placement of “prevention” in the title of the act continues to cause confusion.

Preventing a problem, if possible, is certainly preferable to addressing it after it appears. As child maltreatment prevention expert Deborah Daro states in an issue of The Future of Children devoted to universal approaches to promoting healthy development, doctors don’t send away patients with precancerous cells and tell them to come back when they have Stage 4 cancer. Yet, that is exactly what we do in child welfare. As Daro points out, “our public response lacks an adequate early assessment when people become parents, and we often offer the appropriate level of assistance only after a parent fails to meet expectations or a child is harmed.” For this reason, many child welfare thought leaders like Daro are calling for a new emphasis on preventing maltreatment before it occurs.

The consensus on prevention still leaves the question of how much to invest in universal approaches (known as primary prevention) as opposed to “secondary prevention” approaches that target families who are deemed to be at risk. Secondary prevention has a lot going for it. Targeting a program to those who need it most can be justified on grounds of efficiency. Why spend money reaching people who do not need help? But investing only in secondary prevention has drawbacks, as described by Kenneth Dodge and Benjamin Goodman in the Future of Children issue referenced above. Even the lowest-risk groups have some risk of child maltreatment. And because they are much larger than the high-risk groups, they may account for most cases of maltreatment. Moreover, interventions with targeted groups rarely reach a high proportion of that population, and thus cannot have a detectable impact on the problem overall. Finally, targeted programs are often stigmatized and not politically popular, leading to lower funding–and less participation by targeted groups.

Dodge and Goodman point out that a debate over universal vs. targeted approaches played out when public schooling was first discussed in the United States. Some advocates argued that middle and upper class families could pay for their children to be educated, and that confining public education to the poor would save taxpayers money. Of course the proponents of universalism won out. Even though affluent families continue to be able to buy a more expensive education through higher property taxes and access to private school, one can only imagine the sorry state of our public education system if at been confined to the poor.

As Dodge and Goodman point out, not all universal programs must provide the same services for everyone, and they cite pediatric care as analogy. All children are seen for well-child visits, during which pediatricians screen them for conditions that might warrant services from specialists, and refer them accordingly. Therefore, they argue that “the best strategy may be to embed targeted interventions in a universal strategy that reaches the entire population while offering intensive interventions for targeted subgroups.” This approach, which they call “targeted universalism,” involves screening all families at a single point in time, such as the birth of a child, identifying the family’s risks and needs, and connecting them with community resources for addressing those risks and needs.

This is the approach that they embedded in the Family Connects Program, starting with a home visit fro a nurse. Nurse home visiting is a popular platform for a universal program, and there is a lot of precedent for a universal nurse home visiting program. Universal nurse home visiting is used by many European countries, where it is part of a comprehensive maternal and child health system, and is also used in other parts of the world. Perhaps the best developed application of this approach in the United States is Family Connects, which Dodge and his team at Duke University initiated in Durham, North Carolina in 2008 as Durham Connects. The model is now being implemented in over two dozen communities around the country, and Oregon is rolling it out statewide. Family Connects aims to reach every family giving birth in a community, assess the parents to determine their risks and needs, and refer them to appropriate services. The program rests on three “pillars:” home visiting, community alignment and data and monitoring, as described by Dodge and Goodman.

The first pillar is home visiting by a trained public health nurse who visits the family in the hospital to welcome the baby and offer a free home visit when the baby is about three weeks old. During the home visit, the nurse uses a structured clinical interview to assess risk in 12 key domains that predict adverse outcomes among children. At the end of the interview, the nurse works with the family to develop a plan of action which may include follow-up visits, phone calls, or contact with external agencies. With parental consent, this plan is shared with the baby’s pediatrician and the mother’s primary care provider. Four weeks later, a program staff member calls the family to check on their progress and determine if the referrals were successful. If the family has not succeeded in making the connection, the program either helps the family try again or makes another referral.

The second pillar, called community alignment, is a compilation of community resources available to families at birth, including targeted home visiting programs, early care and education, and mental health. This directory is available in electronic for for nurses to use on their visits. The third pillar is an electronic data system that documents each family’s assessment, referrals, and connections with community agencies. These records, scrubbed of identifying information, are aggregated to provide information about each agency and on a community level to identify gaps between needs and services. To contain costs, Family Connects is limited to seven contacts (phone calls and visits) over the course of 12 weeks. Dodge and Goodman report that the cost of Family Connects ranges from $500 to $700 per family.

Family Connects has been evaluated with two randomized controlled trials (RCT’s) in Durham, NC and one field study in four rural counties in the state. Eighty percent of the intervention families in the first trial scheduled a visit and 86 percent completed it, for a total “completion rate” of 69 percent. In the second trial, the percentages were 77 percent scheduled and 84 percent completed for a total of 64 percent. The first and second RCT’s found 49 and 52 percent of families respectively to have moderate needs, 46 and 42 percent to have serious needs requiring referral to a community resource, and one percent with a crisis needing immediate intervention. Of the families referred to a community agency, 79 percent and 83 percent reported they had followed through and made the connection. In the first RCT, researchers found that intervention infants had 39 percent fewer referrals to Child Protective Services (CPS) than did the control infants by the age of 60 months, controlling for demographic risk factors, as well as a 33 percent decrease in emergency room use.

Nurse home visiting is not the only possible platform on which to base a targeted universal program, Other options for locating a universal service include pediatric practices. There are two different models based in pediatrician’s offices that have shown promise for preventing child maltreatment–SEEK and Healthy Steps. SEEK trains pediatric primary care providers (PCP’s) to use a questionnaire to assess for a specific set of risk factors. The PCP initially addresses identified risk factors and refers the parent to community resources, ideally with the help of a behavioral health professional. Healthy Steps, as described by Valado and coauthors in The Future of Children, functions as a targeted universal model with three tiers. All families receive screenings and access to a child development support line. Second-tier families receive short-term consultations, along with referrals, additional guidance and resources. Families classified in the highest-risk tier receive “a series of team-based well child visits incorporating a Healthy Steps specialist.”

Models based in pediatric practices have had some promising results. A study testing SEEK with a high-risk sample of patients from a pediatric primary clinic in Baltimore found a “striking” 31 percent reduction in CPS reports. The other SEEK study focused on a low-risk population and there were not enough cases of maltreatment to find impacts on abuse and neglect; however, the study found a lower rate of physical punishment and psychological maltreatment reported by participating mothers. A multisite evaluation of Healthy Steps, as described by Velado et al, showed similar effects, such as a 33 percent reduction in the use of severe physical discipline in the intervention group vs the comparison group when the child was 30-33 months of age. The philanthropic partnership Blue Meridian Partners has chosen Healthy Steps as one of five models to receive large grants to help bring them to a national scale as a potential solution to poverty and lack of economic mobility.

Neither of these primary care-based models has been used universally throughout a jurisdiction. Moreover, pediatric care based models have less reach than models based on the birth hospital. Almost all babies are born in hospitals, but fewer infants attend their regularly scheduled well-baby visits. But according to the National Survey of Children’s Health for 2019, only an estimated 89 percent of children aged 0 to five had experienced one or more preventive care visit in the past year. While hopefully the percentage is greater for infants, it is probably less than the nearly 100% who are born in hospitals.

Many questions must be answered in developing a “targeted universal” child maltreatment prevention system.

What should the entry point be, and should there be more than one? Having all families enter the program through the same portal (be it the GYN practice, birth hospital, or pediatrician’s office) would avoid overlap and inefficiency. Choosing the system that meets parents earliest–the OB-GYN office–would allow programs to make a difference at a crucial time but would also miss the children who get little or no prenatal care. The founders of Family Connects chose to use the birthing hospital because it covers the most families, even though they are missing the chance to address problems that begin prenatally. Combining two or more portals may increase a program’s reach and the opportunity to coordinate and extend services. In Guildford County, NC, Healthy Steps is being integrated with Family Connects. Michael Wald, in a forthcoming article in the Handbook of Child Maltreatment, proposes a prevention system that starts with OB-GYN’s and WIC programs in the prenatal stage and continues with universal services at birth through pediatricians, home visitors and family resource centers. All of these entry points in turn would refer families to targeted services. Using more than one portal requires linkages and procedures for hand-off or collaboration, adding complexity to the system, but increases potential coverage.

What should the goals of the system be? A basic question is whether the system would be framed as a child maltreatment prevention system or something broader. It is hard to separate the goal of preventing maltreatment from that of promoting healthy child development, and indeed most of the programs discussed above have broader goals. The mission of Family Connects is “to increase child well-being by bridging the gap between parent needs and community resources.” Healthy Steps has the goal of “promoting the health, well-being and school readiness of babies and toddlers.” Clearly it is hard to separate the goals of child maltreatment prevention and the promotion of child well-being and healthy development.

What should the lead agency be? A key question about universal prevention is which system should take the lead. Child welfare leaders like Jerry Milner, head of the Children’s Bureau under the Trump Administration, have expressed the desire to expand the role of child welfare to include primary prevention. But if the goal is the broader enhancement of child development, and if the main providers of universal services are health professionals rather than social workers, another agency like public health may be a more appropriate home. Moreover, the child welfare system is already overburdened and underfunded. The work of investigating existing abuse and neglect (which will never be totally eliminated), helping parents and children heal, and making sure children have a safe environment to thrive either temporarily or permanently, is work enough for this beleaguered system. It is interesting that many modern child welfare leaders are so discontented with their primary mission that they are crying out to take on prevention. Perhaps the answer lies in the current political climate, which disparages child protective services and foster care, rather than recognizing the crucial role these services play in protecting children from harm,

What should the targeted services be? Michael Wald raises the question of whether a limited set of evidence-based models should be supported as part of a prevention system or whether jurisdictions should be given free rein in program selection. There are arguments for both, but it may be more practical to allow local jurisdictions to choose their own programs, especially since most “evidence-based” programs have only modest effects. But there are many reasons to advocate that every family found to be high-risk receive early care and education (ECE) interventions such as Early Head Start and Educare, which reduce child maltreatment risks in so many different ways, as I argued in an earlier post. The proposed Child Care for Working Families Act should help make such quality programs more available around the country.

How can we engage the highest-risk families? This is perhaps the thorniest question of all. All of the existing and proposed programs discussed above are voluntary, and voluntary programs never succeed in involving all eligible families. Moreover, it is often hardest to enroll and retain the highest-risk families in parenting support programs. We have already seen that Durham Connects provided a home visit to only 69% and 64% of eligible families in its two RCT’s. And considering that only 79 percent and 83 percent accessed the recommended services, the actual completion rate goes down further. In a study of Durham Connects, the researchers found that parents with a higher risk based on demographic factors like age and income were more likely to agree to a home visit but less likely to follow through. They also found that infant health risk, as measured by low birth rate, birth complications, and medical diagnoses, was associated with lower levels of both initial engagement and follow-through. An HHS issue brief suggests many ways to improve a program’s performance in enrolling and engaging families in home visiting programs. Not listed is the idea of including a peer mentor in the program model, which is embedded in some newer initiatives like Hello Baby and the Detroit Prevention Project. But the fact remains that a voluntary program will leave some children unprotected until they are actually harmed by abuse or neglect. Yet, it is clear that a mandatory child abuse prevention program will not be accepted in the U.S–just look at the debate over the COVID vaccine. We can hope that If a universal, voluntary prevention program is adopted, it will gradually gain in acceptance by high-risk and low-risk parents alike as a valuable benefit. In case that does not occur, we must record identifying information about the parents who do not accept the initial offer to participate and and follow up on future outcomes for their children in order to assess the efficacy of the program at preventing maltreatment among the highest-risk groups. Moreover, CPS must have access to this information when they receive a new report on a family.

Can the system be funded by cutting child welfare budgets? Congress has an unfortunate history of cutting funds to unpopular programs prematurely with the hope of achieving savings by a new approach, rather than waiting for a new approach to yield savings. One could mention mental health deinstitutionalization but a closer analogy might be the Family First Act’s moving money away from congregate care toward family preservation services, before states have the foster homes to replace these facilities, thereby simply shifting the cost of such facilities to states. We hope that establishing a robust system of prevention may well eventually result in a reduction of calls to Child Protective Services and in the need for foster care and in-home services. But we cannot reduce funding for traditional child welfare unless and until this effect has occurred, as Brett Drake argued in in a webinar recently conducted by the American Academy of Political and Social Science (AAPSS) in conjunction with their 2020 volume on child maltreatment. Even then it may make sense to retain current funding as the system is currently stretched thin.

