Child Maltreatment 2023: A reduction in child maltreatment victims or a retrenchment of child protection?

“New Federal Report Demonstrates Reduction in Child Maltreatment Victims and Underscores Need for Continued Action,” the Administration on Children and Families (ACF) of the US Department of Health and Human Services proclaimed in releasing the latest annual report on the government response to child abuse and neglect. As in the past several years, ACF’s language suggested that child abuse and neglect are decreasing. But with states around the country changing law, policy and practice to reduce child welfare agencies’ footprint, the number of “child maltreatment victims” cited by ACF is likely more a reflection of policy and practice than an indicator of actual maltreatment.

The annual Child Maltreatment reports, produced by the Children’s Bureau of ACF, are based on data that states submit to the National Child Abuse and Neglect (NCANDS) data system. The new report, Child Maltreatment 2023 (CM2023), provides data for Federal Fiscal Year (FFY) 2023, which ended on September 30, 2024. The report documents the funnel-like operations child welfare protective services (CPS), which at each stage select only a fraction of the cases or children to proceed to the next stage. Exhibit S-2 summarizes the findings of the newest report. Child welfare agencies received 4.399 million “referrals” alleging maltreatment in Federal Fiscal Year (FFY) 2023 and “screened in” 2.1 million of them as “reports” for “disposition” through an investigation or alternative response. The investigation or assessment of those reports resulted in a total of 546,159 children determined to be victims of child abuse and neglect. (The final stage of the funnel involves services and is not covered in this post.) State and local policies and practice affect every stage of this process, as explained in detail below.

Referrals

NCANDS uses the term “referrals” to mean reports to child welfare agencies alleging maltreatment. Agencies received an estimated total of 4,399,000 referrals through their child abuse hotlines or central registries in FFY 2023, according to CM 2023. This is a very slight increase over the previous year and represents about 7.8 million children, or 60 per 1,000 children. As shown in Exhibit S-1, the total number of referrals has been increasing since 2020, when the COVID-19 pandemic resulted in a large drop in referrals. In FFY 2023, the number of referrals surpassed the pre-Covid 2019 total for the first time as the lingering effects of the pandemic, which acted to suppress reports, finally dissipated.

As in past years, the state-by-state tables document large differences in referral rates, from 19.9 per 1,000 children in Hawaii to 171.2 per 1,000 in Vermont–also the top and bottom states in 2022. These differences reflect not just different numbers of calls to child abuse hotlines but also state policy and practice. Vermont reports that it counts all calls to the hotline as referrals, while other states do not do so. For example, Connecticut reported in CM2022 that none of the calls that are assigned to alternative response are included in NCANDS, resulting in a far lower number of calls than the number they actually receive. Referral rates may also affected by a state’s policy on who is required to report and what must be reported. Such policies are disseminated to mandatory reporters through training and agency communications. New York reported implementing in FFY 2023 a new training for mandated reporters that helps them identify when concerns do not rise to a level legally requiring a report be made.” The training also focuses on implicit bias in order to “reduce the number of SCR reports influenced by bias about race or poverty.” The number of referrals in New York dropped by a very small fraction in FFY 2023. Missouri reported in CM2022 that it stopped accepting educational neglect referrals in 2021 as the COVID emergency ended, resulting in a decreased number of referrals received the following year.

Reports

Once a state agency receives a referral, it will be screened in or out by agency staff. In general, referrals are screened out if they are deemed not to contain an allegation of child abuse or neglect, contain too little information to act on, are more appropriately assigned to another agency, or for some other reason do not fall under the mandate of the child welfare agency. In the language used by NCANDS, a referral becomes a “report” once it is screened in. “Reports” are assigned for an investigation or “alternative response.” State data indicates that child welfare agencies screened in 2.1 million referrals, about 47.5 percent of referrals for an investigation or alternative response, and “screened out” the other 52.5 percent as not warranting a response. The number of screened-in referrals was 11.6 percent less than in FFY 2019 and slightly less than in FFY 2022.

A total of 42 states reported a decrease in the number of screened-in referrals in FFY 2023. In their commentaries, several of these states described policy and practice changes that led to their screening out more referrals. Ohio reported that two of its major metropolitan counties, which had significantly higher screen-in rates than the rest of the state, adjusted their screening procedures to be consistent with the rest of the state, resulting in a lower screen-in rate in those counties and statewide. Mississippi reported an increasing the amount of screening it conducted, especially when a report was received regarding a case that was already open; perhaps this is why its screen-in rate dropped from 41.3 to 36.5 per 1,000 children. Nebraska reported dropping a policy to require accepting all referrals from a medical professional involving children under six. Some states explicitly reported that their screening changes were adopted in order to decrease the number of screened in referrals. Kentucky reported adopting a new SDM® screening tool designed to decrease the number of referrals that are “incorrectly accepted for investigation.” Nevada reported a decrease in screened-in referrals because it established new intake processes to ensure that referrals are screened out when they do not meet criteria for acceptance.

“Victims”

The next phase in the funnel of CPS is the determination of whether abuse or neglect has occurred. At this stage, the level of analysis shifts from the case to the child, and the number of “victims” is the result. In NCANDS, a “victim” is defined as “a child for whom the state determined at least one maltreatment was substantiated or indicated¹; and a disposition of substantiated or indicated was assigned for a child in a report.” “Victims” include children who died of abuse or neglect if the maltreatment was verified. Some children receive an “alternative response”² instead of an investigation; these children are not counted as victims. According to CM2023, states reported a total of 546,159 victims of child abuse and neglect in FY 2023, producing a “victimization rate” of 7.4 per 1,000 children.

The number of “victims” reported by states according to the NCANDS definition does not represent the true number of children who experienced abuse or neglect, which is unknown. Many cases of child maltreatment go unreported. Children assigned to alternative response are not found to be victims unless their case is reassigned to the investigation track. And finally, substantiation may not be an accurate reflection of whether maltreatment occurred. Making a determination of whether maltreatment occurred is difficult. Adults and children do not always tell the truth, the youngest children are nonverbal or not sufficiently articulate to answer the relevant questions. So it is not surprising that research suggests that substantiation decisions are inaccurate³ and a report to the hotline predicts future maltreatment reports and developmental outcomes almost as well as a substantiated report.⁴

State “victimization rates” range from a low of 1.5 per 1,000 children in New Jersey to a high of 16.2 in Massachusetts. It is unlikely that Massachusetts has more than ten times more child abuse and neglect victims than New Jersey–a not dissimilar Northeastern state. Policy and practice must be at play, including different definitions of abuse or neglect, levels of evidence required to confirm maltreatment, and policies regarding the use of alternative response or “Plans of Safe Care”⁵ to divert children from investigation, among other factors. Maine reported the second highest “victimization rate.” The Maine Monitor asked experts why this might be so. Among the reasons suggested were the definition of maltreatment; Maine allows abuse or neglect to be substantiated when there is a “threat” of maltreatment, even if there is no finding that it already occurred. In view of the deceptiveness of these terms, I have put the terms “victims” and “victimization rates,” when not preceded by the word “reported,” in quotation marks in this post.

The national “victimization rate” of 7.4 per 1,000 children, is a small decrease from 7.7 in FFY 2022 and the total number of reported “victims” was 19.3 percent less than the total reported in FFY 2019. This “victimization rate” has declined every year since FFY 2018. Of course, this decline is in part a result of the decline in the number of screened-in referrals that was discussed above. Any referral that is screened out is one less reported “victim,” even though some percentage of the screened-out referrals almost certainly reflected actual incidents of maltreatment.⁶ It is also clear that changes in policy and practice have contributed to the decline in the number of “victims” reported by states, as described below.

Policy and practice changes affecting “victimization” numbers

The change in the number of “victims” between FFY 2019 and FFY 2023 ranged from a 52 percent decrease in North Dakota to a 32 percent increase in Nevada, suggesting that these changes may reflect policy and practice more than actual trends in abuse and neglect. And indeed, two of the largest states made it more difficult to substantiate maltreatment in FFY 2022, and both found a decline in the number of maltreatment victims. In Texas, the legislature narrowed the definition of neglect, requiring the existence of both “blatant disregard” for the consequences of a parent’s action or inaction and either a “resulting harm or immediate danger.” Perhaps this helps account for the drop in the number of reported victims from 65,253 in FFY 2021 to 54,207 in FFY 2022. But the number of victims actually rose very slightly in FFY 2023. Perhaps the new definition had been assimilated into practice and was no longer resulting in a decrease in substantiations. In New York, the level of evidence required to substantiate an allegation of abuse or neglect was changed from “some credible evidence” to “a fair preponderance of the evidence” in FFY 2022. The number of victims found in New York dropped from 56,760 in FFY 2021 in to 50,056 in FFY 2022, which the Office of Child and Family Services attributed in its CM 2022 commentary to that change in evidentiary standards. The number of reported victims fell further to 46,431 in FY2023; perhaps the changed evidentiary standards were continuing to take hold or other state policies affecting other parts of the funnel–such as the attempt to rein in mandatory reporting–were contributing factors. The agency did not address this issue in its 2023 commentary.

A few states did mention in their CM 2023 commentary changes in policy or practice that might have contributed to changes in the number of “victims” in FFY 2023. North Dakota attributes a decrease partly to a change in state statute and policy which allows protective services to be provided when impending danger is identified, even without a substantiation. The agency appears to believe that workers are not substantiating as many reports now that they do not need a substantiation to provide services. Arkansas attributed a decrease in victims to the adoption of a new assessment tool that may have contributed to the routing of more reports to the differential response pathway. Kentucky reported that the adoption of new “Standards of Practice” may have contributed to the increase in the number of “victims” reported in FFY 2023.

Fatalities

Based on reports from 49 states (all but Massachusetts), the District of Columbia, and Puerto Rico, CM2023 estimated a national maltreatment fatality rate of 2.73 per 100,000 children. That rate was then applied to the child population of all 52 jurisdictions and rounded to the nearest 10 to provide a national estimate of 2,000. But experts agree that the annual estimates of child fatalities from NCANDS significantly undercount the true number of deaths that are due to child maltreatment. I discussed this in detail in A Jumble of Standards: How State and Federal Authorities Have Underestimated Child Maltreatment Fatalities.

The annual fatality estimates presented in the report increased by 12.3 percent between FFY 2019 and FFY 2022 and then fell slightly from 2,050 to 2,000 in FFY 2023, a fact that ACF mentioned in its press release. Such a small reduction of less than three percent over the previous year cannot be statistically distinguished from random fluctuation, especially because it is based on much-smaller numbers from the individual states. State commentaries illustrate the randomness of these year-to-year changes. In CM 2022, two individual states explained year-to-year jumps in fatalities by explaining that many children in one family died and that a large group of fatalities that occurred the previous year were reported in the current year. But even aside from statistical fluctuations, there are many reasons one cannot rely on year-to-year changes. These include the timing of reports and changes in policy and practice.

Timing

According to CM 2023 (and previous reports), “The child fatality count in this report reflects the federal fiscal year (FFY) in which the deaths are determined as due to maltreatment. The year in which a determination is made may be different from the year in which the child died.” The authors go on to explain that it may take more than a year to find out about a fatality, gather the evidence (such as autopsy results and police investigations) to determine whether it was due to maltreatment, and then make the determination. Alabama, for example, explained in its commentary that the deaths reported in a given year may have occurred up to five years before.

To add to the uncertainty around timing, the writers of CM 2023 are not exactly correct when they state that all states report on the fatalities determined in the reporting year. In their annual submissions to NCANDS, several states add fatalities for the previous year, implying that their practice is to report on fatalities that occurred in a specific time period, not those determined in the applicable year. Four states revised their number of 2022 fatalities in their submissions to CM2023. This suggests that their 2023 reports are in turn incomplete and will be revised in succeeding years. California, for example, explained that:

Calendar Year (CY) 2022 is the most recent validated annual data and is therefore reported for FFY 2023. It is recognized that counties will continue to determine causes of fatalities to be the result of abuse and/or neglect that occurred in prior years. Therefore, the number reflected in this report is a point in time number for CY 2022 as of December 2023 and may change if additional fatalities that occurred in CY 2022 are later determined to be the result of abuse and/or neglect.

