Proposed federal budget cuts to child welfare services might hurt New Jersey’s recent progress in child welfare, the Commissioner of New Jersey’s Department of Children and Families told state legislators last month. The anticipated reduction of more than $100 million would force the department to “revert to its most basic role — that of child protection — not prevention, not support or empowerment, just surveillance and foster care,” DCF Commissioner Christine Norbut-Beyer told members of the state Senate’s Budget Appropriations Committee. The relegation of child protection–or “surveillance and foster care”–to the “most basic” version of child welfare is telling. DCF’s Commissioner, like many other progressive child welfare administrators, no longer views child protection as the primary purpose of child welfare services.
For those who regularly read this blog, the devaluation of child protection and foster care by a high-level administrator over child welfare will not be a surprise. There has been a sea-change in child welfare over the past decade. The mainstream view of the purpose of child welfare has shifted from responding to child abuse and neglect to “upstream prevention.” And why not? Why wait until children are abused and neglected if we can prevent the maltreatment altogether?
There is no denying that ideally, it is better to prevent maltreatment than to respond to it. But the services that are discussed as prevention are mainly in the province of other agencies. In seeking to broaden child welfare services through the Family First Act, Congress added mental health, drug treatment, and parenting training. While the latter can be seen as a function of child welfare, drug treatment and mental health are separate systems. There has been increased emphasis on cash and housing and other antipoverty benefits as child maltreatment prevention; we have large programs to address these problems–much larger than the child welfare system. Even some of the “prevention services” that DCF and other state agencies have adopted, like “Family Success Centers,” provide a wide array of place-based services, most of which do not fall into the traditional orbit of child welfare and would be most appropriately funded jointly with other agencies.
If “prevention” could abolish the need for child protection, then there would be no need for child protection agencies. But we know that no amount of “prevention” (at least as envisioned by today’s child welfare establishment) will eliminate child abuse and neglect. We are often talking about patterns of mental illness, drug abuse, family violence, and poverty that have persisted over generations. And then there are families that are not poor or characterized by generations of dysfunction but where a parent’s mental illness or disordered personality makes them incapable of safely raising children. As Jedd Meddefield describes in his brilliant essay called A Watershed Perspective for Child Welfare, “As critical as it is to fully consider upstream factors, it would be wrong not to do all we can to help children who lack safe families today.
But the fact is that many of today’s child welfare leaders like Norbut-Beyer appear not to be interested in child protection and foster care. They often disparage the “reactive” role of child protective services in contrast to the “proactive” nature of prevention. Many agencies have reactive missions–police, firefighters, emergency rooms–and one could argue these are the most important services of all because they save lives. The analogy with the police is revealing. Police react to allegations of crime just as child welfare agencies react to allegations of child abuse and neglect. To prevent crime, we must not rely on the police, who are overburdened already and not trained and equipped to provide the services needed. Instead we must turn to a whole host of agencies dealing with education, public health, mental health, housing, income security and more–the same agencies that we must mobilize if we want to prevent child abuse and neglect. Nobody is saying that the police need to address the underlying causes of crime.
Norbert-Beyer’s use of the word “surveillance” as a synonym for child protection is telling indeed. She clearly doesn’t see CPS investigators as heroes who go out in sometimes dangerous and certainly uncomfortable circumstances to protect children–and maybe even to save them. It’s not surprising because we have all been told that saving children is not what child welfare is about.1 And foster care? Norbert-Beyer boasts that New Jersey has the lowest rate of child removal in the country, and children who are removed more often than not go to relatives. She’s not very interested in the quality of care these vulnerable young people receive or in all the things her agency could do it improve it, like establishing foster care communities (like Together California) to house large sibling groups or investing in cutting-edge models of high-quality residential care.
When the person who is in charge of child protective services in a state that is acknowledged as a leader in the field calls it “surveillance,” and relegates it along with foster care to “basic” functions that hardly deserve mentioning, it’s hard to have faith that the crucial mission of child protection will be implemented with the passion it deserves. Norbert-Beyer’s comments illustrate the prevalent thinking that leads to the diversion of resources from crucially needed child protective services and foster care to “prevention services” that are and should be provided by other agencies.
See for example this statement from Casey Family Programs, which includes the words “We must continue to evolve from an approach that seeks to “rescue” children from their families to one that invests in supporting families before abuse and neglect occur.” One of the first messages I was given as a CPS trainee is that my job was not to save children. ↩︎
Ten-year-old Begidu Morris died more than three years ago of horrific child abuse by his parents, who adopted him from Ethiopia. But there was no avalanche of media coverage of his death, no interviews with shocked neighbors saying they had no idea the child even existed. No pyramid of teddy bears and flowers outside his home. No arrests of those who tortured and murdered Begidu, and no demonstrations demanding justice. No anguished commentaries from experts on how we failed and what could be done to prevent such tragedies in the future. There is not even a picture of Begidu by which we can remember him. If not for a child fatality summary released by the Florida Department of Children and Families (DCF) two years after Begidu’s death, nobody outside the family, a few neighbors, and a small group of medical, social service, and law enforcement professionals would have known that it happened.
According to the DCF child fatality summary, Begidu Morris collapsed at home in Lee County, Florida, on March 17, 2022 and was transported to Golisano Children’s Hospital. He was diagnosed with subdural hematoma, hypothermia, cardiac arrest, acute respiratory failure, retinal hemorrhages, and metabolic acidosis.Begidu was placed on life support and died on March 22, 2022. Examination showed bruising to Begidu’s head and significant scarring to his buttocks. Begidu weighed 44 pounds, which was in the 0.1 percentile for his age. An autopsy determined that the cause of death was “complications of hypoxic ischemic encephalopathy due to craniocerebral trauma” and the manner of death was homicide.
The CPS investigation
Begidu lived with his adoptive parents, Jack and Consuela Morris, and their biological son. Their two other biological children were in college and returned home for vacations. Begidu and his biological sister were adopted from Ethiopia by the Morrises, when he was about two years old. His sister’s adoption with the Morris family disrupted and she was re-adopted by another family in 2019. After Begidu’s death, the family quickly obtained a lawyer and was “minimally cooperative” with the CPS and police investigations.
The family’s three-bedroom home was described by the investigator as “pristine.” In addition to the master bedroom and the teenage sibling’s room, the third bedroom served as a guest room for the two adult siblings when they returned home from college. Begidu slept in a small closet, where investigators discovered a pile of urine-soaked clothing on a rollaway bed. The door to the closet was locked from the outside and was monitored by a camera. The closet had no ventilation and there were no toys or personal possessions indicating that a child lived there. Begidu’s adoptive parents claimed that he engaged in behaviors such as temper tantrums and fecal smearing.
The CPS investigation concluded that “[a]lthough it was not able to be determined with certainty who inflicted the injury/injuries that led to this child’s death, it can be concluded that the parents either participated in the abuse that led to the child’s injuries and subsequent death, or they participated in concealing the horrific abuse and neglect that he suffered.” It found the parents Jack and Consuelo Morris responsible for Begidu’s death and for “bizarre punishments,” internal injuries, physical injuries, medical neglect, “failure to thrive/malnutrition/dehydration,” failure to protect, and inadequate supervision.
Deaths due to child abuse or neglect are the tip of the huge iceberg of child maltreatment, most of which remains unseen by the public. All of these deaths should be examined, not only to determine whether maltreatment occurred and who was responsible, but also to identify systemic issues that might suggest policy changes to protect other children. Yet, the investigation summary I received showed a complete lack of curiosity and interest by DCF in drawing lessons from this terrible case and making them available to the public.
Isolation is a common element of severe and chronic child abuse cases. Begidu was clearly isolated. He had not visited a medical provider in three years. Most neighbors were unaware that the child even existed. And perhaps most important, he was not attending school–at least not in person. The Investigation Summary contains three different statements about Begidu’s and his adoptive brother’s schooling, stating in one place that the brother was enrolled in Lee County Schools and Begidu was not, in another place that both were homeschooled, and in two different places that each was enrolled in “virtual school.” DCF did not respond to my request to know which statement was correct. Yet this is crucial information.
If Begidu was enrolled in school virtually, it would have been incumbent on the investigator to contact the school and ask about his attendance and any interactions with Begidu and his family. This would be important in establishing if there was any negligence on the part of school staff or any need for policy changes. If Begidu was not in school at all, the question would be whether the state was aware he was being homeschooled. Homeschooling parents in Florida must provide one-time notice to the local superintendent, maintain a portfolio of their children’s work, and turn in an annual assessment by standardized test or portfolio evaluation. We need to know if Begidu’s parents complied with these requirements, and how he fell through the cracks if they did not.
With the lack of protective educators to respond to Begidu’s plight, DCF should have wanted to know if there were any opportunities for his situation to be brought to the attention of other protective adults. While the Morris family had no history with CPS in Florida or in Michigan, where they adopted Begidu, there may have been an occasion when the abuse in this home could have come to light. Begidu’s sister was re-adopted by another family in Florida in 2019. One cannot help wondering if the sister was the previous target of abuse in the home, thus leading to her adoption by another family. In his medical chart from a primary care visit in 2018 or 2019, there was a note that Begidu said he was “going to be just like his sister.” (These may be the only words of Begidu’s to be recorded).
Fully 19 lines of text about Begidu’s sister are redacted from the Investigation Summary, which says only that she lives in another state and had no contact with Begidu or the Morris family. It is likely that the redacted information concerned the circumstances behind the disruption of the sister’s adoption. Did the sister report any concerning treatment to her new adoptive parents? Did anyone involved in the second adoption have information that should have been reported and investigated? Was a coverup part of the new adoption arrangement? Unfortunately, DCF denied my request for this information. DCF appears to have no interest in learning from Begidu’s death and sharing the implications of what they have learned with the wider community in the interests of protecting children in the future.
Whatever the flaws of the investigation were in terms of uncovering systemic issues, DCF ultimately found Begidu’s parents to be responsible for Begidu’s death and the horrific abuse and neglect that preceded it. But shockingly, the agency decided not to remove Begidu’s adoptive brother from the home. According to the case summary, the teenager reported feeling safe in the home, and “sources familiar with the child” reported no concerns for his safety. (One wonders who these sources were and what they knew about Begidu’s abuse.) The investigator also noted that the teen “appeared physically healthy, was enrolled in virtual school, and was visible in the community, including attending a Mixed Martial Arts program several times weekly. He had his own fully furnished bedroom, and he was allowed to have relationships with others outside the home, including his adult siblings who were away at college.” It is clear that this decision did not come easily. According to the investigation summary, “[W]hile it is concerning that [Begidu’s sibling] remains in the home, it should be noted that he does not share the same vulnerabilities that were present with his younger sibling.” This is quite a statement. Apparently, this child was considered “safe” in the home of where his brother suffered unspeakable abuse and died, because he himself was not ill-treated. There was not even a services case opened to make sure that he received therapy for the trauma he has endured.
The criminal investigation
Three years after Begidu’s death, the police have made no arrests in the case. The DCF Investigation Summary states that CPS was involved in multiple meetings, including with the State Attorney’s Office (SAO) and that
“[u]ltimately no action was taken by the SAO as the perpetrator of abuse could not be determined based on the information that was available at the time of their staffing. There were two individuals (the mother and [the brother]) in the home capable of causing the head trauma to the child; the individual responsible for the abuse could not be determined.
The lack of charges is almost incredible. If they could not have charged anyone with the actual homicide, it is hard not to understand how the parents could not have been charged with multiple counts of child abuse, charges that surely exist in Florida as they do in other states. It is hard not to ask the question, as one child advocate put it, could this happen if Begidu were White? The State’s Attorney denied my request for the investigation records on the grounds that “there is still an active investigation.” But it is hard to believe that the police are still seriously working on this case.