What about anti-poverty programs? Adopting a system of targeted universalism to prevent child maltreatment does not directly address poverty, a prime risk factor for abuse and neglect, as discussed in my last post. Targeted universal programs will not change the level of welfare benefits or housing availability. However, it is important to remember that most poor families do not neglect their children, as University of Maryland’s Brenda Jones-Harden mentioned in the AAPSS webinar. Those families that are functioning well will find a way to get the resources they need to care for their children, and the supportive services provided through targeted universalism may help the others do the same. But at the same time, prevention advocates should fight to improve economic supports so that no child is deprived of what he or she needs to grow up into a healthy and functioning adult. Some of the new programs already passed or under discussion under the Biden Administration and the new Congress, such as the expanded child tax credit and the Child Care for Working Families Act, will help make targeted interventions more effective by addressing some of the poverty-related risk factors that cannot be addressed by targeted programs.

There is a growing consensus in the child welfare world that we must focus on prevention of abuse and neglect, and there is an increasing interest in using the approach of targeted universalism. The current historic expansions of the safety net will provide the perfect backdrop for such an initiative by addressing the economic risk factors for child abuse and neglect. With the motivation to build a better society in the wake of the pandemic, the time may be right to develop a universal, targeted system to prevent child maltreatment and allow every child the conditions for optimal development.

Preventing child abuse and neglect: It’s time for a broader approach

April is Child Abuse Prevention Month, the blue pinwheels are on view around the country, and the obligatory emails and tweets are urging people to recognize the month with Facebook frames and Zoom backgrounds. And in the past year or so, prevention has become the word of the day in child welfare. This year, the House of Representatives has passed the Stronger CAPTA Act, which would raise the authorization for prevention services to match that of treatment services. CAPTA provides funds to state child welfare agencies for child abuse prevention, investigation and treatment programs. However when it comes to prevention, child welfare agencies are only a small part of the answer. Preventing child maltreatment requires the involvement of many other sectors of the government and society. It is important for prevention advocates to understand this and to work with other child advocates to support these programs.

In searching for guidance in how to view child abuse and neglect prevention, I came across an excellent 2016 publication from the Centers for Disease Control (CDC). Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities provides “a select list of strategies ….based upon what we know about risk and protective factors as well as empirical evidence on whether they have been shown to affect child abuse and neglect.” The CDC cites a number of risk factors researchers have found to be associated with the perpetration of child abuse or neglect, including young parental age, single parenthood, large number of dependent children, low parental income, parental substance abuse, parental mental health issues, parental history of abuse or neglect, social isolation, family disorganization, parenting stress, intimate partner violence, poor parent-child relationships, community violence, and concentrated neighborhood disadvantage. In addition, children who are younger and have special needs are more at risk of suffering maltreatment. Protective factors include supportive family environments and social networks, and probably other factors like parental employment, adequate housing, and access to health and social services.

Considering risk and protective factors leads to a broader conception of child abuse prevention than the one promoted by federal, state and local child welfare agencies. The CDC report lays out five strategies, all of which contain approaches that have demonstrated success in preventing child maltreatment. I have added a new strategy to CDC’s list and made some other smaller changes which are explained in notes. My modified list of strategies and approaches is summarized in the table below.

Preventing Child Abuse and Neglect

StrategyApproach
Strengthen economic supports to families-Strengthening household financial security
-Family-friendly work policies
Encourage pregnancy planning, spacing and prevention*-Increased availability of long acting contraceptives
-Public engagement and education campaigns
Change social norms to support parents and positive parenting-Public engagement and education campaigns
-Legislative approaches to reduce corporal punishment
Provide quality care and education early in life-Preschool enrichment with family engagement
-Improved quality through licensing and accreditation
Provide parenting support to at-risk parents**-Early childhood home visitation
-Other parenting skills and relationship interventions
-Enhanced case management plus peer engagement***
-Enhanced primary care to address maltreatment risks****
Intervene in maltreating families to lessen harms and prevent future risk-Behavioral parent training programs
-Treatment to lessen harms of abuse and neglect exposure
-Treatment to prevent problem behavior and violence
SOURCE: Modified version of Centers for Disease Control, Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities

Notes on Table

*Strategy added by Child Welfare Monitor

**Strategy and approach titles modified by Child Welfare Monitor

***Approach added by Child Welfare Monitor

****Approach moved from following strategy by Child Welfare Monitor

As the CDC points out, the strategies address different levels, from the individual to the societal. The first four operate on the community or societal level and the CDC hypothesizes that they are most likely to have a “broad public health impact on child abuse and neglect.” The last two strategies operate on the family and individual level and would have a narrower impact focusing on targeted populations.

Strengthen Economic Support to Families: Low parental income is one of the major risk factors for child maltreatment, as documented by multiple studies cited by the CDC. Economic insecurity leads to maltreatment, presumably by making it more difficult to meet children’s needs and provide quality childcare and by increasing parental stress and depression, both risk factors for child abuse and neglect. Approaches to strengthening economic support for families could include both improving economic assistance to low-income families and intervening to support family-friendly work policies like livable wages, paid leave, and flexible and consistent scheduling. The CDC cites studies of several economic support programs for which research has demonstrated a direct effect on child abuse and neglect or associated risk factors. Perhaps the expanded 2021 child tax credit will have such an effect.

Encourage Pregnancy Planning, Spacing and Prevention: The CDC report identified young parental age and large number of dependent children as risk factors for abuse and neglect, but it did not propose a strategy to address those risk factors. But as I have written before, there are strategies to address these risk factors and they should be considered. One approach would be to expand access to long acting removable contraceptives (LARC’s). A statewide campaign to increase availability of LARC’s in Colorado resulted in a halving of the teen birth rate in five years. Another approach would be public information campaigns to inform people of the dangers of early and closely spaced childbearing and the advantages to both parents and children of pregnancy planning and spacing. Research indicate that such campaigns can change people’s health-related behavior, as in the case of smoking cessation and HIV prevention. 

Change social norms to support positive parenting. As the CDC points out, norms about how we discipline our children are especially important to child abuse prevention. An analysis of 50 years of research found that spanking leads to more defiance, and increased antisocial behavior, aggression, mental health problems and cognitive difficulties. A recent study found that the percentage of parents who reported spanking a child in the previous year dropped from 50 percent in 1993 to 35 percent in 2017. Yet corporal punishment remains popular in some communities. While corporal punishment is not necessarily child abuse, it can lead to physical abuse when the parent loses control or goes too far. The CDC recommends both public education campaigns and legislative strategies to reduce the use of corporal punishment. The report cites successful public education campaigns regarding other parenting behaviors, such as emotional abuse. It also cites international studies indicating that bans on corporal punishment were successful at decreasing overall rates of corporal punishment.

Provide quality care and education early in life. Early care and education (ECE) is a particularly appealing child maltreatment prevention strategy because there are so many pathways by which it can operate to reduce child maltreatment. Quality ECE  reduces parental stress, exposes the child to mandatory reporters, and reduces the time spent in an abusive or neglectful home or with an unrelated adult–often the perpetrator of severe or fatal child abuse. ECE approaches with a family engagement component may prevent maltreatment by training parents in positive discipline approaches. Approaches to providing ECE could include expanding government support to programs that combine childcare with educational enrichment and parent involvement and improving standards to increase quality. Studies suggest that childcare programs that include parent involvement are effective in preventing child maltreatment. A 15-year follow up of Child Parent Centers found that children who participated for one to two years had a 52 percent reduction in substantiated child abuse and neglect.

Provide parenting support to at-risk parents. Intervening directly with a targeted population of parents to address risk factors for child maltreatment is perhaps the most popular approach to child maltreatment prevention because it has a clear connection with child maltreatment and often falls under the jurisdiction of child welfare agencies. Such approaches include home visiting programs as well as interventions based in doctor’s offices, preschools, school or mental health clinics. These programs vary in their models and the risk factors they address. Many of these programs focus parent education and training, based upon the assumption that poor parenting skills and ineffective discipline practices can lead to maltreatment. Some interventions focus on the parent-child relationship since poor parent-child relationships are a risk factor for child maltreatment. Many of the home visiting programs include a case management component to help parents set goals for their own lives and access needed services, thus addressing risk factors like substance abuse, mental illness, and parental stress. Home visiting interventions like Nurse Family Partnership, SafeCare and Child First and parent training programs like Incredible Years and Triple P have been found to have small to moderate effects on maltreatment and related risk factors. Another approach is to use the pediatrician’s office to identify families at risk of abuse or neglect, address these risk factors at regular visits, and provide information and referrals. Both SEEK and Healthy Steps are examples of this approach that have had some promising results but needs more evaluation. A new generation of programs, as yet unproven, is connecting at risk families with both a case manager and a family engagement specialist who provides peer support. Examples of that approach include the intensive tier of Allegheny County PA’s Hello Baby program and the Detroit Prevention Project.

Intervene in maltreating families to lessen harms and prevent future risk. In this category, CDC places therapeutic programs that seek to limit the damage caused by prior maltreatment. Such programs are often known as tertiary prevention and aim at preventing further abuse and neglect or healing victims so that they do not proceed to abuse the next generation. The CDC divides these programs into three approaches. One approach is “behavioral parent training programs,” like Parent Child Interaction Therapy. Also included in this approach are SafeCare and Incredible Years, which are also in the secondary prevention category. Another approach is treatment for children and families to lessen the harms caused by abuse or neglect, such as Trauma-Focused Cognitive Behavioral Therapy. And the final approach suggested is treatment to prevent problem behavior and later involvement in violence, which includes programs such as Multisystemic Therapy. All of these programs have shown some impact on maltreatment or associated risk factors.

Of the six strategies discussed above, only the last two generally fall under jurisdiction of child welfare agencies–and and even those are often delivered by public health or behavioral health agencies or pediatricians’ offices. But the other four strategies are often not mentioned in discussions of child maltreatment prevention simply because the latter is considered to be the province of child welfare agencies. It is not surprising that the responsibility for preventing child maltreatment is often attributed to the agencies responsible for identifying and treating it. But as described above, the range of risk and protective factors is much larger than what child welfare agencies have the capacity or mandate to address. CDC suggests that public health agencies are well-suited to take the lead in developing community-wide prevention strategies that bring in the other systems that need to be involved.

It took a public health agency to articulate the broad scope of risk factors that lead to child abuse and neglect and the need for a broad spectrum of approaches to address it. Let us hope that public health agencies on the national, state and local levels can take the lead in pushing for a full spectrum of strategies that deserves the name of child maltreatment prevention.

When Ideology Outweighs what’s Best for Kids: the case of San Pasqual Academy

Image: Jeffery Heil, Twitter.com

In 1998, something extraordinary happened in San Diego County. Galvanized by the heartbreaking stories of local foster youth who were disgorged at the age of 18 from a system that never gave them the tools to thrive, the community came together to create a place where foster youth could prepare for happy and productive futures. In 2001, the San Pasqual Academy (SPA) opened as a result of this unique moment of community solidarity and altruism. Twenty years and over 400 graduates later, SPA is on the chopping block because of federal and state legislation that eliminates any funding for placements that are not standard foster homes, unless they are providing temporary intensive treatment for severe mental health conditions.

The story of SPA began in 1998 when James R. Millikan, the presiding judge of the San Diego Juvenile Court, arranged for a group of foster youths to speak to the County Board of Supervisors, as described in a moving video. It was a transformational moment for many of the listeners, who were essentially unaware of the plight of older foster youth. Supervisors were riveted by young foster care alumni, who described surviving as many 30 placements and being discharged to the streets at the age of 18, with no supports or tools for success. This magic moment resulted in the creation of SPA.

In a rare moment of collaboration by multiple agencies and community leaders, SPA was developed with the support of Judge Milliken, the County Board of Supervisors, the Child Welfare Director, the Office of Education, as well as attorneys, social workers, healthcare providers, educators, law enforcement, foster youth, and other community members. They found a disused boarding school for sale on 238 acres, refurbished it, and opened it in September 2001. The goal was to “provide a safe, stable and caring environment” where youth [could] work toward their high school diplomas, prepare for college and/or a vocation, and develop independent living skills.” The Academy was “designed to be a place its students can call home, providing stable relationships needed for development of social skills and future relationships during their student experience at the Academy and beyond.”