So California is reporting (for CM 2023) a truncated count of child maltreatment deaths for Calendar Year 2022. But it did add 12 fatalities to the count of fatalities that it reported for FFY 2022, raising its total from 164 to 176. California reported 150 fatalities for FY2023; one can assume that additional deaths will be reported in the next report. The four states together added 56 deaths for FFY 2023. Arizona’s total increased from 14 to 39, Maine from three to 10 and Virginia from 39 to 51. .

Policy and Practice: Fatality Definition and Measurement

In addition to timing issues, year-to-year changes in fatality counts can reflect changes in how states screen or define child maltreatment fatalities. In previous issues of CM, states have reported on improvements in their collection of fatality information. Over time, some states have eliminated obsolete practices in screening and information collection. West Virginia reported in its 2016 commentary that it had begun investigating child fatalities in cases where there were no other children in the home. North Carolina ended its restrictive policy of reporting only fatalities determined by a chief medical examiner to be homicide, and it also began efforts to incorporate vital statistics and criminal justice data.

During FY 2023, some states reported changes that may have resulted in a reduced number of child fatalities reported.

Texas did not submit commentary for FFY 2023. But as reported above, it changed its screening policy so that reports involving a child fatality but include no explicit concern for abuse and neglect are not investigated if the reporter and other pertinent sources had no concern for abuse or neglect. DFPS reports that the number of child fatalities it investigated decreased from 997 in FY2022 to 690 in FY2023 (a 31 percent decrease) due to this new screening policy. And the number of child maltreatment fatalities fell from 182 to 164. But with a drastic drop in foster care placements in Texas, there is reason to fear that maltreatment fatalities increased rather than decreased. If that is the case, this change screening policy may have resulted in the failure to investigate and confirm actual maltreatment deaths..
The Illinois Division of Child Protection reported that it added a new administrative review process for sleep-related deaths. A senior administrator reviews the investigation to ensure that death included evidence of “blatant disregard.” DCF links this new policy with a decrease of 24.6% in reported child fatalities in FFY 2023.

Other states reported changes that might result in an increased number of child fatalities reported. Maryland attributed an increase in reported fatalities to a policy change requiring local agencies to screen in sleep-related fatalities as part of its prevention effort. Alaska reported a change that may affect fatality counts in future years: in December 2023 the agency dropped its practice of screening out cases where no surviving children remained in the home; from now on the agency will be making maltreatment findings even when there are no surviving children.

It is regrettable that most state commentaries do not include explanations for the changes in their reported number of referrals, reports, and victims. Worse, several states do not even submit commentaries in time to be included in each year’s report. In CM023, commentaries are missing for Arizona, Hawaii, Kansas, New Hampshire, North Carolina, Oregon, Texas, and West Virginia. Given the importance of the state commentaries for understanding the data they submit, the preparers of the CM reports should reach out to agency personnel in states that have not submitted commentaries by a certain date or have not answered the important questions and ask the questions directly directly. This information is too important to be left out.

It is unfortunate that ACF continues to misuse term “victimization” and “victimization rate” to suggest that child maltreatment (including fatalities) is declining, particularly in its press release and executive summary, which do not provide any explanation of the true meaning of the terms. The deceptive language is not a surprise given the previous Administration’s desire to take credit for ostensible and support the prevailing narrative regarding the need for a reduction in interventions with abusive and neglectful families. One does not have to be a statistician or data scientist to realize that we will never get an accurate measure of child maltreatment because so much of it occurs behind closed doors. Finding fewer victims is one way to reduce CPS intervention in the lives of vulnerable children–and to deny that the reductions are harmful. Sadly, this report will be used as evidence to support policies that continue to roll back protections for our most vulnerable children.

Notes

Substantated is defined as “supported or founded by state law or policy.” “Indicated” is a less commonly used term meaning a “disposition that concludes maltreatment could not be substantiated understate law or policy, but there is a reason to suspect that at least one child may have been maltreated or is at risk of maltreatment.” ↩︎
An “alternative response” includes an assessment and referral to appropriate services if the parent agrees to participate. There is no determination on whether abuse or neglect occurred and no child removal unless the case is transferred to the investigative track. ↩︎
Theodore Cross and Cecilia Casanueva, “Caseworker Judgments and Substantiation,” Child Maltreatment, 14, 1 (2009): 38-52; Desmond K. Runyan et al, “Describing Maltreatment: Do child protective services reports and research definitions agree?” Child Abuse and Neglect 29 (2005): 461-477; Brett Drake, “Unraveling ‘Unsubstantiated,’” Child Maltreatment, August 1996; and Amy M. Smith Slep and Richard E. Heyman, “Creating and Field-Testing Child Maltreatment Definitions: Improving the Reliability of Substantiation Determinations,” Child Maltreatment, 11, 3 (August 2006): 217-236. ↩︎
Brett Drake, Melissa Jonson-Reid, Ineke Wy and Silke Chung, “Substantiation and Recidivism,” Child Maltreatment 8,4 (2003): 248-260; Jon M. Hussey et al., “Defining maltreatment according to substantiation: Distinction without a difference?” Child Abuse and Neglect 29 (2005): 479-492; Patricia L. Kohl, Melissa Jonson-Reid, and Brett Drake, “Time to Leave Substantiation Behind: Findings from a National Probability Study,” Child Maltreatment, 14 (2009), 17-26; Jeffrey Leiter, Kristen A. Myers, and Matthew T. Zingraff, “Substantiated and unsubstantiated cases of child maltreatment: do their consequences differ?” Social Work Research 18 (1994): 67-82; and Diana J. English et al, “Causes and Consequences of the Substantiation Decision in Washington State Child Protective Services,” Children and Youth Services Review, 24, 11 (2002): 817-851. ↩︎
Plans of Safe Care are voluntary plans offered to the families of substance-exposed infants under the Comprehensive Addiction and Recovery Act (CARA). ↩︎
We. know this from child fatality reviews that many children who die have been the subject of previous referrals, which were not substantiated but later found in fatality investigations to have been correct. See discussions of the deaths of Thomas Valva and Gavin Peterson, for example. ↩︎

A Fatal Collision: The Opioid Epidemic and the Dismantling of Child Protection Services in Washington State

by Marie Cohen

“B.B.” was born in 2022 and died of fentanyl poisoning in March 2023. During the ten years before B.B.’s death, DCYF had received 30 reports on B.B.’s family (many before B.B. was born) for issues including use of heroin, marijuana and alcohol in the home; lack of supervision of the children; domestic violence; an unsafe caregiver living with the family; an unsafe and unclean living environment unsecured guns in the home “out-of-control” behaviors by B.B.’s older siblings at school, with the mother described as “out-of-it” and unresponsive to school concerns; concerns about the children’s hygiene; and the mother driving under the influence of marijuana. An in-home services case that had been open since January 2023 was closed days before B.B.’s death.

On August 24, 2024, the Washington Department of Children, Youth and Families (DCYF) proudly announced in a press statement that it had reduced the number of children in out-of-home care by nearly half since 2018. Specifically, the number of children in foster care had fallen from 9,171 in 2018 to 4,971 as of August 14, 2024. “Outcomes like this demonstrate our agency’s commitment to keeping families together and children and youth safe,” DCYF Secretary Ross Hunter said. “Although the number of reports we are receiving remain [sic] consistent, we are seeing fewer children and youth in out-of-home care as families are being referred to support services rather than having children removed from their homes. Indeed, “safely reduce the number of children and youth in out of home care by half” (without a baseline date from which this can be measured) is one of DCYF’s six strategic priorities. But treating the decline in foster care (the direct result of government actions) as a desirable outcome in itself can contribute to a disregard of actual child welfare outcomes like safety and permanency.

How did DCYF reduce foster care by nearly 50 percent?

How did DCYF manage to slash its foster care rolls so radically in such a short time? Without providing specifics, the press release cites DCYF’s implementation of the Family First Prevention Services Act (FFPSA) and its emphasis on “supporting and collaborating with families by providing access to services and programs.” A DCYF spokesperson told the Seattle Times that the department was using services to avoid removing children or to reunite families sooner, citing efforts to connect parents to substance use or mental health treatment programs, bring a social worker into the home to “problem solve,” or “offer practical items, like diapers, car seats and beds.”

Apparently not satisfied with the changes implemented by DCYF, the Washington legislature in 2021 passed the Keeping Families Together Act (KFTA, also known as HB 1227), which took effect on July 1, 2023. Among other provisions, KFTA increased the standard for the court to order removal of a child from the home, which previously required the agency to demonstrate that “reasonable grounds that the child’s “health safety or welfare will be seriously endangered if not taken into custody and that at least one of the grounds set forth demonstrates a risk of imminent harm to the child.” As amended by KFTA, the law now requires the agency to demonstrate “that removal is necessary to prevent imminent physical harm to the child due to child abuse or neglect.” The petition for removal is required to contain “a clear and specific statement as to the harm that will occur if the child remains in the care of the parent, guardian or custodian, and the facts that support the conclusion.” Moreover, the court must consider whether participation by the parents or guardians in “any prevention services” would eliminate the need for removal. If so, they must ask the parent whether they are willing to participate in such services and shall place the child with the parent if the parent agrees.

On a page dedicated to KFTA implementation, DCYF explains that it has implemented the law by adopting new policies and procedures to determine whether to remove a child and by training and supporting staff to implement the new procedures and determine whether there is an imminent risk of serious harm to the child. DCYF reports that internal reviews show that staff are “taking additional steps to prevent removal of a child and to support a safety plan for the family.”

Shortly before KFTA took effect, DCYF, along with the Department of Health, the Health Care Authority, and the Washington State Hospital Association issued new guidelines to birthing hospitals and mandatory reporters. These guidelines stated that infants born substance exposed, but for whom there are no other safety concerns, can receive “voluntary wrap-around services from a community organization” without being reported to CPS. These voluntary services are being provided through federally-mandated “Plans of Safe Care (POSC).” Healthcare providers identifying a substance-exposed infant are instructed to access an online portal where they are directed to call DCYF if safety concerns are identified and to complete a POSC referral if not.

DCYF has been issuing quarterly data updates to assess the impacts of the KFTA. According to the most recent (October 2024) update, the law is having the intended impact of further reducing removals to foster care. DCYF reports a 16 percent decrease in the number of children removed in the July through September quarter of 2024 compared to the same quarter of 2022, before passage of KFTA. However, comparing foster entries for all ages in July through September 2024 to those in the same quarter of the previous year, the data indicate that foster care entries actually increased! Will this be the beginning of the end of the foster care reductions? That remains to be seen.

A longer-term view raises questions about the difference KFTA made, compared to the previous and ongoing efforts by DCYF to reduce foster care placements. Entries into foster care in Washington have decreased annually from 2017 to 2024, as shown in the chart below. The rate of decrease remained about the same between 2019 and 2024, while KFTA was not implemented until July 2023. Perhaps more children would have entered care if not for KFTA, but there is no way to assess the impact of KFTA as compared with DCYF’s ongoing effort to reduce removals.

Source: DCYF, Child Welfare Agency Performance Dashboard, Children Entering Care in SFY, https://dcyf.wa.gov/practice/oiaa/agency-performance/reduce-out-of-home-care/cw-dashboard

The reduction in foster care placements was supposed to be accompanied (and made possible) by an increase in in-home services (which DCYF calls Family Voluntary Services or FVS), and DCYF reports that the number of cases receiving FVS increased by nine percent from 1,809 in SFY2023 to 1,994 in SFY2024. This increase in FVS cases cannot be compared to the 17-percent decrease in children placed in foster care over the same period, as the unit of analysis is different (families rather than children). But the key question is the nature and intensity of these services and whether they really kept the children safe.

