A new report from Eyewitness News has cast doubt on my pieced-together account of the process by which Justyna Zubko-Valva lost custody of Thomas and her other sons. My initial account, relying on reports from other media outlets, suggested that a judge revoked the mother’s custody and gave it to the father in an arbitrary manner without seeking to evaluate either parent’s capability of raising the children. Based on the documents described by Eyewitness News, ot appears that this was not the case. I have updated my post to account for the new information, as described below.
My post initially relied on available media accounts in stating that Judge Hope Schwartz Zimmerman became fed up with Justyna Zubko-Valva for failing to follow two orders, including one to get her children evaluated. In fact, the court documents obtained by Eyewitness News state that the Zubko-Valva was refusing to follow an order that she herself be evaluated, unless the interview could be videotaped. The evaluator refused due to the “sensitive nature of the testing materials.”
Without a psychological evaluation of the mother, Judge Zimmerman stated that she was unable to bring the case to trial. She announced that she was awarding “temporary, temporary” custody to the father. The rationale for that decision is not explained in the quotes from Eyewitness News. Perhaps Judge Zimmerman thought that moving the children would induce Zubko-Valva to obtain the evaluation. Using the children as tools to induce parental compliance would be inappropriate in any case. In this case, the transfer of custody not only failed to achieve the judge’s goal but resulted in the death of one child, horrific abuse of another child, and potential lifelong damage to the two living children. The “temporary, temporary custody” ended up lasting for two years after Valva filed an abuse report against Zubko-Valva and Zubko-Valva later refused supervised visitation, as described below. Nevertheless, my statement the judge cavalierly transferred custody of the boys without evaluating the parents appears to have been wrong. Instead, she apparently transferred custody in order to obtain the evaluation she required
Of course Zubko-Valva could not know that her intransigence about the evaluation would lead to suffering, death and lifelong damage to her children. But there are other disturbing aspects of her behavior cited in the Eyewitness News account. It appears that she did not see her children for two years, from January 2018 until Thomas’ death in January 2020. Eyewitness News stated that visits were cut off in January 2018 due to the abuse accusations against Ms. Zubko-Valva but that another judge, Joseph Lorintz, offered her visits starting in April 2018, when the charges were dismissed. Zubko-Valva reportedly refused to visit the children unless they were moved from Valva’s home–a request which the judge denied. In July 2019 the judge again offered her visits, but said the visits must be supervised because “I’m not going to allow you to see your children after a year and a half without some form of supervision in place.” Eyewitness News reports that Zubko-Valva refused to visit her children in a supervised setting. She reportedly refused the same offer in September, 2019, only four months before Thomas’ death. According to the transcripts cited by Eyewitness News, Judge Lorintz almost pleaded with Zubko-Valva, saying “You haven’t seen your children since January 14, 2018. It may only be a few times, but I need for them to be reintroduced to you.” The transcripts show the judge offering three more times to order visits, without receiving an answer from Zubko-Valva. She would never never again see her son Thomas alive. By refusing the opportunity to see her children, did she miss the chance to save Thomas? We will never know.
Unless the Eyewitness News account of the court transcripts is terribly wrong, it appears that Zubko-Valva was not acting in the best interests of her children when she refused the evaluation and the visits. Her refusal to visit her children is very hard to understand and very concerning as it relates to her current fitness as a parent to her two very damaged young sons. The courts and CPS have already failed these children catastrophically; it is hoped that their continued involvement will serve to protect these children and ensure that they receive the treatment and monitoring they need.
The difficulty of piecing events together based on incomplete press accounts illustrates the need for an independent children’s ombudsman to review such cases of systemic failure and release their reviews (redacted as necessary) to the public. Only with such independent reviews can taxpayers understand how and why the system they paid for has failed. If I knew that such a review was forthcoming, I would not have even tried to come up with a credible narrative of this case without the court transcripts and CPS documents. The public should not have to rely on guesswork to find out how the system failed and what has to change.
The federal Children’s Bureau (CB) has released its annual Child Maltreatment report, containing data provided by the states from Federal Fiscal Year 2018. The high rate of maltreatment victimization and the contrasting numbers and rates between states and populations are two of the major takeaways of the report. A common theme across the report is that differences between states and populations and over time can reflect differences in levels of maltreatment, policy or practice, or even how states collect data.
CB’s annual maltreatment reports use data from the National Child Abuse and Neglect Data System (NCANDS), which is a federal effort that collects and analyzes child welfare data provided voluntarily by the states plus the District of Columbia and Puerto Rico. The data follow children and families from referrals to reports, dispositions and services. One of the most helpful resources is exhibit 2, reproduced below, a flow chart that follows families and children through the process from referral to services. (All tables in this post are reproduced from the report).
Referrals and Reports
During FY 2018, states reported receiving a total of 4.3 million “referrals” (calls to a hotline or other communications alleging abuse or neglect) regarding approximately 7.8 million children. The number of referrals per 1,000 children varied wildly between states, from a low of 15.7 in Hawaii to a high of 167.9 in Vermont. The different referral rates between states may reflect different levels of knowledge about and comfort with child maltreatment reporting, different rates of underlying maltreatment, or even different state practices in defining the term “referrals.” Vermont explains that its high referral rate is the result of its practice of treating all calls to the child abuse hotline as referrals.
The rate of referrals has increased from 50 per 1,000 children in 2014 to 58.5 referrals per 1,000 children in 2018. Differences over time within a state may due to changes in state policy or practice or events in a particular state. For example, Alabama reported that it implemented online mandatory reporter training in 2014, resulting in an increase in referrals. Rhode Island reported a large increase in referrals due to the public trial of a school official for failure to report child abuse, resulting in more than a doubling of hotline calls from school staff.
A referral may be screened in or out by the child welfare agency depending on whether it meets agency criteria. Referrals may be screened out because they do not meet the definition of child abuse and neglect, there is inadequate information, or for other reasons. Screened-in referrals are called “reports” and receive a traditional CPS investigation or an “alternative response” (often called an “assessment”) in states that have two-track or “differential response systems.” These alternative responses, usually reserved for the less serious cases, do not result in an allegation of abuse or neglect but rather are aimed at connecting families with services they might need. Of the 4.3 million referrals, states screened in 2.4 million for an investigation or assessment. The rate of screened-in referrals (known as “reports”) has increased from 29.1 per 1,000 children in 2014 to 32.5 in 2018. The highest number of reports came from education personnel (20.5%), legal and law enforcement personnel (18.7%), and social services personnel (10.7%). Parents, other relatives, friends and neighbors submit the remaining reports.
A total of 3.5 million children received an investigation or alternative response, and states found approximately 678,000 (16.8%) to be victims of child maltreatment; in other words the allegation was “substantiated.” Another 14% received an alternative response rather than an investigation, which meant there was no determination of whether maltreatment occurred. Reports involving 56.3% of these children were unsubstantiated, which meant there was not sufficient evidence to conclude that maltreatment took place.
The 678,000 children who were found to be victims of maltreatment equates to a national rate of 9.2 victims per thousand children in the population, or almost one out of every 100 children. This rate varies greatly by state, from 2.7 in Washington 1 to 23.5 in Kentucky. A lower child victimization rate might reflect less child maltreatment or a system less likely to respond to existing maltreatment or that makes greater use of differential response. Kentucky had the highest proportion of children found to be victims (23.5 per 1000 children or over one in every 50 children) followed by West Virginia, Rhode Island, Massachusetts and Michigan. The ongoing crisis involving opioid and methamphetamine addiction has been blamed for an increase in maltreatment in many states. And indeed, all of the states with the highest rates have been hard-hit by the opioid epidemic and had among the highest opioid overdose death rates in the country in 2017.
The national proportion of children found to be victims of maltreatment has fluctuated since 2014, increasing slightly between 2014 and 2018 from 9.1 to 9.2 per thousand. This small national increase masks large changes in the numbers of victims in certain states, from a 50% decrease in Georgia to a 216% increase in Montana. In their written submissions, the states attribute these diverse trends to changes in child welfare law, policy and practice as well as increases in parental drug abuse and even severe weather events such as Hurricane Maria in Puerto Rico.2Georgia reports a policy change that resulted in a large increase the proportion of cases assigned to the alternative response track, perhaps one reason for the decrease in substantiations. Montana has experienced a surge in children entering foster care due to parental drug abuse, especially methamphetamine, which probably contributed to the increase in children found to be victims.
The disparity in the proportion of children found to be maltreatment victims across states is consistent with the belief that there is no foolproof method of assessing the truth of an allegation and that substantiation may not be a very good indicator of whether maltreatment has taken place. Research has found little or no difference in future reports of maltreatment of children who were the subject of substantiated or unsubstantiated reports
The proportion of children found to be victims of maltreatment decreases as age increases. The rate of substantiated victimization for babies under a year old is 26.7 per thousand. This rate falls to 11.8 percent for children aged one to two and decreases gradually as age increases. This age effect reflects the greater fragility and helplessness of younger children and also the fact that they are less likely to spend time away from their parents (the primary maltreaters). That is one reason why many child advocates support making early care and education available to all children at risk for maltreatment and particularly to those already involved with the child welfare system.