SPA services can be classified into four categories: residential, education, work readiness and child welfare.

  • Residential: The residential component is run by New Alternatives, Inc., a private nonprofit. Youths live in family-style homes with house parents for up to eight children per cottage. “Foster grandparents,” who live on campus for reduced rent, mentor, tutor and engage students in hobbies and activities. An on-campus health and wellness center provides comprehensive health care, including mental health. Housing and supportive services are also available to Academy alumni for up to 24 months. (Twelve alumni are living on campus right now, taking advantage of this crucial safety net in the midst of a pandemic.)
  • Education: The onsite high school program is operated by the County Office of Education. After-school activities include student government, athletics, yearbook, and dances.
  • Work Readiness: Provided by the San Diego Workforce Partnership, services include tutoring, career counseling, job training, internships, employment, vocational electives, and assistance in creating resumes and portfolios.
  • Child Welfare: Social workers from the County Department of Health and Human Services (DHHS) onsite provide case management, services and advocacy.

The resources provided to SPA students are enhanced by the support of Friends of San Pasqual Academy, a dedicated group of community members who provide additional financial support and volunteer work. Friends’ support pays for special events, school supplies, and personal items, all designed to give students a “normal high school experience.” The Friends raise money for maintenance and upgrades to the cottages, the pool and other parts of the facility. They have leveraged outside resources to help SPA. The San Diego Chargers helped build the football field and the Padres built the softball field for SPA.

SPA truly embodies the definition of wraparound services, and the research shows that it works. To assess the effectiveness of the SPA model, New Directions commissioned a ten-year research study that followed 478 SPA alumni, including all youth who attended the academy between February 2001 and June 2011 and left the program between July 2002 and July 2012. The results were summarized in an article titled “Comprehensive residential education: a promising model for emerging adults in foster care,” which was published in Children and Youth Services Review. The findings were impressive. As the authors put it, “Foster youth who participated in the Academy until they were 18 years old or older attained high school diplomas or GEDs at rates far above state and national standards for foster youth. Of the youth who were at least 18 years old when discharged from the Academy, 92% of them graduated with a high school diploma or GED, which greatly exceeds Californias high school graduation/GED rates for foster youth of 45% and for the general population of California youth of 79%….In fact, we are not aware of any other program serving foster youth in the United States…with such high rates of high school diploma/GED completion.”

The evaluators concluded that “the Academy provided its alumni with safety, significant relationships with adults, and well-being that exceed state and national standards for foster youth. Those youth who attended the Academy for longer periods of time through their 18th birthday and participated in extracurricular activities had the most positive outcomes, including safe housing, employment, access to healthcare, attainment of a high school diploma or GED, and attendance at institutions of higher education. The Academy appears to provide a stable, comprehensive residential education program that helps foster youth successfully emerge into adulthood.” A preliminary draft of a follow-up study focusing on current students and alumni is equally glowing.

In addition to the spectacular evaluation mentioned above, SPA has been the subject of several other flattering reports. Five San Diego County “grand juries” (groups appointed by Superior Court judges to investigate, evaluate, and report on the actions of local government) and four county Juvenile Justice Commissions have issued glowing reports on SPA. The most recent report, by the group meeting from 2016-2017, lamented the fact that SPA was operating at only 50 percent of its capacity of 184 students. The Grand Jury recommended that SPA be fully utilized to make full use of its life-saving potential. San Diego’s Juvenile Justice Commission has also issued multiple flattering reports on SPA. In its most recent report, issued in 2018, the commission stated that “SPA continues to be a model facility delivering essentially full service, wrap around services in a residential setting to foster youth.”

Despite the overwhelming evidence of SPA’s life-changing impact, the number of children at SPA declined from 139 in April 2011 to 69 as of February 1, 2021. The most important reason for declining referrals appears to have been the decline in support by child welfare leaders for what is often called “congregate care,” usually meaning any type of setting other than a foster home. This change in mindset was created in large part through influence of two wealthy organizations started by the same family, Casey Family Programs and the Annie E. Casey Foundation, that have used their financial resources to produce reports like Every Kid Needs a Family, lobby legislators, and provide free consultation with states. With the help of the “Casey Alliance,” a new narrative has been created that that all “congregate care” settings are prison-like institutions and any family home is better than a group setting for almost every child.

The change in mindset eventually resulted in legislative changes. California’s Continuum of Care Act, passed in 2015. ended the placement of foster youth in group settings except to provide short term therapeutic care. Thanks to SPA’s known track record and strong support, pilot program was authorized to allow SPA to operate through December 2021. But passage by the U.S. Congress of the the Family First Prevention Services Act (FFPSA) sealed SPA’s fate. Like Continuum of Care, FFPSA essentially eliminated federal funding for placement in settings other than foster homes except for short-term placements for youth who assessed to have a diagnosis that requires a level of care that a family cannot provide. With the implementation of FFPSA scheduled for October, the California Department of Social Services (CDSS) decided to advance the date of SPA’s closure to avoid having to use state funds to maintain it until December. In an undated letter, CDAA informed San Diego County DHHS that SPA must close by October.

Both Continuum of Care and FFPSA were based on the belief that children almost always do better in families than in other, more institutional settings. But as we have written, supporters often misuse data and research to support this belief. Research generally shows children in group care having poorer outcomes than those in foster care. But these studies do not account for the fact that children placed in group care generally have much more severe issues, which is why they were placed in group care in the first place. Moreover, supporters of “a family for every child” fail to define the concept of a family. The cottages at SPA and many other residential facilities offer a family setting, with house parents who play the parental role, as one house parent eloquently described in the video cited above. SPA homes are much more like families than many foster homes, where the foster parent has little interaction with the youth and provides little besides room and board. In fact, the residential component of SPA could be called “enhanced foster care” more accurately than congregate care.

And that raises the related concept of quality, which the reformers ignored. Quality matters much more than the type of setting. It is likely that most parents whose child had to leave home, would prefer a high-quality group setting (even if not family-style) for their children than a low-quality family setting. Anyone who has worked in foster care will know the difficulty of obtaining high-quality settings for older foster youth. Due to the scarcity of foster families, especially those willing to accept older youth, few jurisdictions can afford to be choosy enough about whom they accept and retain. What they do get more often than not are foster homes that provide little beyond room and board (and often those are barely adequate), foster parents who never set foot in the child’s school, refuse to take them to the doctor and the therapist, and quickly return difficult youths to the agency–resulting in multiple placements for each foster youth. Moreover, in my experience as a foster care social worker in the District of Columbia, few of my high school age clients participated in extracurricular activities because foster parents were unwilling to pick them up late from school or take them to weekend games, performances or other activities. Yet, engagement in after-school activities is linked with higher academic performance and college attendance, better health, and fewer problem behaviors.

Opponents of group care also ignore the problem of sibling separation. Many children placed in traditional foster homes are separated from one or more siblings because foster families do not have room for sibling groups. As I argued in Sibling Separation: An Unintended Consequence of the Family First Act, family-style group homes like those provided by SPA have been an important vehicle for keeping siblings together. In addition to providing a home for sibling groups of high school age, SPA accepts siblings of current students who are of middle-school age, allowing them to live at SPA and attend school in the community. The importance of siblings to foster children is such that even some congregate care opponents admit that it is better to place siblings together in congregate care than to separate them into different foster homes.

It is important to note that the restrictions on group care in FFPSA had another purpose aside from the alleged benefits to foster care. Restricting group care, which is more expensive than foster care, was necessary to free up federal funds to pay for the expansion of funding for services to prevent the placement of children in foster care. In other words, to find the money to preserve families, Congress took it away from services to the children who will have to be removed when family preservation fails. As long-time Congressional staffer and child welfare consultant Sean Hughes wrote in the Imprint, the focus among child welfare advocates seems to have shifted almost exclusively toward preventing entry into foster care, with little advocacy being devoted to actually improving the continuum of care for children in out-of-home care.

Current students, alumni and supporters of SPA were stunned by the CDSS letter. A petition on Change.org has obtained almost 11,000 signatures so far. Supporters of SPA have created a Facebook page and deluged public officials with letters and telephone calls. Reverend Shane Harris, the President and founder of the People’s Association of Justice Advocates, says SPA changed his life and gave him a safe place to grow up and is fighting to keep it open. One alumna is quoted on the Save San Pasqual Facebook page as follows: “I really loved living at SPA. I got to create relationships, a family and a strong support system. I also became stable by living here. I was able to attend school and catch up from how behind I was. I succeeded in sports and found outlets to deal with emotions. I couldn’t live in foster homes because the families wouldn’t treat me like their own.” Simone Hibbs-Monroe, valedictorian of the class of 2009 told KUSI News that “SPA has been a community safe haven and the only solution for many foster youth and a dedicated home for many alumni of foster care… “It’s an opportunity for children to feel normal. We are able to play sports, get jobs, have pep rallies, have our first proms, get our drivers’ licenses …..these are all the things that the caring community of San Pasqual offers its youth and its alumni….Often people [say] it takes a village to raise a child. That is San Pasqual Academy.”

Current and former staff have joined the call to save SPA. SPA’s Clinical Director, Rex Sheridan, wrote as follows in an eloquent letter to the County Supervisors and San Diego’s DHHS leadership team. “During my career in mental health and youth services, two decades of which has been in San Diego County, I have had contact with and worked in many different settings dedicated to meet the needs of our most vulnerable youth populations; yet none could even remotely be compared to what is offered at SPA. That is why I have now spent a third of my life committed to and working to develop this program because of first-hand experience witnessing lives transformed, hearts opened back up after years of disconnection, wounds healed after lifetimes of abuse and trauma, siblings reunited after separation, goals reimagined out of hopelessness, skills and knowledge crafted and nurtured out of feelings of incompetence, and new identities and possibilities replacing desperation and fragmentation. And if you think that those experiences sound overstated or dramatic, then you haven’t had the privilege of attending games where youth are cheered for the first time in their lives, one of our talent shows where they perform an original song, or a college road trip where they get to visit universities all over the state and envision a new possibility that was never previously imagined.”

What can be done to save SPA? The state and the county must adopt a stop-gap solution to keep SPA running as they work to permanently amend state law to create a category of residential schools that is eligible for reimbursement. On the federal level, advocates are already working on legislation to amend FFPSA to add residential campuses with family style homes as a placement option. We will share more information as it becomes available.

The proposed closure of SPA is a victory of ideology and greed over humanity and common sense. We need more, not fewer San Pasqual Academies. Rather than shutting it down, the state and county should be ensuring that it is at capacity and boasting that within their borders lies the most effective foster care program in the country.

New Jersey to foster parents: thanks but no thanks!

Foster Parents Needed As COVID-19 Pandemic Strains Families is a typical headline these days, as illustrated in an article from Illinois. The pandemic has imposed new impediments to recruiting and retaining foster parents, including fears of exposure to COVID-19, loss of employment and income, and concerns about supervising virtual schooling. But these issues do not seem to be affecting New Jersey, where prospective foster parents are told that they are not needed, thank you very much! While the state credits its efforts at child abuse prevention and family preservation for its lack of need for foster parents, the explanation seems to lie elsewhere. Over the course of five years, the state has cut in half its rate of confirming allegations of abuse and neglect–resulting in a similar fall in the number of children entering foster care. This is a big change, and one that demands explanation in order to ensure that the agency is continuing to fulfill its mission of ensuring children’s safety in New Jersey.

Would-be New Jersey foster parents who click on “Be A Foster Parent” on the website of the Department of Children and Families (DCF) are greeted with the following message: “Thank you for your interest in becoming a resource parent to children and youth in state care.  Due to the COVID19 Pandemic and its impact on operations, DCF has suspended all new inquiry submissions at this time. Please continue to check our website for any updates.” This is an odd message indeed, as it seems to imply that the pandemic has made recruitment and licensing impossible. But agencies around the country have adapted quickly to move vetting and training online in order to enable new foster parents to enter the pipeline. Not so New Jersey.

When we asked DCF why foster parents are being turned away, we received the following reply from DCF Communications Director Jason Butkowski. “[W]e did experience a 19.17% reduction in out-of-home placements from 2019 to 2020.  This is attributable both to New Jersey’s statewide prevention network and our ongoing work to preserve families and keep children and parents together in their homes while receiving services.”