Adoptions and Severe Abuse
Begidu’s story has similarities with the stories of other children adopted from overseas or from foster care. Few readers could have forgotten the six Hart children, adopted from foster care in Texas, who were starved, beaten, and eventually killed in a 2018 murder-suicide by one of their adoptive mothers. In 2013, a Washington State couple were convicted and sentenced to decades in prison in the death of their Ethiopian adopted daughter, Hanna Williams, who died of hypothermia in 2011 after being forced to sleep outside in the rain. Her malnourished body was covered with bruises and scratches and her brother testified that their adoptive parents beat them and deprived them of food. A Pittsburgh couple was sentenced in 2014 for endangering the welfare of two children they adopted from Ethiopia through withholding food from their six-year-old son and causing abusive head trauma to their 18-month-old daughter. In a dispiriting echo of Begidu’s case, the adoptive mother was sentenced to six to 12 months in jail with daily work release to enable her to go home and care for her biological children. The mother who re-adopted these children saw this sentence as “an indication that the court viewed adopted children as different, since it decided that a woman who abused her adopted kids could be trusted with her biological children.” In 2021, a woman in Washington was charged with second-degree criminal maltreatment for beating and starving a 12-year-old boy that she and her husband adopted from Ethiopia. The prosecution decided to drop the case, as reported by KUOW, stating that the boy had “suffered mental health challenges which will prevent him from testifying.” The child had been re-adopted by one of his schoolteachers, who saw his abuse and came to an agreement with his parents–a possible hint to what may have happened with Begidu’s sister.
The vast majority of adoptive families provide loving homes, and a study from the Netherlands suggests that adoptive families are less likely to maltreat their children than birth families. Nevertheless, observers have noted clusters of cases of severe abuse of adopted children. Such a cluster was noted in the State of Washington at the time of Hanna Williams’ death. A committee led by Washington’s child welfare agency and children’s ombudsman in 2012 published a Severe Abuse of Adopted Children Committee Report, which discussed 15 cases of adopted children who had suffered abuse at the hands of their adoptive families. There was a common pattern of concerning parenting practices in these cases, including physical confinement, withholding food, isolation (including withdrawal from school), forcing the child to remain outside the home; and disparaging remarks about the child. The committee observed that these cases tend to occur “when an adoptive family is ill-prepared or ill matched with a child that suffers from unidentified and/or untreated trauma, abuse, and/or neglect.” The analysis suggests that families may respond to their adopted children’s difficult behaviors caused by past trauma by using punishments like sending a child to bed without dinner, which in turn triggers further behaviors, leading to a vicious cycle of behaviors and punishments culminating in egregious abuse.
The Washington committee made multiple recommendations for avoiding such tragedies in the future, including better oversight of child-placing agencies, strengthening the assessment of prospective adoptive families, and improved training for parents and adoption professionals, and post-adoption support services for families. Some of these recommendations required legislation and other required agency action, and it is not clear whether any of them were implemented.
The trial of Larry and Carri Williams for the death of their adopted daughter, Hannah, was a major event in Washington, with Seattle-area Ethiopians attending proceedings every day, “almost as a vigil” as the Seattle Times described it. But with no arrests in Begidu’s case and no media coverage until two years later, Florida’s Ethiopian community may not even be aware of it. Holding Begidu’s adoptive parents accountable won’t bring him back, but the lack of any meaningful response to his death is an offense to all child victims of abuse and neglect and those who care about them. The only thing that can be done now is to hold his torturers and murderers responsible and learn from his suffering to prevent other children from sharing it.
The original version of this post was published on April 4, 2022.I decided to update and re-publish it after reading a press release from Prevent Child Abuse America stating that “PCAA’s signature home visiting program, Healthy Families America, has been proven to reduce child abuse and intimate partner violence while improving long-term health and educational outcomes.”While I cannot evaluate the claim about domestic violence, the post below show that Healthy Families America has not been “proven” to reduce child abuse.
I have written before about the power of wishful thinking and how it causes people to disregard research and real-life results. A program called Healthy Families America (HFA) offers a good example of the power of wishful thinking. The nation’s oldest and largest charity (now called Prevent Child Abuse America or PCAA) dedicated to the prevention of child abuse launched HFA based on weak evidence that a program in Hawaii could prevent child maltreatment. The first experimental study of the Hawaii program found no impact on child maltreatment but did nothing to derail the launch of HFA, which grew into the centerpiece of PCAA. Studies of HFA programs around the country have found little evidence of reductions in child maltreatment, but the program has continued to grow. The story of HFA is a lesson in the power of wishful thinking and the failure of evidence (or lack thereof) to counteract it.
As told in a helpful history of home visiting, all modern programs can trace their origins to Henry Kempe, whose book, The Battered Child, brought about the recognition of child maltreatment as a national problem. To address child abuse, Kempe called for universal prevention through a network of home health visitors. Inspired by Kempe, modern home visiting began with Hawaii’s implementation of the Healthy Start Project (HSP) in 1975. HSP was developed on the island of Oahu. It had two components: early identification (at the birthing hospital) of families with newborns at risk of child abuse and neglect and home visiting by trained paraprofessionals for those families classified as at-risk who agreed to participate. This initial program was never evaluated, but anecdotal information suggested it was successful in promoting effective parenting, and six similar programs were established on neighboring islands.
The Hawaii Legislature authorized a three-year pilot program focusing on one neighborhood in Oahu, which began in 1985. There was no control group in the pilot study, and the researchers used CPS reports and changes in family stress in participating families to measure program effectiveness. During the three-year pilot, there were few reports of physical abuse, neglect or imminent harm for program participants. Because evaluations of other home visiting programs had found much higher rates of reported maltreatment in comparison group families, these results were viewed as evidence that the program had a positive impact. According to the authors of the first rigorous evaluation of HSP, “The pilot study results might have been given too much weight, given the lack of a control group and the short period of follow-up for most families.” Nevertheless, the results of this unpublished study were enough evidence for the Legislature to expand HSP throughout Hawaii starting in 1989.
Home visiting in general was gathering steam in the 1980s and early 1990’s. In 1990, the U.S. General Accounting Office (GAO) issued a report promoting home visitation as a “promising early intervention strategy for at-risk families.” In its summary of research evidence, GAO focused mostly on health and developmental benefits for children, rather than maltreatment prevention. In 1991, the U.S. Advisory Board on Child Abuse and Neglect issued a report recommending a pilot of universal voluntary neonatal home visitation, stating that the efficacy of home visiting as a preventive measure was “already well-established.” The Board cited the results of a federally-funded demonstration begun 17 years earlier as well as the the nurse home visitation program started by David Olds in 1977. But HSP was not mentioned.
Despite the lack of a rigorous evaluation, the National Committee to Prevent Child Abuse (NCPCA, now called Prevent Child Abuse America), which bills itself as the nation’s “oldest and largest organization committed to preventing child abuse and neglect before it happens,” had become interested in using HSP as the nucleus of a national home visiting program. But first, NCPCA conducted a one-year randomized trial of HSP. The trial suffered from severe methodological limitations, including “less than ideal followup,” differential dropout rates in the program and control groups, the failure to blind interviewers to experimental or control status, and reliance on program staff rather than researchers to measure some outcomes. Nevertheless, the trial concluded that HSP reduced child maltreatment, and this apparently gave NCPCA the assurance it needed to invest in the model.
NCPCA launched Healthy Families America in 1992, with financial support from Ronald MacDonald House Charities. Rather than impose a single service model, HFA was based on a set of principles or critical elements, which included initiation of services prenatally or at birth, assessment of the needs of all new parents in the target area, voluntary nature of services, at least weekly services for families with the highest needs, availability of services for three to five years, comprehensive nature of services, and cultural competence, among others. The typical HFA program included an assessment of all new or first-time parents in a given community at the time their babies are born or prenatally.”
In the meantime, the Hawaii Department of Health recognized the limitations of both the pilot study and the NCPCA study and initiated a more rigorous evaluation of HSP in 1994. This was a randomized controlled trial, with at-risk families identified at the hospital and randomly assigned to the experimental and control groups. In 1999 the results of the Evaluation of Hawaii’s Healthy Start Program were released as part of an issue of the Future of Children journal containing evaluations of six different home visiting models. No overall positive program impact emerged after two years of service in terms of child maltreatment (according to maternal reports and child protective services reports). Early HFA evaluation results, published in the same issue, also failed to find effects on abuse and neglect in three randomized trials, which included the HSP evaluation discussed above and another Hawaii HSP study.
David Olds had had begun testing his Nurse Home Visiting Program in 1977 and already had long-term results on the program in Elmira, NY, as well as shorter-term results for a replication in Memphis, Tenn. That program, now known as Nurse Family Partnership, was very different from HFA. It was restricted to first-time teenage mothers and the home visitors were nurses rather than paraprofessionals. The nurses followed detailed protocols for each visit. The researchers found that among low-income unmarried women (but not other participants), the program reduced the rate of childhood injuries and ingestions of hazardous substances that could be associated with child abuse or neglect. Follow-up of the Elmira group when the children were 15 found that the nurse-visited mothers were significantly less likely to have at least one substantiated report of maltreatment. These results are particularly impressive because they overrode a tendency for nurse-visited families to be reported for maltreatment by their nurse visitors. The researchers concluded that the use of nurses, rather than paraprofessionals, was key to the success of the program.
In their analysis of all six studies published in the Future of Children volume on home visiting, Deanna Gomby et al. concluded that while the HFA and HSP evaluations showed some change in maternal attitudes and self-reported behaviors related to abuse and neglect, only the Nurse Home Visiting Program showed impacts on abuse and neglect other than from self-reports. Gomby and her co-authors also concluded that the results of all six home visiting evaluations were discouraging for those who had high hopes for home visiting for solving an array of problems. All the programs “struggled to enroll, engage and retain families.” Program benefits generally accrued to only a subset of enrolled families and were often quite modest. The authors explained the disappointing results by concluding that human behavior is hard to change, particularly when problems are community-wide. They recommended that “any new expansion of home visiting programs be reassessed in light of the findings presented in this journal issue” and stated that home visiting services are “best funded as part of a broad set of services for families and children.”
But the home visiting juggernaut was already in motion nationwide. And NCPCA, renamed Prevent Child Abuse America in 1999, had already made HFA its centerpiece program. Home visiting grew, and HFA grew with it. In 2010, Congress created the Maternal, Infant and Early Childhood Home Visiting Program (MIECHV), which was re-authorized in 2018 with funding of $400 million per year through FY 2022. HFA is one of the models that are most frequently implemented with MIECHV dollars. Home visiting programs can also receive funding through Medicaid, Title IV-B and IV-E of the Social Security Act, and many other funding sources. HFA now serves over 70,000 families per year at an average cost of over $3,000 for a family in its first year of home visiting.
The infusion of funding for HFA research resulted in a multitude of research projects (both randomized trials and less rigorous studies) and resulting publications. Nevertheless, research has yet to find solid evidence that these programs have an impact on child maltreatment: The California Evidence-Based Clearinghouse for Child Welfare (CEBC), the pre-eminent child welfare program clearinghouse, reviewed 19 research reports on HFA. Its website as of April 2022 gave the program a rating of “4” on a scale of 1 to 5 for prevention of child abuse and neglect, meaning the evidence fails to demonstrate that HFA has an effect on abuse and neglect. Interestingly, that rating no longer appears on the CEBC website, but the earlier version is preserved by the Wayback Machine. As of April 2025, HFA is no longer listed at all in the CEBC’s document titled Home Visiting Programs for Prevention of Child Abuse and Neglect. When I emailed the CEBC to ask about the missing rating, I received an email stating that Healthy Families America “is still currently under review in the Prevention of Child Abuse and Neglect topic area. The rating for this topic area was pulled from the website during the rereview process. Some programs take longer to review due to the amount of research and other factors.”