The rate of children found to be victims of maltreatment varies considerably between racial and ethnic groups. The highest rate is for Native American or Alaska Native children, who were found to be victims at a rate of 15.2 per thousand, followed by African-American children, with a rate of 14 per thousand, compared to 8.2 per thousand for White children, and 1.6 per thousand for Asian children. It is 8.1 per thousand for Hispanic children, who can be of any race. The higher rate of substantiated victimization among African-American and Native American children is a subject of controversy. Some believe it reflects greater tendency of African-American and Native parents to be reported to CPS and later substantiated as perpetrators due to racism. But these differences might also reflect a greater poverty rate for Black and Native children, or cultural factors, such as a preference for corporal punishment in the Black community, or substance abuse in the Native American community.
Neglect continues to be the predominant type of maltreatment. The data shows 60.8% of children were found to be victims of neglect only, 10.7% victims of physical abuse only, and 7.0% to be sexually abused only, with 15.5% suffering from multiple types of maltreatment, mostly commonly neglect and physical abuse. It is important to understand that a given child may be found to have suffered one type of maltreatment when other types are also present. For example, abuse can be hard to substantiate when the parent and child give contradictory accounts, or the child recants, and such children may be substantiated for neglect only when abuse is also present.
For the first time, 18 states reported on victims of sex trafficking. These states reported a total of 339 victims. While one case would be too much, it is encouraging that the scope of the problem is so small compared to other types of maltreatment. This suggests that sex trafficking as a type of child maltreatment is much less widespread than one might have thought given the amount of attention recently attached to this topic through legislation, training, and policy.
There is wide variation among states in the prevalence of different types of substantiated maltreatment. Some of this variation may be due to real underlying differences in parental behavior and some may be due to varying laws, policies and practices. Of particular interest are the states that have much higher percentages of abuse than the national average. While nationally only 10.7% of victims are found to have experienced abuse only, that percentage was 55.3% in Vermont, 48.2% in Alabama, and 39.7% in Pennsylvania. It is known that corporal punishment, which may escalate to abuse, is more popular in Southern states, like Tennessee and Alabama. Vermont’s and Pennsylvania’s high rates of abuse may be due to the assignment of many less-serious cases to an alternative track where there is no disposition (in Vermont) or the disposition is not reported (in Pennsylvania).3 Alabamans are aware of their state’s high abuse rate, which was covered in an excellent story by Al.com that cites the state’s acceptance of corporal punishment as one underlying factor.
For the FY 2018 report, the researchers analyzed three years of data on the presence of alcohol or drug abuse among caregivers. They found that the national percentage of substantiated victims with a caregiver identified as a drug abuser was 30.7% in 2018. Alcohol as a caregiver risk factor was 12.3%. Both of these percentages increased slightly from 2016. As is often the case, there was an astonishing diversity among states, ranging from 2.2% to 45.5% for alcohol abuse, and from 3.1% to 61.5% for drug abuse. This diversity, especially the very low rates in some states, raises concerns about whether they are accurately capturing these factors.
The data show that 90.7% of the victims were maltreated by one or both of their parents. That includes nearly 40% who were maltreated by their mother acting alone and 21.5% by their father acting alone. Relatives (4.7%) and unmarried partners of parents (2.8%) are the largest remaining categories of maltreaters.
There is no standard, mandatory system for reporting child abuse and neglect deaths and it is often extremely difficult to determine where a death was caused by abuse or neglect rather than natural causes. Based on data from all states except Massachusetts, the researchers estimated that 1,770 children died from abuse or neglect in 2018, which is a rate of 2.39 per 100,000 children in the population. That is an 11.3% increase over the estimate for 2014 but this change may reflect data quality rather than a real change in maltreatment deaths. State rates range from 0 (Nebraska) to 6.6 (Arkansas) per 100,000 children but it is hard to know how much of the variation reflects differences in capturing actual child fatality rates. NCANDS maltreatment data are generally viewed as underestimates because, among other factors, many maltreatment fatalities may be unknown to any system or impossible to prove and some states do not report on deaths of children not known to the Child Protective Services Agency. In contrast, the Commission on Child Abuse and Neglect Fatalities reported that the most recent National Incidence Study (where data is collected directly by ACF) reported 2,400 deaths compared to 1,530 deaths in the Child Maltreatment report for a similar period. The CAPTA reauthorization bill which was passed by the House would require the Secretary of the Department of Health and Human Services establish uniform standards for the tracking and reporting of child fatalities and near-fatalities related to maltreatment. This requirement is badly needed.
Like child maltreatment itself, child maltreatment fatalities are more likely occur to the youngest children. Infants under one year old were the most likely to die, at a rate of 22.77 per 100,000. The rate decreases to 6.3 per 100,000 one-year-olds and continues to fall with age. Nearly half of the children who died were younger than one and 70.6% were younger than three. This illustrates again why it is so important to ensure that all children at risk of severe abuse or neglect must be in early care or education.
The child fatality rate for African American children (5.8 per 100,000 children) is over 2.8 times the rates for White children. Mixed-race children had the second highest rate of 3.2, followed by Native American children at 3.12. As discussed above, we do not understand these disparities. They could be due to cultural factors, economic factors, racism in reporting and substantiation, or other factors. The child maltreatment fatality rate for Black children is more than twice that for White children (5.48 vs. 1.94 per 100,000). This is an even greater disparity than the difference in child maltreatment rates (14.2 per 1000 for black children vs. 8.2 per 1000 for white children). Perhaps many Black parents’ embrace of corporal punishment, as described by author Stacey Patton in her important book, Spare the Kids, while not much different in terms of overall percentages from that of White parents, countenances more severe discipline than among other racial and ethnic groups. These disparate child maltreatment death rates should give pause to those self-described anti-racists who want to equalize the rates of investigations, substantiations, and child removals of Black and White children. Such a policy would very likely lead to increased deaths of Black children–hardly an outcome they should welcome.
Of the children who died from maltreatment in 2018, 72.8 percent suffered neglect and 46.1 percent suffered physical abuse, including some children who suffered more than one type of maltreatment. Eighty percent of the deaths were caused by parents or caregivers acting alone or with other individuals. Based on reports from 24 states, 20.3% of the children who died had received family preservation services in the previous five years. And 2.5% had been reunified with their families in the previous five years after being removed.
Approximately 1.3 million children (a duplicated count4) received services at home or in foster care as the result of an investigation or alternative response. This includes 60.7% of the children who were found to be victims of maltreatment and 20.9 percent of the non-victims. It is concerning that such a low percentage of the victims received services. But not every state reports data for every in-home service (especially those provided by other agencies or contractors), so the actual proportion receiving services other than foster care may be higher. Sadly, according to reports from 26 states, only 21.9% of the victims received court-appointed representatives.
About a fifth of the children found to be maltreatment victims (22.5%) and 1.9% of those not found to be victims5 were placed in foster care. It is worth noting that less than half of the maltreatment victims who received services (146,706 out of 391,661) were placed in foster care. The others received family preservation services while remaining at home. Many news reporters and child welfare commentators have incorrectly suggested that no services other than foster care were available to abused or neglected children before the implementation of the Family First Prevention Services Act. This data shows the incorrectness of that assumption.
Infants with prenatal substance exposure
For FFY 2018, States were required to report for the first time on infants exposed prenatally to drugs and alcohol. Forty-five states reported that they had been informed of 27,709 infants born exposed to substances. Nearly 88% of these infants were screened in as appropriate for an investigation or alternative response. It is somewhat concerning that the others were not, given the possible serious effects of prenatal and postnatal substance abuse. Of those screened in, 75.5% had a caregiver identified as a drug abuser, 11.7% had a caregiver identified as a drug and alcohol abuse, and less than one percent had a caregiver identified as abusing alcohol only. The 24,342 children who were screened in in 42 states constituted a shockingly high 10.8 percent of children under one in those states. Of the screened in reports, 68.3 percent were substantiated as victims or abuse or neglect. Nine percent received an alternative response and nine percent were unsubstantiated. The report’s authors caution against comparing states because this was the first year of reporting. The wild disparity between states in the proportions identified suggests they are right to be cautious and that the national figures have a wide margin of error as a result.
The Child Abuse Prevention and Treatment Act (CAPTA) as amended by the Comprehensive Addiction and Recovery Act (CARA) in 2016, requires that all infants “affected by a substance abuse or withdrawal symptoms resulting from prenatal drug exposure, or a Fetal Alcohol Spectrum Disorder” receive a “plan of safe care…addressing the health and substance use disorder treatment needs of the infant and affected family or caregiver.” Thirteen responding states reported that 64% of infants with prenatal substance exposure had a plan of safe care. A separate CAPTA provision requires states to report how many infants had a “referral to appropriate services,” and fourteen states reported that only 42.6% of infants had such a referral. The difference between these two percentages is due to California, which provided data on referrals and not plans of safe care. Only 12.7% of California’s substance-exposed infants had referrals to appropriate services. Since the California’s population is larger, and the percentage receiving referrals was low, the overall percentage was reduced significantly by adding California but the two percentages were the same in the other responding states.
