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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

When ideology can kill: the death of Noah Cuatro

Image: KTLA.com

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Bias accusations

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

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

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

Strength-based practice

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

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

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

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

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

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

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

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

Report of Maltreatment: a major risk factor for child mortality

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lethal reunifications: two children dead in New York and Florida

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

The 694 days of Rashid Bryant

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

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

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

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

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

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

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

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

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

Julissia Batties: from home to hell

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

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

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

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

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

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

Factors Contributing to lethal reunifications

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

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

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

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

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

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

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

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

This is not my first post about a lethal reunification in Florida. In January 2019, I wrote about Jordan Belliveau, who was murdered by his mother eight months after being reunified with her, even while a agency in Pinellas County was still monitoring the family. A caseworker for the agency and later resigned told News Channel Eight that the system “puts far too much weight on reuniting kids with unfit parents and makes it nearly impossible for caseworkers to terminate parental rights.” It does not appear that the state learned from Jordan’s death.

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

Congress must take steps to ensure availability of therapeutic residential care

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Chart One

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

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

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

Chart Two

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

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

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

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

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

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

Child Neglect: a misused and misunderstood term

There is much confusion around child neglect. Opponents of the current child welfare system are fond of stating that most children reported to child protective services (CPS) are suffering from neglect, not abuse, that neglect is synonymous with poverty, and therefore that children are commonly being removed from home because of poverty. While neglect is clearly related to poverty, the facts suggest that the removal of children due to poverty alone is rare. To know more about this most common form of maltreatment, it is necessary to collect more specific data on the types of child neglect that are found when a neglect allegation is substantiated. Nevertheless, child welfare must recognize the important role of poverty in promoting child neglect and the role of poverty alleviation programs in child neglect prevention.

A useful way to distinguish between abuse and neglect of children is that abuse is generally an act of commission, while neglect is an act of omission. According to the Child Welfare Information Gateway, neglect is “commonly defined in state law as the failure of a parent or other person with responsibility for the child to provide needed food, clothing, shelter, medical care, or supervision to the degree that the child’s health, safety and well-being are threatened with harm.” The most commonly recognized categories of neglect include physical neglect (failure to provide for basic physical needs), medical neglect, inadequate supervision, emotional neglect, and educational neglect. Some states include exemptions for certain types of neglect, like religious exemptions for medical neglect. Twelve states and the District of Columbia exclude financial ability to provide for a child from the definition of neglect.

How true are common statements about neglect?

A number of statements about neglect are are frequently made in support of various views and proposals. These are discussed below.

The national child welfare system was established to address abuse, not neglect. This is absolutely true. The discovery of “battered child syndrome” by Henry Kempe at the University of Colorado led to the passage of child protection laws in every state within a few years. On the federal level, the Child Abuse Prevention and Treatment Act (CAPTA), which established the federal role in supporting and monitoring these systems, was also focused on abuse rather than neglect. According to an oft-quoted book about the history of CAPTA, Democrats feared that President Nixon might veto CAPTA if it was viewed as an anti-poverty program, so they took pains to reiterate that child maltreatment could happen to anybody, regardless of socioeconomic status. As a result, the responses to child maltreatment focused on mental health and parent education services rather than economic supports. In his essay, Poverty, Neglect and Cultural Denial, child welfare commentator Dee Wilson recalls that when he began working as a CPS social worker in the 1970’s, all his training focused on battered children. Yet, in his work he encountered battered babies and toddlers maybe “once or twice annually out of 100 to 150 assigned cases.” Instead, he received both in Colorado and later in Washington “a steady diet of reports of child neglect and, to a lesser extent, reports of excessive punishment of children with minor injuries that did not require medical attention.” Academic literature has contributed to the problem by failing to distinguish between abuse and neglect.

Neglect is the main reason for children’s involvement with child welfare. This is also a true statement. According to the latest data collected from the states and published in Child Maltreatment 2019, three-quarters (74.9 percent) of the 656,000 children found to be victims of maltreatment in 2019, were found to be neglected, 17.5 percent were physically abused, 9.3 percent were sexually abused, and 6.8 percent were “other.” Some children were found to be victims of both neglect and another maltreatment type. These percentages should not be viewed as an exact representation of the relative importance of different types of maltreatment. As Font and Maguire-Jack point out, investigators do not have to substantiate every allegation to justify intervention. So If there is more than one type of maltreatment in the home, investigators may not substantiate all of the different types. Thus a child found to be a victim of neglect only may actually have suffered abuse as well. Comparison of substantiation data with other sources, as shown in Font and Maguire-Jack’s table listed below. suggests that “substantiations are likely to grossly understate all forms of child maltreatment, but especially physical abuse.” So neglect does appear to be more common than abuse as a reason for child welfare involvement, but abuse may be be present in a higher fraction of cases than the percentages indicate.

Source: Sarah Font and Kathryn Maguire-Jack, The Nature and Causes of Child Abuse and Neglect.
ANNALS, AAPSS, 692, November 2020. https://journals.sagepub.com/doi/abs/10.1177/0002716220969642?journalCode=anna

Child neglect is strongly related to poverty. This is also true. Research demonstrates that poverty is a major risk factor for child neglect. According to the most recent National Incidence Study of Child Abuse and Neglect, children in low socioeconomic status households experienced maltreatment at five times the rate of other children. Studies have also demonstrated that providing economic supports for families (through programs like tax credits, passing on child support, food assistance, and child care subsidies) have direct effects on child maltreatment. We do not know exactly how poverty affects child neglect but in an excellent article in a journal issue devoted to child maltreatment Feely et al provide a useful way to think about it. They posit that the inverse of neglect is what they call “safe and consistent care or SCC,” which they define as “to provide safe, consistent supervision and constantly provide for children’s basic needs.” As they describe, time and money are two core resources a family needs to provide SCC. For a poor parent, it may be very difficult to provide acceptable levels of time and money simultaneously. So a poor parent might have to choose between going to work and letting the children be unsupervised or inappropriately supervised, or losing their job and letting their children go hungry.

Most parents found to be neglectful are actually just poor. The confusion of poverty with neglect is a trope that is cited again and again by those who advocate restricting government intervention in maltreating families. For example, Jerry Millner and David Keller, the former Associate Commissioner of the Children’s Bureau and his special assistant, have written that It’s time to stop confusing poverty with neglect. They claim that many children become involved with child welfare only because their parents are poor. For example, children might be taken into care because a parent gets evicted or cannot afford childcare and leaves them alone. Despite the popularity of this belief, the evidence does not support it. It is clear that most poor parents do not neglect their children. They find a way to provide safe and consistent care, whether it means extensive research on community resources, creative use of existing supports, or delaying the next birth until adequate resources are available to care for the children they already have. Dee Wilson argues based on his decades of experience in child welfare that “a large percentage of neglect cases which receive post-investigation services, or which result in foster placement, involve a combination of economic deprivation and psychological affliction, beginning with mood disorders such as depression and PTSD,” which often lead to substance abuse as a method of self-medication.