The cost of foster care reductions

The purpose of foster care is to keep children safe when they cannot be protected at home. So the essential question is whether the reduction in foster care placements has occurred without any cost to children. Trends in child fatalities and “near fatalities”¹ due to child abuse or neglect can provide a clue. These deaths and serious injuries are the tip of the iceberg of abuse and neglect. For each child who dies or is seriously injured, there are many more that are living in fear, pain, or hunger, and incurring lifelong cognitive, emotional, and physical damage. There are troubling signs of an increase in child fatalities and near fatalities over the past several years. In its most recent quarterly update, DCYF reports on the number of “critical events” or child fatalities and near fatalities that met its criteria for receiving an “executive review.” These include the deaths of any minor that had been in DCYF custody or received services within a year of the death that were suspected to be caused by child abuse or neglect.² They also include near fatality cases in which the child has been in the care of or received services from DCYF within three months preceding the near fatality or was the subject of an investigation for possible abuse or neglect. DCYF reports that the number critical events it reviewed increased from 23 in 2019 to 51 in 2023 and projects that it will increase to 61 in 2024.³

Source: DCYF, Keeping Families Together Act Quarterly Date Update, October 2024, https://dcyf.wa.gov/sites/default/files/pdf/DataUpdate_HB1227_October2024.pdf

The increase in critical events reflects, in part, the growing opioid crisis in Washington, as well as decisions Washington has made regarding how it intervenes to protect children. Opioid related emergencies have “dramatically increased for the entire population (adults and children) in Washington,” and children have not been immune. Fentanyl is particularly dangerous to young children because it takes only a tiny amount to kill a baby or toddler, who can mistake the pills for candy or put straws or foil meant for smoking the drug in their mouths. The number of fatalities and near fatalities reviewed by DCYF that involved fentanyl climbed from four in 2019 to a projected 35 in 2024. Since 2018, Washington’s Office of the Family and Children’s Ombuds (has observed an annual increase in child fatalities and near fatalities involving accidental ingestions and overdoses. Fifty-seven (or 85 percent) of the 67 incidents examined in 2023 involved fentanyl. Over half of these incidents involved children under three years old and a shocking 14 out of the 85 infants were 12 months old or less. As Dee Wilson and Toni Sebastian point out, the limited mobility and motor skills of infants suggests that some of these infants may have been given a small amount of fentanyl as a means of sedation.

The Washington Legislature was concerned enough about the possibility that KFTA is contributing to an increase in child fatalities and near fatalities in the context of the fentanyl epidemic that it passed a new law (SB 6109) in 2024. The law provides that a court must give “great weight” to the “lethality of high-potency synthetic opioids.….in determining whether removal is necessary to prevent imminent physical harm to the child due to child abuse or neglect.” However, it appears that there is confusion about exactly what that means.

Has DCYF given up on protecting children?

“We know that supporting and collaborating with families by providing access to services and programs increases their number of protective factors, leading to better outcomes,” said DCYF Assistant Secretary Natalie Green. “Giving families the tools they need to thrive and safely parent means more children and youth remain safely at home.”

DCYF, Washington Reduces the Number of Children in Out-Of-Home Care by Nearly Half, August 14, 2024.

But the work of DCYF’s own analysts, in their quarterly KFTA updates, raises doubts about whether DCYF is adequately performing its child protection function. These updates acknowledge that the agency is not removing as many children with a high risk of future encounters with child welfare (in other words, those who have a high risk of being harmed). And they also report that the department has seen “an increasing percentage of moderately high to high risk cases being re-referred to CPS within 90 days of the risk assessment. DCYF also reports that the overlap between KFTA and Plan of Safe Care (POSC) is resulting in fewer screened-in intakes involving substance-exposed newborns because these infants are now being referred to voluntary services under POSC.

There has been a chorus of voices alleging that DCYF is abdicating its child protection responsibilities. One foster parent told the Seattle Times that “she and other foster parents are finding children who now come into their care are in worse shape than they used to be, with more serious mental health conditions or greater exposure to lethal drugs like fentanyl.” She contends they’ve been left too long in unsafe conditions because of the heightened legal standard for removal. In The Erosion of Child Protection in Washington State, Toni Sebastian and Dee Wilson have cited the weakness of the management of Family Voluntary Services, which is often employed as an alternative to foster care.

A survey of executive reviews of 2023 and 2024 child maltreatment child fatalities with DCYF involvement within a year provided examples of problems with screening, investigations, and case management, including the following:

Hotline issues. Reviews documented multiple intakes screened out on the same family even when the family had been the subject of multiple calls. The reviews also suggest that too many cases may be assigned to the Family Assessment Response (FAR) pathway, an alternative to a traditional investigation designed for lower-risk cases. In FAR cases, a social worker assesses the family and refers it to voluntary services. There is no finding about whether maltreatment has occurred and no child removal unless the case is transferred to the investigative track.
Premature closure of FAR cases. Reviewers noted instances in which FAR cases were closed after parents failed to cooperate, without caseworkers considering a transfer to the investigative track or before determining that the parent had followed through with services.
Assessment failures: Reviewers noted multiple failures to adequately assess parents for domestic violence, mental health, and substance abuse; failures to contact collaterals (relatives and friends) and instead relying on parental self-reports; lack of recognition of chronic maltreatment; ignoring evidence of past problems if not included in the current allegation; and failing to anticipate future behavior based on historical patterns.⁴
Inadequate understanding of substance abuse: Reviewers noted the failure to conduct a full assessment of substance abuse including history, behavioral observations, and collateral contacts; disregarding the unique danger to children posed by fentanyl; downplaying the significance of marijuana use, particularly as an indicator of relapse from harder drugs; and disregarding alcohol abuse because it is legal.
Failure to obtain information from treatment and service providers. The failure to communicate with service providers about clients’ participation in services like drug treatment and relying on clients’ self-reports was noted by more than one review team. Sometimes the providers refused to cooperate. Staff told the team reviewing one case about a substance abuse treatment provider that routinely refuses to cooperate, even when parents sign release forms, and routinely tells clients not to cooperate with DCYF.
Lack of subject matter expertise. Reviewers pointed to the lack of deep knowledge about domestic violence, substance use disorder, and mental health among staff doing investigations, assessments, and case management and the need to provide access to subject matter experts when needed.
Failure to remove a child despite safety threats. The team reviewing the case of a four-year-old who died after ingesting fentanyl reported that there were at least two different times where an active safety threat was present that would have justified filing a petition in court to place the child in foster care. However, the staff believed, based on past experience, that the court would have denied the petition and therefore did not file.
Delayed Reunifications: “P.L,.” a toddler allegedly beaten to death by his mother, was in foster care for over three years but his mother’s rights were never terminated. He was on a trial return to his mother for just over five months when he was found dead with bruises and burns all over his body.

Staff shortages and high turnover were mentioned as contributing to the observed deficiencies in case practice in almost every fatality review. In B.B.’s case, the reviewers noted that the office had been functioning with a 50 percent vacancy rate for the last several years, stating that such a vacancy rate leads to high turnover, high caseloads, caseworkers with little experience, and supervisors forced to carry cases rather than support their caseworkers. Even caseloads that comply with state standards may be too high. The standard of 20 families per caseworker in FVS was noted to be unmanageable by one review panel, which noted that FVS cases are often discussed as high risk cases and require multiple contacts per month with family members, services providers, and safety plan participants. As Dee Wilson and Toni Sebastian put it, “[b]etting young endangered children’s lives on in-home safety plans developed and implemented by inexperienced and overwhelmed caseworkers is reckless, ill-advised public policy.”

Conclusions and Recommendations

Treating the decline in foster care as a desirable outcome in itself, as Washington and other states have done, is both disingenuous and dangerous. Any government can slash the foster care rolls reducing or ending child removals, as many “child welfare abolitionists” recommend. The central purpose of child welfare services, including foster care, is to protect children from child abuse and neglect. A reduction in foster care placements that results in the failure to protect children is no kind of success.

DCYF told King5 that “the increase in child fatalities and near fatalities in Washington is not being driven by the change in removal standards under House Bill 1227 or the reduction in the number of children in foster care. It is being driven by the increased availability of a highly addictive and hazardous drug and a lack of substance use disorder treatment in our communities.” But whether the agency’s policy or the drug epidemic is more at fault is not the right question. It is DCYF’s job to protect children given the circumstances that exist, including the drug epidemic and the lack of sufficient treatment, keeping in mind that treatment often does not work the first, second, third or subsequent times.

What can be done? DCYF needs to address the workforce crisis, which will probably require increasing pay and improving working conditions, or even possibly relaxing requirements for employment as a caseworker in investigations, assessment, and FVS. DCYF should consider policy and practice changes such as reducing the FVS caseload cap from 20 cases per worker; Instituting a chronic neglect unit, with expert caseworkers and even lower caseloads, for chronic cases; finding a way to limit the use of FAR to cases that are truly low-risk; and promoting the use of dependency petitions for court supervision when children remain in the home, as suggested by two fatality review committees.⁵ DCYF should request and the legislature should fund a variety of ancillary services for families, starting with therapeutic childcare for all preschool aged children with FVS cases as well as those who have been reunited with their parents. Such childcare would give parents a break and parenting support, keep children safe for a large part of the day, and ensure another set of eyes on the child, among other benefits. Also needed are more residential drug treatment centers where parents can live with their children.

Finally, more transparency is needed so that legislators, advocates and the public have access to the findings of DCYF’s executive review teams. Washington deserves credit for sharing its executive child fatality reviews. But there is no reason that the DCYF should not share its near-fatality reviews as well. We know something about how DCYF failed B.B. and the other children who died. But the public needs access to the reviews of those children who narrowly escaped death as well as those who did not. It is only through such transparency that the public can see the actual impact of all the self-congratulatory proclamations about “safely reducing the number of children in out-of-home care.”

Notes

A “near fatality” is defined by state law as “an act that, as certified by a physician, places the child in serious or critical condition.”
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DCYF relies on the Office of the Family and Children’s Ombuds (OFCO) to determine whether the fatality appears to have been caused by abuse or neglect, therefore requiring DCYF to conduct a review.
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Data collected by OFCO are more confusing. OFCO reviews all fatalities and near fatalities in which the child’s family was involved in Washington’s child welfare system within 12 months of the fatality. There number of near-fatalities reviewed by OCFO increased annually from 21 in 2018 to 70 in 2023, according to its most recent annual report on Child Fatalities and Near Fatalities in Washington State. But fatalities reviewed by OFCO did not show the same pattern. They reached a peak of 87 in 2018 and fell sharply in 2019, then rose yearly until they reached 85 in 2022 and then dropped to 79 in 2023. Nevertheless, adding fatalities and near fatalities together shows an alarming increase in critical incidents from 108 in 2018 to 149 in 2023.
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For example, in the case of “R.W.,” a child who died at age four after ingesting fentanyl, an investigation was closed because the children were staying with relatives, despite the mother’s history of repeatedly removing the children from relatives with whom she had left them. A month later the child was found dead at a motel in the custody of the parents.
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See https://dcyf.wa.gov/sites/default/files/pdf/reports/mk-cfr-final-redacted.pdf and https://dcyf.wa.gov/sites/default/files/pdf/reports/ecfr-os-24.pdf ↩︎

Keeping the public in the dark about child fatalities and near fatalities: findings of a new report

At least 1,800 children die from abuse and neglect every year, and the total is probably considerably greater. Between a third and a half of these deaths may involve families that were already known to Child Protective Services (CPS) through previous reports of maltreatment. In addition, an unknown number of children are severely injured due to maltreatment every year. Legislators, advocates, and the public need timely information about the circumstances leading to these events so they can identify policy and practice changes necessary to protect children. Decades ago, Congress recognized this need and required states to have a policy allowing for disclosure of information and findings about these tragic events. But due to the weakness of the requirement and the federal government’s lack of enforcement, only a few states make meaningful disclosures in the wake of these horrific events, as documented in a new report.