Plans of safe care and referrals are voluntary and do not mean much unless they are followed by the families, providers, and agencies. It would be better to know how many of these infants received foster care and other services after an investigation or family assessment. That would probably require opening a services case for all these families. Congress should consider requiring this, as it would be the only way to follow up on what services these families actually receive.
The fact that almost one in 100 children is found to be a victim of child maltreatment should be of concern to all child advocates, especially because it is likely that many other victims were never reported or found to be victimized. It is hard to interpret comparative data between states, populations, and years because of the difficulty in disentangling the amount of actual maltreatment given the variety of policies and practices in how it is defined and reported. Analysis of the report suggests changes in CAPTA that would make it more useful. For example, Congress should to set uniform standards for reporting child maltreatment fatalities by passing the CAPTA reauthorization bill in 2020. And the new version of CAPTA should be further strengthened to replace the plans of state care with a more substantial response to infant substance exposure.
Pennsylvania’s victimization rate was actually the lowest at 1.8% but this low rate reflects the state’s unusual child protective services structure. Allegations that do not concern abuse or specific very serious types of neglect are labeled as General Protective Services and not counted as referrals or reports for federal reporting. ↩
Puerto Rico had a 43% decline in children found to be maltreatment victims between 2014 and 2018. The territory’s commentary explains that its child population was already decreasing due to emigration even before Hurricane Maria struck in October 2017 and then further declined due to emigration. ↩
Vermont’s extremely high abuse rate rate may be due to the fact that about 40% of its cases are assigned to the alternative response track, which does not result in a disposition, and another sizeable group are assigned to a pathway outside CPS, called family assessment. The cases assigned to these alternative tracks are expected to be less serious and more likely to involve neglect rather than abuse. A similar phenomenon likely occurs in Pennsylvania where most neglect allegation are assigned to General Protective Services and not reported to the federal government. ↩
Individual children were counted more than once if they were involved in more than one CPS case. ↩
Many of these children were probably siblings of children who were found to be victims of maltreatment. ↩
The Family First Prevention Services Act Act was widely hailed as allowing for the first time the use of federal Title IV-E child welfare funds for services to prevent a child’s placement in foster care. Unfortunately, the law has been interpreted in a way that has almost negated this central purpose of Family First. Thanks to a technical-sounding determination about Title IV-E’s place in the hierarchy of programs as payers for services, Title IV-E funds are now unavailable to beef up services that are eligible for funding from other programs.
Before implementation of Family First on October 1, 2019, federal matching funds under Title IV-E of the Social Security Act could be used only to match state spending on foster care. Advocates of Family First and its predecessors argued that providing Title IV-E funds for foster care and not services to prevent it encouraged jurisdictions to place children in foster care rather than helping their parents address their problems and keep their children at home. As I argued in an earlier post, this was a false narrative that disregarded the fact states were already working with families in their homes using other funds, such as Medicaid, maternal and child health programs, and others.
But the advocates won and Family First was passed. It allowed federal Title IV-E matching funds to be used for evidence-based practices (EBP’s) in the categories of “in home parent skill-based programs,” mental health, and drug treatment programs that meet criteria for being “evidence-based” as defined by the Act. These are all considered to be “prevention services” because they are aimed at preventing placement of children in foster care. (Funds can also be spent on kinship navigator programs to help kin who agree to take custody of children temporarily while their parents pursue services.) The Act also created a clearinghouse of programs from which states can choose. The clearinghouse has so far approved nine programs for inclusion and is in the process of considering 21 more.
But the contents of the clearinghouse have much less impact in light of decisions made by Congress and the Children’s Bureau, as explained in a useful webinar from the Chronicle of Social Change. As a result of these decisions, Title IV-E became in effect the “payer of last resort” for the foster care prevention services authorized under the Act .
It would be difficult to overestimate the magnitude of this decision to make Title IV-E the payer of last resort for foster care prevention services. Many of the services that are already included in the clearinghouse or being reviewed now are covered by Medicaid or paid for by other programs in many states. This means that states with more generous Medicaid plans (those covering more people and/or more services) and more participation in other federal programs have less opportunity to use Title IV-E funds for foster care prevention services.
Consider the District of Columbia, which has a generous Medicaid program in terms of whom and what it covers. In my five years as a child welfare social worker in the District, I don’t remember a parent who was not eligible for Medicaid. The District was the first jurisdiction to submit a Family First plan and the first to have its plan approved, but it’s hard to understand the District’s eagerness to make the transition. In its plan, the District’s Child and Family Services Agency (CFSA) indicates that of the seven services in its plan that are currently deemed allowable by Title IV-E, six are funded through other federal sources–Medicaid and the Maternal, Infant, and Early Childhood Home Visiting Program. Therefore, CFSA will be claiming Title IV-E funds for only one allowable evidence-based program–Parents as Teachers (PAT).
So here is the irony. Family First was supposed to revolutionize child welfare by allowing federal foster care funds to be used for family preservation or foster care prevention, whatever one chooses to call it. Never mind that states have been using Medicaid and other funds for this purpose for many years. And now it turns out that with Title IV-E as a payer of last resort, many states will continue to provide these services with other funds. Family First will make little difference except adding a new layer of bureaucracy: states will now have to include these services in their prevention plans even if they are not funded by Title IV-E!
Things are actually worse under Family First for the 27 states that had waivers under Title IV-E. Under the waivers, states were able to use Title IV-E funds in combination with other funds to expand and improve services–an option not available to them now.
It gets even worse. Under Family First, states must spend at least 50% of their Title IV-E prevention funds on practices defined as “well supported” as defined by the Act. It looks like payments made by Medicaid won’t count toward the 50%, so states will need to find enough “well-supported” practices that are not covered by Medicaid in order to meet this requirement, which may cause great difficulty.
Title IV-E’s status as payer of last resort also appears to prevent Title IV-E from paying a provider who does not accept Medicaid for an EBP that is allowed under Medicaid. It is widely known that low Medicaid reimbursement rates restrict the quality and quantity of mental health services available to Medicaid participants. Both jurisdictions where I have served as a foster care social worker, Maryland and the District of Columbia, use their own funds to pay for top-notch providers who don’t accept Medicaid. In both jurisdictions and I suspect many others, children with the most complex mental health needs are enrolled with one of these high-quality providers rather than left to the mercy of the Medicaid-funded agencies, with their long waits for service and high turnover. We rarely or never paid for mental health services to parents but isn’t that just what Family First should allow jurisdictions to do? Where, otherwise, is the revolution in child welfare that Family First was supposed to bring about?
Title IV-E as payer of last resort means that very little will change, except perhaps in some states with very narrow Medicaid programs and little categorical federal funding. To have any hope of fulfilling its promise to keep families together, Family First should be amended to allow Title IV-E to supplement Medicaid and other funding to provide critically needed services to parents.
In July 2018, ten-year-old Anthony Avalos arrived at the Emergency Room with fatal bleeding in his brain. His emaciated and battered body succumbed the next day to years of deprivation and abuse. For four years, the Los Angeles Department of Children and Family Services (DCFS) had received 13 reports on suspected abuse of Anthony and his siblings. For part of that period, his family was actually under the supervision of DCFS.
Many commentators saw parallels between Anthony’s death and that of Gabriel Fernandez in 2013 in the same town of Palmdale, in the Antelope Valley section of Los Angeles County. Gabriel was tortured to death by his mother and stepfather after multiple reports to DCFS failed to result in his rescue from this lethal home.
But based on its review of the family’s case file, Los Angeles County’s Office of Child Protection (OCP) concluded that Anthony’s case was “very different” from Gabriel’s. OCP concluded that it could not say that Anthony might still be alive today if the agency had done things differently. In justifying this conclusion, OCP stressed that the family was not under DCFS supervision at the time of Anthony’s death and that it had been over a year since the last report was made to the child abuse hotline concerning the family.
But in his devastating article, The horrific death of Anthony Avalos and the many missed chances to save him, investigative reporter Garrett Therolf shows that DCFS had many opportunities to save Anthony. It also reveals striking connections between Anthony’s case and Gabriel’s. The same private agency counselor had worked with both boys, and had been questioned in court about Gabriel. A caseworker who had been disciplined for his errors in the Fernandez case actually supervised the social worker who managed Anthony’s case.
Garrett Therolf was kind enough to share the DCFS case file with Child Welfare Monitor. In reviewing the file, we were struck by the many red flags that DCFS ignored and the crucial points where the agency could have intensified the surveillance of the family or removed the children to safety. In this post, we highlight our own observations from the case file, complemented by key information obtained from other sources (such as interviews and grand jury transcripts) by Therolf.
The First Calls: 2013 and 2014
Anthony Avalos first came to the attention of DCFS in February 2013, when he was only four years old and reported that his grandfather sexually abused him. The agency substantiated the abuse but did not set up any ongoing monitoring, relying on his mother, Heather Barron, to keep his grandfather away from him.
In May 2014 the family came to the attention of DCFS again when a caller alleged that Barron, who had four children at the time, was hitting the children with hoses and belts and locking them in their rooms for hours. An allegation of neglect (but not abuse) was substantiated. Barron agreed to the opening of a voluntary case, which was open from May 20, 2014 to December 4, 2014. A social worker named Mark Millman was assigned to manage the case.