The most serious cases of neglect are often chronic. Chronic child neglect can be defined as “a parent or caregiver’s ongoing, serious pattern of deprivation of a child’s basic physical, developmental and/or emotional needs for healthy growth and development.” Chronic neglect by a single mother often opens the door for physical or sexual abuse by her boyfriend. Children who have experienced chronic neglect may suffer “serious cognitive and social deficits because of the….lack of responsive parent-to-child interaction that is essential for healthy child development.” Chronic neglect can have effects similar to trauma, such as difficulties with emotion regulation.

Many child neglect reports are frivolous and unnecessary, cluttering up the system and making it harder to identify serious maltreatment. Many critics of mandatory reporting and CPS cite a study estimating that 37.4 percent of all U.S. children (and 53 percent of Black children) experience a CPS investigation by the age of 18. Some argue that many of these reports are the consequence of a racist system that ensnares too many poor and Black families. Some are supporting bills to end anonymous mandatory reporting in New York and Texas. Another, smaller set of reports has drawn attention, as described by Naomi Schaefer Riley in her article, Reforming Child Neglect Laws. These reports target stable, functional middle class families that have chosen to give their children more independence than many other parents in their geographic and demographic stratum. The case of the Meitiv children, who were picked up by police while walking a mile to their home in Silver Spring, Maryland and became the subject of not one but two CPS cases, drew publicity around the country.

It is clear that some reports coming into hotlines do not warrant investigation, but we do not know what proportion. Annual data submitted by states and compiled in the Child Maltreatment 2019 report shows that that 45.5 percent of referrals (for all kinds of maltreatment) in 2019 were screened out. And of all children receiving an investigation or alternative response, only 18.9 percent were found to be victims of maltreatment. However, research suggests that the likelihood of another report, a substantiated report, or a foster care placement is the same for a child who is the subject of a substantiated versus an unsubstantiated report. Chances are that many of the children with unsubstantiated reports were previously the subject of substantiated reports, or will be the subject of such reports later. Moreover, as Font and Maguire-Jack point out, “it seems unavoidable that some number of non-maltreated children will be reported to CPS if mandatory reporters are acting appropriately.” After all, they are told that they do not need to be sure the maltreatment is occurring, but to leave that decision to CPS. Changing that guidance, in my opinion, would be dangerous to children.

Should neglect be treated differently from abuse?

Even if neglect is not “just poverty,” some commentators argue that it should be treated differently from abuse. Two former directors of large child welfare systems, Tom Morton and Jess McDonald, argue that because child protective services were designed around abuse rather than neglect, they were patterned after the criminal justice system and treat all maltreatment as antisocial behavior. Morton and McDonald argue that because neglect is an act of omission rather than commission, it should be treated differently, The response to neglect should occur in a “public health framework” outside the current child protection system.

I do not agree that we need a separate system to deal with neglect. As I have discussed, many neglected children are also victims of abuse, whether or not it is substantiated by authorities, and neglect by one caregiver can pave the way for abuse by another. We already have a criminal justice system that addresses criminal abuse and neglect separately from the child welfare system. While the effect may seem punitive, the goal of CPS is to make children safe, not punish parents. Both abuse and neglect make a child unsafe, and the first mission of child welfare is to ensure child safety. Splitting this mission into two is probably not be the best way to promote children’s safety.

Even if we do not need a separate system to deal with neglect, we need to recognize the importance of anti-poverty strategies to help families provide safe and consistent care and prevent child neglect. Prevention has become a major priority of child welfare leaders and thinkers, so this is a good time to talk about incorporating poverty alleviation into child maltreatment prevention. In this new vision, as Feely et al propose and as I have discussed in an earlier post, child maltreatment (especially neglect) prevention should not be the responsibility of child welfare agencies alone. This responsibility should be shared by all the agencies responsible for alleviating poverty. The new initiatives proposed by the Biden Administration for child tax credits, universal pre-kindergarten and expanded child care assistance should be a good beginning.

Is it time to drop the term “neglect”?

In an article in The Imprint, Rebecca Masterson of Gen Justice argues correctly that the term “child neglect” has become almost meaningless because it is used so broadly and so deceptively as a symptom of poverty. Masterson argues that “neglect” needs to be replaced by more specific terms, such as abandonment or refusal of medical care. I do not agree that the term neglect should be dropped. Just as “child abuse” is an umbrella term that includes physical abuse, sexual abuse, and emotional abuse, “neglect” has value as an umbrella term that refers to acts of omission that harm children, in contrast to abuse, which is an act of commission. It makes sense to have these umbrella categories.

But the umbrella categories of “abuse” and “neglect” should not be put in the same list of categories as the specific acts (or lack thereof) underneath the umbrellas. Unfortunately, state and local data systems often list “neglect” as a category along with other more specific terms for types of neglect. This results in bizarre analyses where “neglect” is often described as the most common category of child maltreatment–more common than its subcategories–as if anything else is possible! Just as social workers do not have to check off “abuse” as well as “physical abuse,” in their agency database, they should not be asked to check off “neglect,” as well as specific types of neglect. In order to fix this problem everywhere, and to make sure we have comparable data from all states, the federal government should mandate that all states use the same subcategories of abuse and neglect, and that “abuse” and “neglect” not be among the specific categories.

In devising these alternative categories, we also must be careful to avoid confounding neglect with conditions that may cause it, such as substance abuse and mental illness. These are contributing factors that should be noted in databases and shared with the federal government but are not in themselves forms of neglect. And indeed, in some jurisdictions, like the District of Columbia, substance abuse is not considered neglect unless it is considered to impair parenting.

Child neglect is the most common form of child maltreatment, yet it received little attention in the first decades of the modern child welfare system. It took a long time for child welfare scholars and leaders to recognize the importance of neglect. Unfortunately now that they have recognized its importance, many leaders are using this new knowledge in order to support their proposals to upend child welfare in ways that may be harmful to neglected children. This misuse of the concept of neglect can be addressed by requiring that child welfare agencies collect uniform data on the types of neglect that are being found. That being said, it is important for child welfare leaders to understand the importance of poverty alleviation strategies in preventing maltreatment in general and to recognize that this job does not belong to the child welfare system.

The death of David Almond: a perfect storm, or the tip of the iceberg?

Image: WJAR

I have been trying to avoid writing more posts about children failed by state systems that exist to protect them. No matter how many reports are written, these fatalities continue to occur with devastating regularity, and I’m not sure if my posts do any good. But despite my resolution to avoid such stories, I feel compelled to write about David Almond, a fourteen-year-old boy with Autism Spectrum Disorder who died of abuse and neglect on October 21, 2020. I have to write about David for many reasons, including the sheer number of red flags that were disregarded by child welfare, schools and courts in his case; the light his death sheds on risks to children with special needs, and what it shows about the peril posed to abuse victims by the quarantines due to COVID-19.