HFA was not designed to work with families that have already been found to abuse or neglect their children but that did not stop child welfare agencies from spending federal and state funds delivering HFSA to families under the Family First Prevention Services Act (FFPSA). Despite the lack of evidence of its impact on maltreatment, HFA received a rating of “Well Supported” from the clearinghouse established by FFPSA to determine whether a program can receive federal funding under Title IV-E of the Social Security Act. To get such a rating, the program must show improved outcomes based on at least two randomized trials or rigorous quasi-experimental studies. But these outcomes could be any sort of “important child and parent outcome,” (not just reduction of child abuse or neglect) and there is no standard for how to measure each outcome. Based on its review of all HFA studies that met their criteria for inclusion, the Clearinghouse found 23 favorable effects, 212 findings of no effect, and four unfavorable effects across 16 outcomes. This included five favorable effects on child safety based on parents’ self-reports of maltreatment, with no favorable effects on other measures of child safety. Self-report is generally frowned upon as a measure of child maltreatment, for obvious reasons. A positive impact of HFA might reflect that participants in HFA were more eager than control group members to provide the “right answer” to questions about maltreatment.
The “well-supported” rating from the Title IV-E clearinghouse allowed states to spend Title IV-E funds on services to families with a child welfare in-home case. To take advantage of this new market, HFA announced in September 2018 that families referred by the child welfare system were now able to enroll as long as the child in question was 24 months of age or younger, as opposed to the original requirement that services start at or before birth. To serve these families, HFA introduced special child welfare protocols. HFA advertises these protocols on its website, stating that “HFA’s evidence and the flexibility of enrollment make HFA a great prevention choice for states and child welfare organizations seeking to strengthen families and reduce the number of children placed in foster care.” (Note that there is no mention of reducing abuse and neglect!)
Today, the diversity of HFA programs makes evaluation of the program as a whole impossible. According to the website, “HFA puts communities in the driver’s seat. Local HFA programs are able to choose their eligibility criteria, parenting materials, and hire the staff they deem best to do the job. With the amount of flexibility offered, HFA has been able to be successfully implemented in a wide variety of communities.” It is hard to imagine what the evaluation of one HFA program means about the effectiveness of other programs under the same name.
Critical examination of the HFA website shows that the organization skews its portrayal of available research to present it in the most favorable light and avoids direct statements that the program prevents child abuse and neglect. On its Evidence page, HFA claims the “highest rating possible from CEBC in the category “Home Visiting Programs for Child Well-Being,” without mentioning that in the category “Home Visiting Programs for the Prevention of Child Abuse and Neglect,” HFA is currently unrated after the statement that it was unable to demonstrate an effect was removed. The page goes on to group the effects of HFA into three categories, stating that participants “build nurturing relationships with their children,” “champion their children’s health and development,” and “cultivate a flourishing future for their family.” Reductions in abuse and neglect are not mentioned in the description of how parents “build nurturing relationships with their children.”
It is disappointing that an organization that defines its mission as child abuse prevention, decided to fund HFA before it was proven to prevent child maltreatment and continued with this commitment even after the disappointing evaluations of 1999 might have led them to diversify their investment. That PCAA continues to use charitable contributions made for the prevention of child abuse and neglect to fund a program that has not been proven to accomplish this goal, raises serious ethical questions. Twenty-three members of the 45-person staff (which has grown by five staff in three years !) listed on the Prevent Child Abuse website have duties linked to Healthy Families America.
The story of HFA is not an unusual one. I have written about the similar disregard for evidence in the promotion of models such as Homebuilders and blind foster care removals. Such stories are all too frequent. They show us how wishful thinking can drive leaders to disregard research, especially after they have made a premature decision to commit to one program or course of action.
The Texas Department of Family and Protective Services has reported a dramatic decline in child maltreatment fatalities from 199 in FY 2021 to 99 in FY in 2024. Perhaps most surprising about the purported decline in fatalities is that it occurred alongside a massive drop in the number of children placed in foster care from 16,028 in Fiscal Year 2021 to 9,623 in Fiscal Year 2022, with similar numbers of children placed in 2023 and 2024.
Supporters of recent changes in Texas law regarding child maltreatment were quick to highlight these findings as evidence that foster care can be greatly reduced or eliminated with no adverse effects on child safety.
But these claims do not stand up under careful scrutiny. Changes to policy and practice can result in dramatic year-to-year changes in official counts of child maltreatment fatalities, and Texas has implemented at least three significant policy or practice changes during this period.
First, a Texas law that took effect September 21, 2021 tightened the definition of neglect to require the presence of “blatant disregard” for the consequences of an act or failure to act that results in harm to the child or that creates an immediate danger to the child’s physical health or safety. This new requirement means that deaths that would have been attributed to maltreatment prior to the law change are now not investigated at all or not confirmed as maltreatment. Indeed, DCF cites this changed definition as one cause of the decline in reported fatalities between FY 2021 and FY 2024.
Child fatality numbers were also affected by a practice change implemented by DCF that involves the way the agency handles reports of child fatalities. Previously, DCFS assigned all child death reports it received for a full investigation. But starting in September 2022, reports to the Texas Child Abuse Hotline that involve a child fatality but include no explicit concern for abuse and neglect are treated as “Case Related Special Requests,” requiring field staff to confirm that the reporter or first responders had no concern for abuse or neglect. If there are any concerns for abuse or neglect, the child fatality is then sent for a full investigation, but otherwise there is no further action. DFPS reports that the number of child fatalities it investigated decreased from 997 in FY2022 to 690 in FY2023 and 587 in FY 2024. DFPS attributes this decline in investigations to both this practice change and to the legislature’s change in the definition of neglect.
There is one newer policy change that DFPS announced in its recent report. Investigations that are closed “with a disposition of reason to believe for neglect with a fatal severity code” receive a further level of review. It seems possible that this level of review may be reducing the number of reported cases even further.
Given all these policy and practice changes affecting the count of child maltreatment fatalities, It seems highly likely that Texas did not see an actual reduction in these deaths, but rather reclassified them as not due to child maltreatment. Perhaps it is not surprising that neither DFPS nor the supporters of weaker child protection are interested in exploring what is really happening to vulnerable children in the aftermath of the drastic decline in the use of foster care.
This post was originally published as a guest commentary in the Baltimore Sun.
Last month, the Baltimore Banner reported on an alarming rise in the number of child fatalities due to maltreatment in Maryland, as shown by a federal report. The number of child abuse and neglect deaths reported by Maryland to the federal Children’s Bureau was 83 for Fiscal Year 2023, up from 27 a decade before, a rate higher than any state but Mississippi.
After initially responding with confusion, the Maryland Department of Human Services (DHS) explained that the numbers it reported to the feds were erroneous. Actually, the state was aware of 47 children who died of abuse or neglect in 2023, which was still a 75% increase from 2013. “We continue to discover where data was routinely released without any validation or reconciliation,” a deputy DHS secretary told the Banner.
But members of the legislature were already alarmed and began talking about withholding funds until the agency was able to report accurate data about child fatalities as well as the conditions of children in foster care. Eager to demonstrate its desire for transparency, DHS announced that it was pivoting to support a bill requiring the agency to promptly release information about children in foster care who die from suspected maltreatment.
But this legislation would not apply to children who died while in the custody of their parents or guardians. It would not apply, for instance, to five-year-old Zona Byrd, who starved to death last year after being returned to her parents’ custody; four-year-old Amir James, who arrived at the hospital covered in cuts and bruises and died from skull fractures that caused his brain to bleed, while his twin brother survived similar injuries; 16-month-old Zavier Giron, who had several broken ribs, a dislocated femur and a perforated intestine when he died; and two-year-old Charlee Gamble, who was shot in the head by an unsecured gun that her father purchased illegally and left on a TV stand. The bill would apply only to cases of abuse or neglect in foster care — even though they are a rare occurrence. Indeed, less than 1% of perpetrators of child maltreatment fatalities reported nationwide for Fiscal Year 2023 were foster parents or staff of a group home or residential treatment facility.
The chair of the Maryland House Judiciary Committee conducting a hearing on the bill wondered if the bill was too narrow, but one of the sponsors, Del. Susan McComas, responded, “Whether it’s a little step or a big step, I don’t really care. I think we need to do something. And I think we could start with just this.”
The sentiment to do something is admirable, but in this case it will likely not even make a dent in the lack of public accountability and transparency when children die of maltreatment.
To prevent such tragedies, we need improved data collection, timely notification and greater transparency by agencies that investigate such fatalities and are responsible for protecting children. Maryland should pass a bill that requires prompt notification of any child fatality that has been reported to child protective services. Eleven other states already do this. Without such notifications, legislators and the public may never know about some child abuse deaths, especially those that did not result in criminal charges. In addition, DHS should be required to respond promptly to requests for further information about all suspected child maltreatment fatalities, not just those where the child was in foster care or state custody. It is only by achieving such transparency that DHS can work with the legislature, researchers and child advocates to prevent these tragic events in the future.
Recognizing implicit bias in mandated reporting training is a national focus for addressing racial inequity in child welfare. States from New York to Washington have updated their training for mandatory reporters to include implicit bias or highlight the distinction between neglect and poverty in an effort to reduce racial disparities in child welfare involvement. My recent experience taking the updated training in Washington DC made clear that there is a fundamental conflict between preparing mandated reporters for their responsibility to report and advising them to assess their biases before reporting. The basic conflict is this: the core training instructs mandatory reporters to report any suspicion of abuse or neglect, while the implicit bias unit urges mandatory reporters to doubt their instincts and reconsider their duty to report.
In FY 2023, the District of Columbia’s Child and Family Services Agency (CFSA) updated its online mandated reporter training to include a module focused on understanding and addressing implicit bias for mandated reporters. This training is required for all mandated reporters, who include both professionals (doctors, nurses, teachers, social workers, etc.) and volunteers who work with children. I had taken the training several times in the past–first for my work as a social worker with CFSA and later as a mentor to a foster youth. I had my first experience with the updated training last month as part of my preparation to serve as a Court Appointed Special Advocate (CASA) for a child in foster care.
The Implicit Bias Module
The implicit bias module appears to have been shoehorned into the existing DC mandatory reporter training right after a brief introduction to mandatory reporters and their role. The video introducing the section explains that implicit bias harms “families of color” in the child welfare system, without providing any evidence of such harm. It goes on to assert that “the point of this portion of the training is to make sure that reporting is based on observations and not assumptions. Ultimately we want mandated reporters to consider this before responding to a child’s disclosure of suspected abuse or neglect: Do I have any implicit bias in my decision to call or not to call the hotline.” It may sound reasonable, but as the training unfolds, a conflict with the goals of the overall training and mandatory reporting itself becomes clear.