Under DCFS Supervision: June-December 2014
In June, 2014 a PhD. psychologist who evaluated Barron concluded that she “appeared to have poor parenting skills as shown by her lack of patience towards her two children that displayed energetic behavior….At this time…. the assessor believes that her capacity to provide suitable care for her children is severely limited by her poor parenting skills, poor judgment, and denial and lack of awareness of her mental health issues.” The evaluator recommended a variety of services for Barron. She refused to participate in individual therapy–probably the most essential. But there is no indication that case manager Millman even read the report, let alone followed up to see if the services were provided or successfully completed. Barron did participate in in-home services to improve her parenting skills, which were provided by an agency called the Children’s Center of the Antelope Valley.
Once services got under way, reports from the provider were not encouraging. A July 2014 progress report from the Children’s Center indicated that Barron was “having a difficult time maintaining her composure when the children misbehave.” In its August 2014 report, the agency reported that Barron was overwhelmed. The agency case manager recommended therapy for Ms. Barron but she again refused saying she was not interested in talking about the past.
On October 9, 2014, a counselor at the Children’s Center called the hotline with concerns about the family. The counselor had tried to discuss her concerns with Millman but he seemed to “blow it off.” She reported that Barron, who had recently given birth to a fifth child, was “ very aggressive and angry and showed no nurturing to any of her children, even the infant.” She reported that she observed Barron yanking one child by the arm, yanking her daughter’s hair while brushing it, and calling the children names like “punk” and “bitch.”
The social worker assigned to investigate the new allegations was not concerned. He observed that Barron and her children were ”interacting positively” and “that mother and children had secure attachment as seen by their interaction.” Barron’s admission that she hit the children with a belt and used hot sauce to punish them for talking back did not seem to bother him. It appears that he was influenced heavily by Millman, who expressed no concern for the family. He reported that Ms. Barron “has her hands full and is doing her best….…She does cuss and yell but [is] doing all she can to provide appropriate care.”
The automated risk assessment performed as part of every investigation showed a high risk of abuse and neglect and recommended promotion to a court case. The investigator overrode this recommendation, stating that the children were already involved in a voluntary case and getting services. And somehow, despite the mother’s own admission, the investigator closed the referral as “inconclusive” for physical abuse, as well as emotional abuse and general neglect.
Another Children’s Center therapist called DCFS on November 5, 2014, alleging she overheard one child say “She’s bad because she whips our ass.” The caller said that Barron continued to get frustrated easily. She quoted Barron as telling one of the children, ‘Don’t think, because she is here, I won’t whip your ass.’” This referral was “evaluated out” with no explanation.
Case Closed: December 2014
The voluntary case was closed on December 4, 2014 with the following comments: “The mother has been compliant with services and receptive to outside resources. Although the family has received two new referrals, the allegations were assessed unfounded/ inconclusive. Mother has agreed to continuing counseling for the children.” The agency arranged for the family to receive this counseling through a new agency, Hathaway Sycamores Counseling. There was no indication that the mother had made any progress in addressing her parenting issues. Nor was there a rationale given for directing the counseling toward the children rather than the mother.
Hathaway-Sycamores was the same agency that worked with Gabriel Fernandez, as mentioned above. As Therolf reveals, Anthony was even assigned to the same counselor, Barbara Dixon, who worked with Gabriel. Dixon testified in court that she had observed extensive injuries to Gabriel but did not report them to the hotline, despite being a mandatory reporter. The fact that she still had her job is mind-boggling. According to Therolf, “her case notes show that she counseled [Gabriel] to listen to his mother more attentively and to finish his homework.”
Kareen Leiva Enters the Picture: 2015
As Therolf describes, Barron met Kareem Leiva in 2015 and began a relationship that would last several years and result in Barron’s seventh child. Within months, the father of Anthony’s two-year-old brother reported to police that Leiva was abusing his son. There was no DCFS investigation but DCFS did open a court case involving that child and his parents, resulting in regular visits to the home by a social worker, Mindy Wrasse.
On June 12, 2015, the same father went to the police again after an agency-supervised visit with his son, reporting that his son had bruises on his arm and face. The social worker observing the visit had confirmed the bruising and reported that the child repeatedly said “Mommy is mean” during the visit. The father reported that the child seemed to have bruises at every visit. Ms. Barron reported the two-year-old fell in the shower, and the toddler reportedly confirmed the report. A two-year-old’s ability to confirm this verbally–and to take a shower on his own–shows suspicious precocity for his age. Despite the other siblings giving two different accounts of the bruising, the referral was ruled unfounded on the grounds that all of the children had similar stories. Additionally, the risk of maltreatment was found to be high and the recommendation was to promote to a case. But this recommendation was overriden because there was already an open case involving the two-year-old and his mother. That case closed in October 2016, leaving no DCFS personnel in contact with the family.
The Children Beg for Help: September 2015
On September 18, 2015, the hotline received a call, revealed by Therolf to be from the principal of Anthony’s school, recounting disturbing reports by Anthony of his treatment at home. A similar call came in from a sheriff’s deputy the next day. According to Therolf’s investigation, the children were visiting their uncle, David Barron, and told him about the horrific treatment they received from Barron and her boyfriend, Karim Leiva. David Barron refused to allow his sister to pick up the children and called the police instead. Anthony and his two oldest siblings described to the deputy who responded a litany of horrific punishments by Barron and Leiva. They reported Barron made them. squat against the wall for long periods of time, a torture she called the “Captain’s Chair.” They also described beatings, food deprivation, being locked in their rooms, and Leiva’s hanging Anthony’s brother from the stairs.
When the DCFS investigator met with Anthony, he told her “Heather is my old mom. This is my new house. I am part of the Barron family now. I’m never going to see Heather again. She locks us up in our rooms and makes us starving.”
But sadly, the agency that was responsible for Anthony’s safety did not allow him to stay in his safe “new home.” The investigator spoke with three staff members of Hathaway-Sycamores, the agency providing home-based services to the mother. The three reported that they were “constantly in the home” and that the mother did not hit the children. They said the children did not seem frightened, never talked of abuse, and there were no locks on the doors. The contrast with the reports of the Children’s Center a year earlier is striking. Given what came out after Anthony’s death, it is clear that the providers from the Children’s Center were much more discerning. Or perhaps Hathaway-Sycamores was in the grips of an ideology that values family preservation over child safety–a belief system that has led to many other children being abandoned to a horrible fate. In any case, it is incredible that DCFS was still using this agency after its role in Gabriel’s death.
Heartbreakingly, Ms. Barron was allowed to take the children home from her brother’s house. Not surprisingly, they recanted all the allegations once deprived of the protection of their aunt and uncle. Instead, they said their aunt and uncle told them to make these allegations. The wholesale retraction is suspicious because of the similarity and unusual nature of the allegations and the young age of the children, as well as the number of previous reports of abuse. It doesn’t take a genius to realize that the children may have been frightened into recanting their allegations. But the investigator decided that the aunt and uncle were manipulating the children and had instigated the allegations. (Therolf reports that she was new to the job and testified in court that she was unaware that survivors of abuse often retract their accounts.). The allegations were found to be “inconclusive “and the referral was closed with a disposition of “situation stabilized.”
One last chance of rescue missed: April 2016
On April 28, 2016, DCFS received another report, which Therolf learned came from a domestic violence center staffer who was working with Barron. Two of Anthony’s brothers had bruises on their faces. Barron said they had been in a fight, but the boys told the reporter that Karim Leiva made them fight each other. They also reported being locked in their rooms and deprived of food for long periods of time. Barron stated that Leiva had not been in the home since the previous September. In interviews with the investigator, Anthony, his sister, and the five year-old brother all denied the allegations. Anthony and his sister denied that Leiva was in the house or even that they knew him–a denial which should have raised serious concerns to the investigator. Wrasse, the social worker who was monitoring the open case involving Anthony’s brother, said the children definitely knew who Leiva was–and she thought he was coming regularly to the house. The investigator of the previous report also declared definitely that the children knew Leiva.
Despite all these inconsistencies, the allegations were all judged “unfounded” or “inconclusive,” and the disposition was “situation stabilized.” The risk assessment showed a high risk of abuse or neglect and a recommendation to “promote” the case. But the recommendation was disregarded because there was already a social worker on the scene–the same worker who was sure Leiva was coming into the home regularly. Her involvement ended in October 16, and then the children were totally on their own.
There were no more allegations until it was too late for Anthony. At some point, Ms. Barron cut ties with her brother and sister-in–law and moved Anthony to a school that did not know his history. Nobody was left to protect him. It is nevertheless surprising that no reports came from the children’s schools–a fact that deserves further investigation. According to Therolf, Anthony’s teacher noticed that he was “often nervous about something.” Such nervousness is not normal and should have triggered a response. But that is an issue for another post.
June 2018: Anthony’s suffering ends
Anthony’s fate was sealed when he told his his mother that he liked boys and girls. Leiva overheard this conversation. The following night, his siblings later reported, Leiva picked up Anthony by his feet and slammed his head on the floor repeatedly. The next morning, Barron called 911, saying Anthony had fallen. He was taken to the hospital and died the next day.