Interestingly, a message sent earlier to prospective foster parents gave a different answer. In May, 2020, would-be foster parents received a message saying, “In New Jersey, the number of youth in foster care continues to be reduced each year because we are focusing first on kinship placements,” as quoted in an article by Naomi Schaefer Riley. We asked Mr. Butkowski which explanation was more accurate–prevention and family preservation or kinship placements–but received no answer.

So what is going on in New Jersey? Certainly, foster care numbers have been decreasing. According to the data portal maintained by Rutgers University, annual entries to foster care fell from 5,504 in 2013 to 2,525 in 2019, as shown in the chart below. The rate of decrease in foster care entries became even steeper between 2018 and 2019, with a decrease of 23.7 percent in the number of entries in that one year alone. The total number of children in foster care dropped from a high of 7,775 in May 2014 to 4,463 in February 2020–before the pandemic closures occurred. So what could be causing this drastic decline in foster care placements and caseloads?

Source: NJ Child Welfare Data Hub, available from https://njchilddata.rutgers.edu/portal/entering-placement-reports#

One possibility might be a decline in child abuse and neglect, which Butkowski is implicitly assuming by attributing part of the fall in foster care cases to DCF’s “statewide prevention network.” In that case, one might expect reports to child abuse hotlines to decline significantly. But according to monthly state reports, calls to child abuse hotlines hardly changed between 2014 and 2019, decreasing very slightly from 165,458 to 164,417. Of course we cannot be sure that reports are an accurate measure of child maltreatment; but one might expect a significant reduction in hotline calls if a large reduction in maltreatment were occurring.

DCF’s Butkowski also credited the agency’s work to “keep children and parents together in their homes while receiving services” as a reason for declining foster care entries. It is true that most substantiations of abuse or neglect do not result in foster care. Instead, DCF works with many families in their homes to help them avoid future maltreatment. But DCF has been emphasizing in-home services for years. Of all the children who were under DCF supervision in foster care or in-home services, the percentage receiving in-home services rather than foster care was 84.7 percent in May 2014 and 90 percent in February 2020. So children were somewhat more likely to receive in-home services in 2020 than in 2014, but the difference was small and not likely to explain the big fall in the foster care rolls.

So with hotline calls basically unchanged, and only a slight increase in the emphasis on in-home services, how did New Jersey manage to reduce its foster care entries by almost half in six years? One can think of the child welfare process as a funnel, starting with referrals, the child welfare term for hotline calls. As we discussed, those have fallen only slightly. Only some referrals are screened-in and accepted for investigation; many are rerouted or receive no action because hotline workers determine that they do not concern abuse or neglect. But a reduction in screened-in referrals is not part of the explanation for New Jersey’s drop in foster care placements. New Jersey reported that 60,934 referrals were screened in in FFY 2019, compared with 59,151 in FFY 2013–a slight increase.

The next step in the child welfare funnel is investigation, and here the count shifts from the number of referrals to the number of children. According to data submitted to New Jersey to the Administration for Children and Families (ACF) and published in Child Maltreatment 2019, the number of children receiving an investigation in New Jersey increased slightly from Federal Fiscal Year (FFY 2015) to FFY 2019–from 74,546 to 78,741. However there was a stunning drop in the proportion of these children who were found to be abused or neglected (known as “substantiation” in the child welfare world). In FFY 2015, 13.0 percent of the children who received investigations (or 9,689 children) were found to be abused or neglected. In FFY 2019, only 6.5 percent of the children receiving investigations (5,132 children) were found to be victims of maltreatment. In other words, among the children who were involved in investigations, the proportion who were found to be maltreated dropped by half. Similarly, the number of children found to be maltreatment victims dropped by 47 percent. (This is very similar to the 44.6 percent decrease in foster care entries between those years shown in the Rutgers data portal cited above).

Note: The substantiation rate is the number of children found to be maltreatment victims divided by the number of children who were the subject of CPS investigations. Data are from Child Maltreatment 2019, available at https://www.acf.hhs.gov/sites/default/files/documents/cb/cm2019.pdf

It turns out that aside from Pennsylvania, which is not comparable to other states because it does not report on most neglect allegations, New Jersey had the lowest rate of substantiation per 1,000 children of all the states in FFY 2019. Only 2.6 children per 1,000 were found to be maltreated, compared to a national rate of 8.8 children per 1,000. In FFY 2015, this rate was 4.9 per 1,000 children in New Jersey–almost twice as high.

How did the number and percent of children found to be victims of child maltreatment drop so much in New Jersey over a four-year period, despite little decline in hotline calls? We asked DCF this question but received no reply. In the notes it submitted to ACF with its 2019 data, DCF acknowledged a decrease in the number of substantiated victims of maltreatment and stated that this is consistent with a continued trend–but provides no explanation. Perhaps policy or practice has changed to make it more difficult to substantiate abuse or neglect, through a change in definitions or in the standard of proof, or perhaps in training or agency culture. But such a change was not mentioned either by Butkowski or in DCF’s submission to ACF.

Let us revisit DCF’s previous message to foster parents saying that “In New Jersey, the number of youth in foster care continues to be reduced each year because we are focusing first on kinship placements.” This is an interesting statement because it implies that these kinship placements are not through the foster care system. It is important to understand that children can be placed with relatives in two ways. A child can be found to be a victim of maltreatment and placed with a relative, who becomes licensed as a foster parent. In New Jersey, 1,619 foster children (or 41 percent of the 3,951 children in foster care) were living with licensed kinship foster parents in November 2020. But these children are included in the state’s count of children in foster care, so they cannot account for the caseload drop. DCF must have been referring to something else.

Perhaps DCF’s earlier message to foster parents referred to the agency’s increasing use of a practice called “kinship diversion.” As described in an issue brief from ChildTrends, kinship diversion is a practice that occurs during an investigation or an in-home case when social workers determine that a child cannot remain safely with the parents or guardians. Instead of taking custody of a child, the agency facilitates placing the child with a relative. If this occurs in the context of an investigation, kinship diversion may result in a finding of “unsubstantiated” even when abuse or neglect has occurred, on the grounds that the child is now safe with the relative. We have no idea how widespread this practice is in New Jersey or nationwide since neither New Jersey nor other states report the number of these cases. However, the system of informal kinship care created by diversion has been called America’s hidden foster care system and nationwide it appears to dwarf the provision of kinship care within the foster care system.

There are many concerns about kinship diversion, as described in an earlier post: caregivers may not be vetted or held to the same standards as foster parents; they and the children they are caring for do not receive case management and services; they do not receive a foster care stipend and may have to depend on much-lower public assistance payments; there is nothing preventing caregivers giving children back to the parents without any assurance of safety; and parents are not guaranteed the due process rights and help with reunification that come with having their children in foster care. Because of the various concerns around kinship diversion, litigation has been filed in several states challenging this practice.

There is one other possible explanation that comes to mind for DCF’s foster parent surplus–dropping foster care rolls due to the COVID-19 pandemic. We removed data from the time of the pandemic from the above discussion to avoid confounding its effects with those of policy and practice changes but we need to ascertain whether the pandemic’s impact on calls to the hotline has affected entries into foster care. As in most states, hotline calls in New Jersey fell sharply in the aftermath of school closures and other pandemic measures. The number of child maltreatment referrals between March (the onset of school closures and quarantines) and November 2020 (the last month for which data are available on the DCF website) was 98,306, compared to 131,344 in the same period of 2019–a drop of 25 percent, based on monthly reports from DCF. It is likely that fewer calls from teachers now teaching virtually were a major factor behind this drop in hotline calls.

Entries into foster care also fell sharply in the wake of the pandemic. Foster care entries dropped from 1,949 in March through November 2019 to only 1,211 in the same months of 2020–a drop of 37.9 percent–which may have reflected in part the reduction in hotline calls and in part the continuing decrease in foster care entries that we have described. But the number of children in care did not drop nearly as much as entries into care. Between February and November 2020, the total number of youth in care decreased only 11 percent from 4,463 to 3,951. This drop is surprisingly low–in fact it is less than the decrease in the foster care caseload during the same months of 2019 (16.1 percent). The small size of this caseload decline reflects the fact that foster care exits dropped even more than foster care entries. Exits from foster care dropped from 2,754 in March through November 2019 to 1,661 in the same months of 2020. That is a drop of over 1,093, when the drop in foster care entries was “only” 738.[1] As a result, it appears that the number of children in foster care was higher, rather than lower, due to the pandemic. Therefore, it does not appear that the pandemic contributed to the decline in demand for foster parents.

One might expect to hear expressions of concern, or at least interest, in the recent precipitous drop in the number and rate of substantiations and in the foster care caseload from the court-ordered monitor charged with ensuring that New Jersey’s child welfare system is fulfilling its mission of protecting children. Since 2006 New Jersey has been operating under a settlement agreement in a lawsuit filed in 1999. The Court Monitor is Judith Meltzer, Executive Director of the Center for the Study of Social Policy (CSSP). In its most recent report, CSSP praised DCF for maintaining its progress toward meeting all the benchmarks required to exit the lawsuit, despite the challenges posed by COVID-19. Ironically, the report mentions DCF’s progress in “Prioritizing Safety.” The report does not mention the precipitous drop in foster care entries or substantiations before the pandemic or the fact that the state is turning away prospective foster parents.

New Jersey may be the first state to have stopped accepting applications for foster parents, and the reasons cited by DCF do not seem to explain this unusual event. Careful study of DCF data shows that the rate at which allegations of abuse or neglect are substantiated has been cut in half, and that there has been a similar reduction in entries into foster care. This cut in the substantiation rate could be due to policy or practice changes making it harder to confirm child maltreatment or it could be due to an increased tendency to place children with relatives without establishing officially that maltreatment has occurred. Without an adequate explanation from the state, the extent to which either of these factors is driving these trends is unknown. It is imperative to know the explanation of this trend to ensure that DCF’s new policies and practices are not compromising its mission of keeping children safe.

[1]: Reasons for this drop in foster care exits may include court shutdowns and delays and suspension of services parents need to complete their reunification plans.

Declining child abuse? The misuse of data in child welfare

Lowest number of maltreatment victims in five years, crowed the Administration on Children and Families (ACF), summarizing its annual report, Child Maltreatment 2019. Child welfare newsletter The Imprint eagerly repeated the claim, claiming that the Number of Child Abuse and Neglect Victims Reached Record Low in 2019. The venerable Child Welfare League of America followed suit in its Children’s Monitor saying “Data Shows Decline in Child Abuse in FY2019.” It is only by reading the report that one learns that the decline was not actually in the number of victims of abuse or neglect. Instead, it was a decline in the number of children who were found by Child Protective Services (CPS) to be abused or neglected, which is not the same thing at all.

Child Maltreatment, the Children’s Bureau’s annual report on child abuse and neglect, is based on data from the states, the District of Columbia, and Puerto Rico collected through the National Child Abuse and Neglect Data System (NCANDS). Child Maltreatment 2019 is based on data from Federal Fiscal Year (FFY) 2019, which ended September 30, 2019. (Note that these data reflect the year before the inception of the coronavirus pandemic.) Displayed below is a summary of four key national rates reported by ACF between 2015 and 2019. The first indicator shown is the referral rate, which describes the number of calls and other communications describing instance of child maltreatment per 1,000 children. Next is the screened-in referrals rate, which includes referrals that are passed on for investigation or alternative response. Once screened in, only some reports are referred for investigation, and the third set of bars represents children who received an investigation per 1,000 children. The fourth group shows the rate of children found to be abused or neglected–or those who received a substantiation. Let us go over these numbers in more detail.

*Note that Investigation and Substantiation Rates are based on number of children, not referrals
Source: Child Welfare Monitor tabulation of data from Child Maltreatment 2019, available from
https://www.acf.hhs.gov/sites/default/files/documents/cb/cm2019.pdf

Total referrals: A referral is a call to the hotline or another communication alleging abuse or neglect. In 2019, agencies received an estimated total of 4.4 million referrals, including about 7.9 million children. The “referral rate” was 59.5 referrals per 1,000 children in FFY 2019. This rate has increased every year since 2015, when it was 52.3 per 1,000 children. It is worth noting that the referral rate differs greatly by state, ranging from 17.1 referrals per 1,000 children in Hawaii to 171.6 per 1,000 children in Vermont, as shown in the report’s state-by-state tables. These differences in referral rates may stem from cultural differences regarding the duty to intervene in other families, differences in publicity for child abuse hotlines and ease of reporting, or temporal factors like a recent highly-publicized recent child abuse death.