The implicit bias module continues by explaining that nationally and in DC, mandated reporters call the CFSA hotline about Black families disproportionately more than White families; this leads to more “Black and Brown” children having in-home cases or entering foster care because they are assessed more closely. A graph has been provided, with text saying “In this graph, disproportionality is where you see that Black and Brown children make up approximately 64% of hotline calls. However, only 57% of people in the District are a race/ethnicity other than white.” Unfortunately, one does not see this in the graph, which does not include hotline calls at all! It does include children who are the subject of an investigation after a call to the CFSA hotline, and it shows that Black children made up 57 percent of the investigated children, while comprising 53 percent of the population. That is a very small disparity, and in any case could reflect unequal rates of abuse and neglect between Black and White children. The data does show a larger Black-White disparity in confirmed maltreatment (71 percent of the children confirmed as maltreated are Black) and “foster care” (whether this is children in care or entries into care is unclear) at 92 percent. But these increasing disparities come in at the investigation stage (where the substantiation and foster care decisions are made), not at the reporting stage, calling into question the need for training mandatory reporters about implicit bias. To make matters worse, the data on investigations contain a whopping 40 percent without race or ethnicity data; 26 percent of the confirmed maltreatment data, and 23 percent of the in-home case data also lack race and ethnicity information. (Note that the bars of the graph have been shifted by one column to the left of the corresponding columns from the numerical table, as in the original.) So it is impossible to draw meaningful conclusions from these data.
Source: DC Mandated Reporter Training, Lesson 3, page 6, available from
Other than the mention of the hotline call data, which is missing from the graph, the only analysis of the data in the text reads as follows. “Disparity occurs when these children and families have cases open to either in home or foster care support. As you can see that [sic] 85% of in-home cases, and more than 92% of foster care cases in 2020 were opened with Black and brown families, while again the District’s make-up is only 57% Black and brown.” The inclusion of “brown families” is somewhat disingenuous. The graph shows that Hispanics and Asians, the only “brown” children with non-zero populations on the graph, are underrepresented in investigations, confirmed maltreatment, foster care, etc.1 Switching categories, the lecturer goes on to state that “At every stage, Black and Indigenous families face racial discrimination and unequal treatment.” DC is not known to have a large indigenous population; there is no row on the table for Native Americans, and Native Hawaiians and Pacific Islanders are zero percent of every category except that they are listed as making up two percent of children aging out of foster care in 2019.
A central motif of the training is that the confusion of poverty with neglect contributes to the racial and ethnic disparities in child welfare. The video states that “under current law, most children in the US are separated for neglect, a code word that typically represents conditions of poverty, resulting in disproportionate separation and harm to Black families….” But there is a problem with this. We know that neglect is often associated with serious drug abuse and/or mental illness. After all, most poor people don’t neglect their children. Moreover DC Code Section 16.2301 forbids a court to find maltreatment when the deprivation of food, clothing, shelter or medical care is due to the parent’s lack of financial means. The law does not allow removing children because of poverty in DC, and the small number of removals compared to investigations in DC (224 children placed in foster care compared to 3,767 investigations in FY 2024) suggests that CFSA does not remove children for poverty alone.
The training includes practice scenarios to help trainees distinguish between poverty (or “need” according to the training) and neglect. The participant must read the scenarios and decide whether they represent need (and presumably do not call for a hotline report) or neglect. After providing their own answer, trainees learn the “right answer” according to CFSA. One of the three “need” scenarios is particularly troubling and is reproduced here:
The 4-year-old child came into the center smelling of a strong smell and her nails are long and dirty. There is sticky stuff on her chest that is black underneath her shirt on her skin. The child often comes to the center unbathed. She was wearing shoes that were too small, but the dad was made aware, and he got her new shoes. The child comes in with an old pamper not changed, soaked or soiled. Sometimes she comes to school with the same clothes on from the day before or sometimes wears the same clothes for three days.
The child does not talk or engage with staff or peers. The mother has been observed yelling at the child and all she does is cry. The child covers her eyes but does not ask for anything.
The caller is aware that the family was recently evicted after the mother lost her full-time job and they are being supported on the income made from the father’s part-time employment. The family moves from the homes of family and friends because they refuse to go to a shelter. Caller suspects sometimes the family may sleep in the car.
The characterization of this scenario as “need” rather than neglect is troubling. The combination of factors that are cited suggest something more than poverty. The fact that the child “does not talk or engage with staff and peers,” and that the mother “has been observed yelling at the child and all she does is cry” suggest problems this beyond the realm of need. The refusal to go to a shelter under current conditions, when the District of Columbia guarantees shelter to families with children and has replaced its dilapidated shelter with modern new facilities, increases the likelihood that this is a case of neglect.
In the content that follows, a video tells mandatory reporters that although they are required by law to report suspected abuse or neglect, they should not make reports “solely based on assumptions, schemas, or biases.” It seems rather disrespectful to think that a doctor, nurse, teacher, social worker or volunteer would do this. Trainees are presented with the following questions to ask before making a report.
This is confusing indeed. Is the agency saying that mandatory reporters should not make a report “solely out of legal obligation,” even though they are legally required to report and could receive consequences for not doing so? Providing resources to assist the family is fine, but if there is abuse or neglect, does that exempt the reporter from the duty to report? It seems unlikely and unwise.
“Granted,” the presenter continues, “there are many times when you recognize your legal obligation, have the resources to support a family, and have checked your biases, and a report still needs to be made.” But the speaker goes on to state that “Each of us holds a responsibility to address disproportionality and disparity in the lives of Black and Brown families in the District.” She then invites us to “walk through how we can do this together,” by listening to two videos that are a total of five minutes in length. The first video, on “Mitigating Bias” counsels reporters to follow a three-step process consisting of of “deliberate,” “reflect,” and “educate,” with each step containing mutiple steps or suggestions. Mandatory reporters then learn about “cultural humility” and its three attributes: “lifelong learning and critical self-reflection,” “recognition and challenging of power imbalances,” and “institutional accountability.” And then training participants are told that “[u]ltimately, our goal is to ensure that children who are experiencing neglect in the District receive the support they need to thrive within their families. To do this effectively, we each have to ensure our implicit biases, whether personal or institutional, are not the foundation for calls to the CFSA hotline.” Apparently, no children in the District need to be removed from their families in order to thrive; even though the agency providing the training removed 244 children in the last Fiscal Year, as mentioned above.
To sum up, the implicit bias section of the training teaches child-serving professionals and volunteers that mandatory reporting harms Black children and that to avoid that harm, mandatory reporters must engage in a lengthy deliberative process before making a report. Mandatory reporters learn nothing of the costs of not making a report, which include the possible death of a child. They also learn nothing about the different risks facing Black children, who are three times more likely than White children to die of maltreatment.2 Instead, they are told that “we are delinquent in addressing the institutionalized racism and bias that pervades our family and wellbeing systems. This has been perpetuated by the misconception that we are nobly rescuing children from dangerous situations.” The clear implication is that making a report is much more risky than not making one.
A Case of Mixed Messages
After at least an hour of training on implicit bias, mandatory reporters finally arrive at the original training, which seems mainly unchanged. They learn about how to respond to a child’s disclosure of abuse or neglect. They learn they must report when they have reasonable cause to believe a child has been, or is in immediate danger of, being abused or neglected. They learn what and how to report. They learn that the identity of reporters is confidential and that failure to make a report can be punished by a fine of up to $1,000 or imprisonment for up to 180 days. They learn about different types of abuse and neglect, which children have higher risks of being maltreated, situations in which CFSA does not intervene, what happens when a report is made, and how child welfare services work in the District of Columbia. They are told to “[r]eport any suspicion of child abuse and neglect,” and that “every call matters!” A key instruction is buried in the section on how to distinguish discipline from child abuse. It says: “The good news is, as a mandated reporter, you do not need to know the details or all the facts before making a report. You just need to be suspicious of abuse/neglect and CFSA’s response, if it does respond, will do the rest.” (This should be moved to the top and emphasized, as it may have been in an earlier version of the training). In closing, trainees are told that:
Abuse and neglect place children at great risk of physical and emotional injuries and even death. As a mandated reporter, the District is expecting you to do the following:
Recognize the signs of child abuse and neglect.
When children have the courage to disclose abuse or neglect to you, take them seriously.
When you suspect or know of incidents of child abuse or neglect, call CFSA at (202) 671-SAFE.
Be responsible for calling the CFSA Hotline yourself, even if you have informed your supervisor.
If necessary, be helpful and available during the investigation.
The fundamental conflict between the training’s two messages is clear. According to the original training, abuse and neglect are dangerous to children and it is our responsibility to report. According to the implicit bias section, it is reporting that is dangerous and needs to be inhibited. Neglect is a serious type of maltreatment according to the original training but a “code word”d according to the implicit bias section. It is not really surprising that the implicit bias element of the training seems to be in opposition to the preexisting content. Perhaps those who inserted this content would prefer to eliminate mandatory reporting training entirely and are just trying to minimize it within the requirements of current law. But the half-measure of trying to train the implicit bias out of mandatory reporters creates a training that simply does not make sense.
In addition to this fundamental disconnect, the training exhibits many factual errors and is padded with extraneous content. The factual errors are discussed in an addendum to this post. The extraneous content includes discussions of the racial wealth gap and instructions for “self-reflection, in which trainees are instructed to define their values by a three-step process that is painstakingly described in a three-minute video. Perhaps the most striking extraneous content is a section that describes in detail six types of “mental models related to diversity, equity and inclusion.” One of the six types is “active opposers,” who are typically deeply rooted in their choice to be a strong opponent of DEI. These are the people whose minds cannot be changed and who are committed to disrupting the work of DEI.” One cannot help wondering how the current federal leadership would respond if they knew of this content, and being offended at the disrespect for the time of busy professionals or volunteers.
In summary, there is a fundamental conflict between the original message of CFSA’s mandatory reporter training and the message of the implicit bias unit that has been added to it. Unlike the original message stressing the duty and importance of reporting suspected abuse and neglect, the new message states that reporting damages children and families of color and should be avoided whenever possible. This fundamental conflict is not unique to the District and by necessity affects all mandatory reporter trainings that attempts to temper the duty to report by inserting considerations related to race and ethnicity.
From U.S. Children’s Bureau, Child Maltreatment 2023, page 59. States reported that 6,04 per 100,000 Black children were found to be victims of a child maltreatment fatality compared to 1.94 per 100,000 White children. These are deaths that have been confirmed as due to maltreatment by child protective services, medical examiners, or police, a process that may be affected by bias. ↩︎
Addendum: Factual Errors in CFSA’s Mandatory Reporter Training Implicit Bias Module
The implicit bias module in CFSA’s mandatory reporter training curtains numerous factual errors and omissions. Here are a few.
“National studies by the US Department of Health and Human Services reported that minority children and in particular black children are more likely to be in foster care than receive in-home services even when they have the same problems and characteristics as White children.” I asked the CFSA’s Communications Director for a citation and I found the exact language in one of the three references that were provided–a 2019 ABA brief entitled Race and Poverty Bias in the Child Welfare System: Strategies for Child Welfare Practitioners. A footnote referred readers to an essay by Dorothy Roberts for PBS’ Frontline program. That essay in turn attributes the same quote to “a national study of child protective services by the U.S. Department of Health and Human Services” with no citation. When consulted, ChatGPT references the outdated 1996 National Incidence Survey of Child Abuse and Neglect, which has been superseded and contradicted by the more sophisticated study published in 2010.
“Rates of child abuse are not higher for children of color than white children. People of color do not treat their children worse than White families do. Racial disproportionality in CW is due to systemic racism, cultural misunderstandings, stereotypes, and biases that influence the decision to report alleged child report or neglect to CPS.” This is simply not true. First, we don’t have definitive evidence of child abuse rates as it occurs in secret, may not be reported, and investigations may not come up with the right results. But all the evidence we have indicates that Black families do abuse and neglect their children more than White families. This is likely due to 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 well as a legacy of intergenerational trauma associated with these factors as well.