Anthony’s siblings initially denied any abuse, but as soon as they were questioned by an expert forensic interviewer, they revealed all the horrors that were occurring in the home. As punishment for minor transgressions, they were made to kneel on rice with weights in their hands, were kept awake all night (with water thrown into their faces by Barron or Leiva if they fell asleep), and were whipped with a belt or extension cord on the buttocks or soles of their feet. Anthony was singled out of special punishment. Leiva would pick him up by the feet and slam him on the floor head-first, as he did the night before Anthony died. By dying, Anthony saved his siblings from this nightmare home. They were removed from the home Barron and Leiva , who have been charged with first-degree murder for Anthony’s death.
DCFS had many chances to save Anthony but it wasted them all. This gifted, sensitive, and loving child was condemned to years of suffering ending only with his death. OCP was set up to protect children in the wake of Gabriel Fernandez’s death. It’s sad that this office ended up basically whitewashing Anthony’s. Now we are waiting for their report on why four-year-old Noah Cuatro was killed when DCFS disregarded an order to remove him from his home. Based on the Avalos report, the chances of a thorough investigation by OCP are slim.
When a child is found to be seriously or fatally abused, the perpetrator is often found to be a male caregiver. But a new study using data from pediatric emergency rooms provides powerful evidence of the correlation between caregiver characteristics and the likelihood of abuse.
The new study is the first to compare caregiver features among children with injuries due to abuse to those with accidental injuries. The article was published in the Journal of Pediatrics, and a summary is available online on the Science Dailywebsite. The authors used data on 1615 children under four who were brought to a pediatric emergency department. Overall, 75% of the injuries were classified as accidents, 24% as abuse and 2% as indeterminate.
The differences between the likelihood of abuse versus accident among different groups of caregivers are striking. Abuse was determined to be the cause of injury to only 10% of the children for whom a female was the only caregiver at the time of injury and fully 58% of children who were with a male caregiver when injured. There was a big difference between fathers and boyfriends however; an “alarmingly high” 94% of the children who were alone with the mother’s boyfriend at the time of injury were determined to be abused, as compared to “only” 49% of injured children who were with their fathers at the time of injury.
Analysis of the 83 cases of severe injury (including fatalities) provided even stronger evidence of the connection between male caregivers and abuse. The authors found that “nearly all cases of severe injury in which fathers and boyfriends were present involved abuse, and for fatalities, the fathers and boyfriends were most commonly present as lone caregivers. Mothers were rarely present alone when severe abusive injuries occurred.”
Among female caregivers, one group was more likely associated with injuries and that was babysitters. Fully 34% of the children left alone with babysitters were found to be victims of abuse
The researchers point to several policy implications of their study. First, they highlight the importance of asking who was caring for the child at the time of injury as part of the investigation to determine whether an injury is the result of abuse. Second, they call for abuse-prevention strategies to focus on male caregivers and female babysitters. (Currently, such programs, like shaken baby education, often focus on mothers.)
But the authors do not mention another policy implication that is equally important. Ensuring that all low-income children have access to high-quality early care and education (ECE) is a logical implication of the study.
As I have written in an earlier post, there are many pathways by which ECE can prevent maltreatment. Free, high quality ECE would provide mothers with an alternative to leaving their children with caregivers who are unsuitable to the task–be it boyfriends, fathers, or babysitters. ECE has other child welfare benefits as well. Staff who are trained as mandatory reporters ensures that more adults will be seeing the child and able to report on any warning signs of maltreatment. Quality ECE programs that involve the parents can also improve child safety by teaching parents about child development, appropriate expectations, and good disciplinary practices. They may also connect parents with needed supports and resources in the community and help them feel less isolated and stressed.
Of course the benefits of ECE extend far beyond child welfare in the narrow sense. We are worried about school readiness for low-income children and we know that much of brain development occurs between the ages of 0 and 3. That’s why quality ECE has been such a priority for the early childhood community. But child welfare policymakers have not yet caught onto the importance of ECE as a means of preventing child maltreatment.
An excellent issue brief from the Administration on Children and Families recommends improving access to ECE for families that are already involved with child welfare. That is a great proposal, but the child welfare field is beginning to focus on prevention rather than only treatment. We must explore ways to provide access to ECE among children who are at risk of child abuse and neglect. Expanding access to subsidized child care among lower-income families, because income is so highly correlated with child maltreatment, would be a good beginning.
Prevention is the word of the day in child welfare. A key part of prevention is making sure children spend their time with caregivers who will not harm them.
Another little boy is dead in Los Angeles County after being left in the hands of his abusers by the Los Angeles County Department of Child and Family Services (DCFS). This time, the victim was four-year-old Noah Cuatro. Noah’s family had been the subject of at least 13 calls to the county’s child abuse hotline. He had been removed from his abusive parents for two years but was returned to him less than two months before he was killed.
Noah’s death is the third since 2013 of child who had been the subject of multiple reports and investigations by child welfare authorities in the remote Antelope Valley of Los Angeles County. In June, 2018, Anthony Avilas was tortured to death by his mother and her boyfriend, who are facing capital murder charges. In 2013, eight-year-old Gabriel Fernandez suffered the same fate. His mother is serving a life sentence and her boyfriend is on death row.
At least 13 calls had been made to the county’s child abuse hotline alleging that Noah’s parents were abusing their children, according to a devastating article in the Los Angeles Times.
Although the case file has not been released, sources revealed some of the contents to the Times reporters. In 2014, DCFS substantiated an allegation that Noah’s mother had fractured the skull of another child. In 2016, Noah was removed from his home and remained in foster care for two years. He was ultimately placed with his great-grandmother, who states that she often told DCPS social workers about concerning behavior her granddaughter displayed at her visits with Noah. She also claims that Noah begged her not to let him go.
Once Noah returned home, reports of abuse continued to be phoned in in February, March, April and May 2019. One report alleged that Noah was brought to the hospital with bruises on his back. A report on May 13 alleged that his father had a drinking problem, was seen kicking his wife and children in public, and sometimes when drinking voiced his doubt that Noah was his child.
At least one DCFS social worker took these reports seriously. On May 14, sources told the Times, she filed a 26-page report to the court requesting an order to remove Noah from his parents. And the judge granted that report the next day. But weeks went by–and the order was not implemented, even after new allegations came in that Noah had been sodomized and had injuries to his rectum. Noah died on July 6, more than seven weeks after the order was granted.
We do not know why Noah was not removed, because state law requires that the agency conduct its own investigation before the case file can be released in child fatality cases. We do know from another Los Angeles Times article that DCFS has already changed its policy on court removal orders to say that such a delay should be an “extreme exception” and must be brought to the director of the agency and approved by his Senior Executive Team.
Why so many tragedies in the Antelope Valley? Given its small population, Antelope Valley has a disproportionate number of deaths caused by a parent or caregiver of children already known to DCFS. according to calculations by the Chronicle of Social Change. Nobody knows if this higher death rate is due to cultural or economic features of the area or to challenges in staffing DCFS. Difficulties in attracting and retaining staff in this remote part of the county have been described in numerous reports, most recently an audit of DCFS and a report on the death of Anthony Avalos.
On July 23, the Los Angeles County Board of Supervisors unanimously approved a motion requiring DCFS to work with other agencies and educational institutions to develop a staffing plan to alleviate staff shortages and turnover in the Antelope Valley. I It also directs DCFS to immediately develop a Continuous Quality Improvement Section and fill approximately 20 positions which will allow for increased case reviews, initially focused on the Antelope Valley section.
These are good steps that are surely needed, given the staffing problems in Antelope Valley. However, until we know the reason the court order requiring Noah’s removal from the home was disregarded, we don’t know if these steps will address the proximate cause of Noah’s death–the failure to remove him from his home when a social worker clearly recognized the need for it. It appears that this removal order was overriden by someone above the social worker – but we need to know why and by whom. This crucial decision may have little to do with staffing problems and more to do with other factors–such as an ideological preference for parents’ rights or a reluctance to remove children.
Sadly, there is no provision in California or LA County requiring an in-depth case review to be released to the public. This never happened in the cases of Anthony Avalos or Gabriel Fernandez. In order to get to the bottom of these horrendous deaths, Los Angeles County’s Board of Supervisors should pass legislation requiring such a review. Washington’s state’s statute requires a review (by experts with no prior involvement in the case) when the death or near-fatality of a child was suspected to be caused by child abuse or neglect, and the child had any history with the Children’s Administration at the time of death or in the year prior. These reviews must be completed within 180 days and posted on the agency’s website. Florida has a similar requirement, as I have described in an earlier post.
The father and siblings of Anthony Avalos filed a $50 million suit against DCFS and one of its contractors only a few weeks after Noah’s death. They allege that the department “was complicit in the abuse and neglect of Anthony and his half-siblings.” The same attorney is now representing Noah’s grandmother, and a lawsuit is sure to follow. How many more deaths will it take before the county can be relied on to protect its vulnerable children from suffering and death inflicted by their parents?
Illinois’ child welfare services to families that are allowed to keep their children have major systemic flaws that put children at risk. Most importantly, there is extreme reluctance to remove children from their homes and place them in foster care. Those are the findings of a review from Chapin Hall at the University of Chicago that was commissioned by the Governor in the wake of several deaths of children whose families were being supervised by the state.