The Massachusetts Office of Child Advocate (OCA) issued a scathing report in March that revealed “multiple missed opportunities for prevention and intervention prior to the death of David Almond and the discovery of the serious physical and emotional injuries to his brothers.” David’s family was under the supervision or monitoring of the Department of Children and Families (DCF), the juvenile court, the education system and many service providers at the time of David’s death. Reading OCA’s account of the family’s involvement with DCF alone, it is hard to comprehend the many misguided actions and missed opportunities that allowed David to be returned to a family patently unable to care for him and then to deteriorate physically and emotionally over a period of seven months, culminating in his death. The attachment to this blog lays out the sad chronology assembled by OCA, which I summarize more briefly below..

David, Michael and Noah Almond were triplets born in February, 2006 in Syracuse, NY and diagnosed with Autism Spectrum Disorder at the age of about two. Between 2006 and 2013, the triplets were removed from their parents three times by the New York State Office of Children and Family Services (OCFS) due to substance abuse, mental illness, “deplorable living conditions,” medical neglect, inadequate supervision, and “a general lack of basic care.” After working toward termination of the parents’ rights, OCFS inexplicably shifted gears and a New York Family Court awarded full custody of the boys, now aged ten, to Almond, who was living in Massachusetts, in September 2016.

Upon receiving custody, Almond moved the boys to the one-bedroom apartment in Fall River, Massachusetts, which he shared with his partner, Jaclyn Coleman, and his mother, Ann Shadburn. Almond had been removed as a child from Shadburn, whose parental rights to all her children had been terminated due to abuse and neglect. Almond and Coleman were both in DCF custody for part of their childhoods due to abuse and neglect, mental illness, physical violence, and substance abuse. By August 2017, Coleman had a new baby (Aiden) and three reports had already come into Masachusetts’ child abuse hotline concerning the family.

In October 2017, all four children were removed from Almond and Coleman because of abuse and neglect, parental substance abuse, unsanitary home conditions, medical neglect, and the triplets’ excessive absences from school. In the words of OCA, “This was the fourth time in the triplets’ young lives that they were removed from Mr. Almond for the identical pattern of abuse and neglect.” But four strikes was not enough. The parents agreed to a plan requiring them to engage in therapy to address longstanding substance abuse and mental health issues, submit to random drug tests, participate in family therapy with the triplets, complete psychological evaluations, and complete parenting classes. Aiden was placed in foster care and the triplets were eventually placed in a residential facility specializing in autism spectrum disorder and intellectual disability.

While the triplets thrived in their residential facility, Coleman and Almond displayed minimal compliance with their plans, and the children’s permanency goal was changed to adoption in January 2019. But in July 2019, the children’s goal was changed back to reunification based on the parents’ improved compliance with their case plan, and Aiden was returned home the next day. This occurred, as OCA put it, “despite Mr. Almond’s failure to engage with therapy, despite Ms. Coleman’s limited engagement with therapy, and despite the lack of any documentation of any change in Mr. Almond and Ms. Coleman’s ability to parent, specifically their ability to parent children with special needs.” OCA attributes this decision mainly to a parenting evaluation conducted by a contractor that did not adequately assess the caregivers’ ability to care for the children.

In December 2019, DCF Fall River area office management decided to begin the reunification process for the triplets. This decision was made despite concerns raised by the family support provider and the case management team (social worker and supervisor) that the parents were canceling appointments, and more generally regarding their ability to care for the triplets. Management set a target date of January 2020 for the reunification. They disregarded requests for a delay from the case management team, the residential facility and the boys’ school. These requests were based in part on the need of children for a slower transition given the children’s disability, the logic of waiting until June to eliminate an extra change of school, the limited engagement the parents had demonstrated with services, the difficulties inherent in having seven people in a one-bedroom apartment, and the threat of eviction by the landlord if the boys returned home.

As the reunification date grew nearer, Almond and Coleman canceled scheduled visits with the boys, canceled appointments with the parenting support provider, and failed to take steps to secure larger housing. During the first day visit of the boys to the home on January 10, 2020, Coleman stated that reunification was moving too fast and that the family was not yet ready for overnight visits because the apartment was too small. At the first overnight visit on February 7, Almond and Coleman reported that Noah became aggressive, and he was returned to his facility that night. After this home visit, Noah refused to return to the apartment and was allowed to remain at his residential facility. The goal of reunifying him with his parents was dropped. This young autistic boy’s self-advocacy may have saved his life.

On February 11, 2020, the residential care facility took the “extraordinary” step of sending DCF a letter opposing the reunification of David and Michael with Almond and Coleman, citing the inadequate physical environment of the home to meet the children’s therapeutic needs; the fact the parents were facing eviction; and the need for a slower, more appropriate transition plan. The reunification was delayed, but by one month only. The case management team referred the family for Applied Behavioral Analysis (ABA) Services, an evidence-based approach used in both the residential program and school that the boys attended. This service was considered essential for a successful reunification, but there was a waiting list of at least six months for ABA services. Instead of delaying the reunification, DCF chose to secure “continuum services” for the family even though these services targeted one child only (Michael) and were not a substitute for ABA’s services, which are specific to the needs of autistic children.

David and Michael were returned to Almond and Coleman on March 13, 2020, barely two months after their first day visit. Four days after the reunification, the state’s COVID-19 restrictions went into effect. Starting within days of the boys’ return home and continuing until David’s death, OCA states that Almond and Coleman “deliberately avoided contact with the DCF case management team, the Fall River Public Schools, the continuum service provider, and the parenting support service provider.” They often claimed to have phone or internet access issues that prevented them from responding or being on video. When offered help in dealing with these issues, they refused or provided conflicting information.

Between March and September 2020, the case management team conducted monthly virtual visits with the family and received many communications from providers and schools. During this period, the team missed multiple red flags and opportunities to prevent the tragedy that eventually occurred. The team disregarded evidence from their own virtual visits, such as Coleman’s berating of David for his alleged behavior and her coaching of the boys to provide the desired responses to the case manager’s questions. But they never sought to interview David and Michael outside the presence of the adults. Exactly two months before David’s death, DCF received received a new CPS report about conditions in the home and substance abuse by Coleman and Almond. But the case management team accepted Coleman’s attribution of the report to a malicious neighbor and did not request drug tests for Coleman and Almond.