Federal Law and Policy Regarding Disclosure

In 1996, Congress amended the Child Abuse Prevention and Treatment Act (CAPTA) to ensure that information from child fatalities and near fatalities that are caused by abuse or neglect can be used to correct systemic problems and prevent future occurrences. This provision —42 U.S.C. 5106a(b)(2)(A)(x)—requires that “every state’s plan for spending CAPTA funds contain “an assurance in the form of a certification by the Governor of the State that the State has in effect and is enforcing a State law, or has in effect and is operating a statewide program, relating to child abuse and neglect that includes . . . provisions which allow for public disclosure of the findings or information about the case of child abuse or neglect which has resulted in a child fatality or near fatality.”

This provision has many weaknesses, as described in more detail in a new report called Keeping the Public in the Dark: How Federal and State Laws and Policies Prevent Meaningful Disclosure about Child Maltreatment Fatalities and Near Fatalities, which was prepared for Lives Cut Short, a project to document and direct attention to child maltreatment fatalities. First, the provision requires only that the governor certify the existence of a disclosure requirement, not that it actually exist. Moreover, the language is so vague that it leaves all details to the individual jurisdictions. To make matters worse, the US Department of Health and Human Services (HHS) never wrote regulations to flesh out the vague statutory requirements. Instead, HHS provided guidance in the form of questions and answers in its Child Welfare Policy Manual (CWPM). The CWPM does not have the same force as federal regulations, but some states clearly pay attention to it and have mirrored it in their laws and policies.

Unfortunately the CWPM leaves many questions unanswered and even adds new ones. There are several federal confidentiality requirements embodied in different laws, and the CWPM does not explain the order of preference. Instead, different sections of the CWPM actually contradict each other, with one answer stating that the disclosure requirement trumps previously enacted confidentiality laws and several other answers reminding states to comply with existing confidentiality requirements. To make matters worse, revisions in 2012 introduced new opportunities to avoid disclosure, specifically letting states allow exceptions “in order to ensure the safety and well-being of the child, parents and family or when releasing the information would jeopardize a criminal investigation, interfere with the protection of those who report child abuse or neglect or harm the child or the child’s family.” The exception for “safety and well-being of the child, parents and family” completely undercuts the previous language in the CWPM.

The 2012 revision also included a list of the information and findings to be disclosed, which would have been extremely helpful had it not added a new opportunity to withhold certain information. Specifically, the CWPM (Section 2.1A.4, Question 8) prescribes that states must release:

“information describing any previous reports or child abuse or neglect investigations that are pertinent to the child abuse or neglect that led to the fatality or near fatality; the result of any such investigations; and the services provided by and actions of the State on behalf of the child that are pertinent to the child abuse or neglect that led to the fatality or near fatality.”

This language allows states to withhold information that is actually relevant to the question of whether and how a fatality or near fatality could have been prevented. For example, a state could decide a prior incident of neglect was irrelevant if the cause of death was abuse. But the same parent often perpetrates multiple types of maltreatment, especially chronically maltreating parents who have had multiple encounters with the child welfare system. A state’s decisive intervention in response to prior maltreatment may save a child from death or near-death by another form of maltreatment.

State Laws and Policies Regarding Disclosure

The report reviews state laws and policies governing disclosure of information and findings in cases where child maltreatment resulted in a child fatality or near fatality. The review shows that many state laws and policies fall far short of what is needed to ensure adequate public information about how child protections may have failed. The major findings include:

Despite the federal requirement, not every state has a policy for publicly disclosing findings or information about child fatalities and near fatalities. Out of the 50 states and the District of Columbia, four states appear to have no such policies. Another four states have a policy for fatalities but not near fatalities.
Among the 47 jurisdictions that do have laws or policies for disclosing maltreatment fatality and near-fatality information, only 35 require the release of findings and information about child maltreatment fatalities, and all but four of those require that of near fatalities as well. Twelve allow but do not require the release of findings and information about these incidents.
Many state laws and policies are vague, and many contain restrictions that violate the Congressional intent to make information about child maltreatment and agency operations publicly available.
Seventeen states have laws or policies that require releasing some information without request. These releases vary from a few basic facts on each incident to a comprehensive review of the victim’s family’s history with child welfare. Only nine issue notifications of fatalities or near fatalities that are suspected to be due to maltreatment.¹ Without such notifications, the public may not even know an incident has occurred, so they certainly will not ask for information about it.

Recommendations

CAPTA should be amended to clarify the language regarding child fatalities and near fatalities due to maltreatment and establish parameters for states in interpreting the law. The new language should make clear that states must release findings and information about fatalities and near fatalities, and disclosure must be required rather than simply allowed. The law should prescribe the types of information that can be withheld and when disclosure can be postponed, and it should deny states the option of withholding other information or refusing to release information altogether. It should spell out the findings and information that must be released. It should clarify that the CAPTA language overrides other confidentiality provisions in federal law. It should also require that states notify the public of child fatalities and near fatalities that are reported to child abuse hotlines and accepted for investigation.

But recent attempts to reauthorize CAPTA have failed, and these changes seem unlikely in today’s ideological climate, where child safety often takes a back seat to other concerns. It is probably more realistic to focus on changes to state legislation. A good state disclosure policy, in compliance with CAPTA, should cover fatalities and near fatalities. It should be mandatory and contain no vague terms, conditions, or exceptions. Permitted redactions should be limited to the names of living children in the family and reporters of maltreatment and (temporarily) any information that would cause specific material harm to a criminal investigation. There should be no prohibition on sharing information deemed to be against the best interests of or harmful to the injured child or any other child in the household.

At a minimum, a disclosure policy should require prompt public notification of all fatalities and near fatalities reported to the hotline and accepted for investigation, along with a documented rationale for not investigating others. The notifications should include whether the family had past involvement with CPS and a brief summary of prior reports and responses by the agency. There should be no requirement that the historical information be “pertinent to the abuse or neglect that caused the fatality,” as suggested by the CWPM. Upon completion of the investigation, if it is determined that the fatality resulted from abuse or neglect, the department should be required to release a detailed summary of prior reports involving the family or household and of agency responses, including investigations, in-home cases, child removals, and family reunifications, The agency’s complete files on the perpetrators and their children, with certain identifying information redacted, should be available to any person upon request.

A study of the policies of 50 states and the District of Columbia toward disclosing information regarding child maltreatment fatalities and near fatalities shows that many fall drastically short of embodying Congress’s intent in adding Section 106(b)(2)(B)(x) to CAPTA. Most of these difficulties stem from the deficiencies of the language itself and the guidance provided in HHS’s CWPM. While changing CAPTA’s language would be the most efficient way to enable improvement around the country, it is more likely that legislators and child advocates at the state level will collaborate on legislation requiring full transparency around these deaths. We cannot make progress in preventing severe and life-threatening child maltreatment unless legislators, advocates, and the public can access comprehensive information about what led to these tragic events.

Rhode Island provides notifications of suspected maltreatment only for fatalities and near fatalities only if the child was the subject of an open case; other notifications occur only after maltreatment is confirmed. ↩︎

The tragic life and death of Gavin Peterson: Utah’s statement leaves many questions unanswered

This post was prepared for and originally appeared on the website of Lives Cut Short, a project to document and analyze child maltreatment fatalities in the United States. See my interview with KUTV about this post here.

On October 10, the Utah Department of Children and Family Services (DCFS) finally released a statement summarizing its involvement with Gavin Peterson, who died on July 9, 2024 at the age of 12. Gavin’s father, stepmother, and older brother are awaiting trial on reckless child abuse homicide, among other charges. The much-awaited “CAPTA statement” from DCFS (named for the federal law requiring that states have a policy to disclose “information and findings” about child maltreatment fatalities and near fatalities) provided some new information but raised new questions, especially when contrasted with media accounts.

The DCFS statement begins with a disclaimer. Gavin came from a “two-household family” and was residing with his biological father, Shane Peterson, and father’s long-term girlfriend, Nichole Scott, at the time of his death. The agency explains that although it “worked with each household at several points in Gavin’s life as early as 2013,” the statement includes only “information relevant to Gavin in the household where his death occurred.” It is not clear from this disclaimer what information was withheld from the public, either because it was from the other household or because DCFS decided it was not “relevant to Gavin.”

Some of that information can be pieced together from media coverage. Gavin’s mother, Melanie Peterson, told a reporter at KSL TV that she lost custody of all four of herchildren in 2014 or 2015. Court documents obtained by the reporter showed that two-year–old Gavin was found unsupervised outside of his home in 2014, and that in the same year Melanie pleaded guilty to allowing a child to be exposed to illegal drugs or drug paraphernalia. Melanie told the reporter that she never regained custody of her children from the courts, but that Shane Peterson unofficially returned her third child to her in 2018 and her second child in 2019. (Her first child was apparently Tyler, who is charged in Gavin’s death, and Gavin was the fourth child.)

DCFS’ statement provides a chronology of abuse and neglect reports and agency responses, which are summarized below along with our commentary in italics.

May 28, 2019

The first report of abuse in Shane Peterson’s home is received. DCFS investigates and finds that Nichole Scott had physically abused another child in the home. The Peterson family accepts voluntary in-home services. After a month of services, DCFS concludes the safety concerns have been resolved and closes the case.

The “other child” was clearly Gavin’s sister Mayloni Peterson, now 19. She told KSL TV that she was abused even more severely than Gavin at the time, and was even punished for his actions. She described being beaten, tied to her bed, fed only once or twice a day, forced to perform labor in the household and at her grandmother’s house. She reported that Scott once shaved off all her hair as punishment for combing her hair without permission and strangled her in the car following a failed attempt to run away. On Saturday, May 25, 2019, Mayloni told her father that she accidentally broke a sprinkler while mowing the lawn. Her father took her to her mother’s house without warning and left her there, possibly saving her life. Melanie Peterson reported that Mayloni was malnourished and “with all her hair buzzed off.” After hearing what her daughter had been through, Melanie made a report to DCFS after the Memorial Day holiday–clearly the May 28, 2019 report. (Mayloni mentioned a report that was made by her school in March; it is not clear whether that report was omitted by DCFS because it was “not relevant to Gavin.”)

February 27, 2020

DCFS receives a call reporting abuse of Gavin in “another household.” DCFS finds Gavin to be a victim of abuse and files a court petition. On May 27, the court orders both households to participate in DCFS in-home services.

Melanie Peterson told KSL TV that she took a picture of an emaciated Gavin in February 2020. It would be the last time she saw him. She alleges that Nichole and Shane Peterson found out about the photo and made a false allegation about her, thereby ending her visitation rights pending a judgment by DCFS. That “false complaint” was likely the February 27, 2020 report, which resulted in an open case for both households.

August 24, 2020

While the two households are receiving in-home services, DCFS receives a call reporting concerns about Gavin’s treatment in his father’s home. The information does not “meet the criteria required by Utah state law to open an investigation,” but the intake worker shares the information with the in-home caseworker.

May 21, 2021

The “Peterson family” successfully completes” in-home services, and the judge closes the case. No information is provided about what these services were.

September 2, 2022

DCFS receives a report from “someone concerned about Gavin’s well-being, after observing some of his behaviors.” The hotline worker decides the report does not meet the legal criteria for opening an investigation. A supervisor approves this decision.

This report most likely came from Gavin’s school, and his “behaviors” included eating food from the trash. Cafeteria worker Rachel Reynolds told KSL TV that she suspected Gavin was hungry even before the school’s COVID-19-era free meal program ended in August 2022 and Gavin began taking leftovers from the trash. Her colleague Jan Davis said that she and a coworker began paying for Gavin’s lunch. That ended when Nichole Scott demanded they stop buying his lunch. But the workers continued to “sneak food” to him, according to Reynolds.

March 28, 2023

DCFS receives a report regarding physical neglect of Gavin and opens an investigation. Two days later, DCFS receives another report, which is added to the open investigation. Gavin is interviewed at school without his parents and does not disclose abuse. On May 8, 2023, DCFS receives a third report alleging physical abuse of Gavin. The investigator visits the home for a second time, interviews the adults and interviews Gavin outside the presence of the alleged abusers. The case is closed on May 15 with no finding of abuse or neglect.