This report follows an earlier one, discussed in a previous post, by the Inspector General (OIG) for the Illinois Department of Children and Family Services (DCFS) stating that child safety and well-being are no longer priorities for the agency. One problem area identified in that report was Intact Family Services, which are the services provided to families in order to prevent further abuse or neglect without removing the child. OIG’s 2018 annual report included an eight-year retrospective on the deaths of children in Intact Family Services cases, which concluded that in many of these cases the children remained in danger during the life of the case due to violence in their homes, when DCFS should have either removed the children or at least sought court involvement to enforce participation in services,
Increasingly, child welfare systems around the country have been relying on services to intact families (often called in-home or intact family services) in order to avoid placing children into foster care. In 2017, according to federal data, only 15% of children who received services after an investigation or assessment were placed in foster care; the other 85% were provided with services in their homes. These services may become even more predominant with implementation of the Family First Prevention Services Act, which allows federal Title IV-E funds to reimburse jurisdictions for the cost of such services.
It is important for child welfare agencies to be able to work with families that remain intact. This allows the agency to monitor the children’s safety and avoid the trauma of placement in foster care while working to ameliorate the conditions that might lead to a foster care placement. But agencies must be cognizant that not every family can be helped this way, keep a close watch what is going on in the home, and be ready to remove children when necessary to ensure their safety. The deaths of children who have received Intact Family Services in Illinois have raised questions about whether the agency is accomplishing these tasks.
In Illinois, Intact Family Services (referred to below as “Intact”) are provided mostly by private agencies under contract with DCFS. The Chapin Hall report found systemic issues that create barriers to effectively serving intact families.
Avoiding foster care placement: Perhaps the most important issue observed by the researchers was the high priority that Illinois places on avoiding placement of children in foster care. As a result of many years of such efforts, Illinois now has the lowest rate of child removal in the country. Intact staff expressed the belief that “recommendations to remove children based on case complexity, severity, or chronicity will not be heard by the Division of Child Protection (DCP) or the Court.” As a result, Intact supervisors are reluctant to reject referrals of families even when they believe a family cannot be served safely in the home. They are also reluctant to elevate cases for supervisory review when they have not been able to engage a high risk family.
Supervisory Misalignment: In the past, negotiations between DCP and Intact over the appropriateness of a referral occurred on a supervisor-to-supervisor level, allowing Intact to push back against unsuitable referrals. An administrative realignment that placed investigators and Intact under different administrations eliminated this ability of Intact to contest inappropriate referrals. According to the researchers, this resulted in the opening of Intact cases for families with “extensive histories of physical abuse” that Intact staff believed they could not serve effectively.
High Risk Case Closures: Intact service agencies are expected to work with a family for six months and then close the case with no further involvement by DCFS. The researchers learned that there was no clear pathway for intact staff to express concerns when they been unable to engage a family. As a result, some providers told the researcher that they may simply close the case when a family will not engage.
Staffing Issues: Caseload, capacity and turnover. The researchers found that DCP investigators are overwhelmed with their high caseloads and are desperate to make referrals to Intact to get families off their caseload as soon as possible. The prescribed caseload limit of 15 cases per worker is very hard to manage, and some workers carry even more cases. Moreover, DCP workers tend to stop managing safety plans and assessments as soon as a referral is made to Intact, which leaves children in limbo until services begin. For their part, Intact workers’ caseloads are often over the prescribed limits and are not adjusted for travel time or case complexity. Moreover, the difficulty of their clientele makes the current caseload of 10:1 difficult to manage. High turnover among Intact workers, investigators and other staff can also contribute to the information gaps and knowledge deficits mentioned below.
Role Confusion: DCP workers and Intact workers seem to have different views of the role of the DCP worker, according to the researchers. DCP workers view their role as making and justifying the decisions about whether to substantiate the referral and remove the child. However, the Intact Family Services policy calls upon them to engage the family and transmit all necessary information to the Intact staff. Cultural differences between the two sets of workers compound the problems.
Information Gaps: Because of the role ambiguity mentioned above, investigators often fail to pass on crucial information to Intact workers. Yet, these workers often cannot access investigators notes or key features of the case history. Moreover Chapin Hall’s reviews of the two recent deaths of toddlers in intact cases found that much of the family’s history was inaccessible because cases were expunged or purged. DCFS expunges most unsubstantiated reports and shreds investigators files and appears to be more aggressive about such expungements than most other states, according to a previous DCFS Director, George Sheldon.
Service Gaps: The researchers also mentioned gaps in service availability, especially long waiting lists for substance abuse prevention, which make it very difficult to engage families as well as providers.
The authors made a number of recommendations for addressing these problems they identified. These include:
Work with courts and State’s attorneys to refine the criteria for child removal in complex and chronic family cases;
Develop and refine protocol for closing Intact cases;
Direct attention to cases at greatest risk for severe harm; revisit the use of predictive models which should be transparent, based on broad input and be supported by ethical safeguards’
Clarify goals and expectations across staff roles;
Utilize evidence-based approaches to preventive case work;
Improve the quality of supervision;
Adjust the preventive services offered through Intact to meet the needs of the population;
Restructure Intact Services to address the supervisory mismatch with DCP; and
Redesign the assessment and intake process to reduce redundant information, improve accuracy or assessments to support decision-making and improve communication across child serving systems.
We would have liked to see a recommendation to modify Illinois’ policy of expunging and purging all unsubstantiated investigations. At a hearing in May, 2017, the DCFS Director, George Sheldon, expressed his support for allowing DCFS to keep records of all investigations, even if they are unsubstantiated. Research suggests that it is very difficult to make accurate decisions about whether maltreatment has occurred; moreover, unsubstantiated reports are as good as substantiated ones in predicting future maltreatment. Examples of children killed after families have had multiple unsubstantiated reports have been observed all over the country.
This report should be a must-read for all child welfare agencies. Children in many states have died of abuse or neglect after intact cases have been opened for their families. (Think about Zymere Perkins in New York or Anthony Avalos and Gabriel Fernandez in Los Angeles.) Many of the issues identified by the Chapin-Hall report may have contributed to these deaths as well, particularly the extreme avoidance of child removals that has condemned so many innocent children to death ever since the widespread push to reduce the foster care rolls, supported by a coalition of wealthy and powerful foundations and advocacy groups.
An investigation by the Boston Globe’s Kay Lazar has drawn public attention to the foster care placement crisis in Massachusetts. The opioid epidemic has led to a spike in the demand for foster homes, but the Department of Children and Family Services (DCF) has been unable to recruit and retain enough foster parents. Therefore, children newly removed from their homes often have no place to spend the night, sometimes spending it in a car with a social worker awaiting a call to say a bed is available up to 100 miles away.
And the trouble doesn’t end with the first overnight placement. One third of foster children in Massachusetts were moved at least three times during their first year in the system. According to one social worker quoted, relatively healthy children come out of care with behavioral problems and attachment issues due to their devastating experiences in foster care.
Lazar and her paper are to be commended for making the public aware of these unacceptable flaws in the Commonwealth’s treatment of its most vulnerable citizens. But by interviewing only a small group of child welfare experts with similar perspectives, Lazar missed some of the obvious common sense solutions to these problems.
Take the lack of emergency foster homes, which results in many children spending their first night in foster care in a car waiting for a bed. There is an obvious solution, and that is to establish temporary regional shelters so that every child can find a warm bed and a welcoming hug on what may be the most traumatic night of their lives.
So why was this solution not mentioned? Many states have seen their emergency shelters become warehouses for children for whom a placement cannot be found. As a result, some states have closed these facilities–instead of improving them. But these closures don’t solve the problem that homes are not available.
Smarter jurisdictions, often working with nonprofits, use emergency shelters for children newly removed from their homes. A nonprofit called Amara operates temporary shelters for children who have just been removed from their homes in Seattle and Tacoma, Washington. The shelters are a haven for traumatized children where they receive loving care from staff and volunteers. And they offer social workers a much needed three to five days to find a foster home that is the best match available–not just the first to answer the phone.
There is a no obvious solution to the overall shortage of foster home beyond the first few nights of a placement. Lazar rightly draws attention to the bad treatment that foster parents receive from an agency that fails to provide information about the children who are placed with them, does not provide the therapy and services the children need, pays them too little to support the kids, doesn’t train them in caring for traumatized children, and requires them to adhere to conflicting and outdated regulations. By all means these problems must be fixed–for the sake of the children as well as the foster parents. But it is unlikely that they will rectify the shortfall of foster homes. More creative and courageous solutions are necessary.
Providing free housing and/or salaries for foster parents might help increase the supply of foster homes. An Oklahoma nonprofit is building larger homes where foster families can live rent-free in exchange for taking in larger sibling groups. SOS Children’s Villages Illinois operates several foster care communities in which full-time professional foster parents care for large sibling groups of up to six children. Child welfare agencies should work in partnership with local nonprofits to develop such programs.