“Although African American families tend to be assessed with lower risk than White families, they are more likely to have substantiated cases, have their children separated, or be provided family based safety services.” I could not find any resource on the internet that indicates that Black families tend to be assessed with lower risk than White families It is true that Black children tend to have more substantiated cases, have their children removed, or receive in-home services. But that is before controlling for family characteristics that affect risk. The only research article cited by CFSA actually reported that when they controlled for family risk factors, agency and geographic contexts, and caseworker characteristics, Black children were not at significantly higher risk of substantiation or removal.
The death of Gavin Peterson from starvation last year after years of abuse and multiple calls to child protective services regarding his treatment set off an outcry in Utah and around the country. Media reports appeared throughout the country, legislators expressed their outrage, hearings were held, and concerned citizens rallied. But halfway through the legislative session that followed Gavin’s death, it appears that there will be no policy changes that will prevent more children suffering Gavin’s fate. Instead, his name has been invoked to support bills that would not have saved him, and, ironically, legislation that could increase the risks for children like Gavin who are withdrawn from school seems poised for passage.
As described in an earlier post, Gavin Peterson died of starvation in July 2024 at the age of 12, almost a year after his father and stepmother withdrew him from school, ostensibly to homeschool him. Gavin had been the subject of multiple reports to the Utah Division of Child and Family Services (DCFS), including at least four reports from his school describing him as eating food from the trash and with other signs of neglect and abuse. An investigation found no maltreatment but did result in his father and stepmother withdrawing him from school, a common response of abusive parents to being investigated, and too often a precursor of a child’s death from abuse. Gavin’s withdrawal from school was his death warrant, because there were no more caring adults to report on his suffering.
There are several types of legislation that might have helped prevent future Utah children suffering Gavin’s fate. Perhaps most effective would be to increase the protections for homeschooled children. For example, the Make Homeschool Safe Act developed by the Coalition for Responsible Home Education proposes that no person who has been found to have engaged in child abuse or neglect can operate a home school. It is not clear from the limited information provided by DCFS whether Gavin’s stepmother had been found to have committed abuse or neglect, but given that a case was open on the family for a year, it seems likely that she was. In addition, the bill would allow no person to withdraw a child from school for homeschooling within three years of an investigation of potential abuse or neglect unless there is a risk assessment by a child protective services worker and monthly risk assessments for the first 12 months of the child’s withdrawal from school. Such a law, if implemented faithfully, might well have saved Gavin.
But far from placing controls on homeschooling, Utah legislators are bent on removing them in the wake of Gavin’s death. For the past close to two years, Utah has required parents who homeschool their children to sign an affidavit swearing that they have never been convicted of child abuse. Admittedly, this seems to be a pretty toothless requirement, as compared to requiring a check of police and CPS records. But the homeschooling community has decided that even this weak law is offensive, as the Salt Lake Tribune has reported. Homeschooling families thronged the Capitol on February 25 to demonstrate their support for a bill that would eliminate this requirement. Its sponsor, Representative Noeleen Peck, justified the bill by saying the requirement “didn’t work” and was “confusing.” Some districts misinterpreted it to require a background check, she said. Perhaps that misinterpretation–giving the requirement teeth after all–explains the overwhelming support for this bill among homeschooling parents. The Committee voted unanimously to recommend the bill eliminating the requirement.
One bill (HB83) that did get introduced in Gavin’s name would not have protected him, despite being a good bill. It would make it easier for police or social workers to obtain a warrant to view a child and a home for the purposes of investigating a report of child abuse or neglect. This bill addresses a real problem in Utah which gained attention through another horrific abuse case in the same year. Parenting influencer Ruby Franke was starving and torturing her two youngest children. Police tried to check on them, but Franke would not respond to the door and a judge would not issue a warrant to allow them to enter the home. HB83 presumably would have enabled police to obtain a warrant to enter the Franke home and perhaps discover the children’s plight.
The sponsor of HB83, state Rep. Christine Watkins, told the House Judiciary Committee that this bill was in direct response to the cases of Gavin Peterson and the children of Ruby Franke. But the case history that was released by DCFS describes no instance of police or DCFS being denied access to Gavin’s home. DCFS visited the home twice in March, 2023 and interviewed Gavin outside the presence of his parents. But he did not disclose the abuse, probably for fear of retaliation by the abusers. Certainly the difficulty of accessing children at home is a problem worth correcting, but it was not apparently related to Gavin’s death. In any case, the bill did not make it out of its first committee hearing and does not seem likely to advance.
Sadly, it appears that the most consequential bill that will be passed in response to Gavin’s death is a measure that would eliminate the cost of reduced-price school lunches. The bill’s sponsor, House Rep. Tyler Clancy, told KJZZ that Gavin Peterson’s death helped build support for the bill. “It shakes you to your core when you read a story about a young person like Gavin Peterson starving to death,” Clancy said. Clancy’s compassion is commendable, but this bill would not have helped Gavin, who died almost a year after he was removed from school. There is something disturbing about using Gavin’s name to support a bill, however beneficial, that wouldn’t have helped him.
It is hard to understand how well-intentioned legislators, in the aftermath of a tragedy like Gavin Peterson’s death, can use his name to support legislation (no matter how worthwhile) that would not have prevented the tragedy in the first place. Whether it is the lack of bandwidth among legislators and staff or the dominance of preconceived notions about what constitutes the problem. It’s even harder to understand legislators voting to reduce protections for children who are withdrawn from school less than a year after Gavin’s death. The Utah Legislature is not unique in its failure to produce meaningful reforms after tragic failures in child protection. But it is the children trapped in their houses of horror that must pay the price.
“New Federal Report Demonstrates Reduction in Child Maltreatment Victims and Underscores Need for Continued Action,” the Administration on Children and Families (ACF) of the US Department of Health and Human Services proclaimed in releasing the latest annual report on the government response to child abuse and neglect. As in the past several years, ACF’s language suggested that child abuse and neglect are decreasing. But with states around the country changing law, policy and practice to reduce child welfare agencies’ footprint, the number of “child maltreatment victims” cited by ACF is likely more a reflection of policy and practice than an indicator of actual maltreatment.
The annual Child Maltreatment reports, produced by the Children’s Bureau of ACF, are based on data that states submit to the National Child Abuse and Neglect (NCANDS) data system. The new report, Child Maltreatment 2023 (CM2023), provides data for Federal Fiscal Year (FFY) 2023, which ended on September 30, 2024. The report documents the funnel-like operations child welfare protective services (CPS), which at each stage select only a fraction of the cases or children to proceed to the next stage. Exhibit S-2 summarizes the findings of the newest report. Child welfare agencies received 4.399 million “referrals” alleging maltreatment in Federal Fiscal Year (FFY) 2023 and “screened in” 2.1 million of them as “reports” for “disposition” through an investigation or alternative response. The investigation or assessment of those reports resulted in a total of 546,159 children determined to be victims of child abuse and neglect. (The final stage of the funnel involves services and is not covered in this post.) State and local policies and practice affect every stage of this process, as explained in detail below.
Referrals
NCANDS uses the term “referrals” to mean reports to child welfare agencies alleging maltreatment. Agencies received an estimated total of 4,399,000 referrals through their child abuse hotlines or central registries in FFY 2023, according to CM 2023. This is a very slight increase over the previous year and represents about 7.8 million children, or 60 per 1,000 children. As shown in Exhibit S-1, the total number of referrals has been increasing since 2020, when the COVID-19 pandemic resulted in a large drop in referrals. In FFY 2023, the number of referrals surpassed the pre-Covid 2019 total for the first time as the lingering effects of the pandemic, which acted to suppress reports, finally dissipated.
As in past years, the state-by-state tables document large differences in referral rates, from 19.9 per 1,000 children in Hawaii to 171.2 per 1,000 in Vermont–also the top and bottom states in 2022. These differences reflect not just different numbers of calls to child abuse hotlines but also state policy and practice. Vermont reports that it counts all calls to the hotline as referrals, while other states do not do so. For example, Connecticut reported in CM2022 that none of the calls that are assigned to alternative response are included in NCANDS, resulting in a far lower number of calls than the number they actually receive. Referral rates may also affected by a state’s policy on who is required to report and what must be reported. Such policies are disseminated to mandatory reporters through training and agency communications. New York reported implementing in FFY 2023 a new training for mandated reporters that helps them identify when concerns do not rise to a level legally requiring a report be made.” The training also focuses on implicit bias in order to “reduce the number of SCR reports influenced by bias about race or poverty.” The number of referrals in New York dropped by a very small fraction in FFY 2023. Missouri reported in CM2022 that it stopped accepting educational neglect referrals in 2021 as the COVID emergency ended, resulting in a decreased number of referrals received the following year.
Reports
Once a state agency receives a referral, it will be screened in or out by agency staff. In general, referrals are screened out if they are deemed not to contain an allegation of child abuse or neglect, contain too little information to act on, are more appropriately assigned to another agency, or for some other reason do not fall under the mandate of the child welfare agency. In the language used by NCANDS, a referral becomes a “report” once it is screened in. “Reports” are assigned for an investigation or “alternative response.” State data indicates that child welfare agencies screened in 2.1 million referrals, about 47.5 percent of referrals for an investigation or alternative response, and “screened out” the other 52.5 percent as not warranting a response. The number of screened-in referrals was 11.6 percent less than in FFY 2019 and slightly less than in FFY 2022.
A total of 42 states reported a decrease in the number of screened-in referrals in FFY 2023. In their commentaries, several of these states described policy and practice changes that led to their screening out more referrals. Ohio reported that two of its major metropolitan counties, which had significantly higher screen-in rates than the rest of the state, adjusted their screening procedures to be consistent with the rest of the state, resulting in a lower screen-in rate in those counties and statewide. Mississippi reported an increasing the amount of screening it conducted, especially when a report was received regarding a case that was already open; perhaps this is why its screen-in rate dropped from 41.3 to 36.5 per 1,000 children. Nebraska reported dropping a policy to require accepting all referrals from a medical professional involving children under six. Some states explicitly reported that their screening changes were adopted in order to decrease the number of screened in referrals. Kentucky reported adopting a new SDM® screening tool designed to decrease the number of referrals that are “incorrectly accepted for investigation.” Nevada reported a decrease in screened-in referrals because it established new intake processes to ensure that referrals are screened out when they do not meet criteria for acceptance.
“Victims”
The next phase in the funnel of CPS is the determination of whether abuse or neglect has occurred. At this stage, the level of analysis shifts from the case to the child, and the number of “victims” is the result. In NCANDS, a “victim” is defined as “a child for whom the state determined at least one maltreatment was substantiated or indicated1; and a disposition of substantiated or indicated was assigned for a child in a report.” “Victims” include children who died of abuse or neglect if the maltreatment was verified. Some children receive an “alternative response”2 instead of an investigation; these children are not counted as victims. According to CM2023, states reported a total of 546,159 victims of child abuse and neglect in FY 2023, producing a “victimization rate” of 7.4 per 1,000 children.