The team ignored concerning reports from providers and schools. These included the termination of services by the parenting services provider due to Coleman and Almond’s failure to engage with services; consistent reports from the continuum services provider that Coleman refused to allow them to speak to Michael, the targeted child for these services, and were resistant to the support and the strategies offered to address the boys’ behaviors; and David was never allowed to see the therapist obtained by DCF. DCF heard from Fall River Public Schools that Coleman and Almond refused the Chromebooks offered by the school in May but never submitted the paper packets they had chosen to complete instead. Instead, DCF learned that that the boys were not logging into school in the fall semester (a report Coleman denied, as she was logging into the schools’ electronic attendance system to falsely mark the boys “present.” ). They learned that David had missed his physical in July and two subsequently scheduled appointments.

David’s school, despite making multiple concerning reports to DCF case management, also missed many chances to save David. In one striking example, a school attendance officer came to drop off Chromebooks for David and Michael only 20 days before David was found dead. Coleman met the officer outside, refusing him entry in the apartment, and the offer did not attempt to see the boys. Apparently he was there solely to drop off the devices and not to see David or discuss with this family his lack of engagement with school since the previous March. If that officer had seen David and noticed his physical state, David might be alive today.

On the morning of October 21, 2020, emergency medical personnel responded to a 911 call regarding David; he was bruised, emaciated, and not breathing. He was transported to Charlton Memorial Hospital and pronounced deceased. Michael was found emaciated but responsive, and Aiden was well nourished and appeared physically unharmed. Substances believed to be heroin and fentanyl were found in the apartment. Michael and Aiden were immediately removed from Almond and Coleman, who are in jail and facing criminal charges.

OCA found that DCF missed multiple opportunities to protect David and his brothers. DCF gathered insufficient information from service providers and failed to analyze the information they did get; underestimated the impact of Almond and Coleman’s substance use; failed to recognize that Almond and Coleman were using access to technology as a tactic to avoid participation in services for themselves and their children; misinterpreted the “successful” reunification of Aiden (a non-disabled child) as a predictor of a successful reunification for the triplets; disregarded the triplets’ need for a gradual transition to the home; failed to secure the recommended essential services for David and Michael to be stable and successful at home; made David responsible for his own physical safety rather than teaching him to distinguish between appropriate and inappropriate interactions how to to communicate concerns to a trusted adult; and failed to adequately identify and adjust to the complications imposed by the COVID-19 pandemic.

OCA found that DCF management failed to understand that the physical environment of the home, a small one-bedroom apartment, did not meet the needs of the triplets. This is despite hearing this concern from the DCF case management team, Almond, Coleman, Almond’s legal counsel, legal counsel for David and Michael, and several provider agencies.  Incredibly, it appears that DCF management interpreted concerns from the various professionals as “an inappropriate consideration of the family’s financial means.” They seem to have disregarded the importance of physical space in the therapeutic management of autistic children and also the fact that Coleman and Almond seemed uninterested in finding a larger apartment and provided multiple excuses for not following up on housing applications.

As OCA states, “It is widely recognized that in times of crisis and economic stress there is an increase in child abuse and neglect.” Yet, OCA found that DCF did not treat the COVID-19 pandemic as a cause for reevaluation of the appropriateness of David and Michael’s reunification and did not consider the implications of the pandemic for the safety or well-being of the children. DCF seemed oblivious of Coleman and Almond’s use of the pandemic to isolate the children. Bizarrely, DCF case management staff urged school staff not to hold Coleman accountable for David and Michael’s complete absence from school, arguing that the problem was lack of technology access in the home. Case management staff also advised Coleman repeatedly to contact the school to explain that technology was the barrier to David and Michael’s participation, in order to prevent the school from filing a child neglect report against her.

Amazingly, DCF did not categorize David and Michael as high-risk children to receive in-person home visits during COVID-19. DCF appeared not to understand that that the boys’ disability, the long history of abuse and neglect in this family, the caregivers’ avoidance of contact with providers, and their reports about David’s behaviors, injuries and illnesses were all signs of children at risk. Moreover, the DCF administration has not issued statewide guidance that provides DCF personnel instructions about how to assess safety and risk during virtual home visits.

And perhaps most shockingly, DCF missed the deterioration in David’s physical and emotional state between March 13, 2020, and his death on October 21. The residential program and school where David lived and studied until March 2020 described him as having good social interaction skills, as being communicative, as having no significant behavioral issues or self-injurious behaviors, as having no aggression toward others and as having the ability to take care of his own activities of daily living. Yet within weeks of reunification Coleman was reporting that David was noncompliant, aggressive, harmed himself, and needed assistance with activities like toileting. During virtual home visits with DCF, David was always quiet and minimally communicative, while Coleman often berated and shamed him for behaviors and defiance. The case management team accepted her account and disregarded the conflict with his observed behavior and past accounts. David was a healthy weight when he left residential care. At his death, David had lost approximately 60 pounds from his last recorded weight in December 2019. It is hard to understand how anyone could have missed such a drastic change, even through a video screen.

OCA found that the Juvenile Court, including the attorney for David and Michael, did not serve as a check on the many egregious decisions of DCF. Instead, perhaps because they all agreed to return the boys home, the court and attorneys relied too heavily on DCF to determine the direction of the case. They accepted DCF’s interpretation of Aiden’s “successful” reunification as an indication of the likelihood of a similar outcome for the triplets, disregarding the differences between Aiden and the autistic triplets; failed to require a submission of a realistic reunification plan despite the judge’s statement that such a plan would be needed; accepted DCF’s narrative of the triplets’ “successful” reunification even though court reports contained information from service providers about the family’s failure to participate in services; disregarded multiple concerns about the small size of the family’s apartment and the stress it caused, based on the apparent belief that it was inappropriate to consider inadequate housing as a barrier to reunification; and never requested an analysis of the effects of the COVID-19 pandemic on the family’s ability to care for these high-needs children.

The education system’s failure of David and Michael was almost as egregious and shocking as that of DCF and the court. OCA found that the state Department of Elementary and Secondary Education (DESE) did not have the resources to monitor the provision of a free and appropriate public education in real time by local school districts during the COVID-19 pandemic. Despite their policy of prioritizing high-risk students for in-person learning, DESE “allowed families to choose the fully remote option for any reason and without a stated reason. In fact, districts were instructed not to counsel families of high risk students to choose in-person learning even if the district felt that remote learning would not be successful for a particular student.” DESE did not set higher standards for monitoring or support for high-risk students, such as those with disabilities and those involved with DFS, regardless of their choice of learning option. DESE issued no guidance to school staff on how to recognize abuse and neglect in a virtual environment. Nor did they address mandatory reporting of attendance issues until January 2021.