Screened-in referrals (reports): A referral can be either “screened in” or screened out because it does not meet agency criteria. In FFY 2019, agencies screened in 2.4 million referrals, or 32.2 referrals per 100,000 children. This was a decrease in the rate of screened-in referrals per 1,000 children after three straight years of increases. This percentage of referrals that were screened in varied greatly by state, ranging from 16 percent in South Dakota to 98.4 percent in Alabama. States reporting a decrease in screened-in referrals gave several reasons, such as a change in how they combine multiple reports and a decision to stop automatically screening in any referral for a child younger than three years old.

Children who received an investigation (child investigation rate): Once a report is screened in, it can receive a traditional investigation or it can be assigned to an alternative track, which is often called “alternative response” or “family assessment response.” (Two-track systems are often labeled as “differential response.”) This rate represents the number of children who received an investigation as opposed to an alternative response. Only an investigation can result in a finding of abuse or neglect; an alternative response generally results in an offer of services. Like the referral rate, the investigation rate increased from 2015 to 2018 and then decreased in 2019. This rate also varies widely between states and over time. Some states eliminated or expanded their differential response programs in 2019, resulting in more or fewer investigations, as described in the report.

Substantiation: A “victim” is defined in NCANDS as a “child for whom the state determined at least one maltreatment was substantiated or indicated; and a disposition of substantiated or indicated was assigned for a child in a report.” The report’s authors refer to the number of such children per 1,000 as the “victimization rate.” But clearly substantiation does not equal actual victimization. The difficulty of making a correct decision on whether maltreatment has occurred is well-documented. Stories of families with repeated reports that are never substantiated or not confirmed until there is a serious injury or even death are legion. So are reports of parents wrongly found to be abusive or neglectful. Therefore, we have chosen to use the term “substantiation rate” instead of ‘victimization rate.” This rate varies greatly by state, from 2.4 per 1,000 children in North Carolina to 20.1 in nearby Kentucky.[1] The national substantiation rate in FFY 2019 was 8.9 per 1,000 children, down from 9.2 per 1,000 in FFY 2019 and FFY 2015. States reported a total of 656,000 (rounded) victims of substantiated child abuse or neglect in FFY 2019–a decline of four percent since 2015.

So does this decline in the number and rate of substantiations really connote a decline in child abuse and neglect? The range in substantiation rates among states argues against this idea. Unless states differ by almost a factor of 10 in the prevalence of child abuse and neglect, these numbers must reflect factors other than the actual prevalence of maltreatment. And indeed the report’s authors acknowledge that “[s]tates have different policies about what is considered child maltreatment, the type of CPS responses (alternative and investigation), and different levels of evidence required to substantiate an abuse allegation, all or some of which may account for variations in victimization rates.” Changes in these policies and practices can account for changes in these rates over time. Moreover, changes in all the earlier stages of reporting, screening, and assignment to investigation or alternative response contribute to changes in the substantiation rate. In 2019, screened-in referrals and investigations per thousand-children both decreased, which clearly contributed to the decrease in the substantiation rate.

It is interesting to note that while referrals increased every year between FFY 2015 and FFY 2019, both screened-in referrals and investigations decreased in FFY 2019. This suggests a general tendency among states to be less aggressive in responding to allegations of maltreatment, perhaps in accord with the prevalent mindset among child welfare leaders nationally and around the country, as discussed below.

Understanding the difference between “victimization” and “substantiation” and the many possible causes of a decrease in this rate reveals the deceptiveness of ACF’s statement that “[n]ew federal child abuse and neglect data shows 2019 had the lowest number of victims who suffered maltreatment in five years.” Lynn Johnson, the HHS assistant secretary for children and families, is quoted in ACF’s press release as saying that “[t]hese new numbers show we are making significant strides in reducing victimization due to maltreatment.” Unless Johnson and the ACF leadership intended to mislead, it appears they are woefully ignorant of the meaning of these numbers.

Most regular leaders of this blog already know why ACF wants to support the narrative of declining child maltreatment. The current trend in child welfare policy, regardless of political party, is to oppose intervention in families. Republicans who oppose government spending and interference in family life have made common cause with Democrats who think they are reducing racial disparities and supporting poor poor families by allowing parents more freedom in how they raise their children, even if it means leaving children unprotected. Members of both parties came together to pass the Family First Act, which encoded this family preservation mindset into federal law.

Child Welfare Monitor has pointed out many other instances where ACF or by other members of the child welfare establishment in the interests of supporting the family preservation mindset. For example, we wrote about the Homebuilders program, which was classified by a federally-funded clearinghouse as “well-supported” despite never having been proven effective for keeping families together. In fact, Homebuilders had to be classified as well-supported because it was one of the key programs touted by ACF and others in promoting the Family First Act and other policies promoting family preservation.

So if ACF’s “victimization” data do not in fact tell us what is happening to abuse and neglect rates, what else is available? We call on Congress to pass an overdue re-authorization of the Child Abuse Prevention and Treatment Act and include a fifth National Incidence Study of Child Abuse and Neglect. Data for the last study was collected in 2005 and 2006; it is high time for an update which should put an end (at least temporarily) to the misuse of NCANDS data as an indicator of trends in child maltreatment.

President Biden has called for ending a “culture in which facts themselves are manipulated and even manufactured.” We hope that ACF under its new leadership, as well as the rest of the child welfare establishment, will take these words to heart and commit themselves to truth and transparency from now on.

[1]: Pennsylvania has a substantiation rate of 1.8, even lower than that of North Carolina, but in Pennsylvania, many of the actions or inactions categorized as “neglect” are classified as “General Protective Services” and not included in the substantiation rate, making its data not comparable to that of the other states and territories.

[2]: Massachusetts did not provide data on FFY 2019 child maltreatment fatalities.

The Detroit Prevention Project: Preventing child maltreatment by supporting at-risk families

Connect With Us - Brilliant Detroit

The current mainstream discourse in child welfare is all about prevention: reaching families before maltreatment occurs instead of intervening afterwards. Many jurisdictions pay lip service to this mantra by making services available to high-risk communities but not targeting these services to the families who need them most. The Detroit Prevention Project, launched by the Michigan Department of Health and Human Services (DHHS) in conjunction with an innovative organization called Brilliant Detroit, is different. It reaches out to families at risk of child maltreatment with an intensive case management and peer mentorship intervention aimed at preventing child abuse and neglect.

“One of the top priorities of the new administration when it comes to the child welfare system is to connect with families and provide them with support and resources before there is a need for Children’s Protective Services to file court petitions,” said JooYeun Chang, who served previously as the head of the Children’s Bureau and Managing Director of Casey Family Programs and came to Michigan in 2019. “We believe children are better off when they are with their families as long as we can work with families to make sure the children are safe.”

Interest in preventing child maltreatment before it occurs has been increasing in child welfare. But the drop in CPS reports under virtual schooling, which deprives the current system of its main trigger for action, has led to even more interest in prevention.  In Michigan, DHHS had already begun to formulate plans for shifting toward a more proactive approach but COVID-19 accelerated those efforts, according to a recent article from Second Wave Media.

The new program, called the Detroit Prevention Project, pairs families at risk for child maltreatment with two workers, each performing a different function. Peer mentors, also known as “parent partners,” are community members who have experience in navigating the child welfare system in Detroit. They receive training in mental health peer support and how to work within MDHHS systems. Benefits navigators connect families to community resources such as food, housing assistance, education, and employment. The use of peer mentors or counselors is a newer approach in child welfare that has been shown to produce positive effects on outcomes associated with reduced child maltreatment. While many other programs use either peer mentors or benefits navigators, combining the two is an innovative approach.

DHHS decided to pilot its new approach in two of the zip codes with the highest rates of referrals of child abuse and neglect in the state. They chose to work with Brilliant Detroit, an organization founded in 2015 to “provide a radically new approach to kindergarten readiness in neighborhoods,” according to its website. The program has created family centers in neighborhoods which attempt to provide families of children aged 0 to 8 with all the services (emphasizing health, family support and education) needed to ensure school readiness and provided needed family support. Co-Founder and CEO Cindy Eggleton was awarded a 2021 Purpose Prize from AARP for her work in founding and directing Brilliant Detroit.

Families are also given access to a variety of programs already offered by Brilliant Detroit. These range from anger management and GED classes to nutrition workshops and fitness activities. Also offered are community based playgroups, intensive tutoring for the kids, family literacy programs, “parent cafes” to help parents connect, workforce and financial literacy training, free sports for children, and more.

The program is strictly voluntary and is being offered to a group of families drawn from two sources. DHHS is referring families that were the subject of a child protective services investigation in the past year based on their score on its Structured Decision Making (SDM) Tool. SDM is an actuarial assessment system, used by many states, to assess risk and make decisions about how to handle a case. Families that had an investigation closed with a score of III (evidence of abuse or neglect but a low or moderate level of risk to the child) or IV (insufficient evidence to show that abuse occurred but future risk of harm to the child) are normally referred to community services. These families will be invited to participate in the Detroit Prevention Project. Brilliant Detroit is also offering the program to families that it already knows from its neighborhood work.

The goals of the program are as follows, according to the document provided by Brilliant Detroit:

  • Reduce the number of at-risk families in zip codes 48205 and 48288 that are reported from child abuse and neglect;
  • Align existing MDHHS programs with Brilliant Detroit’s network of partners to create a comprehensive continuum of services.
  • Provide data on the efficacy of the model
  • Construct a model that can be scaled up through additional funding and community based partnerships.

The Detroit Prevention Project was jointly developed with leadership from the Skillman Foundation and Casey Family Programs. Skillman suggested that MDHHS talk to some of their partners on the ground, including Brilliant Detroit, to flesh out the ideas, which led to the partnership. The funding is being provided by MDHHS, Casey and Skillman. When it reaches full scale, the program will serve 400 families.

The Detroit Prevention Project embodies the prevailing sentiment in child welfare in favor of preventing abuse and neglect before they occur. This push has been led from the top by the Children’s Bureau, where Chang’s successor Jerry Milner has been a forceful advocate for this approach. Many states have responded with enthusiasm and new programs. However, some states have created new programs (like the Family Success Centers recently opened by the District of Columbia based on New Jersey’s model) without targeting them to children that are at risk of child abuse or neglect. Without a systematic effort to reach out to the families who need these services most, there is no assurance that these families will receive the services.

DHHS might want to consider using the Detroit Prevention Model to reach further upstream, following the example of Allegheny County, Pennsylvania. Allegheny County’s Hello Baby program reaches out to parents of new babies to offer them a tiered set of services. Families with the most complex needs based on a predictive risk model are offered the most intensive approach which, similar to the Detroit Prevention Program, matches each family with a peer counselor and a case manager. Given Brilliant Detroit’s mission of focusing on children from zero to eight and DHHS’s focus on prevention, this would be a natural step for both partners.

Participation in the Detroit Prevention Program is strictly voluntary, which means that some of the most troubled families will refuse to participate. Research indicates that it is difficult to engage the highest-risk families in voluntary services. We hope that the program will collect and report on the number of families refusing to participate and track their future maltreatment reports, in order to assess the extent of this problem. If it is extensive, leaders may need to consider using a family’s refusal to participate as the trigger to initiate an investigation.

Michigan DHHS should be commended for the implementation of the Detroit Prevention Program. We hope that child welfare leaders in other states are watching this initiative carefully. We also hope that DHHS will subject this program to intensive evaluation so that we can learn from this experiment experiment.

Hidden child maltreatment: One more reason to vaccinate teachers and open schools

With the end of the holiday break, about half the nation’s public students are not returning to school buildings but instead are continuing with virtual education. The impacts of school building closures on education, the economy and student mental health have been widely covered. But there is another consequence of virtual education that has not been as widely reported–the loss of the protective eye on children that their teachers and other school staff provide. Now that the COVID vaccine is becoming available, it is urgent that we get teachers vaccinated and students back to school.