These three reports likely came from the school.The school district reported the school made “multiple calls” about Gavin, and Rachel Reynolds said that at least four calls were made by cafeteria workers and the principal. Reynolds personally observed the nurse and school principal call DCFS when she brought Gavin to the nurse with fingers that looked swollen and infected from picking. Jan Davis mentioned that Gavin came to school with a chipped tooth shortly after Nichole Scott learned that cafeteria staff were feeding Gavin. Perhaps that accounted for the abuse allegation.

In August 2023, Gavin was withdrawn from school for schooling at home. There are no more reports until July 29, 2024. Utah has no policy in place for monitoring children withdrawn from school following allegations of abuse or neglect,

July 9, 2024

DCF receives a report that Gavin is in the emergency room with injuries that appeared to be the result of abuse or neglect. He dies the same day.

The police investigation into Gavin’s death has revealed that Gavin was abused for years, was kept locked in an uncarpeted room without bedding or blankets while adults monitored him with multiple cameras, and was often beaten or starved, sometimes given only bread and mustard to eat. Nichole Scott, Shane Peterson, and Tyler Peterson were arrested and charged with child abuse homicide, aggravated child abuse, and endangerment of a child, and are awaiting trial. Gavin’s treatment can be defined as torture, a type of child abuse that some have observed may be increasing in Utah and around the country. These cases often include confinement, starvation, beating, and isolation.

Unanswered Questions

Utah’s report on Gavin Peterson’s death, when compared with the media accounts from Gavin’s mother, sister, and school staff, raises more questions than it answers.

The May 28, 2019 report: The allegations that Mayloni made to her mother, who presumably included them in her May 28, 2019 report, concerned multiple reports of physical abuse, confinement, and forced labor. Both children should have had a physical exam and a forensic interview. How is it possible that allegations of this magnitude (that turned out to be true) resulted in a case that was closed in a month and that was also described as “voluntary”?

The February 2020 report: This report about the abuse of Gavin in another household is clearly the “false allegation” stemming from his mother’s photograph of an emaciated Gavin. How did that result in a substantiation against her for abuse? The case was open for more than a year during the height of the COVID-19 pandemic. Were the visits virtual? Does that explain why the caseworker observed nothing of concern? Why did Melanie never get her visitation rights back after the case was closed?

The August 24, 2020 report: What concerns were raised and why did they not meet the criteria to open an investigation? Was this report really shared with the in-home worker and did that worker try to determine whether they were true?

The September 2022 report: How was this report, obviously from the school and conveying that Gavin was seeking food in the trash, not judged to meet the legal criteria for an investigation, even by a supervisor?

The reports in March and May of 2023: Why did the investigation conducted from March to May 2023 fail to find the abuse of Gavin, which was so obvious to school personnel? Wasn’t Gavin very thin? Shouldn’t he have received a physical examination? If he denied the abuse, was the investigator unaware that is what scared children do? Was there any discussion of taking him to a Child Advocacy Center for a forensic interview?

Key Takeaways

The first major takeaway of this report is that Utah’s CAPTA report does not tell us whether DCFS did all that it could do to protect Gavin. The information shared in the report complies with state policy, which in turn complies with the very vague requirements of federal law. But much more detail is needed including documentation of the reasoning behind rejecting certain reports as worthy of investigation, the entire record of each investigation including interviews and documents, and a report of every interaction with the family during the in-home case. A few states post “critical incident reviews” for some death and near fatality cases. But such reviews are expensive, not all cases get reviewed, and internal reviewers may be biased on behalf of the agency. The only way to ensure accountability and inform needed changes is to release the full case file on the family, with certain names redacted,¹ for at least the five years preceding the fatal or near fatal event.

The second major takeaway is that in spite of the lack of detail, the information provided strongly suggests that the problems in this home were longstanding and there were many opportunities for DCFS to discover them. It appears that systemic issues prevented the diagnosis of issues that should have been obvious. A former DCFS caseworker told KUTV that she left the agency “after struggling with overwhelming caseloads and a culture of simply ‘checking boxes.” She explained that while cases demanding immediate action are usually addressed, other cases showing red flags are dismissed too soon as “safe enough.” She placed primary blame on the legislature for not allocating adequate resources, saying that workers want to do their jobs, but they are being placed in impossible situations. “It’s unfair to put them in these situations where they don’t have the time to produce quality work, or if they do decide to put in the time, they’re sacrificing so much.”

The third major takeaway is that Gavin’s fate was sealed once he was withdrawn from school and the reports stopped coming in. In its Make Homeschool Safe Act, the Coalition for Responsible Home Education proposes that a child cannot be withdrawn from school for homeschooling within three years of being investigated for abuse or neglect, regardless of the outcome, unless there is a risk assessment by social services or child welfare that finds that the child will not be endangered by being schooled at home, and the home educator agrees to a monthly risk assessment for the next 12 months.

Gavin Peterson was failed by the agency that was meant to protect him, A few children suffering similar torture have been lucky enough to escape to safety, like the boy who escaped from the home of parenting youtuber Ruby Franke and saved himself and his sister from likely death. But most children in these situations have no recourse unless the people being paid to protect them have the time, training, support and resources to investigate fully and respond appropriately. To ensure that happens, the public must have access to the complete records of cases in which the system has failed.

For example, the names of children and people who reported maltreatment. ↩︎

How New York keeps the public in the dark about high-profile child abuse and neglect deaths

This essay was originally published on the website of Lives Cut Short, a project to document child maltreatment deaths in the United States since 2022, for which I serve as Senior Project Associate

Jahmeik Modlin was found in a skeletal condition in a Harlem apartment stocked with food. He died the next day, and his three older siblings were hospitalized with severe malnutrition. The family had been on the radar of the Administration for Children’s Services (ACS) since 2019, before Jahmeik was born. But the agency closed its last case with the family in 2022 after determining that the children were safe, a source told the New York Times. A spokeswoman for ACS declined to offer further information, citing state law designed to protect siblings of fatal abuse victims.

According to data states submit to the federal government, about 1800 children die of abuse and neglect every year, but this figure is widely recognized to be an undercount. Among those deaths, studies suggest that between a third and a half involve families who were already known to the child protection system (CPS) through previous reports. Even in other cases where the family had no prior contact with CPS, other systems may have interacted with the child and perhaps could have intervened. Legislators, advocates and the public must have access to timely information about the circumstances leading up to child maltreatment fatalities so they can identify missed opportunities and policy and practice changes necessary to protect children. For that reason, Congress in 1996 added a provision in federal law that requires all states to provide assurances to the federal Department of Health and Human Services that they have provisions for disclosing findings and information regarding child fatalities and near fatalities from maltreatment.

Lives Cut Short surveyed state laws and policies governing access to information about child maltreatment fatalities and near fatalities. The resulting report, Keeping the Public in the Dark: How Federal and State Laws and Policies Prevent Meaningful Disclosure about Child Maltreatment Fatalities and Near Fatalities, shows that most states have such laws and practices but many of them are vague, and many have provisions that conflict with the purpose of ensuring public access to critical information. Among such provisions are those that prohibit releasing information that might harm surviving children in the families where a child was killed or seriously injured by maltreatment.

New York, at first glance, appears to be more transparent than most states in making information and findings about child maltreatment fatalities available to the public. The New York State Office of Children and Family Services (OCFS), which supervises local agencies such as ACS, is required to review all local investigations of child fatalities reported to the State Central Register and to publish a summary report within six months of the investigation. Disclosure of this information, however, occurs only if the state or local commissioner determines that it is not “contrary to the best interests of the child, the child’s siblings or other children in the household.” While the law does not provide a comprehensive definition of “contrary to the best interests,” the OCFS website does explain that OCFS conducts what it calls a “best interests determination,” sometimes assisted by “experts” from the agency’s Statewide Child Fatality Review Team. The process considers “whether publishing a fatality report is contrary to the best interests of a child’s siblings or other children in the household, what effects publication may have on the privacy of children and family, and any potentially detrimental effects publication may have on reuniting and providing services to a family.”

To understand the impact of the “best interests” determination, one needs to know the proportion of child fatalities for which New York withholds reports. The identifying numbers that the state assigns to its child fatality reports provide a useful clue. All these numbers start with a two-letter abbreviation for the region (AL for Albany, BU for Buffalo, etc.), continue with the last two digits of the year, and end with a three-digit number, starting from 001. For example, the first Albany report for 2022 would be identified as AL-22-001. Assuming that all missing numbers represent reports withheld under the “best interests determination,” about one-quarter of reports on 2022 fatalities in New York State were withheld.

The Child Abuse and Neglect Deaths Integrated Database (CANDID), maintained by Lives Cut Short, allows us to determine which child deaths reported in the media had a corresponding fatality report released by New York OCFS. CANDID combines information on child maltreatment fatalities from media reports, official fatality reviews or reports, and other available sources. New York State’s fatality reports do not include names, but they do include the dates of death as well as details about the circumstances. Therefore, one can attempt to match media coverage with the OCFS review of the same fatality. But very few maltreatment deaths occurring in 2022 and covered by the media had an OCFS review released to the public. It appears that the reviews of high-profile deaths that received media coverage were withheld based on “best interest determinations.”

These cases included:

The death of Bryleigh Klino, a profoundly disabled 17-year-old whose parents have been charged with endangering her welfare. Hospital employees observed numerous signs of abuse and neglect on Bryleigh’s body;
The drowning of six-month-old Dalilah Crespo, whose death was ruled a homicide;
The death from abusive head trauma of four-month-old Cairo Dixon-Sanchez, for which his father pleaded guilty;
The fentanyl poisoning death of 11-month-old Liam Sauve, who ingested 23 times the amount of fentanyl that could kill an adult and whose mother pleaded guilty for his death;
The death of three-month old Genevieve Comager, whose father was charged with shaking her to death;
The beating death of nine-year-old Shalom Guifarro, whose mother has been sentenced to 16 years for her killing;
The death of two-year-old Ermias Taylor-Santiago of a fentanyl overdose, which was ruled a homicide;
The death of blunt force trauma of Xavier Johnson, whose mother’s boyfriend was charged with beating him to death;
The fatal heroin overdose death of six-month-old Denny Robinson, found with a heroin bag in his mouth in a house that was connected with a major drug trafficking operation;
The drug and alcohol poisoning of 14-year-old Hailey Hasbrouck, allegedly by her father and his girlfriend, who allegedly gave her the “toxic cocktail;”
The “suspicious” death of seven-year-old Hunter DeGroat, found unresponsive in his home;
The death of two-year-old Aniyah Wyatt-Wright, allegedly punched to death by her father;
The murder of three-year-old Shaquan Butler, beaten to death in a Queens homeless shelter after being reunified with his parents after being removed from them by ACS.

It is probably not a coincidence that OCFS has elected not to release information on most of the egregious fatalities that were covered in the media. Many of the published state fatality reviews concern deaths due to unsafe sleep factors, accidental drownings, and other fatalities that do not result in criminal charges and are therefore never known to the public. It is possible that OCFS is trying to shield the surviving children in the cases listed above because readers may be able to identify them by putting together the reports and the media coverage—as we did. But these are the very cases for which the information is most urgently needed. The nature of these cases suggests the existence of serious and chronic conditions that might have resulted in previous reports and involvement with CPS. Any harm that public release of the report would cause when the incident has already been covered in the media is dubious.
It’s hard to avoid wondering if the exclusion of these cases from disclosure protects the agency more than the children. And to avoid guessing that Jahmeik’s death will join the list of those cases for which reports are never published.

We cannot make progress in the prevention of severe and life-threatening child maltreatment unless legislators, advocates and the public have access to comprehensive information about what led up to these tragic events. Congress tried to provide this access through a provision in federal legislation, but states have couched this requirement in vague language or hedged it with qualifications that prevent the release of critical information—or any information at all in some cases—as in New York. Only Congress can fix the gaps in the federal law, but state legislatures can act in the meantime to ensure their disclosure laws serve the purpose of improving child welfare in their states.