In addition to the failures of DESE, Fall River Public Schools (FRPS) missed multiple opportunities to save David. The shift to remote learning, coinciding exactly with the transfer of David and Michael to FRPS, meant that David was never seen by, or spoken to, by any school employee from March 2020 to the time of his death in October 2020. To their credit, school staff made numerous attempts to communicate with the parents and resolve alleged technology problems. Yet, David and Michael’s teachers never attempted to make contact with the boys directly via telephone. While they raised concerns about the boys’ lack of participation to the DCF case management team, school staff never elevated this concern by filing a neglect or truancy report. Moreover, FRPS set no attendance or participation requirements, and David was incredibly promoted to high school after being completely disengaged from his school since being transferred there in March. DESE and FRPS guidance for the fall 2020 concerning attendance tracking, contact, and grading never filtered down to school staff, perhaps preventing an intervention in the last month of David’s life.

There was another entity that could have intervened to raise concerns about the safety of the children, and that was the Massachusetts Probation Service (MPS). Massachusetts children in child welfare cases are assigned a probation officer whose role is to verify compliance with court orders, report to the court on the status of these orders and monitor the well-being of the children. The officer in this case had regular contact with the family and seemed to have a much more clear-eyed view of their problems than did DCF, which did not act on his expressed concerns. However, he did have a worrisome conversation with Coleman only days before David’s death in which she reported on the deterioration of both boys, that they had regressed to wearing adult diapers, that David was picking at his skin causing sores and bleeding, and that Michael had to be hospitalized for self-injury. The officer could have brought these concerns to the attention of the court before the next hearing but did not do so–possibly due to a culture discouraging such communications–and missing the last opportunity to save David.

Several questions remain even after the comprehensive review by OCA. First, what explains the New York Court’s decision to reunify the triplets with their father after taking steps toward terminating his rights? It is very concerning that OCA was not able to obtain this information in its review of court data. A court decision like this would have to be documented and would presumably been based on recommendations from Onondaga County (NY)’s Office of Children and Family Services (OCFS). It is not clear whether OCA requested documents from OCFS, and whether such a request was refused. It is necessary to understand what occasioned this about-face by New York. One cannot help wondering if the agency realized the boys would not be adopted was trying to avoid the expense of caring for the boys into adulthood.

OCA was also unable to explain the DCF area management’s unwillingness to reconsider the appropriateness of the reunification plan in the face of objections from their case management team and almost everyone else involved. OCA states that there was no pressure from the Juvenile Court, Almond, Coleman, their attorneys, nor the children’s attorney to rush a transition home. DCF administration also confirmed during this investigation that there were adequate funds in the Fall River Area Office’s budget to continue the triplets residential placement. Once again, as in New York, one has to wonder whether, despite the existence of “adequate funds” for the boys’ placement, there was in fact pressure on the local DCF office to return the boys due to the financial costs of their placement. Such budget concerns might have explained the unseemly rush to reunify despite the unavailability of a crucial service and adequate housing and the clear logic of waiting until the triplets completed their educational program in June 2020.

It is hard to avoid speculating about whether Almond and his paramour actually wanted custody of David and Michael. It appears that Almond and Coleman wanted Aiden back (not surprising as he was Coleman’s son and not disabled) and that is why they began to cooperate somewhat with services after an initial period of total noncompliance. There is no evidence that the couple were pushing for the return of the triplets and many indications that they tried to delay it as long as possible. Canceling visits to the boys and appointments with providers and failing to take steps to find a larger apartment could all be taken as signs of reluctance to receive the boys at home. Caring for triplets with autism plus a baby is not easy for anyone, it is hard to imagine a troubled couple like this one doing it, especially without the help that was recommended by the expert.

There is no excuse for the sheer inhumanity displayed in this household. Nevertheless, the case does call to mind the reports that are coming from all parts of the country regarding our national failure to help parents care for their mentally ill or developmentally disabled children–a crisis that is leading good parents to consider relinquishing custody of their children in order to obtain the services they need. It is possible that Almond and Coleman (not being good parents in the least) were trying hard to relinquish custody but were unsuccessful in unloading their unwanted triplets onto New York and Massachusetts. The eagerness of agency management to shed this burden and the reluctance of Almond and Coleman to take it on made for a toxic mix that killed David Almond, and left both of his brothers with lifelong wounds.

The OCA report contains many pages of recommendations for DCF, which include improving supervision, reviewing and revamping agency policies on contacts with collaterals, clients with disabilities, reunification; revamping the safety assessment process; setting standards for when and how virtual visits can be conducted, establishing a robust quality assurance system with additional monitoring at critical decision-points in a case and for higher-risk cases, and creating a “culture of continuous learning” where the “identification and correction of errors, miscalculations, or misinterpretations is encouraged and commended.” Many more recommendations targeted the juvenile court, the Probation Services, and the public schools.

While this report is unique due in its exploration of the complications due to the COVID-19 pandemic, we have seen too many similar reports from all of the country over many years. Most recently, Maine’s child welfare ombudsman found that the system continues to struggle with making an informed decision about whether to send a child home from foster care and whether to end agency supervision of reunified children. In a review of 82 cases closed in the past year, they found 20 cases where reunification practices were at issue.

Commonwealth Magazine notes that OCA conducted comprehensive investigations in 2013 and 2015, following three high-profile child deaths. Since 2015, the Legislature and Gov. Charlie Baker’s administration have increased funding for DCF by more than $200 million, added more than 650 positions, reduced caseloads, and introduced numerous reforms. Yet, Fall River State Representative Carole Fiola pointed out that many of the same patterns of agency malfunction were found in the earlier reports. This is indeed discouraging. Perhaps stronger measures are required.

A “three strikes law” for abuse and neglect might be one such stronger measure. Perhaps parents should not be given another chance after three or more removals. And this question brings up the role of ideology, especially as it might be expressed by managers who are unfamiliar with the actual details of the case. In the current child welfare climate, it often seems that parents can do no wrong. As noted repeatedly in the this case, there was too little focus on the problems that brought the children into care, and too little assessment of whether these problems were truly solved before the children were returned. This may not be atypical or surprising, given the current emphasis on family preservation and “strength-based” approaches to working with families, which ask social workers to minimize problems and find strengths wherever they can. There is certainly value in this perspective as a corrective to an earlier focus exclusively on problems, but taken too far it can be deadly.

The reluctance of the agency, lawyers and court personnel to consider housing adequacy as a prerequisite to reunification was another dysfunctional intrusion by ideology into case practice. Today’s dominant narrative asserts that children are being removed from families due to poverty that is being couched as neglect by intrusive child protective services systems. Poverty should not be a reason for removal nor should it be a barrier to reunification. But this case was not so simple. Almond and Coleman took no steps to apply for larger housing, despite being offered many opportunities to do so. It is possible that their reluctance to apply stemmed to their hope that they would not be saddled with the three boys. But the reigning narrative may have blinded agency management, court and lawyers to this concerning lack of action by the boys’ father and his paramour.