In the wake of the coronavirus emergency beginning last March, almost all public school buildings in the nation closed, with few if any reopening before the end of the term. Many systems reopened buildings for fully in-person education or “hybrid” (partially virtual) models in August or September, and others opened their buildings later. As of Labor Day, 62 percent of U.S. public school students were attending school virtually, but only 38 percent were still online-only by early November, according to a company called Burbio, which monitors 1,200 school districts around the country. However, a spike in COVID cases beginning in November resulted in many systems returning to virtual education, with 53 percent of students attending virtually by January 4, 2021. Burbio expects a decrease in this percentage over the next six weeks as systems open up again after the virus spikes abate.

Almost immediately after the school closures last spring, reports began rolling in about the failure of online education to reach many students, especially those who were poor and most at risk of school failure. Some students lacked computers or internet access; others were unable to engage remotely in education. There is deep concern about the long-term impact of school building closures on young people’s academic performance, particularly for those at most risk of poor outcomes. With the passage of time, more information began to flow in about other consequences to children of missing school, such as worrisome impacts on their mental health.

But many child welfare professionals and advocates have long shared another concern. They worried about unseen abuse and neglect among the children stuck at home with increasingly stressed parents and not being seen by teachers and other adults. This is especially concerning for younger children, who are less likely to seek help on their own. And indeed, as soon as schools closed around the country last March due to the COVID pandemic, almost every state reported large drops in calls to their child abuse and neglect hotlines. The loss of reports from teachers (who make one in five of reports nationwide) was probably the major contributor, combined with the loss of reports from other professionals, friends, and family members seeing less of children due to stay-at-home orders and physical distancing.

After the academic year ended, data became available that that allowed comparison of reports, investigations, and findings of maltreatment in the pandemic spring compared to the spring of 2019. These analyses showed a large difference between reports, investigations, and substantiations of maltreatment in 2020 relative to 2019, followed by a convergence in data during the summer when schools are normally closed. In our local blog, we analyzed data from the District of Columbia Child and Family Services Agency (CFSA). For this post we used our DC data and information from three other jurisdictions for which data was readily available: New York City, Los Angeles, and Florida.[1]

In the District of Columbia, schooling has remained virtual since the onset of the pandemic, with a small number of students joining their virtual classrooms from school buildings while supervised by non-teaching staff. Figure One shows the number of reports received at the CFSA hotline in January through September 2019 and 2020. The contrast between the two years is obvious. In the “typical” year of 2019, the number of reports increased every month until May,[2] dropped to a much lower level in July and August when schools were closed, and then bounced up in September after schools reopened. The pandemic year of 2020 looked very different. The number of calls fell from February to March with the closure of schools, followed by a much larger drop in April, and stayed fairly flat until a modest rise in September with the opening of school. It’s as if summer vacation started in March, with a slight increase of reports when virtual school started again. In every month of the pandemic, the number of hotline calls in 2020 was considerably less than its counterpart in 2019. The total number of hotline calls received between March and June and in September (roughly the period affected by COVID-19) fell from 7916 in 2019 to 4681 in FY 2020, a decrease of 40.8 percent.

Source: CFSA Data Dashboard, https://cfsadashboard.dc.gov/, data analyzed by Child Welfare Monitor DC.

New York City data show a similar picture, as shown in a report from the Administration for Children’s Services (ACS) comparing hotline calls in 2020 to those in previous years. It is clear that 2020 is the outlier, with reports in 2017 through 2019 displaying similar seasonal patterns. In contrast to the previous years, reports fell in March 2020 with the schools closing on March 16 and then plunged in April during the first full month of school closure. There was a slight uptick in May and then reports remained basically flat before jumping up in October (when school buildings reopened) and falling again in November after schools closed again on November 19. ACS does not provide the numbers for each month but for January through November of 2020, there were 46,375 reports compared to 59,539 during that period in 2019. That is a difference of 22 percent; this difference would clearly be greater if we were able to look only at the weeks when schools were closed due to COVID-19.

Figure Two

Source: NYC Children, Flash Monthly Indicators Report, December 2020, available from https://www1.nyc.gov/assets/acs/pdf/data-analysis/flashReports/2020/12.pdf

Data from Los Angeles, where school buildings have not yet reopened, tell a similar story–a decline in reports in March after the pandemic emergency and school closures and then a big drop in April, the first full month when schools were closed. Referrals remained below the previous year for the rest of 2020, though the difference narrowed. The total number of referrals was 44,959 in March through November of 2020, compared to 61,515 in the same period of 2021–a decrease of 26.9 percent, and the decrease would be greater if only the weeks of school were included.

Figure Three

Data from Los Angeles Department of Children and Family Services, https://dcfs.lacounty.gov/resources/data-and-monthly-fact-sheets/, analyzed by Child Welfare Monitor

It is interesting to look at Florida, where the governor mandated that school buildings open in the fall semester. Florida data for last spring looks a lot like that for DC, New York City, and Los Angeles. But referrals almost matched 2019 during June and July, with the onset of summer break. August 2020 referrals were slightly lower than those in August 2019, perhaps because many schools opened virtually, but the gap narrowed again in September, October and November as more schools opened in person. And the shape of the fall curves was nearly identical in both years, with referrals rising in October.

Figure Four

Data from Florida Department of Children and Families, https://www.myflfamilies.com/programs/childwelfare/dashboard/intakes-received.shtml?Landing%20Page%20InvRec=2, analyzed by Child Welfare Monitor

Not everybody agrees that the loss of reports from school staff is a problem. Teachers have sometimes been criticized for making too many reports, and some analysts have suggested that the COVID closures might serve a useful function by eliminating frivolous or inappropriate reports. Indeed, some analyses have shown that the reports that are being made tend to be more serious or high-risk, suggesting that more of the less serious reports are being suppressed. If there was a large increase in the percentage of reports accepted for investigation or found to be substantive, there might be less reason to worry. But this does not appear to be the case.

  • In the District of Columbia, as shown in Table One at the bottom of the article, the percentage of reports accepted for investigation was slightly greater in 2020 than in the previous year. But as Figure Five shows, this percentage increase in accepted reports was not enough to substantially narrow the large gap between the number of accepted reports in the two years. Both the number of hotline calls accepted for investigation and the number of substantiated investigations showed the same sharp decrease as the number of reports to the hotline.
  • Similarly, the number of investigations in New York City showed the same precipitous drop from 2019 to 2020 as did the number of reports, as Figure Seven shows. And the percentage of investigations that “showed some credible evidence of abuse or neglect” in January through September 2020 was actually one point lower than that in the same period of 2019.
  • In Los Angeles, the percentage of referrals accepted for investigation actually declined during the pandemic, as indicated in Table Two below. So the year-to-year gap in number of referrals accepted for investigation (see Figure Seven) was even greater than the gap in total referrals. (Los Angeles does not provide data on substantiated reports.)
  • In Florida, as indicated in Table Three, there was a very slight increase in the percent of of intakes accepted for investigation during March-May 2020 compared to the same period in 2019. But as Figure Eight shows, the total numbers were much lower than in the previous year. (Florida does not provide data on the number of reports that were substantiated.)

It is clear from data in the four jurisdictions described here that reports to child abuse hotlines fell steeply in all four jurisdictions after the pandemic school closures, absolutely and relative to the same months of the previous year. In Florida, where schools reopened in September, reports increased to almost the level of the year before. It seems indisputable that measures imposed to fight COVID-19 were behind these changes and highly likely that school building closures were a large factor behind the reporting reductions. Moreover, as reports decreased, so did the numbers of reports investigated and substantiated, thus dashing any hope that only frivolous reports were being weeded out by the school closures.

Now that a vaccine is available, some Governors in states that have not reopened schools have proposed plans to prioritize teachers for vaccines and finally reopen buildings. Governor Gavin Newsom of California has offered a reopening plan including prioritization of school staff for vaccinations throughout spring 2021. West Virginia Governor Jim Justice has announced his plan to open pre-K, elementary, and middle schools for in-person learning on Tuesday, Jan 19. High school students will return to in-person school only in less-heavily-infected counties. Justice announced that the state will vaccinate all teachers and school personnel over the next two to three weeks as part of Phase One of the state’s vaccination plan.

Data from around the country clearly show that child welfare agencies received fewer reports, conducted fewer investigations, and made fewer findings of child abuse or neglect in times and places where schools were virtual. This fact adds to the many other reasons to open all closed school buildings as soon as possible. Opposition from teachers and their unions has been a major reason for keeping schools virtual. It is understandable that teachers were reluctant to return to buildings. But now, availability of vaccines makes it possible for schools to reopen throughout the country without endangering teachers–as long as all teachers are offered the vaccine before returning to classrooms. The high costs to to students of closed school buildings, among which undetected abuse should be included, mean that we should not wait any longer to bring students back to school in person.

[1]: These jurisdictions were chosen as large state or county child welfare systems that had readily available about reports, investigations and substantiations. Many other large jurisdictions do not post such data.

[2]:DC’s pattern of increasing reports from January through May is different from the other jurisdictions and may be related to its law requiring schools to report educational neglect when a student accumulates ten unexcused absences in a school year.

Table One: Hotline Calls Accepted for Investigation, District of Columbia

Source: https://cfsadashboard.dc.gov/; Data analyzed by Child Welfare Monitor DC

Figure Five

Source: https://cfsadashboard.dc.gov/; Data analyzed by Child Welfare Monitor DC

Figure Six

Source: NYC Children, Flash Monthly Indicators Report, December 2020, available from https://www1.nyc.gov/assets/acs/pdf/data-analysis/flashReports/2020/12.pdf

Table Two

Source: https://cfsadashboard.dc.gov/; Data analyzed by Child Welfare Monitor DC

Figure Seven

Table Three: Intakes Accepted for Investigation, Florida

Source: https://www.myflfamilies.com/programs/childwelfare/dashboard/intakes-received.shtml?Landing%20Page%20InvRec=1; Data analyzed by Child Welfare Monitor

Figure Eight

Data from https://www.myflfamilies.com/programs/childwelfare/dashboard/intakes-received.shtml?Landing%20Page%20InvRec=1; Data analyzed by Child Welfare Monitor

What can happen when a child is left in an abusive home: the sad case of Lisa Montgomery

Lisa Montgomery: Mercury News.com

Many Americans recall the horrific case of Bobbie Joe Stinnett, who in 2004 was strangled to death, her belly sliced open, and her baby removed. There is no doubt that the perpetrator was Lisa Montgomery, who brought the baby home, announcing that she had given birth. What most of us don’t know about is the nightmarish childhood that led to Ms. Montgomery’s crime, and the extent to which family members and authorities knew of her suffering and did not take action.

On January 12, Lisa Montgomery is scheduled for execution–the first woman to be executed on federal death row for 70 years. In a hearbreaking op-ed published by the New York Times, writer Rachel Louise Snyder explains Lisa’s hellish upbringing and the multiple failures that allowed the torture to continue.

As Snyder describes, Lisa Montgomery was born to a family “rife with mental illness, including schizophrenia, bipolar disorder, and depression.” Lisa’s father left the family when she was a toddler. Her family moved once a year or more, spending time Washington, Kansas, Colorado, and Oklahoma. Lisa’s mother, Judy Shaughnessy, abused her “in extreme and sadistic ways,” according to interviews with nearly 450 family members, neighbors, lawyers, social workers, and teachers. She was forced to sit in a high chair for hours if she did not finish her food. Her mouth was covered with duct tape so frequently that she learned not to cry. According to her mother, her first words were: “Don’t spank me, it hurts.”

Lisa’s older half sister, Diane Mattingly, told Elle Magazine that Lisa’s mother hit them with brooms and belts. She forced Diane to eat raw onions until she cried and once stripped her naked and put her out of the house in freezing temperatures, telling her not to come back. She made nightly trips to a bar, leaving the girls with “babysitters” who raped Diane, whose “sole purpose in life” was to protect her little sister. At the age of eight, Lisa lost her sole protector when Diane was removed from this home and placed in foster care with a loving family. Diane reports that she vomited all the way to the foster home, knowing the fate that awaited four-year-old Lisa without her protection.

Lisa’s stepfather, Jack Kleiner, a “rampant alcoholic,” began to assault her sexually when she was about 13. He built a “shed-like room” next to the family’s trailer in Tulsa Oklahoma and kept her there. He brought friends over to rape her, “often for hours, often three at once.” As if that was not enough, Lisa’s mother began to prostitute her to pay household bills.