To learn about current law in your state, see the new report: Keeping the Public in the Dark: How Federal and State Laws and Policies Prevent Meaningful Disclosure about Child Maltreatment Fatalities and Near Fatalities.

As foster care removals plummet, where’s the promised help for families?

Year after year, states and the federal government continue to release annual data showing a decline in the number of children in foster care, congratulating themselves on keeping families together. They seem to have forgotten that reductions in foster care were supposed to be accompanied by increased services so that children could be safely maintained at home. Unfortunately, there seems to be little to no interest on the part of the federal Children’s Bureau, Members of Congress, advocates, or the media in whether such services are actually being provided.

The newest report from the Adoption and Foster Care Analysis and Reporting System (AFCARS) showed that the number of children in foster care dropped to 368,530 on September in 2022–a drop of 5.8 percent over the previous year 15.6 percent since 2018. “We are encouraged by the continued decrease in the number of children entering foster care and staying in foster care and we will continue working with our state, tribal and territorial partners to ensure an emphasis on family well-being and safe family reunification,” said Jeff Hild, the Principal Deputy Assistant Secretary of the Administration on Children and Families (ACF) in a press release heralding the new numbers. ACF gave credit to the Family First Prevention Services Act (FFPSA), which “helped change the conversation to be about prevention of foster care placements and preservation of families.”

It seems premature to celebrate the shrinkage of the foster care rolls as a triumph without knowing what is happening to the children remaining at home who would have been removed in a different year. How many of these children are living with abuse or neglect that will leave lasting scars or impair their development, if not endanger their lives? Supporters of the Family First Prevention Services Act (FFPSA), which passed in 2018, said that declining foster care counts would result from providing support to parents who needed help to address the problems (like substance abuse, mental illness and poor parenting skills) that led to their maltreatment of their children.

After an allegation of abuse or neglect is substantiated, an agency can place a child in foster care or open a case for in-home services, among other options.¹ FFPSA made it possible to use the same federal funds for foster care and in-home services, allowing children to stay at home safely while their parents addressed the issues that put them at risk. A major purpose of FFPSA was to enable states to use federal funds that were formerly available only for foster care to pay for parenting support, mental health, and drug treatment that would enable children to stay safely with their families. The rationale for this change was that allowing foster care funds to be used for such services was necessary to enable states to keep kids out of foster care.

However, FFPSA has not made massive federal resources available for such services. ACF estimates that only 18,400 children in the entire country were served by Title IV-E prevention services programs in FY 2023, at a cost of $167 million. But perhaps states are using their own funds to pay for these services? After all, foster care is more expensive than services provided to families in their homes. Both require case management, but instead of the cost of room and board for foster youth, providing in-home services usually involve referring parents to mental health and drug treatment services often funded by Medicaid or paying for parenting support programs that cost less than foster care. (Of course the supporters of FFPSA ignored this basic fact and claimed the legislation would revolutionize child welfare!). States were already providing these services before FFPSA and they could have increased them without the promised federal funding.

But believe it or not, nobody knows if more children and their families are receiving in-home services as the foster care rolls decline, since the federal government doesn’t ask states for this information. While states were already required to report the number of children entering foster care, leaving it, and in care at a point in time, FFPSA did not add a requirement to provide the same data on services provided to children and families in their homes, now that they were also covered by federal Title IV-E funds.² Hoping some states might track this data of their own accord, I searched the data publications and dashboards on the websites of the ten states with the largest number of children in foster care according to the most recent AFCARS report,³ but I was able to obtain this data for only California and Texas.

California has by far more children in foster care than any other state, 45,924 children at the end of September, 2022, which was 12.4 percent of the national total. Fortunately, there is extraordinarily good data from the California Child Welfare Indicators Project (CCWIP), a collaboration between University of California at Berkeley and the California Department of Social Services. The CCWIP dashboards include data on the number of entries into foster care and the opening of Family Maintenance cases, as in-home cases are called in California. Entries into foster care declined precipitously from April 2019 to March 2020 and continued declining, though more slowly, through March 2024. Family Maintenance case openings also declined continuously throughout the period. Thus, there was no increase in Family Maintenance case openings to compensate for the decline in removals. Or put in a different way, the total number of cases opened for child welfare services dropped from 46,264 at the beginning of the period to 29,969 at the end–a drop of 35 percent. Rather than a shift from foster care to in-home services, there has been a shrinkage of children reached by child welfare services overall.

Source: California Child Welfare Indicators Project, Entries, https://ccwip.berkeley.edu/childwelfare/reports/Entries/MTSG/r/ab636/l and Case Openings, https://ccwip.berkeley.edu/childwelfare/reports/CaseOpenings/MTSG/r/ab636/l.

Texas has the third largest state foster care caseload, after Florida. The Texas data are a bit more confusing. The number of children entering foster care dropped from 16,028 in 2021 to 9,623 in 2022, an incredible 40 percent, while the number of children entering in-home services declined steeply as well, resulting in a 35.7 percent drop in all case openings. Both drops may well have been related to a new Texas law that took effect on September 1, 2021 and changed the definition of neglect to an action or lack of action that puts a child in “immediate danger” of harm, rather than “substantial risk” of harm as the previous language read. The bill also put restrictions on child removals, requiring that children can be removed only from parents who display “blatant disregard” for their actions, or whose inaction “results in harm to the child or creates an immediate danger to the child’s physical health or safety.” Interestingly, in 2022, foster care entries actually rose slightly in Texas, while family preservation entries sprung back to where they were in FY2021, resulting a substantial increase in total case openings that year. Nevertheless, the overall trend over time was a decrease in foster care entries, family preservation case openings and the total number of children receiving help through open in-home or out-of home cases. That total dropped from 72,181 to 48,619 over five years–a drop of 32.6 percent–almost the same as the drop in California’s child welfare case openings.

Source: Texas Department of Family and Protective Services, CPS Conservatorship, Removals, https://www.dfps.texas.gov/About_DFPS/Data_Book/Child_Protective_Services/Conservatorship/Removals.asp, and CPS Family Preservation, Children Entering Services, https://www.dfps.texas.gov/About_DFPS/Data_Book/Child_Protective_Services/Family_Preservation/Children_Entering_Services.asp

Florida, the state with the second largest number of children in foster care, reports on the numbers of children entering foster care but not on the number entering in-home cases. One can, however, compare the number of children in foster care at a point in time with the number of children and young adults receiving in-home services. Both numbers have been decreasing and the number of children receiving in-home services has been consistently about half of the number of children in foster care. But these numbers don’t tell us whether declining entries to foster care have been offset by increasing entries to in-home services. In general, foster care cases last longer than in-home cases. Not knowing the average length of stays in foster care and in-home cases, and how they have changed over time, one cannot tell whether in-home case openings have made up for the reduced number of entries into foster care.

The Florida data show why point-in-time data cannot be used to answer the question of whether the decline in foster care entries has been accompanied by a rise in in-home case openings. Unfortunately, none of the other eight states with the highest caseloads provide this data on their websites. Illinois and Indiana provide point-in-time data on foster care and in-home participants. The other five states with the largest caseloads–Ohio, New York, Pennsylvania, Arizona, and North Carolina–display no data on in-home case participants at all.

If California and Texas are typical, states have not been increasing their provision of in-home services to make up for declines in foster care. Instead, the total number of abused and neglected children being helped by in-home or out-of-home services (or foster care) has declined by as much as a third in five years. But we cannot assume that California and Texas represent the entire nation. It is unfortunate that the writers of FFPSA did not requiring states to include data on in-home case openings and total caseloads, given that the legislation allowed federal funds to be used for this purpose. States have not begun tracking and reporting on this data on their own, and are triumphantly proclaiming the drop in foster care without even reporting on whether in-home services are being provided instead. When Congress considers desperately-needed fixes to FFPSA, a requirement that states report in-home case data analogous to the foster care data in the AFCARS system should be included in the new legislation.

Notes

Other options include referring a family to a community provider or even doing nothing nothing if the abuse or neglect was assumed to be a one-time event unlikely to occur. The family may also refuse in-home services, and the agency would then have to decide whether to file a court petition to require such services ↩︎
States must provide to National Child Abuse and Neglect Data System (NCANDS) information on how many children receive “postresponse services,” meaning services after a child protection investigation. But unfortunately, “postresponse services” includes foster care and provides a duplicated count, counting children every time they are the subject of an investigation, so it is not useful in telling us how many children receive in-home services. ↩︎
State foster care data can be accessed from https://www.acf.hhs.gov/cb/report/trends-foster-care-adoption. According to the latest information, the ten states with the largest number of children in foster care on September 30, 2022 were California, Florida, Texas, Illinois, Ohio, New York, Missouri, Pennsyhlvania, Arizona, and Indiana. ↩︎

Controlling the narrative: How the state of Washington is trying to censor the foster parent voice in court

by Christina Faucett

I am honored to publish this essay from Christina Faucett. Christina has been a licensed foster parent in the state of Washington for six years and has adopted one child from the foster care system. Prior to becoming a foster parent, she was a CASA for three years. She is currently a member of the DCYF Parental Advisory Group and is passionate about fixing what is broken in our child welfare system to keep Washington kids safe. She lives in the Seattle area with her husband and daughter. You can follow her on X at @DCYFWAtch.

In 2023, the Washington State Department of Children, Youth, and Families (DCYF) completely rewrote their Caregiver Report to Court form. This form is the only voice foster parents have in the dependency process, since they are not parties to the case, and thus are not entitled to receive legal counsel, file motions, read pleadings, or speak in court unless called on by the judge. Given this, one might expect that changes to the caregiver report form would by preceded by extensive communication and feedback from caregivers as part of the editing process. This did not happen.

I first became aware of these changes in the fall of 2023 when I was provided the new form to submit in my foster child’s dependency case. I then reached out to connections I had in DCYF to ask how these changes had come about, and who had participated in the process of editing the form. After being stonewalled by DCYF employees, I submitted a Freedom of Information Act (FOIA) request, the results of which I finally received a couple of weeks ago.

My FOIA response revealed that the committee convened by DCYF to make the changes to the caregiver report to court included only one caregiver. However, it included three representatives of birth parents, including one former birth parent who had a child in foster care, a parent attorney and a social worker from the Office of Public Defense (which represents and provides assistance and advocacy for birth parents in dependency cases), along with other court and DCYF employees, and one CASA representative. At no point were caregivers informed of this committee’s existence, invited to participate on the committee, or asked to give feedback on the committee’s proposed changes.

The only foster parent representative on the committee works with Amara’s Family Connections Program, which encourages foster parents to maintain relationships with biological parents. Although this foster parent is a representative for what is called the “1624 Consultation Team” (named for the bill that created the group), which is a group of elected foster parent representatives who are supposed to raise the questions and concerns of foster parents in meetings with DCYF, no other 1624 representatives appear to have been informed of the pending changes. The Foster Parent Association of Washington also does not appear to have been informed of the pending changes. An August 2, 2023 post to their website states, “This seems to have been a sudden change and not everyone in the system is aware of it.”

Adding to the confusion, DCYF released two different Caregiver Report to Court forms, a long form and a short form. However, the forms have some completely different questions. For example, “Are you maintaining open and viable communication with the child’s biological parent?” is only included in the short form, not the long form. Even after an entire year of work on this by the committee, the reports still have numerous typos and errors. The new report was released with instructions that caregivers could submit it to the child’s CASA, not just their social worker, even though the CASA program in some counties did not want this responsibility and refused to submit the forms to the court on behalf of caregivers.

While not all of the changes to the caregiver report form are bad, a quick look makes it clear that DCYF is trying to limit input from foster parents to information that supports reunification, while simultaneously diminishing their opportunity to highlight their own relationship with the child (whom they may have raised for years, possibly from birth).