The number of “victims” reported by states according to the NCANDS definition does not represent the true number of children who experienced abuse or neglect, which is unknown. Many cases of child maltreatment go unreported. Children assigned to alternative response are not found to be victims unless their case is reassigned to the investigation track. And finally, substantiation may not be an accurate reflection of whether maltreatment occurred. Making a determination of whether maltreatment occurred is difficult. Adults and children do not always tell the truth, the youngest children are nonverbal or not sufficiently articulate to answer the relevant questions. So it is not surprising that research suggests that substantiation decisions are inaccurate3 and a report to the hotline predicts future maltreatment reports and developmental outcomes almost as well as a substantiated report.4
State “victimization rates” range from a low of 1.5 per 1,000 children in New Jersey to a high of 16.2 in Massachusetts. It is unlikely that Massachusetts has more than ten times more child abuse and neglect victims than New Jersey–a not dissimilar Northeastern state. Policy and practice must be at play, including different definitions of abuse or neglect, levels of evidence required to confirm maltreatment, and policies regarding the use of alternative response or “Plans of Safe Care”5 to divert children from investigation, among other factors. Maine reported the second highest “victimization rate.” The Maine Monitor asked experts why this might be so. Among the reasons suggested were the definition of maltreatment; Maine allows abuse or neglect to be substantiated when there is a “threat” of maltreatment, even if there is no finding that it already occurred. In view of the deceptiveness of these terms, I have put the terms “victims” and “victimization rates,” when not preceded by the word “reported,” in quotation marks in this post.
The national “victimization rate” of 7.4 per 1,000 children, is a small decrease from 7.7 in FFY 2022 and the total number of reported “victims” was 19.3 percent less than the total reported in FFY 2019. This “victimization rate” has declined every year since FFY 2018. Of course, this decline is in part a result of the decline in the number of screened-in referrals that was discussed above. Any referral that is screened out is one less reported “victim,” even though some percentage of the screened-out referrals almost certainly reflected actual incidents of maltreatment.6 It is also clear that changes in policy and practice have contributed to the decline in the number of “victims” reported by states, as described below.
Policy and practice changes affecting “victimization” numbers
The change in the number of “victims” between FFY 2019 and FFY 2023 ranged from a 52 percent decrease in North Dakota to a 32 percent increase in Nevada, suggesting that these changes may reflect policy and practice more than actual trends in abuse and neglect. And indeed, two of the largest states made it more difficult to substantiate maltreatment in FFY 2022, and both found a decline in the number of maltreatment victims. In Texas, the legislature narrowed the definition of neglect, requiring the existence of both “blatant disregard” for the consequences of a parent’s action or inaction and either a “resulting harm or immediate danger.” Perhaps this helps account for the drop in the number of reported victims from 65,253 in FFY 2021 to 54,207 in FFY 2022. But the number of victims actually rose very slightly in FFY 2023. Perhaps the new definition had been assimilated into practice and was no longer resulting in a decrease in substantiations. In New York, the level of evidence required to substantiate an allegation of abuse or neglect was changed from “some credible evidence” to “a fair preponderance of the evidence” in FFY 2022. The number of victims found in New York dropped from 56,760 in FFY 2021 in to 50,056 in FFY 2022, which the Office of Child and Family Services attributed in its CM 2022 commentary to that change in evidentiary standards. The number of reported victims fell further to 46,431 in FY2023; perhaps the changed evidentiary standards were continuing to take hold or other state policies affecting other parts of the funnel–such as the attempt to rein in mandatory reporting–were contributing factors. The agency did not address this issue in its 2023 commentary.
A few states did mention in their CM 2023 commentary changes in policy or practice that might have contributed to changes in the number of “victims” in FFY 2023. North Dakota attributes a decrease partly to a change in state statute and policy which allows protective services to be provided when impending danger is identified, even without a substantiation. The agency appears to believe that workers are not substantiating as many reports now that they do not need a substantiation to provide services. Arkansas attributed a decrease in victims to the adoption of a new assessment tool that may have contributed to the routing of more reports to the differential response pathway. Kentucky reported that the adoption of new “Standards of Practice” may have contributed to the increase in the number of “victims” reported in FFY 2023.
Fatalities
Based on reports from 49 states (all but Massachusetts), the District of Columbia, and Puerto Rico, CM2023 estimated a national maltreatment fatality rate of 2.73 per 100,000 children. That rate was then applied to the child population of all 52 jurisdictions and rounded to the nearest 10 to provide a national estimate of 2,000. But experts agree that the annual estimates of child fatalities from NCANDS significantly undercount the true number of deaths that are due to child maltreatment. I discussed this in detail in A Jumble of Standards: How State and Federal Authorities Have Underestimated Child Maltreatment Fatalities.
The annual fatality estimates presented in the report increased by 12.3 percent between FFY 2019 and FFY 2022 and then fell slightly from 2,050 to 2,000 in FFY 2023, a fact that ACF mentioned in its press release. Such a small reduction of less than three percent over the previous year cannot be statistically distinguished from random fluctuation, especially because it is based on much-smaller numbers from the individual states. State commentaries illustrate the randomness of these year-to-year changes. In CM 2022, two individual states explained year-to-year jumps in fatalities by explaining that many children in one family died and that a large group of fatalities that occurred the previous year were reported in the current year. But even aside from statistical fluctuations, there are many reasons one cannot rely on year-to-year changes. These include the timing of reports and changes in policy and practice.
Timing
According to CM 2023 (and previous reports), “The child fatality count in this report reflects the federal fiscal year (FFY) in which the deaths are determined as due to maltreatment. The year in which a determination is made may be different from the year in which the child died.” The authors go on to explain explain that It may take more than a year to find out about a fatality, gather the evidence (such as autopsy results and police investigations) to determine whether it was due to maltreatment, and then make the determination. Alabama, for example, explained in its commentary that the deaths reported in a given year may have occurred up to five years before.
To add to the uncertainty around timing, the writers of CM 2023 are not exactly correct when they state that all states report on the fatalities determined in the reporting year. In their annual submissions to NCANDS, several states add fatalities for the previous year, implying that their practice is to report on fatalities that occurred in a specific time period, not those determined in the applicable year. Four states revised their number of 2022 fatalities in their submissions to CM2023. This suggests that their 2023 reports are in turn incomplete and will be revised in succeeding years. California, for example, explained that:
Calendar Year (CY) 2022 is the most recent validated annual data and is therefore reported for FFY 2023. It is recognized that counties will continue to determine causes of fatalities to be the result of abuse and/or neglect that occurred in prior years. Therefore, the number reflected in this report is a point in time number for CY 2022 as of December 2023 and may change if additional fatalities that occurred in CY 2022 are later determined to be the result of abuse and/or neglect.
So California is reporting (for CM 2023) a truncated count of child maltreatment deaths for Calendar Year 2022. But it did add 12 fatalities to the count of fatalities that it reported for FFY 2022, raising its total from 164 to 176. California reported 150 fatalities for FY2023; one can assume that additional deaths will be reported in the next report. The four states together added 56 deaths for FFY 2023. Arizona’s total increased from 14 to 39, Maine from three to 10 and Virginia from 39 to 51. .
Policy and Practice: Fatality Definition and Measurement
In addition to timing issues, year-to-year changes in fatality counts can reflect changes in how states screen or define child maltreatment fatalities. In previous issues of CM, states have reported on improvements in their collection of fatality information. Over time, some states have eliminated obsolete practices in screening and information collection. West Virginia reported in its 2016 commentary that it had begun investigating child fatalities in cases where there were no other children in the home. North Carolina ended its restrictive policy of reporting only fatalities determined by a chief medical examiner to be homicide, and it also began efforts to incorporate vital statistics and criminal justice data.
During FY 2023, some states reported changes that may have resulted in a reduced number of child fatalities reported.
Texas did not submit commentary for FFY 2023. But as reported above, it changed its screening policy so that reports involving a child fatality but include no explicit concern for abuse and neglect are not investigated if the reporter and other pertinent sources had no concern for abuse or neglect. DFPS reports that the number of child fatalities it investigated decreased from 997 in FY2022 to 690 in FY2023 (a 31 percent decrease) due to this new screening policy. And the number of child maltreatment fatalities fell from 182 to 164. But with a drastic drop in foster care placements in Texas, there is reason to fear that maltreatment fatalities increased rather than decreased. If that is the case, this change screening policy may have resulted in the failure to investigate and confirm actual maltreatment deaths..
The Illinois Division of Child Protection reported that it added a new administrative review process for sleep-related deaths. A senior administrator reviews the investigation to ensure that death included evidence of “blatant disregard.” DCF links this new policy with a decrease of 24.6% in reported child fatalities in FFY 2023.
Other states reported changes that might result in an increased number of child fatalities reported. Maryland attributed an increase in reported fatalities to a policy change requiring local agencies to screen in sleep-related fatalities as part of its prevention effort. Alaska reported a change that may affect fatality counts in future years: in December 2023 the agency dropped its practice of screening out cases where no surviving children remained in the home; from now on the agency will be making maltreatment findings even when there are no surviving children.
It is regrettable that most state commentaries do not include explanations for the changes in their reported number of referrals, reports, and victims. Worse, several states do not even submit commentaries in time to be included in each year’s report. In CM023, commentaries are missing for Arizona, Hawaii, Kansas, New Hampshire, North Carolina, Oregon, Texas, and West Virginia. Given the importance of the state commentaries for understanding the data they submit, the preparers of the CM reports should reach out to agency personnel in states that have not submitted commentaries by a certain date or have not answered the important questions and ask the questions directly directly. This information is too important to be left out.
It is unfortunate that ACF continues to misuse term “victimization” and “victimization rate” to suggest that child maltreatment (including fatalities) is declining, particularly in its press release and executive summary, which do not provide any explanation of the true meaning of the terms. The deceptive language is not a surprise given the previous Administration’s desire to take credit for ostensible and support the prevailing narrative regarding the need for a reduction in interventions with abusive and neglectful families. One does not have to be a statistician or data scientist to realize that we will never get an accurate measure of child maltreatment because so much of it occurs behind closed doors. Finding fewer victims is one way to reduce CPS intervention in the lives of vulnerable children–and to deny that the reductions are harmful. Sadly, this report will be used as evidence to support policies that continue to roll back protections for our most vulnerable children.
Notes
Substantated is defined as “supported or founded by state law or policy.” “Indicated” is a less commonly used term meaning a “disposition that concludes maltreatment could not be substantiated understate law or policy, but there is a reason to suspect that at least one child may have been maltreated or is at risk of maltreatment.” ↩︎
An “alternative response” includes an assessment and referral to appropriate services if the parent agrees to participate. There is no determination on whether abuse or neglect occurred and no child removal unless the case is transferred to the investigative track. ↩︎
Theodore Cross and Cecilia Casanueva, “Caseworker Judgments and Substantiation,” Child Maltreatment, 14, 1 (2009): 38-52; Desmond K. Runyan et al, “Describing Maltreatment: Do child protective services reports and research definitions agree?” Child Abuse and Neglect 29 (2005): 461-477; Brett Drake, “Unraveling ‘Unsubstantiated,’” Child Maltreatment, August 1996; and Amy M. Smith Slep and Richard E. Heyman, “Creating and Field-Testing Child Maltreatment Definitions: Improving the Reliability of Substantiation Determinations,” Child Maltreatment, 11, 3 (August 2006): 217-236. ↩︎
Brett Drake, Melissa Jonson-Reid, Ineke Wy and Silke Chung, “Substantiation and Recidivism,” Child Maltreatment 8,4 (2003): 248-260; Jon M. Hussey et al., “Defining maltreatment according to substantiation: Distinction without a difference?” Child Abuse and Neglect 29 (2005): 479-492; Patricia L. Kohl, Melissa Jonson-Reid, and Brett Drake, “Time to Leave Substantiation Behind: Findings from a National Probability Study,” Child Maltreatment, 14 (2009), 17-26; Jeffrey Leiter, Kristen A. Myers, and Matthew T. Zingraff, “Substantiated and unsubstantiated cases of child maltreatment: do their consequences differ?” Social Work Research 18 (1994): 67-82; and Diana J. English et al, “Causes and Consequences of the Substantiation Decision in Washington State Child Protective Services,” Children and Youth Services Review, 24, 11 (2002): 817-851. ↩︎
Plans of Safe Care are voluntary plans offered to the families of substance-exposed infants under the Comprehensive Addiction and Recovery Act (CARA). ↩︎
We. know this from child fatality reviews that many children who die have been the subject of previous referrals, which were not substantiated but later found in fatality investigations to have been correct. See discussions of the deaths of Thomas Valva and Gavin Peterson, for example. ↩︎
“B.B.” was born in 2022 and died of fentanyl poisoning in March 2023. During the ten years before B.B.’s death, DCYF had received 30 reports on B.B.’s family (many before B.B. was born) for issues including use of heroin, marijuana and alcohol in the home; lack of supervision of the children; domestic violence; an unsafe caregiver living with the family; an unsafe and unclean living environment unsecured guns in the home “out-of-control” behaviors by B.B.’s older siblings at school, with the mother described as “out-of-it” and unresponsive to school concerns; concerns about the children’s hygiene; and the mother driving under the influence of marijuana. An in-home services case that had been open since January 2023 was closed days before B.B.’s death.