When she was 18, Lisa married her 25-year-old stepbrother, the son of her mother’s fourth husband, who also raped and abused her. By the age of 23 she had four young children (whom she in turn abused and neglected) and suffered from episodes of mania and psychosis. She eventually remarried. In the years before her crime, she repeatedly claimed to be pregnant and then to have lost the baby–despite the fact that she had been sterilized after the birth of her fourth child. One week before Christmas in 2004, Lisa Montgomery arrived at a meeting she had set up with a pregnant dog-breeder, Bobby Jo Stinnett, ostensibly to adopt a puppy. Instead, she took Stinnett’s life and left with her child.

Lisa Montgomery most likely suffered from fetal alcohol syndrome and by the time she was arrested for her crime she was diagnosed with bipolar disorder, temporal lobe epilepsy, complex post-traumatic stress disorder, dissociative disorder, psychosis, and traumatic brain injury. Scans of her brain showed damage and abnormal patterns in the areas responsible for regulating social and emotional behavior and memory, which can be affected by trauma. Her “Adverse Childhood Experiences” (ACES) score was 9 out of 10 and global functioning score showed “severe impairment in daily activities.”

Perhaps the most shocking information in Dr. Snyder’s article is the extent to which many people in authority knew of her abuse and did nothing.

  • Lisa’s older sister was sent to foster care due to abuse or neglect, but there was no help for Lisa. In any child welfare system, Lisa’s life should have been investigated as well. If she was not removed, her family should have at least been monitored. (Her sister says she was afraid to say anything to her foster parents, not wanting them to know of her history of rape and abuse for fear they would send her away. She has regretted this decision for all her life.).
  • An A student in elementary school, Lisa was placed in special needs classes in middle school. An administrator thought this academic deterioration might be due to “deep emotional trauma” but it appears that the school took no action to uncover or report the underlying cause.
  • As a teenager, Lisa told her cousin, a deputy sheriff in Kansas, about being raped by Kleiner and his friends. He told investigators that he knew she was telling the truth and still regrets taking no action.
  • When Lisa’s mother divorced Jack Kleiner, she forced Lisa to testify about the rapes for their divorce proceedings. The mother sat unmoved during Lisa’s testimony. A social worker found Lisa’s claims believable and turned the file over to the Tulsa County District Attorney’s Office, where no action was apparently taken.

It is difficult to understand how so many people in positions of authority knew about Lisa’s plight and did not interfere. The family’s repeated moves from state to state may have been part of the answer, as by the time a pattern was observed the family might have been gone. The events are too far in the past to determine who failed and why. But Lisa’s fate is a cautionary tale against ignoring any suspicion of child abuse.

Sadly, many child welfare leaders and advocates are currently recommending that state intervention in abusive and neglectful families be scaled back or even eliminated, just one more swing of the national pendulum on child welfare. There are concerns about the tendency for teachers and community members to over-report minor concerns that do not rise to the level of abuse. There are also criticisms that some systems are too quick to remove children from their homes instead of trying to help the parents take better care of their children. A new coalition calls for the elimination of “the forcible surveillance and separation of children from their parents.”

Lisa’s case tells us why we must not eliminate mandatory reporting of child abuse and neglect. If anything, we need to enhance training for mandatory reporters in order to increase the reporting of real maltreatment while reducing unnecessary reports. However, given the extreme costs of continuing abuse, it is better to tolerate some frivolous reports than to miss future Lisa Montgomerys.

Nor do we want to eliminate the forcible removal of children from their homes, as some child welfare critics propose. Rather, in the words of former child welfare administrator BJ Walker, systems must learn “to differentiate between the small fraction of parents who have neither the skill nor will to keep children safe [like Judy Shaughnessy], and those who have the capacity to learn, and overcome existing vulnerabilities and limitations.”

Lisa’s story is particularly timely now because abused children are more isolated than ever while school buildings in many places are closed due to COVID-19. Reports to child abuse hotlines dropped drastically around the nation as schools closed, but there is reason to believe that the job loss, deaths, and social isolation caused by COVID-19 have led to increases, not decreases, in child maltreatment. Who knows how many Lisas are suffering in silence now?

Studies have documented the relationship between child abuse and many of the adverse outcomes endured by Lisa Montgomery, including brain damage, diminished executive functioning and cognitive skills, poor mental and emotional health, post-traumatic stress, and adult criminality. Ending the suffering of children should be enough reason to require reporting and investigation of child maltreatment, the huge costs to society of severe child maltreatment provide another incentive to make sure severe maltreatment is found and stopped. If Lisa Montgomery could have been saved, Bobbie Joe would have been saved as well.

Note to my faithful readers: Please excuse the long gap in time since my last post. I’ve been busy working on my local blog, Child Welfare Monitor DC. That blog contains posts that are specific to the District of Columbia but may be of interest to observers of child welfare around the country. Please check it out and consider subscribing!

Therapeutic residential care: A necessary option for foster youth with greater needs

Photo by kat wilcox on Pexels.com

The tide of opinion in the U.S. child welfare arena has been turning against institutional settings for foster youth for some time. A spate of reports of child abuse and improper disciplinary techniques in residential facilities for young people has intensified calls for the elimination of residential care as an option for foster youth. But as all who are intimately involved in the child welfare world know, therapeutic residential care is a critical part of the continuum of services that must be available for foster youth.

Media investigations have targeted abusive behavior by staff at poor-quality residential facilities around the country, with a spotlight on a for-profit company called Sequel. Concern and outrage reached a fever pitch when a 16-year-old boy died at a Sequel home in Michigan after being restrained for 12 minutes. The Imprint and the Texas Observer co-published a harrowing account of Residential Treatment Centers (RTC’s) in Texas, documenting horrific instances of abuse at multiple centers around the state.

Unfortunately, some commentators, like the author of the report on Texas RTC’s, are using reports of abuse and violence to support ending all residential care rather than getting rid of bad providers. These critics of residential care miss two basic points. First, there are children who, for a variety of reasons, are not having their needs met in a family setting. These are the children who bounce from foster home to foster home, spend nights in agency offices or hotels, or even end up sleeping in cars with their caseworkers. Many have endured years of trauma, including physical and sexual abuse, severe neglect, and living in dangerous and chaotic conditions. Some have cognitive or neurological issues caused by drug exposure in utero or severe neglect. Some have violent outbursts, many are verbally aggressive, and many have difficulty in making attachments. These children need treatment delivered in a residential setting before they can function safely and thrive in a family setting.

Perhaps some of these youths could heal and thrive in a home with professional therapeutic foster parents, an option which is gaining increasing popularity. These foster parents are highly-trained and paid to take care of children with complex needs full-time. This is an option that deserves more attention but its growth is probably limited by both the lack of willing and qualified candidates and the expense.

Residential care abolitionists also miss the importance of quality. Residential programs can range from outright abusive to very high quality and highly successful in achieving positive outcomes for their clients. In an op-ed in The Imprint, Dana Dorn and Kari Sisson of the Association of Children’s Residential Centers explain that “High-quality residential interventions have the ability to change lives for the better and are a critical part of the continuum of behavioral health services. They have well-trained and supported staff who provide individualized, trauma-informed, youth-guided, family-driven care in environments that are safe, welcoming and encourage healthy relationships.” The authors stress that providers who are incompetent or “prioritize profits” over people should not be allowed to stay in business.

Opponents of residential care often use faulty reasoning to make their point. They often state that children who attend residential care have worse outcomes than those in family care without explaining that it is the most traumatized, troubled kids with complex histories who are placed in residential facilities. Those children would be expected to have worse outcomes than their peers because they have often had the worst past experiences by the time they finally have access to treatment.

The State of Washington provides a cautionary tale of what can happen when residential care in a state almost disappears. Budget pressures stemming from the 2008 recession dovetailed with the growing sentiment against residential options, as described in an excellent article in The Imprint by Elizabeth Amon. Between 2009 and 2019, over 200 residential beds in 13 locations disappeared. Unfortunately, the state lacks enough appropriate placements for youth with psychiatric, behavioral and developmental needs. These young people end up staying overnight in offices, emergency one-night foster homes, hotels, and cars–or sent to out-of-state facilities including some operated by Sequel. Not only are these arrangements anti-therapeutic, but they are extremely expensive, as Amon points out.

In Texas, where the Imprint focused on the poor quality of many RTC’s, child welfare administrators are worried about the declining number of residential centers. Every year, at least one RTC stops contracting with the state due to inadequate reimbursement, which means they cannot pay workers enough to retain them. As a result, the number of Texas foster children sleeping in offices and hotels spiked last year, according to an article in the Austin American-Statesman. These were mainly teenagers with trauma histories and/or significant behavioral and mental health issues, according to a state official.

In New Mexico, the Department of Children, Youth and Families (CYFD) contracts with ten residential treatment centers in the state, but that is not enough to care for all the foster youth who need therapeutic residential care, as the Secretary told the Santa Fe New Mexican. As a result New Mexico still sends children to out-of-state facilities. The Secretary has requested more funding for additional therapeutic residential care resources.

In Maryland, the Baltimore Sun and WYPR reported last February that dozens of children were spending weeks or even months in psychiatric units of hospitals without a medical reason because social workers had nowhere else to place them. Often these children were placed in psychiatric units after experiencing a crisis in a foster home. Most of these children are not ready to move to a foster home upon discharge and need a higher level of supervision and therapeutic care. But there are waitlists for the roughly 350 spots at Maryland residential treatment facilities, and for out-of-state facilities as well. These long hospital stays are destructive and traumatic to the children as well as extremely expensive.

Last January, I wrote about similar problems in Oregon, New York, California, and Illinois. Residential critics miss the point. If states don’t have quality residential facilities, or any residential facilities at all, they will send their kids to facilities run by operators like Sequel, put them up in offices, hotels, temporary placements or cars, or leave them in hospitals. That’s why only three out of 40 states and territories sending children to Sequel facilities have severed ties with the company, despite its awful track record.

Those who oppose all residential care for foster youths are blind to the challenging problems of some foster youth, the life-changing potential of quality therapeutic residential care and the vast differences between high and low-quality residential facilities. We need to make sure quality residential services are well funded and regulated to keep children out of offices, hotel rooms, abusive or out-of-state facilities, and hospitals. Legislators at all levels of government must recognize the need for adequate funding of this crucial service necessary to heal the wounds of our most fragile foster youth.

“Upending child welfare” means devaluing Black children’s lives

Image; University of Houston/Center for study of Social Policy

In the wake of the killing of George Floyd by police, expressions of outrage from around the country and calls for police reform were soon followed by calls for completely abolishing police forces. It did not take long before a chorus of cries were launched to eliminate child welfare as we know it as well. Child welfare was described as yet another system that controls and punishes people of color. Yet, these calls disregard the suffering of Black children who are abused and neglected; it also ignores the evidence on the reasons for Black families’ high level of involvement in child welfare.

The call for the abolition of child welfare did not come out of the blue after George Floyd’s death. It is the direct descendant of a movement that began around 2004, when a coalition of foundations, nonprofits, and academics formed around the idea that the “disproportionate” representation of Black children in child welfare stemmed from a racist system.[1] This coalition launched a well-funded campaign to reduce the representation of black children in child welfare and especially foster care. They issued reports, held conferences, and provided training and technical assistance to help states analyze their disproportionality problems. The movement seemed to run out of steam afternew research (described below) debunked their major thesis, but it regained strength in the wake of the Black Lives Matter movement, and came roaring to the forefront after George Floyd’s killing.

One of the leaders in the earlier coalition, the Center for the Study of Social Policy, has joined with the Graduate College of Social Work at the University of Houston to launch a movement entitled upEND, with the aim of ending child welfare as we know it. Several representatives of upEND have published an article in the Journal of Public Child Welfare which attempts to explain their thesis. The upEND argument relies on two assertions: that the high rate of Black child and family representation in the child welfare system is due to racism within the system, and that this high rate of representation harms Black children and families. Unfortunately, these assertions are largely wrong, as I explain below.

ASSERTION ONE: The difference in Black vs. white involvement in the child welfare system are due to a racist child welfare system.[2]

There is no disagreement about the truth of upEND’s statement that Black children and families are more likely to be involved in child welfare than White children and families. In its article, upEND cites studies concluding that Black children are more likely to be reported to child abuse hotlines, more likely to be investigated, more likely to be found to be maltreated, and more likely to be placed in foster care. The ultimate result is that of this chain of disparities at each phase of the child welfare pathway is that in 2018, black children represented 14% of the total child population but 23% of all kids in foster care.