David’s case warns us to beware of the blanket statements often pushed by the child welfare establishment. It is often accepted as common knowledge that children do best with their family of origin, that in rare cases where children cannot remain at home the best placement is a relative (like Ann Shadburn?), and that congregate care is always the worst placement for children. None of these “truths” were correct for David and his brothers. Perhaps David’s story will lead some leaders and commentators to ask themselves what a home really is, and to understand that it is the presence of love, not the type of setting, that matters to a child.

“It is tempting to characterize this case as resulting from a ‘perfect storm,'” says the OCA, while not expressing an opinion on whether that is an apt characterization. The “perfect storm” explanation is often used by governments to argue against placing significant weight on individual cases, no matter how egregious. “A system should not be judged by one case, no matter how sad or sensational,” said Joette Katz, Commissioner of Connecticut Department of Children and Families (DCF) as reported by the Hartford Courant. Katz was talking about the death of Matthew Tirado, an autistic 17-year-old, on February 14, 2017 from prolonged abuse and neglect by his mother. Matthew had been known to Connecticut’s Department of Children and Families since the age of five, as revealed by a heartbreaking  report from Connecticut’s Office of the Child Advocate. Yes, A System Should be Judged by One Case was my answer to Katz. If David’s death was the outcome of a perfect storm, it was also the tip of the iceberg. If professionals are capable of making the kind of mistakes they made over and over again in this case, similar mistakes are obviously occurring in other cases. For every David Almond or Matthew Tirado, there must be many other children left in abusive and neglectful homes who never come to our attention because they are not actually killed albeit suffer lifetime damage. But the cost in current suffering and future damage is incalculable.

Certainly the COVID-19 pandemic was a large part of the “perfect storm” leading to David’s death. Thankfully, the pandemic appears to be easing and schools should be open full time next fall. However many jurisdictions plan to retain a virtual option next fall. OCA expressed concern that even though an in-person option was offered to the boys in Fall 2020, parents were allowed to choose virtual education without any stated reason and even if the district felt that remote learning would not be successful for a particular student. OCA made many recommendations for improving the oversight of children in virtual education but did not make a recommendation that addressed this finding. It is my view that jurisdictions should establish guidelines for approval of virtual education for each student and require a waiver for any student whose guardians request virtual education for reasons that are not included in these guidelines. Many advocates for children and domestic violence victims, such as Andrew Campbell, have warned from the outset of the pandemic of the dangers facing people who locked in with abusers. David’s case showed how right they were and that planning for future emergencies needs to include better provisions for such vulnerable people, including school-aged children.

COVID-19 will end, but I will continue to write about the Davids, the Matthews and all of the children who are failed by the agencies that exist to protect them. I will continue to write about them until we learn to value our children more than money or ideology, and until we decide as a nation that children will no longer be collateral damage in the pursuit of other goals, whether pandemic containment, “family preservation,” or budget savings.

Attachment: Chronology of the case of David Almond, from the Office of the Child Advocate Report

February, 2006: David, Michael and Noah Almond were born in Syracuse, NY to Sarah and John Almond, as described in OCA’ s devastating report. The triplets were all diagnosed with Autism Spectrum Disorder at the age of about two.

2006 to 2013: the triplets were removed from their parents three times by the New York State Office of Children and Family Services (OCFS) due to substance abuse, mental illness, “deplorable living conditions,” medical neglect, inadequate supervision, and “a general lack of basic care.” Their mother had no contact with them after the final removal, and their father moved to Massachusetts. OCFS began steps to terminate the parents’ rights to the boys, but never completed the process.

September 2016: A New York Family Court awarded full custody of the boys to Almond, who was living in Massachusetts, in September 2016, after years of minimal or no contact. Almond moved the boys to the one-bedroom apartment in Fall River, Massachusetts, which he shared with his partner, Jaclyn Coleman, and his mother, Ann Shadburn. All three had a history of abuse and neglect as a victim or perpetrator. Shadburn’s parental rights to all of her children, including John Almond, had been terminated. Almond and Coleman were both in DCF custody for part of their childhoods due to abuse and neglect, mental illness, physical violence, and substance abuse.

June 2017: The first two abuse or neglect reports were called into the Massachusetts hotline concerning the children. Another report came in that August, citing Coleman’s substance abuse and questions about the parents’ ability to meet the needs of their newborn son, Aiden, as well as of the triplets.

October 2017: All four children were removed from Almond and Coleman because of abuse and neglect, parental substance abuse, unsanitary home conditions, medical neglect, and the triplets’ excessive absences from school. In the words of OCA, “This was the fourth time in the triplets’ young lives that they were removed from Mr. Almond for the identical pattern of abuse and neglect.” But four strikes was not enough. The parents agreed to a plan requiring them to engage in therapy to address longstanding substance abuse and mental health issues, submit to random drug tests, participate in family therapy with the triplets, complete psychological evaluations, and complete parenting classes. Aiden was placed in foster care and the triplets were eventually placed in a residential facility specializing in autism spectrum disorder and intellectual disability.

January 2019: While the triplets thrived in their residential facility, Coleman and Almond displayed minimal compliance with their plans, and the children’s permanency goal was changed to adoption.

July 2019; the goal for all of the children was changed back to reunification after reports that Coleman and Almond’s compliance with their plans had improved, and Aiden was returned home the next day. This occurred, as OCA put it, “despite Mr. Almond’s failure to engage with therapy, despite Ms. Coleman’s limited engagement with therapy, and despite the lack of any documentation of any change in Mr. Almond and Ms. Coleman’s ability to parent, specifically their ability to parent children with special needs.” OCA attributes this decision mainly to a parenting evaluation conducted by a contractor that did not adequately assess the caregivers’ ability to care for the children.

December 2019: DCF management decided to begin the reunification process for the triplets. This decision was made despite concerns raised by the family support provider and the case management team (social worker and supervisor). DCF management set a target date of January 2020 for the reunification. They disregarded independent requests for a delay from the case management team, the residential facility and the boys’ school.

January 10, 2020. The boys had their first day visit to the home and Coleman stated that reunification was moving too fast and that the family was not yet ready for overnight visits because the apartment was too small.

February 7, 2020: At the first overnight visit on February 7, Almond and Coleman reported that Noah became aggressive, resulting in a physical altercation. As a result, Noah was returned to his facility that night. After this home visit, Noah refused to return to the apartment and was allowed to remain at his residential facility. The goal of reunifying him with his parents was dropped.

February 11, 2020: The congregate care provider took the “extraordinary” step of sending DCF a letter opposing the reunification of David and Michael with Almond and Coleman, citing the inadequate physical environment of the home to meet the children’s therapeutic needs; the fact the parents were facing eviction; and the need for a slower, more appropriate transition plan. The reunification was delayed, but by one month only.

March 13, 2020: David and Michael were returned to Almond and Coleman, barely two months after their first day visit, while remaining in the legal custody of DCF. Four days after the reunification, the state’s COVID-19 restrictions went into effect.