Some examples of changes:

A question soliciting caregivers’ thoughts on the Department’s case plan has been replaced with a question asking “Do you have any additional information that may help reunite the child or youth successfully with their biological family?”
A general question about how the child’s visits with parents are going has been replaced with, “What’s working well with family time? Explain.”
Other changes imply that caregivers have obligations they do not have. For example: “How have you included the parents of the child in the medical and dental appointments?” It is the social worker’s responsibility, not the caregiver’s, to inform parents of medical/dental appointments. The communication question mentioned above likewise implies that caregivers have an obligation to communicate directly with biological parents. Caregivers may have many legitimate reasons (including privacy and safety reasons) not to communicate directly with birth parents.
The old form had two questions about the child’s relationship with the caregiver and adjustment to living in the caregiver’s home. On the new long form these questions have been replaced with one question which is relegated to the bottom of the form under “additional information.” The short form doesn’t even ask caregivers about their relationship with the child living in their home; it only asks about the child’s behavior in the home. A question asking caregivers to “Describe child or youth’s interactions with positive adults (i.e., coaches, teachers, church, mentors, other relatives)” is given higher billing on the long form than the questions about their relationship with their primary caregiver.

DCYF has lost around 800 licensed foster homes since 2019, and since their six-month pause on issuing all new foster parent licenses from November 2022, to April 2023, the number of unfilled emergent placement needs has skyrocketed. If DCYF wants to achieve their goal of eliminating short-term stays for foster children and youth in offices and hotel rooms by December 2024, they need to start treating caregivers with the respect they deserve, not trying to further stifle their voices.

We are not here to save children: abuse and neglect deaths after contact with child welfare services in the District of Columbia, 2019-2021

To my readers: This blog summarizes a report that is the culmination of nine months of work. It is part of my advocacy for children in the District of Columbia, which I share in my blog, Child Welfare Monitor DC. But I think this post and the underlying report will be of interest to child advocates, policymakers and researchers around the country because the findings and issues discussed are widely applicable.

“We are not here to save children.” That is what I was told on the first day of my training as a child protective services worker at the District of Columbia’s Child and Family Services Agency (CFSA). And indeed, the District is on the cutting edge of the current movement in child welfare around the country that considers child protective services as a “family policing system” that unnecessarily harasses and separates families, especially families of color. The problem with this perspective is that some families do not provide a safe environment for children to grow and develop. In some of these families, children die. That is what happened to the 16 children whose cases are discussed in a new report, which is summarized in this post. And indeed, analysis of the limited information provided suggests that CFSA did not take advantage of the opportunities it had to protect children even after long histories of CFSA involvement in their families. As a result, three children were beaten to death, three more were poisoned by opioids, and others died of burns, a car accident, and unknown causes when the deaths might have been preventable if the agency had been more protective.

When a child dies of abuse or neglect after that child’s family has been on the radar of the agency designed to protect children, it is important for the public to know whether and how this death could have been avoided. The essential question is whether the agency could have prevented the death by doing something differently. Did staff miss any red flags, and therefore fail to take action when necessary? If the death was preventable, what factors must be remedied in order to prevent such failures in the future? It is not enough for the agency itself to have access to this information, or to have an internal team review it. Agencies can fail to learn from their mistakes when they are blinded by ideology, self-interest or just inertia.

For those reasons, federal law requires every state to have a law or program that includes “provisions which allow for public disclosure of the findings or information about the case of child abuse or neglect which has resulted in a child fatality or near fatality.” In compliance with this requirement, DC Code requires the Mayor or the Director of CFSA, upon written request or on their own initiative, to provide findings and information related to “[t]he death of a child where the Chief Medical Examiner cannot rule out child abuse, neglect, or maltreatment as contributing to the cause of death.” In March 2023, we requested such findings and information for all the fatalities that met the criteria and were reviewed by CFSA’s internal fatality review team between 2019 and 2021. It took more than six months of meetings and emails to receive the information that is presented in this report. We agreed to restrict our request to cases reviewed in 2019, 2020 and 2021 and to withdraw our request for information on near-fatalities, which CFSA only began tracking in October, 2022.

Not surprisingly, CFSA interpreted the disclosure requirements in a way that restricted the information provided as much as possible. If a medical examiner did not rule the manner of death to be an abuse or neglect homicide or “undetermined,” no information was provided. Therefore, the agency did not release any information on cases where the manner of death was labeled as accidental, even if it found a parent responsible for the death or removed the children. The “accidental” deaths for which information was not provided included one child who died after he was left in a baby swing for two hours, which most ordinary people would consider to be neglect. The death of seven-week-old Kyon Jones, whose mother told police that she threw his body in a dumpster after she rolled over him while high on PCP, was not included because his body was never found and therefore it did not meet the criteria for release of the information–even though CFSA removed the surviving children from their mother.*

In addition to omitting some cases in which neglect or abuse played a role, CFSA heavily redacted the information it did provide, with many pages and large portions of others blacked out. CFSA refused to provide the names of the children, parents and caregivers, providing a rather convoluted interpretation of DC Code, which clearly requires the release of this information. (See the full report for more information about their reasoning). In three cases, the child’s identity was clear from media coverage of the case, and we used the child’s name. A major source of redactions was the exclusion of “personal or private information unrelated to the child fatality.” It appears that CFSA’s legal team interpreted this term much more broadly than a social worker or researcher would, because they redacted almost all information about parents’ history of criminal activity, substance abuse, mental illness, and domestic violence–which are obviously relevant to many of the fatalities we are discussing.

On investigations, it is unfortunate that DC Code requires that the agency release only ”a description of the conduct of the most recent investigation or assessment” rather than all investigations regarding the family in question. It appears that the agency interpreted “the most recent investigation” as the fatality investigation itself rather than the most recent investigation before the fatality, but the law ought to require a description of all previous investigations. The agency also disregarded language that requires it to provide “the basis for any finding of either abuse or neglect.”

For most cases, we received very little information aside from a list of the previous referrals (reports to the CPS hotline) including only the date of the report, the allegation category and the disposition; an account of in-home and foster care case activities for the families that had such cases; and an account of the investigation of the fatality itself. The information about the parents was heavily redacted, and almost the entire history of agency involvement was blacked out in most cases. Despite the limited information provided, the redacted summaries included some new information, some of which was startling and disturbing. The report is based on the 16 case summaries provided by CFSA, occasionally supplemented with information from the agency’s annual fatality reports, which are available to the public. These cases affected 15 families, as one family had two fatalities in one year. Unless otherwise noted, the information is based on the case summaries. The full report, from which this blog is excerpted, contains summaries of each case.

Cause and Manner of Death

CFSA classifies child deaths by cause and manner. “Cause of death” is the specific disease or injury that led to the death. Manner of death refers to the circumstances that caused the death, and falls into five categories: natural, accidental, suicide, homicide, and undetermined. Of the 16 cases for which information was provided by CFSA, three (19 percent) were abuse homicides, six (37 percent) were neglect homicides, and seven (44 percent) were undetermined in manner. The latter were the cases for which CFSA provided information because the Medical Examiner was unable to rule out child abuse or neglect homicide as the manner of death.

The most common causes of death were blunt-force trauma and opioid poisoning, each claiming the lives of three children, as shown in figure below. The remaining children died from a variety of causes, including drowning, asphyxia, thermal and scald injuries, injuries from a car accident, and unknown causes.

Abuse deaths: Blunt Force Trauma

Three of the children died of blunt force trauma–one of the two most common causes of death in the sample. The murders of two of these children – Makenzie Anderson and Gabriel Eason – – became known to the horrified public through press coverage of their deaths in February and April of 2020. Each of them died from head trauma inflicted by a parent or stepparent. Makenzie suffered from multiple contusions to the face and head, skull fractures, and other injuries, and her mother pleaded guilty to manslaughter, receiving a ten-year prison term with seven years suspended on the condition that she obtain mental health treatment and have no unsupervised contact with children. Gabriel’s autopsy found abrasions and contusions to the head, face and torso; contusions to the heart and thymus gland; liver and kidney laceration; new and healing fractured ribs; and a brain hematoma. His stepfather was sentenced to 12 years and eight months in prison and his mother, who did not seek medical help for Gabriel or his critically-injured three-year-old brother, was sentenced to four years of probation and three years of supervised release.

But there was a third homicide by blunt force trauma. A three-year-old girl died of trauma to the abdomen in the home of an aunt where she was placed by CFSA after being removed from her drug-addicted mother. Her injuries included contusions to the forehead and abdomen, a lacerated liver, and blood in the abdominal cavity. No charges were filed against either the aunt or her boyfriend, and the case received almost no public attention.

Neglect deaths: Opioid Poisoning and other causes

Three children (a three-year-old girl, a three-year-old boy, and a three-month-old girl) died of synthetic opioid toxicity, with fentanyl implicated in all three deaths. (One of the children had also ingested a controlled substance called eutylone.) There is no information about how the children might have ingested the drugs, but all lived with parents who were known or alleged to abuse substances. These deaths never became known to the public, which is not surprising since it appears that none of the parents were arrested or charged.

A 17-month-old boy died of “complications of thermal and scald injuries,” and his mother told the investigator that she had no idea how it happened or how he ended up face-down in the bathtub several hours later. A seven-year-old died of injuries from a car accident. His mother was a long-time substance abuser and was arrested for Driving Under the Influence (DUI) in the accident. She was driving from Florida to Washington and her children were not sitting in car seats or belted in. A five-month-old boy died of asphyxia by drowning after being left alone in the bathtub with a one-year-old sibling while their mother searched for her car keys.

Deaths for Which the Manner was Undetermined

Two deaths has known causes but the manner – whether abuse or neglect or something else – was not determined. A twelve-year-old girl with asthma died of an untreated bacterial infection and pneumonia but also had enough bruising from two separate beatings in the previous two days to support a CFSA substantiation of the mother for physical abuse. It is unclear why this was not considered a medical neglect homicide. A ten-month-old girl died of asphyxia but the manner of death was undetermined. Her mother had left her in the care of her father and returned to find her unresponsive.

The cause as well as the manner of death was unknown or undetermined in five cases. These included an 18-month-old boy with a subdural hematoma, which could have been caused by abuse or a fall, an 11-month-old girl whose mother reported leaving her unsupervised on her stomach with a bottle in her mouth for about 40 minutes, a nine-month-old boy put to bed with a bottle and found face-down on a pillow; a two-month-old girl who died while sleeping with her mother, and a three-month-old girl found unresponsive by her parents one morning. Unsafe sleep practices may have contributed to some of these deaths, but other unsafe sleep fatalities were categorized as accidents, for which case summaries were not provided.

Demographics

A quarter of the children who died were younger than six months old and half of them were one-year-old or younger. Another quarter were two or three. This is not surprising as young children are more vulnerable and similar results are found nationally. But older children were not invulnerable to abuse or neglect, including the seven-year-old who died in a car accident and the 12-year-old who died of an untreated bacterial infection and pneumonia.

Fifteen of the decedents were African American and one was classified as “African-biracial.” According to the latest data from Kids Count, 54 percent of children in the District of Columbia are Black. So Black children were overrepresented among the children who died of maltreatment or possible maltreatment. The overrepresentation of Black children among children who died points to Black children’s particular need for protection. And it suggests that current emphasis in the District and around the country on reducing the involvement of Black families in child welfare may cause more suffering and more deaths among Black children.

The prevalence of large families among those that lost a child due to abuse or neglect is striking. More than two thirds of the mothers of children who died by maltreatment had four or more children. The average mother in the group had 4.6 children, often with more than one father.

Histories of System Involvement

All the families had been the subject of at least one report to the CFSA hotline before the fatality, or else they would not be included in this report. But many of the families that lost a child had experienced a large number of reports prior to the fatality. Among the 16 fatalities included in this report, only six occurred in families that were the subject of five reports or fewer in the last five years. Five occurred in families that had between six and 10 reports, three occurred in families with 10 to 15 reports, and one family had 24 reports. Three of the families had actually experienced a previous child fatality–a shocking statistic considering the rarity of child fatalities overall.