However, the real controversy (although buried in the upEND article) is about the reasons for this disparity. Is it due to a racist child welfare system, as upEND and its allies posit, or due to a difference in the underlying rate of child abuse and neglect among Black versus White families? Data suggest it is the latter. Of course, it is difficult to measure child maltreatment, which makes this question hard to answer. Although the U.S. Children’s Bureau collects annual data on official reports of child maltreatment and agency dispositions of these reports, these numbers leave out unreported maltreatment and may reflect erroneous determinations by investigators. To provide a better estimate, the Bureau periodically conducts National Incidence Studies (NIS) of child abuse and neglect. These studies are designed to estimate more accurately the incidence of child maltreatment in the United States by using community professionals to report on the actual cases of maltreatment that they have seen during the reporting period.

According to the most recent national incidence study, NIS-4, conducted in 2010 on data collected in a year spanning 2005 and 2006, Black children were almost twice as likely to be abused or neglected as white children. It estimated that 24.0 of every 1,000 black children experienced maltreatment severe enough to cause harm in the study year as compared to 12.6 per 1,000 white children.[3] There is other research evidence that Black and White maltreatment rates differ, including studies finding that black children have higher rates of preventable injury deaths; and “evidence that other predictors or markers of maltreatment are higher for black children, including maternal arrest rates, traumatic brain injury rates, parent self-reported maltreatment rates, intentional injury rates, and homicide rates.” A study published in the journal Pediatrics in 2017 concluded that the child abuse fatality rate for children aged four and under was 8.0 per 100,000 African-American children, compared with 2.7 per 100,000 white children.

A conference convened in 2011 by Harvard, Chapin Hall at the University of Chicago, the National Council of Juvenile and Family Court Judges and the National Court Appointed Special Advocates, brought together leading scholars on child welfare and race from around the country. A research brief summarizing the conference concluded that “there is a significant black/white maltreatment gap, one that roughly parallels the gap in official maltreatment reports. This evidence contradicts the belief that black children are included at high rates in the child welfare system because of bias.” One speaker noted that “African American children are at least as likely to be underserved as overserved” by current child removal rates. The authors of the brief suggested that the higher rate of maltreatment of Black children stems from the history of slavery and racism, which led to higher poverty and concentration in impoverished neighborhoods characterized by crime, substance abuse, unemployment, and limited community services. As Randall Kennedy of Harvard Law School put it, “given the history of race and racism, given the deplorable conditions suffered disproportionately by black families—conditions that produce high rates of substance abuse and other self-destructive behavior—it would be surprising if black children did not have higher rates of contact with the child welfare system than white children.”

In her important book, Spare the Kids: Why Whupping Children Won’t Save Black America, Stacey Patton has added to this narrative by linking the legacy of slavery to current patterns of discipline by Black parents. Introduced to whipping by White slaveholders, Black parents adopted a similar practice to train their children to be docile workers and avoid worse punishments from their masters. Even today, Patton contends, some Black parents justify “whupping” their children as the only way to prevent them from being shot or locked up.

In other words, there is a strong argument that disproportionality is rooted in racism. But It’s not a racist child welfare system that results in disproportional representation of black children in the child welfare system. Rather, it is the our country’s history of slavery and continuing oppression of our Black citizens that has created the difference in child maltreatment which in turn resulted in disproportional representation of Black and White children in child welfare.

ASSERTION TWO: The disparity between Black and White representation in child welfare systems causes “pervasive and persistent harm” to Black children and families. 

The next pillar of upEND’s argument is that differences in child welfare involvement cause harm to Black children and families. The authors emphasize the placement of Black children in foster care, stating that “the act of forcible separation of children from their parents is the source of significant and lifelong trauma.” It is first worth noting that most children involved with child welfare are not separated from their families. Nationally, more children receive in-home services than are removed to foster care.[3] Moreover, it is not always clear that separation from parents is traumatic for a child. A child’s reaction to placement depends on the child’s age, the quality of the attachment with the parent, the type of environment from which the child is removed, and the way the placement is handled, according to Vera Fahlberg’s authoritative book, A Child’s Journey through Placement. A child who has been emotionally neglected and has no connection to the parent may have “almost no reaction” to the placement, Fahlberg points out. Moreover “if a child is actually fearful of his living environment, he may not react as adversely to the separation. Indeed, relief is occasionally observed.” And even if the child is traumatized by separation from abusive or neglectful parents, that child may still benefit from being removed from that environment.

There is an extensive literature on the harmful and often lifelong consequences of abuse and neglect. These can include impaired brain development, health problems; diminished executive functioning and cognitive skills; poor mental and emotional health; attachment disorders and social difficulties; post traumatic stress; unhealthy sexual practices; juvenile delinquency; alcohol and other drug use; and intergenerational transmission of maltreatment, as described in an issue brief from the Children’s Bureau. The specific outcomes for each child depend on “the child’s age and developmental status at the time of maltreatment, the type, frequency, duration, and severity of the maltreatment, and the relationship between the child and the perpetrator,” according to the Bureau.

Advocates of upending child welfare often point out that most children are removed for neglect rather than abuse, and they suggest that neglect is synonymous with poverty. But the actual prevalence of neglect versus abuse is unknown. One must remember that there may be several types of abuse and neglect in one family but the investigator may not be able to substantiate all of them. There may very well be abuse in a family where only neglect was substantiated. Moreover, the kind of neglect that leads to child welfare involvement is often serious or chronic and is not at all synonymous with poverty. Chronic neglect can lead to serious cognitive and social difficulties, chronic disease, and difficulties in emotion regulation similar to the effects of trauma, as discussed in another brief from the Children’s Bureau. Moreover, chronic neglect often “opens the door” for physical or sexual abuse by a mother’s male partner.

Even though child maltreatment can cause lifetime harm to its victims, one might still believe with upEND that the treatment (child welfare services) is worse than the disease, at least for Black children. To address this contention, Richard Barth and other well-known child welfare scholars recently published a review of the literature entitled Outcomes following child welfare services: what are they and do they differ for Black children? They reviewed more than 50 rigorous studies of outcomes following a child welfare intervention and found “very little reason to believe that children’s outcomes are worsened by participation in child welfare services.” They noted that the vast majority of children received short-term services, with only a fraction placed in foster care. Based on their analysis, they found that child welfare in general results in improved outcomes in the areas of safety and education for both White and Black children and generally neutral effects on health, mental health and behavioral outcomes. Moreover, they concluded that child welfare may protect Black children in particular against some future harms as early death, transitions to juvenile services (for girls), and early childbearing.  The authors found no evidence that Black children are doing worse than other children as a consequence of system involvement. Perhaps most important, the researchers found that Black parents and youth, like their White peers, are generally positive about their experience with child welfare. (Most interesting were the two surveys of 21-year-olds that found about two-thirds saying that they were lucky to have been placed in foster care.)

It is very sad that the measurable benefits of child welfare on children’s outcomes are so modest. This may be a consequence of the poor quality of services that are generally provided to many children and their parents. Far from the intensive parenting and enrichment that abuse and neglect victims need, many foster children and youth receive benign neglect at best and outright abuse at worst. As I have written based on my experience, many foster homes provide little nurturing and attention. The system is particularly unsuccessful for older youth with behavioral problems, who are often moved from home to home, placed in residential programs which vary from highly therapeutic to abusive, or spend nights in agencies and hotels, as described in an excellent blog post by Dee Wilson. Moreover, the services provided to children and families by other systems, like mental health and drug treatment, are often low-quality and plagued by waiting lists and provider turnover.

upEND’s policy prescription

In order to end racial disproportionality and its harmful effects, upEND proposes “the abolition of the child welfare system as we know it.” While the exact meaning of this phrase is not specified, the writers make it very clear that abolition means “that the forcible and involuntary separation of children from their parents is no longer viewed as an acceptable form of intervention.” To bolster their proposal, the authors contend that for Black families in America, forced family separation has its roots in the dehumanizing system of slavery.

The historical connection of child removal to racism and slavery is not clear. White children were removed from their families by child welfare agencies long before Black children. Dorothy Roberts, who herself has called for the abolition of child welfare, traces the intellectual roots of child removal to the early progressives around the turn of the twentieth century, who tried to address poverty by placing poor immigrant children in orphanages or sending them to work on rural farms. As Roberts describes in her famous book, Shattered Bonds: the Color of Child Welfare, “black families were virtually excluded from openly segregated child welfare services until the end of World War II.” When public agencies began to take over child welfare from private agencies, they started to turn their attention to Black children. But the disproportionality took some years to appear, according to statistics cited by Roberts. So it is hard to understand the logic of the claim that the practice of child removal by child welfare is rooted in racism.

While not clear on exactly what shape the new child welfare system (if any) would take, upEND states that it will replace the current child welfare system with “community-based supports for the care and well-being of children that are designed by and for families and communities…” The authors call for a broad range of policies including: creating and expanding critical safety net programs and affordable housing; expanding the use of informal care and supports for kin care providers; ending the use of congregate care placements; strengthening the efforts states must make to prevent foster care placement; and eliminating “arbitrary timelines” to terminate parental rights.

The authors do not explain how they would respond to maltreatment of children whose parents are not capable of protecting them, or who have seriously harmed them. As a member of the District of Columbia’s Child Fatality Review Panel, I have learned about many deaths of children whose families had long histories of contact with the city’s child welfare system. These families were the subject of numerous calls to the child abuse hotline for physical abuse, school absenteeism, children left alone, parents under the influence of drugs or alcohol or both–often multiple types of abuse and neglect for the same family. Some of these calls were set aside as not worth investigating, in some cases child protective services found no cause for intervention, and in some cases the intervention was not enough. Whether the child was accidentally crushed as an infant while sleeping with a parent on drugs or alcohol, beaten to death by a parent or the mother’s boyfriend, or shot as a teenager by a member of a rival crew after years of unresolved problems in the home, these children were abandoned by the system that was set up to protect them. upEND’s prescriptions would likely result in more such deaths, even more serious injuries and damage to children, and much more suffering.

As upEND proposes, we need to address the the unconscionable inequality and poverty that affects a disproportionate number of Black families by creating a true safety net and making affordable safe housing available to everyone. To add to their list, we also need to reform policing and criminal justice to eliminate a huge source of stress on Black families. But we cannot wait to protect children until present inequities and the impacts of past ones are eliminated. We should develop programs specifically aimed at preventing abuse and neglect among high-risk families of any race as soon as a child is born, such as Pennsylvania’s new Hello Baby program. Another promising approach is to provide high quality early childhood education accompanied by family support to all infants who are at risk of maltreatment. And as we work toward eliminating child abuse and neglect before they occur, we must continue to respond to children who are currently being maltreated. We must improve the accuracy of this response by eliminating any racial or other biases that result in false positive or negative findings of maltreatment. For example, the use of predictive risk modeling to screen hotline calls has been shown to reduce the disparity between the case opening rates between Black and White children.

As Barth and his colleagues put it, not responding to maltreatment of Black children is a “violation of children’s essential rights.” If we accept upEND’s prescription for eliminating differences in child welfare representation between Black and White children, we will subordinate the rights of children for safety, security and love to the rights of parents to complete autonomy in childrearing. For those who say Black Lives Matter, the this is a sad lack of concern for Black children’s lives.

[1]: The term “disproportionate” or “disproportionality” refer to the fact that a higher proportion of Black children are involved in child welfare relative to White children. In general I prefer to use a more neutral term, such as black children’s “higher level of involvement” or “representation” in child welfare.

[2]: I have taken the. liberty of formulating these assertions to reflect the actual pillars of upEND’s argument. As stated in the article, it appears that their first pillar is that there are racial disparities. But there is no disagreement about that. The authors gloss over the reasons for these disparities, which is the actual point of disagreement between the child welfare abolitionists and others.

[3]:Black children were also nearly twice as likely to experience maltreatment as defined by the more inclusive “endangerment standard.” This broader concept of maltreatment affected 49.6 per 1,000 Black children as compared to 28.6 per 1,000 White children.

[4] According to the Children’s Bureau’s most recent Child Maltreatment report, less than half of the maltreatment victims who received services in Fiscal Year 2018 (146,706 out of 391,661) were placed in foster care. Unfortunately, we do not have these data by race.