But Massachusetts needs to face the facts. There will never be enough high-quality foster homes for all the children who need them. As Stan Rosenberg, former President of the Massachusetts Senate and a former foster youth, wrote in the Globe, many foster parents are loving and caring but others are in it for the stipend and the children placed with them will suffer the consequences. A high-quality group home or residential facility can be much more nurturing and family-like than a low-quality foster home. More such facilities (often known as “congregate care”) are needed in order to prevent our abused and neglected children and youth being re-traumatized by repeated moves between foster homes.
Children who have trouble finding permanent placements tend to be older and/or have more severe behavioral, neurological and cognitive problems which stem from many years of trauma, deprivation, and often in utero substance abuse. Some of these children cannot thrive in traditional foster homes, which are not trained to deal with their difficult behaviors. There are many high-quality group homes around the country where dedicated staff devote their lives to changing the trajectories of these wounded children.
But the political climate has been opposed to such facilities for a long time, as Child Welfare Monitor has often discussed. Congregate care facilities have been closing for years as states have deprived them of funding and stopped sending children there–even if they have to be left in dangerous homes, placed in barely-adequate foster homes, or bounced from home to home. The percentage of children in Massachusetts placed in congregate care facilities decreased from 22% in 2007 to 17% in 2017.
The bias against congregate care has been enshrined in the Family First and Prevention Services Act, (FFPSA) passed as Title VII of the Bipartisan Budget Act of 2018. Under FFPSA, states will no longer be able to draw upon federal funds for congregate care except for children who have been judged too disturbed to thrive in a foster home by a “qualified professional.” These facilities must meet new criteria for licensure, and congregate care placement will be reviewed at every court hearing. Moreover, a child cannot remain in one of these placements for more than 12 consecutive months (or 6 months for a child under 13) without written approval from the head of the child welfare agency.
Sadly, ideology is reinforced by the reluctance of public officials to ask their taxpayers to find room in their hearts to fund high-quality facilities to these neediest of all children. Such facilities are much more expensive than foster homes and many have been starved out of existence around the country.
Instead of discussing the need for more congregate placements, Lazar quotes advocates who state that more children could be maintained in their own homes if adequate services could be provided to their parents. Yet, as she herself states, about 80% of the children in DCF’s caseload are living at home while the agency attempts to help their families avoid foster care. A spate of deaths of children in DCF-supervised homes since 2014 has distracted the agency from any attempt to reform foster care. Do we really want to put more children at risk to avoid spending money to nurture and house our most vulnerable children?
The 21st National Conference on Child abuse and Neglect (NCCAN) sponsored by the Children’s Bureau of the U.S. Department of Human Services (HHS) took place in Washington DC from April 24-26, 2019, and there could be no better window onto the child welfare zeitgeist. NCCAN’s defining spirit was perfectly embodied in the conference theme, Strong and Thriving Families. But the main takeaway for this blogger was how far the field has strayed from its central and defining mission–protecting children.
From the first words booming out of the speaker in the hotel ballroom, the conference plenary sessions focused relentlessly on a two-part message. First, the worst thing to do for abused and neglected children is to remove them from their families and we should stop doing it right now. Second, child welfare should focus on primary prevention–preventing child maltreatment before it occurs.
Removing abused and neglected children from their families is the worst thing you can do to them. That was the main message delivered by plenary speaker Amelia Franck Meyer, one of PEOPLE Magazine’s 25 Women Changing the World. Meyer made extensive use of the animal kingdom to make her points about the mother-child relationship. She started with baby ducks imprinting onto their mothers and went on to mother bears. When one of own children is not having their needs met at school, Meyer says she will stop at nothing to ensure that the little one’s needs are met. And that’s why all kids need their mother, she explained, because your mother “always has your back.”
“Mama bear” would not be the best term to describe many of the mothers I saw as a foster care social worker, or the ones whose children’s deaths I have been reviewing as part of the District of Columbia’s Child Fatality Review Committee. The moms who expose their babies to brain-damaging substances in utero, sleep through the night aided by drugs or alcohol while their infants die, can’t be bothered to bring their children to school for 30 days in a semester, leave them in the care of volatile boyfriends, or inflict bruises and cuts are hardly mama bears. And, despite what we may want to believe, some children need to be rescued from such mothers.
Meyer also told us that we should not think of children as individuals but as part of families, which sounds a bit like a return to an earlier century. And of course she did not forget to the modern trope that child welfare is not about saving children from their families but rather about helping families protect their children.
In his closing plenary session, Children’s Bureau Chief Jerry Milner urged us to stop using the term “birth parent,” “which undermines the singular parent-child relationship.” That term helps separate the idea of procreation from that of nurturing–something that Milner clearly does not want to do. We also can’t talk about “dysfunctional” families, according to Milner. If only not talking about them would make them function well!
Milner urged participants to picture a different type of child welfare system, where “families are given what they need to thrive, not just survive.” In an interview with the Chronicle of Social Change, Milner suggested that what families need to prevent maltreatment includes “parenting education and support, community-based substance abuse prevention and treatment services, ready access to needed medical and mental health services and trauma-informed services to help parents heal from their adverse experiences.”
Milner did not mention child care, housing, or increased cash assistance–services that many would argue poor families need to thrive. But that’s not surprising given that he’s a member of the Trump Administration. Even expanding access to parenting classes, drug treatment and mental health services does not sound like an administration priority–unless the funds come from reprogramming current spending, which seems to be what Milner has in mind. By his own report, he tells child welfare officials who are afraid of adding a new set of primary prevention functions to their current overwhelming mandate that they should do it instead of what they are already doing, not in addition to it! Apparently he believes that cutting funds for CPS investigations and foster care would provide ample funding for primary prevention.
So what’s wrong with all this? Isn’t primary prevention the most logical approach to any social ill? Unfortunately, there are a few problems with making it the only approach:
We don’t know much about what works to prevent child abuse and neglect. The most touted programs involve home visiting, and we don’t have a lot of evidence that they work to prevent child abuse and neglect. The California Evidence Based Clearinghouse for Child Welfare (CEBC) has rated only one home visiting program as “well-supported” by the research evidence as a means of preventing child maltreatment, and that program (Nurse Family Partnership) is limited to first-time low-income mothers. CEBC rates only one program (SafeCare) as “supported by the research evidence” as a program to prevent child maltreatment. And all of these programs have been strictly voluntary–which leaves out the families that are most dangerous to their children.
Many primary prevention programs don’t belong in the child welfare agency. Mental health and drug treatment serve a broader clientele than parents involved in child welfare and are generally provided by different agencies. And while Milner was careful not to mention housing, child care, or cash welfare, these don’t belong under the jurisdiction of child welfare agencies either.
Even if we had a better idea about what worked, we might reduce maltreatment but not eliminate it. We would need a method of investigating possible occurrences and protecting (even sometimes rescuing) the children at risk. It’s like saying we need to shut down hospitals. Of course we want to prevent gun violence, car accidents, cancer, and outbreaks of preventable infections diseases. But we certainly need to have hospitals available in case we fail.
Given NCCAN’s focus on primary prevention, it is not surprising that the Family First and Prevention Services Act received almost no mention throughout the conference, even though it is the biggest change to federal child welfare legislation in two decades and takes effect in October–and federal guidance is woefully lacking. Jerry Milner has already said that Family First is only the first step toward transforming child welfare. What he really wants is a block grant that would allow states to shift funding from CPS, foster care, and family preservation to primary prevention. And that could result in further starvation of CPS, foster care and in-home services (which need more funding, not less) in the name of a mission that should be carried out by other agencies.
On Monday, conference participants returned to the real world, where media outlets in Illinois and nationwide were reporting on five-year-old AJ Freund, who was beaten to death on April 15. His parents, who reported his disappearance three days later and tearfully attended a vigil shortly thereafter, have been charged with his murder. As the Chicago Tribune put it,
Witnesses in all corners of AJ’s life saw signs of abuse or neglect. A doctor, neighbors, police and others knew or suspected that much was amiss over the years. Many of them sounded alarms that were recorded by the courts and the Illinois Department of Children and Family Services, which once again finds itself struggling to explain why a child on its watch is now dead….Yet AJ, who was born with opioids in his system, was left to live in a filthy house of horrors where it appears he was hurt again and again.
And if Jerry Milner and Amelia Franck Meyer have their way, many more AJ’s will suffer and die without anyone to rescue them. Because they believe that child welfare agencies should not be in the business of rescuing children.
DCFS has lost focus on ensuring the safety and well-being of children as a priority. This is evidenced by several recent cases and the clear lack of attention to assuring children and families receive adequate, thorough, and timely responses and needed services. Investigators, caseworkers and supervisors are unmanaged, and unsupported. Children are dying, children are being left lingering in care, children are being left in in psychiatric hospitals beyond medical necessity causing them to lose hope. This is not just unacceptable it is HARMFUL
That startling statement was made by the Acting Inspector General (IG) for Illinois Department of Children and Families to News Channel 20 about its most recent annual report. During FY 2018, the Office of Inspector General (OIG) reviewed 97 deaths and one serious injury of children whose families were involved in the child welfare system within the preceding 12 months. Of the 98 families involved, at least 52 were the subject of of a completed child abuse or neglect investigation during the previous 12 months; fully 37 of these investigations failed to find any abuse or neglect and were closed without any action to protect the child. Twelve of the 98 families were the subject of an open investigation when the child died, eight were involved in an open family service case, and three had had a family case closed within a year of the death. (See the full count of deaths by case status at the bottom of this article.)