On August 24, 2024, the Washington Department of Children, Youth and Families (DCYF) proudly announced in a press statement that it had reduced the number of children in out-of-home care by nearly half since 2018. Specifically, the number of children in foster care had fallen from 9,171 in 2018 to 4,971 as of August 14, 2024. “Outcomes like this demonstrate our agency’s commitment to keeping families together and children and youth safe,” DCYF Secretary Ross Hunter said. “Although the number of reports we are receiving remain [sic] consistent, we are seeing fewer children and youth in out-of-home care as families are being referred to support services rather than having children removed from their homes. Indeed, “safely reduce the number of children and youth in out of home care by half” (without a baseline date from which this can be measured) is one of DCYF’s six strategic priorities. But treating the decline in foster care (the direct result of government actions) as a desirable outcome in itself can contribute to a disregard of actual child welfare outcomes like safety and permanency.
How did DCYF reduce foster care by nearly 50 percent?
How did DCYF manage to slash its foster care rolls so radically in such a short time? Without providing specifics, the press release cites DCYF’s implementation of the Family First Prevention Services Act (FFPSA) and its emphasis on “supporting and collaborating with families by providing access to services and programs.” A DCYF spokesperson told the Seattle Timesthat the department was using services to avoid removing children or to reunite families sooner, citing efforts to connect parents to substance use or mental health treatment programs, bring a social worker into the home to “problem solve,” or “offer practical items, like diapers, car seats and beds.”
Apparently not satisfied with the changes implemented by DCYF, the Washington legislature in 2021 passed the Keeping Families Together Act (KFTA, also known as HB 1227), which took effect on July 1, 2023. Among other provisions, KFTA increased the standard for the court to order removal of a child from the home, which previously required the agency to demonstrate that “reasonable grounds that the child’s “health safety or welfare will be seriously endangered if not taken into custody and that at least one of the grounds set forth demonstrates a risk of imminent harm to the child.” As amended by KFTA, the law now requires the agency to demonstrate “that removal is necessary to prevent imminent physical harm to the child due to child abuse or neglect.” The petition for removal is required to contain “a clear and specific statement as to the harm that will occur if the child remains in the care of the parent, guardian or custodian, and the facts that support the conclusion.” Moreover, the court must consider whether participation by the parents or guardians in “any prevention services” would eliminate the need for removal. If so, they must ask the parent whether they are willing to participate in such services and shall place the child with the parent if the parent agrees.
On a page dedicated to KFTA implementation, DCYF explains that it has implemented the law by adopting new policies and procedures to determine whether to remove a child and by training and supporting staff to implement the new procedures and determine whether there is an imminent risk of serious harm to the child. DCYF reports that internal reviews show that staff are “taking additional steps to prevent removal of a child and to support a safety plan for the family.”
Shortly before KFTA took effect, DCYF, along with the Department of Health, the Health Care Authority, and the Washington State Hospital Association issued new guidelines to birthing hospitals and mandatory reporters. These guidelines stated that infants born substance exposed, but for whom there are no other safety concerns, can receive “voluntary wrap-around services from a community organization” without being reported to CPS. These voluntary services are being provided through federally-mandated “Plans of Safe Care (POSC).” Healthcare providers identifying a substance-exposed infant are instructed to access an online portal where they are directed to call DCYF if safety concerns are identified and to complete a POSC referral if not.
DCYF has been issuing quarterly data updates to assess the impacts of the KFTA. According to the most recent (October 2024) update, the law is having the intended impact of further reducing removals to foster care. DCYF reports a 16 percent decrease in the number of children removed in the July through September quarter of 2024 compared to the same quarter of 2022, before passage of KFTA. However, comparing foster entries for all ages in July through September 2024 to those in the same quarter of the previous year, the data indicate that foster care entries actually increased! Will this be the beginning of the end of the foster care reductions? That remains to be seen.
A longer-term view raises questions about the difference KFTA made, compared to the previous and ongoing efforts by DCYF to reduce foster care placements. Entries into foster care in Washington have decreased annually from 2017 to 2024, as shown in the chart below. The rate of decrease remained about the same between 2019 and 2024, while KFTA was not implemented until July 2023. Perhaps more children would have entered care if not for KFTA, but there is no way to assess the impact of KFTA as compared with DCYF’s ongoing effort to reduce removals.
The reduction in foster care placements was supposed to be accompanied (and made possible) by an increase in in-home services (which DCYF calls Family Voluntary Services or FVS), and DCYF reports that the number of cases receiving FVS increased by nine percent from 1,809 in SFY2023 to 1,994 in SFY2024. This increase in FVS cases cannot be compared to the 17-percent decrease in children placed in foster care over the same period, as the unit of analysis is different (families rather than children). But the key question is the nature and intensity of these services and whether they really kept the children safe.
The cost of foster care reductions
The purpose of foster care is to keep children safe when they cannot be protected at home. So the essential question is whether the reduction in foster care placements has occurred without any cost to children. Trends in child fatalities and “near fatalities”1 due to child abuse or neglect can provide a clue. These deaths and serious injuries are the tip of the iceberg of abuse and neglect. For each child who dies or is seriously injured, there are many more that are living in fear, pain, or hunger, and incurring lifelong cognitive, emotional, and physical damage. There are troubling signs of an increase in child fatalities and near fatalities over the past several years. In its most recent quarterly update, DCYF reports on the number of “critical events” or child fatalities and near fatalities that met its criteria for receiving an “executive review.” These include the deaths of any minor that had been in DCYF custody or received services within a year of the death that were suspected to be caused by child abuse or neglect.2 They also include near fatality cases in which the child has been in the care of or received services from DCYF within three months preceding the near fatality or was the subject of an investigation for possible abuse or neglect. DCYF reports that the number critical events it reviewed increased from 23 in 2019 to 51 in 2023 and projects that it will increase to 61 in 2024.3
The increase in critical events reflects, in part, the growing opioid crisis in Washington, as well as decisions Washington has made regarding how it intervenes to protect children. Opioid related emergencies have “dramatically increased for the entire population (adults and children) in Washington,” and children have not been immune. Fentanyl is particularly dangerous to young children because it takes only a tiny amount to kill a baby or toddler, who can mistake the pills for candy or put straws or foil meant for smoking the drug in their mouths. The number of fatalities and near fatalities reviewed by DCYF that involved fentanyl climbed from four in 2019 to a projected 35 in 2024. Since 2018, Washington’s Office of the Family and Children’s Ombuds (has observed an annual increase in child fatalities and near fatalities involving accidental ingestions and overdoses. Fifty-seven (or 85 percent) of the 67 incidents examined in 2023 involved fentanyl. Over half of these incidents involved children under three years old and a shocking 14 out of the 85 infants were 12 months old or less. As Dee Wilson and Toni Sebastian point out, the limited mobility and motor skills of infants suggests that some of these infants may have been given a small amount of fentanyl as a means of sedation.
The Washington Legislature was concerned enough about the possibility that KFTA is contributing to an increase in child fatalities and near fatalities in the context of the fentanyl epidemic that it passed a new law (SB 6109) in 2024. The law provides that a court must give “great weight” to the “lethality of high-potency synthetic opioids.….in determining whether removal is necessary to prevent imminent physical harm to the child due to child abuse or neglect.” However, it appears that there is confusion about exactly what that means.
Has DCYF given up on protecting children?
“We know that supporting and collaborating with families by providing access to services and programs increases their number of protective factors, leading to better outcomes,” said DCYF Assistant Secretary Natalie Green. “Giving families the tools they need to thrive and safely parent means more children and youth remain safely at home.”
But the work of DCYF’s own analysts, in their quarterly KFTA updates, raises doubts about whether DCYF is adequately performing its child protection function. These updates acknowledge that the agency is not removing as many children with a high risk of future encounters with child welfare (in other words, those who have a high risk of being harmed). And they also report that the department has seen “an increasing percentage of moderately high to high risk cases being re-referred to CPS within 90 days of the risk assessment. DCYF also reports that the overlap between KFTA and Plan of Safe Care (POSC) is resulting in fewer screened-in intakes involving substance-exposed newborns because these infants are now being referred to voluntary services under POSC.
There has been a chorus of voices alleging that DCYF is abdicating its child protection responsibilities. One foster parent told the Seattle Times that “she and other foster parents are finding children who now come into their care are in worse shape than they used to be, with more serious mental health conditions or greater exposure to lethal drugs like fentanyl.” She contends they’ve been left too long in unsafe conditions because of the heightened legal standard for removal.In The Erosion of Child Protection in Washington State, Toni Sebastian and Dee Wilson have cited the weakness of the management of Family Voluntary Services, which is often employed as an alternative to foster care.
A survey of executive reviews of 2023 and 2024 child maltreatment child fatalities with DCYF involvement within a year provided examples of problems with screening, investigations, and case management, including the following:
Hotline issues. Reviews documented multiple intakes screened out on the same family even when the family had been the subject of multiple calls. The reviews also suggest that too many cases may be assigned to the Family Assessment Response (FAR) pathway, an alternative to a traditional investigation designed for lower-risk cases. In FAR cases, a social worker assesses the family and refers it to voluntary services. There is no finding about whether maltreatment has occurred and no child removal unless the case is transferred to the investigative track.
Premature closure of FAR cases. Reviewers noted instances in which FAR cases were closed after parents failed to cooperate, without caseworkers considering a transfer to the investigative track or before determining that the parent had followed through with services.
Assessment failures: Reviewers noted multiple failures to adequately assess parents for domestic violence, mental health, and substance abuse; failures to contact collaterals (relatives and friends) and instead relying on parental self-reports; lack of recognition of chronic maltreatment; ignoring evidence of past problems if not included in the current allegation; and failing to anticipate future behavior based on historical patterns.4
Inadequate understanding of substance abuse: Reviewers noted the failure to conduct a full assessment of substance abuse including history, behavioral observations, and collateral contacts; disregarding the unique danger to children posed by fentanyl; downplaying the significance of marijuana use, particularly as an indicator of relapse from harder drugs; and disregarding alcohol abuse because it is legal.
Failure to obtain information from treatment and service providers. The failure to communicate with service providers about clients’ participation in services like drug treatment and relying on clients’ self-reports was noted by more than one review team. Sometimes the providers refused to cooperate. Staff told the team reviewing one case about a substance abuse treatment provider that routinely refuses to cooperate, even when parents sign release forms, and routinely tells clients not to cooperate with DCYF.