April 2020: At the monthly virtual DCF visit Ms. Coleman reported that there were no concerns regarding the children’s behaviors and the children had access to a laptop for the purposes of schooling. The DCF case management team did not recognize that Ms. Coleman provided contradictory information to the continuum service provider. 

May, 2020: Ms. Coleman rescheduled a DCF virtual home visit supposedly due to technology access issues. During this phone call, Ms. Coleman reported to the DCF case management team that David was vomiting from having too many snacks and was lying in his own vomit. The DCF case management team did not follow up with Ms. Coleman about how David was feeling or the possibility that David could be sick another reason. When the virtual home visit happened ten days later, Coleman took a “strong and controlling role in the communication between the DCF case management team and the children.” She prompted the children to provide specific answers to the DCF case management team questions. In the same month, the parenting support service provider cancelled the service with Almond and Coleman due to their lack of engagement with the service. Also in May, the school offered Chromebooks to David and Michael. This offer was turned down by Coleman in favor of having the boys complete paper packets. But paper packets were never submitted for either of the boys, and the school took no action.

June 2020, the continuum service provider shared with DCF Coleman’s report that Almond physically restrained David due to David’s aggression and that David was completing his chores, which included scrubbing the floor with a toothbrush. Later in the month, the continuum service provider informed DCF that Ms. Coleman reported being fearful that David and Michael would both attack her at the same time and that David refused to take his medication. The provider reported that Coleman refused an outdoor visit and was not using the provider’s emergency service line that they repeatedly urged her to use.

June 2020: In the monthly virtual DCF visit, Coleman tried to stop the boys from answering a question about whether they wanted to visit with their brother Noah, whom they had not seen since March. OCA believes that “Ms. Coleman intentionally prevented David and Michael from virtually visiting with Noah to isolate them from Noah and isolate them from the congregate care program staff that knew them well and might have identified concerns.”

June 17, 2020: A foster care review panel was held and reviewers found that “Mr. Almond and Ms. Coleman were meeting the needs of the children and participating in the continuum services. According to OCA, “It is unclear if the foster care review panel was aware that the parenting support service provider closed the case in May due to a lack of responsiveness from Mr. Almond and Ms. Coleman, and it was unclear also if the panel knew of the continuum service provider’s description of the challenges facing the family.” 

July 17, 2020: The Court returned legal custody to Almond despite the lack of improvement in his and Coleman’s participation in services and no change in Coleman’s description of the boys’ behavioral challenges . Almond was not present at the hearing. On the same day Coleman refused both an outdoor and an indoor visit. According to OCA, “The DCF case management team did not observe the children, the home, or Mr. Almond or Ms. Coleman between June 19, 2020 and July 17, 2020 when David and Michael were legally returned to Mr. Almond’s care.” 

July 22, 2020: At the monthly DCF virtual visit, Coleman berated David in front of the case management team for his behavior. When Michael contradicted Coleman’ account of David’s behavior, she said he was “making her look like a liar.” But at no point did the case managers seek to interview David or Michael outside Ms. Coleman’s presence.

August 2020: The continuum service provider informed the DCF case management team that Ms. Coleman had reported David scratched his collar bone until it had become raw. The DCF case management team did not follow-up with Almond or Coleman about this injury. The continuum service provider also expressed that the family was not fully engaging with the service and that the children needed Applied Behavioral Analysis (ABA) services. 

August 21, 2020: DCF received a report about conditions in the home and substance abuse by Coleman and Almond. The case management team conducted a virtual home visit three days later. Coleman attributed the report to a malicious neighbor and denied the substance abuse. The team accepted her self-report and did not request drug tests for Coleman and Almond. Coleman attributed a bandage on David’s nose to self-injury and when David was asked, he followed Coleman’s prompting to corroborate her account. As OCA points out, the team neither considered the significance of self-injury as a sign of distress nor considered the possibility of parental violence as the cause of the injury.

September 14, 2020: On September 14, 2020, Michael was brought to an out-of-state hospital emergency department for an injury that Coleman reported was self-inflicted. Michael was admitted for overnight observation and discharged home the next day. This injury was not reported to DCF.

September 25, 2020: The DCF case management team had its last virtual home visit with the family. Ms. Coleman described David as having behavioral issues, and David refused to speak. Between September 20, 2020 and October 3, 2020, the family canceled or did not attend all their scheduled appointments with the continuum service provider. 

On October 1, 2020, a school attendance officer came to drop off Chromebooks for David and Michael. Coleman met the officer outside and he did not attempt to see the boys as he was there solely to drop off the devices and not to see David or discuss with this family his lack of engagement with school since the previous March. If that person had seen David and noticed his physical state, David might be alive today. Twice in October, a teacher contacted DCF to report that the boys were not logging into school. The OCF team contacted Coleman, who denied that report.

October: The DCF case management team was made aware that David’s individual therapist had only been successful in contacting the family one time since August. Ms. Coleman told the case management team why that therapist was not appropriate for David. 

October 5 and October 14, 2020: A teacher from Fall River Public Schools contacted the DCF case management team and reported that David and Michael were not logging into school virtually. The DCF case management team contacted Ms. Coleman, who denied this report and reported both David and Michael were attending school virtually 

On October 7, 2020, the team learned that David had missed his physical in July and two subsequently scheduled appointments. A case review was held on October 14, 2020. Almond and Coleman did not attend. The review panel “inexplicably found that Mr. Almond and Ms. Coleman were meeting all the children’s needs in the home. This determination was made despite concerns regarding the family’s lack of consistent engagement and utilization of services, that David and Michael had not attended school or received any special education services since their reunification in March, and despite Ms. Coleman’s reports of David engaging in serious self-injurious behaviors.”

October 14, 2020: Another foster care review meeting was held in the absence of Almond and Coleman. In OCA’s words, “The foster care review panel inexplicably found that Mr. Almond and Ms. Coleman were meeting all the children’s needs in the home. This determination was made despite concerns regarding the family’s lack of consistent engagement and utilization of services, that David and Michael had not attended school or received any special education services since their reunification in March, and despite Ms. Coleman’s reports of David engaging in serious self-injurious behaviors.” 

October 21, 2020: Emergency medical personnel responded to a 911 call regarding David; he was bruised, emaciated, and not breathing. He was transported to Charlton Memorial Hospital and pronounced deceased. Michael was found emaciated but responsive, and Aiden was well nourished and appeared physically unharmed. Substances believed to be heroin and fentanyl were found in the apartment. Michael and Aiden were immediately removed from Almond and Coleman, who are in jail and facing criminal charges.