Not all of the deaths or serious injuries can be attributed to DCFS failure to protect a child. Twenty-seven deaths were ruled natural; most of the children involved had serious medical issues. Some of the deaths (including most the 16 youths in foster care)1 were sadly due to violence, car accidents, drug abuse by older youths and other circumstances not under the Department’s control. Heartbreakingly, two older teens in foster care died of abuse that was inflicted on them as infants and left them medically compromised.
However, many of the case reviews suggest DCFS missed danger signs and opportunities to save vulnerable children. Thirteen children were killed by a parent, step parent, parent’s paramour, another relative or unknown perpetrator within a year of an open investigation or service case. These children were beaten, starved, stabbed, and shot to death. The cause of 23 deaths of children in families that recently interacted with DCFS is still undetermined; many are currently being investigated. Most of these children were infants; many of the deaths appeared to be linked to unsafe sleep practices and at least four raised concerns of abuse. The deaths of 24 children with an open or recently open case were classified as accidental. Fourteen of these deaths were attributed to asphyxia, suffocation, or sleep related causes; there were also two accidental drownings, an accidental hanging, and an accidental shooting of a three-year-old by an 11-year-old, as described below.
The OIG completed “full investigations” of four cases that have drawn extensive media attention:
Seventeen-month-old Semaj Crosby was found dead under a couch in her home 30 hours after being reported missing. There was both an open in-home case and a pending child protection investigation of the family at the time Semaj was reported missing. The family had been the subject of 11 investigations during the two years before her death. The mother received SSI for cognitive delays but was never assessed to determine her ability to keep her children safe. Semaj’s seven-year-old brother was psychiatrically hospitalized three times for threatening to kill himself during the time the family’s case was open. A family service caseworker visited the home the day before the toddler was reported missing, and a child protection investigator had been to the house the day the report was made. No immediate safety concerns were reported by this investigator, even though the health department deemed the apartment uninhabitable after the body was found. Criminal and child neglect investigations are pending.
Four-year-old Manual Aguilar was killed, apparently starved to death, and his body was burned post-mortem. Four years before his death, Manual and his three siblings were removed from their mother’s custody after she left the three older children in a car overnight at temperatures hovering around freezing, while Manual was left in a stranger’s care. The children were returned home a year before Manual’s death despite the mother’s failure to progress in therapy and an unfounded investigation stemming from bruises to one child that his older siblings reported were inflicted by the mother during an overnight visit. Five months before Manual’s death, the two older siblings texted to their former foster parent that their mother was beating them, but the investigation was unfounded when they recanted. The mother has been charged with murder.
A daycare center reported that a two-and-a-half-year-old appeared to have cigarette burns on both hands. The reporter also said the child’s face had been swollen on two prior occasions, and an unknown male accompanying the mother was seen to hit the child across the face a week before. The investigator closed the case without investigating adequately either the child’s burns or the family’s allegation that they occurred at the daycare. Two days following the investigation’s closure, the child experienced cardiac arrest and died four days later. The autopsy concluded that the manner of death was undetermined and suspicious, but a child protection investigation did not find evidence to find anyone responsible for the death.
An eleven-year-old girl accidentally shot her three-year-old brother in the head while playing at home. This child survived and and this appears to be the only non-fatal case reviewed. The parents had left four of their children, of which the eleven-year-old was the oldest, at home alone. The father had eight drug convictions and had been arrested multiple times for physically assaulting the mother. The investigation of the shooting was the eleventh investigation of this family since 2008. One investigation had occurred when the father barricaded himself in the home with the mother, who was eight months pregnant, and the screaming and crying children. The children’s eight-year-old sibling was in residential care in the custody of DCFS at the time of the shooting and the agency was required to monitor the at-home siblings as well. Nevertheless no visits by case managers to the home were documented in the 45 months before the shooting with one exception. A case manager attempted to visit the home 21 days before the shooting but was not allowed in. .
The acting Inspector General told a reporter that understaffing may have contributed to the state’s inability to prevent child deaths. Following the death of Semaj Crosby, the OIG investigated a media report that child protection workers in the local office were offered incentives for early case closure. The IG found that while Semaj’s family was involved with DCFS, the entire region was understaffed (at times as low as 66% of staff needed), resulting in excessive caseloads for investigators. In December 2016, the field office administrator offered a $100 gift card to the investigator who could close the most cases in January. The IG found similar incentive programs for early case closure around the state.
The OIG also found that “a large contributing factor to the caseload problem was that the previous director had several management initiatives that seemed to take priority” over any attempt to redistribute caseloads. One of these initiatives, Rapid Safety Feedback, received some media attention last year. DCFS awarded a multimillion-dollar contract to two out-of-state firms using a “propriety algorithm to identify cases most likely to result in death or serious injury.” There were concerns that this contract was one of several no-bid contracts given to a circle of former associates of the previous director, as described by the Chicago Tribune. The contract was terminated after 25 to 50 percent of cases were flagged as having a a greater than 90% probability of death or serious injury in the next two years, alarming and overwhelming social workers. At the same time, the algorithm failed to predict the death of Semaj Crosby and other children who were killed while under supervision by DCFS.
The OIG report identified two areas of “chronic misfeasance,” or conduct that is lawful but inappropriate or incorrect. One of these areas is “intact family services,” which is DCFS-speak for the services provided to families to prevent further abuse or neglect without removing the child. OIG’s 2018 annual report included an eight-year retrospective on the deaths of children in intact family services cases. The OIG concluded that in many of these cases the children remained in danger during the life of the case due to violence in their homes, when DCFS should have either removed the children or at least sought court involvement to enforce participation in services.
A second area of “chronic misfeasance” identified in the 2019 report which has also drawn media coverage is the practice of leaving foster children in psychiatric hospitals “beyond medical necessity,” or after they are stable enough to be cared for outside that setting because there is no appropriate placement. OIG reported that the number of such episodes increased from 273 in FY 2017 to 329 in 2018. “The availability of community-based services and resources for youth with significant mental and behavioral needs continues to be at crisis levels.”
The OIG’s overall conclusion–that child safety and well-being are no longer priorities for DCFS–is sobering. But even more alarming is the fact that this description could be applied to many or even most other states. Although we don’t have numbers for most states, every year brings stories from around the country of children killed after long histories of contact with child welfare authorities. Twenty-seven percent of the fatality cases analyzed by the Administration on Children and Families for its Child Maltreatment report had at least one Child Protective Services contact within the past three years. State child welfare agencies tend to hide behind strict privacy protections in order to avoid releasing information on child protection failures, even though the case information could be released without including the names of the families involved. As a member of the District of Columbia’s Child Fatality Review Commission, I hear at almost every monthly meeting about one or more children who died after the family was called to the attention of CPS multiple times. And yet, I am not allowed to share any information about these cases with anyone, including legislators.
At least in Illinois, thanks to the DCFS Inspector General, the public and its elected representatives are given the opportunity to learn about failures to protect children while in the custody of their parents as well as those the custody of DCFS. This information helps make the case for change. The OIG report was the subject of a hearing in Springfield. The Governor has already requested an increase of more than $70 million for 126 new staff and technology upgrades.
Unfortunately, most states do not have an independent agency like the Illinois OIG to look out for children who are served by the agency both at home and in care. In a report issued on April 4, 2018, the National Council of State Legislators found that only 11 states have “an independent and autonomous agencies with oversight specific to child welfare,” although they seem to have missed Illinois. All states need such an autonomous agency. Somebody needs to reveal the truth about how we fail our most vulnerable children–and what it would take to do better.
Number of Child Deaths by Case Status from OIG Report
Case Status*Number of deaths or serious injuries
Pending Investigation at time of child’s death………………………………………………………12
Unfounded Investigation** within a year of child’s death……………………………………37
“Indicated” Investigation*** within a year of child’s death…………………………………..15
Youth in care………………………………………………………………………………………………………………16
Open Placement/Split custody****……………………………………………………………………………..3
Open Intact Case*****………………………………………………………………………………………………….8
Closed Intact Case within a year of child’s death……………………………………………………….3
Child of Youth in Care……………………………………………………………………………………………………1
Child Welfare Services Referral (no allegation of abuse or neglect)………………………….2
Preventive services to assist family but not as result of indicated investigation………1
*When more than one reason existed for the OIG investigation, the death was categorized based on “primary reason.”
**An investigation in which the agency was unable to verify that abuse or neglect occurred.
***An investigation in which abuse or neglect by the parent was found to have occurred.
****Child was in home with siblings in foster care
****A case in which the family was receiving services while the child remained in the home.
Of the 16 children who died while in foster care, a 14-year-old and an 18-year-old died of gunshots by unrelated perpetrators, two died as a consequence of abuse by their parents in infancy, three were infants in care of relatives and cause of death was undetermined for two and suffocation for one, two died of methadone or opioid intoxication, one 18-year-old died in a car accident and five died of natural causes. ↩