Lack of subject matter expertise. Reviewers pointed to the lack of deep knowledge about domestic violence, substance use disorder, and mental health among staff doing investigations, assessments, and case management and the need to provide access to subject matter experts when needed.
Failure to remove a child despite safety threats. The team reviewing the case ofa four-year-old who died after ingesting fentanyl reported that there were at least two different times where an active safety threat was present that would have justified filing a petition in court to place the child in foster care. However, the staff believed, based on past experience, that the court would have denied the petition and therefore did not file.
Delayed Reunifications: “P.L,.” a toddler allegedly beaten to death by his mother, was in foster care for over three years but his mother’s rights were never terminated. He was on a trial return to his mother for just over five months when he was found dead with bruises and burns all over his body.
Staff shortages and high turnover were mentioned as contributing to the observed deficiencies in case practice in almost every fatality review. In B.B.’s case, the reviewers noted that the office had been functioning with a 50 percent vacancy rate for the last several years, stating that such a vacancy rate leads to high turnover, high caseloads, caseworkers with little experience, and supervisors forced to carry cases rather than support their caseworkers. Even caseloads that comply with state standards may be too high. The standard of 20 families per caseworker in FVS was noted to be unmanageable by one review panel, which noted that FVS cases are often discussed as high risk cases and require multiple contacts per month with family members, services providers, and safety plan participants. As Dee Wilson and Toni Sebastian put it, “[b]etting young endangered children’s lives on in-home safety plans developed and implemented by inexperienced and overwhelmed caseworkers is reckless, ill-advised public policy.”
Conclusions and Recommendations
Treating the decline in foster care as a desirable outcome in itself, as Washington and other states have done, is both disingenuous and dangerous. Any government can slash the foster care rolls reducing or ending child removals, as many “child welfare abolitionists” recommend. The central purpose of child welfare services, including foster care, is to protect children from child abuse and neglect. A reduction in foster care placements that results in the failure to protect children is no kind of success.
DCYF told King5 that “the increase in child fatalities and near fatalities in Washington is not being driven by the change in removal standards under House Bill 1227 or the reduction in the number of children in foster care. It is being driven by the increased availability of a highly addictive and hazardous drug and a lack of substance use disorder treatment in our communities.” But whether the agency’s policy or the drug epidemic is more at fault is not the right question. It is DCYF’s job to protect children given the circumstances that exist, including the drug epidemic and the lack of sufficient treatment, keeping in mind that treatment often does not work the first, second, third or subsequent times.
What can be done? DCYF needs to address the workforce crisis, which will probably require increasing pay and improving working conditions, or even possibly relaxing requirements for employment as a caseworker in investigations, assessment, and FVS. DCYF should consider policy and practice changes such as reducing the FVS caseload cap from 20 cases per worker; Instituting a chronic neglect unit, with expert caseworkers and even lower caseloads, for chronic cases; finding a way to limit the use of FAR to cases that are truly low-risk; and promoting the use of dependency petitions for court supervision when children remain in the home, as suggested by two fatality review committees.5 DCYF should request and the legislature should fund a variety of ancillary services for families, starting with therapeutic childcare for all preschool aged children with FVS cases as well as those who have been reunited with their parents. Such childcare would give parents a break and parenting support, keep children safe for a large part of the day, and ensure another set of eyes on the child, among other benefits. Also needed are more residential drug treatment centers where parents can live with their children.
Finally, more transparency is needed so that legislators, advocates and the public have access to the findings of DCYF’s executive review teams. Washington deserves credit for sharing its executive child fatality reviews. But there is no reason that the DCYF should not share its near-fatality reviews as well. We know something about how DCYF failed B.B. and the other children who died. But the public needs access to the reviews of those children who narrowly escaped death as well as those who did not. It is only through such transparency that the public can see the actual impact of all the self-congratulatory proclamations about “safely reducing the number of children in out-of-home care.”
Notes
A “near fatality” is defined by state law as “an act that, as certified by a physician, places the child in serious or critical condition.” ↩︎
DCYF relies on the Office of the Family and Children’s Ombuds (OFCO) to determine whether the fatality appears to have been caused by abuse or neglect, therefore requiring DCYF to conduct a review. ↩︎
Data collected by OFCO are more confusing. OFCO reviews all fatalities and near fatalities in which the child’s family was involved in Washington’s child welfare system within 12 months of the fatality. There number of near-fatalities reviewed by OCFO increased annually from 21 in 2018 to 70 in 2023, according to its most recent annual report on Child Fatalities and Near Fatalities in Washington State. But fatalities reviewed by OFCO did not show the same pattern. They reached a peak of 87 in 2018 and fell sharply in 2019, then rose yearly until they reached 85 in 2022 and then dropped to 79 in 2023. Nevertheless, adding fatalities and near fatalities together shows an alarming increase in critical incidents from 108 in 2018 to 149 in 2023. ↩︎
For example, in the case of “R.W.,” a child who died at age four after ingesting fentanyl, an investigation was closed because the children were staying with relatives, despite the mother’s history of repeatedly removing the children from relatives with whom she had left them. A month later the child was found dead at a motel in the custody of the parents. ↩︎
Complete Fiscal Year 2024 data now on the Dashboard of the District of Columbia’s Child and Family Services Agency (CFSA) reveal significant changes over the previous fiscal year. Most striking is a large jump in the number of incomplete investigations and a concomitant decline in “substantiated” and “unfounded” reports. The number of children entering foster care increased for the first time in over ten years. There was a drop in in-home case openings but a similar increase in foster care placements during the year. The agency did not respond to this writer’s questions about the meaning of these trends.
Referrals
Total referrals (or calls to the CFSA hotline) have increased for the second year in a row. After falling in 2020 and remaining below 2019 levels in 2021 and 2022, the number of referrals jumped from 16,899 in FY2022 to 20,246 in FY2023 and then rose more modestly to 20,978 in 2024–an increase of 3.6 percent. Prominent child welfare scholars like Emily Putnam-Hornstein have concluded that referrals are the best available indicator of actual maltreatment due to the strong correlation between referrals and future reports (regardless of the outcome of any associated investigation) and also evidence of the difficulty of correctly determining whether maltreatment has occurred. Thus, the increase in referrals may well be a sign of increasing maltreatment. Contributing factors might be the end of COVID-19 assistance programs and the growing mental health, substance abuse, and housing crises in the District.
Childcare and school personnel continued to make more than half of the referrals to CFSA, with another 13 percent coming from law enforcement and 11 percent from friends and neighbors. All three of these groups made more referrals in FY2023 than FY2024, while counselors, therapists, social workers and medical professionals made fewer, suggesting that children may be seeing fewer of these professionals with the disappearance of virtual options spawned by the pandemic.
Looking at CFSA’s response to the referrals, the largest portion, or 73 percent, were screened out. That compares to only 19 percent that were accepted for investigation. The remaining referrals were either linked to an existing investigation (three percent) or classified as an information and referral that does not involve an allegation of abuse or neglect. These percentages are quite similar to those of the previous year.
An investigation can have five different dispositions. According to the definitions provided in the Dashboard, unfounded means that there is not enough evidence to conclude that the child has been maltreated or at risk of being maltreated. “Substantiated” means that there is enough evidence to conclude that the child has been maltreated or is at risk of maltreatment. “Inconclusive,” means that “there is insufficient evidence to substantiate the report but there still exists some conflicting information that indicate the abuse or neglect may have occurred.” “Incomplete” means that the investigation could not be completed due to barriers like inability to locate the family, a family’s refusal of access to the home, or finding out that the family lived out of state.
There was a big jump in the number of investigations categorized as incomplete, from 525 in FY2023 to 1,442 in FY2024. That was an increase from 15% of all investigations to 38% of all investigations. As a consequence of the increase in incomplete investigations, the number and percentage of investigations that were unfounded and substantiated dropped drastically. The number of investigations that were substantiated fell from 799 (21 percent of investigations) in FY2023 to 606 (or 16 percent of investigations) in FY2024. Unfounded remained the most common disposition in FY2024, but the proportion of cases that were unfounded dropped from 58 percent to 41 percent.
CFSA’s communications director did not respond to several emails asking for an explanation of the the jump in incomplete investigations. But it seems likely that this trend stems from the workforce crisis that is affecting CFSA and other child welfare and human services agencies around the country. A spreadsheet that the agency provided to the DC Kincare Alliance shows 27 out of the 36 social workers performing investigations as of August 2024 were carrying more than the 12 to 15 cases that CFSA uses as an indicator of satisfactory performance. This included 19 social workers carrying 20 or more cases and five social workers carrying more than 30 cases. Even more concerning is that the number of social workers doing investigations fell from 42 in January 2024 to 36 in August 2024, according to the spreadsheet.
If social workers are not able to complete the required interviews and collect needed information timely, endangered children may suffer further harm. It is possible that most of the incomplete investigations have been essentially concluded with a determination of findings, leaving only the completion of needed documentation and forms undone as workers hurried to start new investigations. Such a scenario might be somewhat less alarming but would still raise concerns that overburdened social workers are not able to thoroughly investigate allegations, thereby endangering vulnerable children.
In-Home Case Openings and Foster Care Placements
The table below shows the number of in-home case openings and children entering foster care by year. These two numbers cannot be added together because because in-home entries are reported at the case level (with multiple children in many cases) and foster care entries are reported at the child level. However the trends over time can be compared, showing that the number of in-home cases opened dropped between FY2023 and FY2024 while the number of children entering foster care increased. This was the first time the number of children entering foster care increased since FY2021, after the drop in foster care placement due to COVID-19.\
The total number of children served in home and in foster care on the last day of every quarter are available on the CFSA Dashboard and can be added to yield the total number of children served on that date. The chart below shows that the total number of children served on the last day of the fiscal year (September 30) stayed basically the same between FY2023 and FY2024. But the number of children being served in their homes decreased by 50 while the number in foster care increased by 49. FY2024 reverses a trend of annual decreases in the number of children in foster care going back at least as far as 2011.
The increase in the number of children in foster care between September 30, 2023 to September 30, 2024 reflects an excess of entries to foster care over exits from care during FY2024. Specifically, the number of children in foster care at the end of the fiscal year should reflect the number of children in foster care at the end of FY2023, plus the number of entries to foster care during the year, minus the number of exits from foster care. While there is a discrepancy of two between the results of this calculation and the foster care caseload reported by CFSA, the numbers confirm that there were about 50 more entries than exits, so the caseload increased. A similar calculation cannot be performed for children served in their homes, as the entry data are based on cases, not children.
It may be reassuring that the number of children served by CFSA changed so little in FY2023. One can hope that despite the high percentage of incomplete investigations, CPS workers are doing what is necessary to find the children that need help and simply leaving some of the paperwork for later. However, such a situation is not sustainable without endangering children. And the 3.6 percent increase in the number of referrals between FY2023 and FY2024 was not met with an increase in the number of children served, which may be a result of the incomplete cases.
It is not possible to understand the FY2024 data without further information from CFSA. How alarming the increase in incomplete investigations may be depends on whether these investigations are truly incomplete or basically finished except for forms and documentation. More concerning still, CFSA caseload data indicates that there are fewer than half the number of social workers doing this work now than in previous years. It is good that the total number of children being served has not dropped precipitously along with the drop in completed investigations. But the public needs to know more about how CFSA is functioning and what it is doing to alleviate the workforce crisis.
Child Welfare Monitor 