Foster care didn’t kill Ma’Khia Bryant

Makiyah Bryant Credit: Paula Bryant From People.com

It is always disheartening when people take advantage of a tragedy to support their own views or interests, even when the facts don’t support it. The tragic death of Ma’Khia Briant is an example of this tendency. As soon as it was disclosed that Ma’Khia was in foster care, advocates and pundits began to argue that her death is “indicative of deeper problems in the foster care system,” as the Washington Post put it. That the case illustrates problems with foster care cannot be denied–but most of the damage to Ma’Khia clearly occurred before her placement in foster care.

For the few who have not heard, 16-year-old Ma’Khia Bryant was shot to death by a police officer in Columbus Ohio who was responding to a 911 call from her younger sister saying that “grown girls” were attempting to fight and stab them. Officer Nicholas Reardon found Ma’Khia swinging a knife while pinning a 22-year-old woman against a car. He fired four shots, striking Ma’Khia, who died shortly thereafter.

When it became known that Ma’Khia was in foster care, many foster parents and advocates raised serious concerns about how the system contributed to her death. Noting that teens should not be unsupervised in a foster home, experts interviewed by the Washington Post raised concerns about the low standards for foster parents who care for Ohio teens, which some tied to the scarcity of foster parents willing to care for teens.

As a social worker in the District of Columbia, I had a very similar experience. Many foster parents refused to take in teens. As a result, it appeared that the standards to become a foster parent for teens were minimal. Many of the foster parents who cared for my teen clients in DC foster care provided little more than room and board, not the loving care these children needed. Few had ever visited the child’s school, doctor, or therapist. They were typically not home during the day, as foster parents are not paid enough to forego full-time work. Moreover, as in Ohio, foster parents who have enough room were often landed with several teens, each with a history of trauma–a recipe for conflict. 

Another way the system failed Ma’Khia may have been by failing to help her grandmother, Jeanene Hammonds, retain custody of Ma’Khia and her sister, who spent their first 16 months in foster care living with her. But when her landlord threatened to evict her for having too many people in the house, the Children’s Services social worker had no solution other than telling her to drop the girls off at the agency, according to what Hammonds told the New York Times. If the agency had licensed her as a foster parent, she could have moved to a larger apartment. But information from case files quoted by both the Times and the DIspatch suggests that the agency believed Hammonds was not meeting the girls’ needs or making sure they received needed therapy. I cannot assess the truth of either the grandmother or the agency’s statements, but I can say that as a social worker I was often frustrated by my inability to help relatives obtain housing needed to obtain custody of children in foster care.

Some advocates are using Ma’Khia’s death to ask for needed changes in the system, like a crisis response team, better training for foster parents, and more help for relatives willing to take custody of children in foster care.  They should also be advocating for better options for troubled teens in foster care. These teens need either professional foster parents who are paid to be home all day and and trained to work with traumatized teens or high-quality, trauma-informed residential facilities where they receive the therapeutic care that they need before graduating to a less restrictive setting. 

Less responsible or informed advocates are using this tragedy to argue for the abolition of foster care. The Washington Post quotes Hana Abdur-Rahim of the Black Abolitionist Collective of Ohio, who said that“a lot of times people’s children get taken away because they can’t afford to take care of them, or they don’t have proper housing….So if we had more resources, children would not get taken away from their families.”

Abdur-Rahim’s statement embodies the popular trope that what child welfare systems call “neglect” is really poverty, and that children are being removed due to poverty alone. Anyone who has been a social worker in child welfare will tell you that removals for poverty alone are quite rare; that neglect usually involves some combination of drug abuse, alcohol abuse, mental illness, disorganization and family violence; and, in any case, that chronic neglect can be more damaging to a growing child than abuse. 

It is not surprising that Ma’Khia’s mother, Paula Bryant, would not say why her daughter was removed in the first place. The Columbus Dispatch has reported that Ma’Khia, her younger sister, and two brothers were removed from Bryant in March 2018, after police responded to an “incident” at a residence. Police reported the four children were unsupervised and made allegations of abuse against their mother and an older sibling. A neighbor who spoke to the New York Times says she can still remember the fights between Bryant and her daughters, stating that “the girls ran out of the house terrified, and were hanging out in the backyard screaming while the mom was yelling at them.” Children’s Services already knew of the family due to repeated complaints that the two youngest children were absent from school. And in February 2017, according to the Times, Bryant brought her four children to Children’s Services saying she could no longer handle them. The grandmother, Ms. Hammond, told the Times that it was difficult having the four Bryant children because “they came from a lot of dysfunction.”

Aside from this historical information, the behavior of Ma’Khia and her sister provides evidence of their traumatic history.  According to the Post and the Times accounts, Ma’Khia’s sister Ja’Niah told police officers she called to the home 23 days before Ma’Kiah’s death that she would to “kill someone” unless she was placed in another home. Ma’Khia was killed while threatening someone with a knife, and Ja’Niah told the Times that Ma’Khia was triggered when the one of the older women spit toward her family. To anyone familiar with foster youth, these statements and behaviors suggest girls who were traumatized not by foster care itself but by a long history of neglect and violence in their home.

Children’s Services was trying to help Ms. Bryant get her children back but in court filings obtained by the Columbus Dispatch the agency reported that the mother “repeatedly failed to comply with the plan, which included mental health counseling, or even to consistently show up for scheduled visitations with Ma’Khia and her sister.” Court reports also indicate that the father did not respond to outreach by the court or agency. In December 2019, Children’s Services asked the court to suspend the mother’s visitation because of “emotionally damaging” interactions between her and her daughters, according to the Dispatch. And in January 2020 the agency filed a motion seeking permanent custody of the girls. Court action was delayed by the COVID-19 pandemic and was still pending at the time of Ma’Khia’s death.

Ma’Khia’s mother, father and grandmother are now united in calling for an investigation of Ohio’s foster care system in the wake of her death. It is depressing but not surprising that the mother who abused and neglected Ma’Kiah and the father who would not engage with Children’s Services are now blaming the foster care system for her death.

None of this exonerates the foster care system for the unacceptable quality of the care Ma’Khia was apparently receiving at the foster home where she was killed. When society removes a traumatized child from an unsafe home, it adds one more trauma to that child’s history. It owes that child more than an environment only slightly better than what she was removed from. A good system might have saved Ma’Khia from the trajectory she was on when she was removed. To that extent, a struggling foster care system, and ultimately our society’s indifference to these most vulnerable children, bears some responsibility for Ma’Khia’s death.

To argue that foster care should not exist is to say that children should be allowed to grow up in homes characterized by chronic violence, abuse and neglect. As Lily Cunningham, a mental health counselor, told the Washington Post, “The question always is Why is this child or family in foster care? But the right question should be: What can we be doing now to enhance the lives of children in foster care?” Foster care should be improved so that it can become a place of healing, from which children can return to families that have done the work needed to get their children back.

This post was edited on May 8, 2021 to incorporate new information shared by the New York Times.