The families of the two children – Makenzie Anderson and Gabriel Eason – whose abuse homicides shocked the District of Columbia in February and April 2020 were both known to CFSA before the deaths, and the last report to the hotline came five months before the fatalities of both children. Makenzie Anderson’s family was reported to the hotline eight times within five years of her death. The last report alleged exposure to unsafe living conditions, inadequate supervision, and substance abuse by a parent, caregiver, or guardian. All those allegations were unfounded (not confirmed) by CFSA. Gabriel Eason’s family was the subject of 17 prior calls to the hotline since 2012, including 12 in the five years preceding Gabriel’s death. The most recent report was for unexplained physical injury in October 2019 and was also unfounded by CFSA.

Substance abuse by the parent or caregiver was the most frequent allegation CFSA received regarding the families in the five years before the deaths, with 30 substance abuse allegations collectively accumulated by the families of the 16 dead children during that period. Another eight reports concerned positive toxicity of a newborn, a reflection of parental substance abuse. Substance abuse by the parents was observed or alleged in the families of all but four of the victims included in this report. Inadequate supervision was the second most common allegation, with 25 allegations concerning the 15 families. Almost as common was educational neglect, referring to children with excessive school absences, with 24 allegations received in the five years preceding the fatality. Ten of the 15 families had at least one report for educational neglect before the child’s death. Another major theme was exposure to domestic violence, with 17 allegations received by the families. Domestic violence was mentioned in nine of the 16 case histories as the subject of an allegation or in notes from social workers or police.

Most of these families could be described as “chronically neglectful.” According to the Child Welfare Information Gateway, “Chronic child neglect occurs when a caregiver repeatedly fails to meet a child’s basic physical, developmental, and/or emotional needs. Chronic neglect can have long-term, negative consequences for child health and well-being.” Working with chronically neglectful families is especially difficult and requires special training and skills, which many CFSA social workers may lack. Perhaps that is one reason why they struggled so hard to engage some of these families. Four of the children died while an in-home case was open. Three out of four of the in-home case narratives from CFSA portray caregivers who evaded offers of help from CFSA and other providers and refused to cooperate with efforts to monitor conditions in their homes.

System Failures

The information received suggests several areas where failures in policy and practice by CFSA and other agencies may have allowed these deaths to happen. These areas include:

Screened out and unsubstantiated reports: Research points to the difficulty of determining correctly whether a child has been maltreated, as well as the absence of significant differences in subsequent outcomes between children with a substantiated allegation of maltreatment and those with an unfounded allegation. Without information on how hotline and investigation decisions were made, we cannot assess the agency’s performance in these areas. But the fact that most previous reports for families with a subsequent death were screened out or unfounded is concerning.
Flawed management of in-home cases: Four of the deaths reviewed here happened while an in-home case was open for the family. In three of these cases, workers struggled to complete face-to-face visits with the families because parents evaded these visits. Social workers and supervisors could have filed a petition to involve the court, an option known as “community papering.” But they did not exercise this option–or they started too late, as in the case of the child who died after a meeting was finally scheduled to discuss community papering the case. The meeting was cancelled after the agency received word of the child’s death.
Too many chances: The mother of the seven-year-old killed in the 2020 car accident had been given numerous chances to recover from drug addiction and had relapsed many times over 18 years of involvement with CSFA. The family of the 17-month-old who died of complications of thermal and scald injuries had 24 referrals to CFSA between 2016 and 2021. Three in-home cases were opened and closed, but the children were not removed until the little boy died.
A fragmented health care system: In its findings on Gabriel Eason’s death, CFSA pointed out that Gabriel was taken to different medical providers for his various injuries. Because they use different information systems, the providers could not see records of the earlier injuries.

The reaction of CFSA and the criminal justice system after the fatalities obviously did not contribute to the fatalities themselves but may illustrate a pattern that contributes to future deaths. Specifically, CFSA’s tendency to place siblings informally after fatalities and the police and US District Attorney’s failure to charge parents raise concerns.

Informal placements after fatalities: CFSA, and child welfare agencies around the country, have been criticized for relying on informal placements with family members, rather than formally removing the children, placing them with the relatives, and opening a case to monitor their safety and well-being. In at least four of the 16 cases reviewed here, CFSA did not officially remove the siblings of the children who died but instead relied on informal placements with fathers or other relatives to keep them safe. Nothing was done to assure that the children were not returned to the home from which they had been removed as soon as the investigations closed, or to verify that the parents or caregivers had rectified the conditions leading to the child deaths.
Failures by the criminal justice system: The failure to bring charges against some of the parents and caregivers described here is quite concerning, particularly in the case of the three-year-old who died of blunt-force trauma and the infant and two three-year-olds who died of opioid poisoning. There has been considerable criticism of the US Attorney’s office in the District (which handles adult criminal prosecutions) for its low rate of opting to charge people for crimes. We do not know if the problem is the Metropolitan Police Department’s failure to bring the cases to the US Attorney or the latter’s failure to pursue them.

Recommendations

Without seeing the full case studies that were available to CFSA’s internal review committee, we cannot make detailed recommendations about how to avoid child maltreatment fatalities for children known to CFSA. The minimal recommendations that CFSA’s internal review team made show the need for the City Council, advocates and the public to have access to these complete case studies: in its 2021 report the agency made no recommendations other than those dealing with the fatality review process! Therefore, our first recommendation is to the City Council, urging it to require that CFSA release comprehensive case histories on all proven or suspected child maltreatment fatalities. Our next blog post will discuss the legislative changes that are needed.

The lack of information on how screening and investigation decisions in particular were made precludes specific recommendations. Perhaps a new audit of the hotline is in order. Some changes to hotline screening policy might be advisable, especially around educational neglect. School absences should be investigated regardless of the age of the child (requiring a change in the law) and their academic performance. And perhaps investigative workers could benefit from better training in forensic interviewing techniques that might help them better evaluate parents’ and childrens’ statements for veracity and perceive more subtle signs of abuse or neglect.

The case narratives make clear that in-home social workers struggled to complete home visits to the families of the children who later died. The agency must change its policy to encourage “community papering,” making court involvement routine after a certain number of missed visits or other instances of noncooperation. CFSA might also want to consider strengthening its in-home practice, perhaps by reinstating the Chronic Neglect Units, which were eliminated barely a year after they were implemented. These units would employ specially-trained social workers with lower caseloads and longer time periods to work with families.

Despite the current ideology favoring family preservation and reunification at all costs, the agency must also recognize that sometimes it must give up on a parent and find a safe, permanent alternative for the children. Giving parents multiple chances with successive children over many years belies the true purpose of child welfare services – to protect children.

Not all needed changes fall in CFSA’s bailiwick. Reforms in the criminal justice system are also necessary to ensure that parents who killed one child cannot harm more children. Couples who refuse to cooperate with prosecutors, and parents who expose children to opioids due to their own abuse or drug dealing must also be charged. Other jurisdictions do it, and the District must do it as well.

DC Health and medical providers also have a crucial role to play in making children safer. Encouraging the adoption of a comprehensive medical information platform across the region to prevent families from using different doctors to hide abuse and neglect would be a welcome step. A campaign by DC Health to educate young women on how an early pregnancy, especially when followed quickly by others, compromises their future and that of their children, is a crucial necessity. It must be accompanied by improved access to long-acting reversible contraceptive methods.

In summary, even with the very minimal information we received, some conclusions emerge. CFSA’s extreme deference to parents and guardians emerges clearly through the redactions in these narratives. This is in direct contrast to the picture that is being painted by the foundations, advocacy groups and public agencies dominating the child welfare conversation. Their accounts portray interventionist child welfare agencies that remove children rather than giving their families the help they need and want. We are seeing the opposite here: families who evade offers of help from the agency and providers and refuse to cooperate with efforts to monitor conditions in the home. The goal of such parents often appears to be to avoid surveillance by outsiders rather than to improve their ability to care for their children. And CFSA workers often seem unwilling or unable to intervene in a way that will protect these children.

‘The tragic deaths of children whose families are known to CFSA are the tip of a much larger iceberg. For every child who dies of abuse or neglect, an unknown number of others are living in fear or pain from abuse, suffering chronic neglect that will cause lifelong intellectual an emotional damage, or lacking the loving attention necessary for optimal mental, emotional and physical development. Sadly, it is only the children who die whose cases can be used to learn lessons to prevent similar tragedies in the future. This information must be public, so that the public can push for a system that protects all children who are not receiving the parental care they need to survive and thrive.

*The case, which received media coverage, was included and easily identifiable in

The child placement crisis: It’s time to lose the slogans and find real solutions

By Judith Schagrin

A note from Child Welfare Monitor: It is a privilege to publish this important essay by Judith Schagrin. Judith earned an undergraduate degree from the University of Pennsylvania and a master’s degree in social work (MSW) from the University of Maryland School of Social Work. She unexpectedly found her passion in public child welfare, and more specifically, foster care after helping start an independent living preparation program for young people in care. After a decade as a foster care social worker specializing in adolescence in a large Maryland county department of social services, she supervised two different units before becoming the county’s director of foster care and adoptions, serving in this position for twenty years. She also worked part-time for the Agency’s after-hours crisis response for a decade. For almost 10 years, she served as a respite foster parent for a private foster care agency, and since 2008, has mentored a young person who aged out of care in California and came east for college. In 2001, with a little help from her friends, Judith founded Camp Connect, a weeklong sleepaway camp to reunify brothers and sisters living apart in foster care and provide memorable experiences siblings can share for a lifetime. For the past 23 years – one year virtual – she has spent the week at Camp Connect immersed in the care of Maryland’s foster children and youth.

The closing of children’s mental hospitals in the 1980s, the subsequent closure of detention centers leaving foster care to take up the slack, the movement to shutter all group homes and residential treatment programs and the prohibition of out-of-state placements have created a slow-motion train wreck whose results could have been predicted easily at every new chain in the sequence. Those results include children and youth staying in psychiatric hospitals long after being ready for discharge, “boarding” in emergency rooms and “placed” in hotels at a cost of $30,000 to $60,000 per child per month. From my 35-year vantage point as a caseworker, supervisor, and then running foster care and adoptions in a large Maryland county, I’ve had a front row seat to the evolution of this crisis and the failure to come up with real solutions.

Deinstitutionalization

The first in a series of events that created this crisis occurred in the 1980s, when the deinstitutionalization that began for adults in the 1960’s with the civil rights movement expanded to include children. Until then, youth remained in state hospital facilities for as long as a year or even more. The closure of those state facilities led to the expansion of Medicaid-funded residential treatment centers (RTC’s), that stepped in to provide the longer term care once provided in the state hospitals. In turn, group homes proliferated to meet the needs of youth discharged from RTC’s. The advent of Medicaid was instrumental in expanding prIvate psychiatric treatment options, including hospitals. But over time, Medicaid stopped funding even 30 days of treatment, limiting payment to only a few days of crisis intervention.

Today, many youth, especially older youth, are entering foster care not because of what we traditionally think of as maltreatment, but due to parental incapacity or unwillingness to care for them due to acutely problematic behavior, and behavioral health and/or developmental needs. Services to meet these needs are often missing or inadequate, and parents of children with high-intensity needs cannot find residential treatment except through the child welfare system. Medicaid doesn’t pay for treatment and care in a group home of any kind; access in Maryland requires the child welfare system’s physical or legal custody.

New approach to juvenile justice

In the early 2000’s, a series of Supreme Court decisions brought welcome changes to juvenile justice and shifted the country from the ‘get tough’ approach of the ‘80’s and 90’s to the ‘kids are different’ era. Moving from punishment to rehabilitation and minimizing detention in favor of community services makes sense on both humanitarian and neuroscience grounds. But it meant that youth who once fell under the purview of Juvenile Services now required child welfare intervention when parents or other caregivers were unwilling or unable to continue to provide care. The mother evicted from four apartments because of her son’s property damage; the grandmother who stepped in years ago and is no longer able to cope with her granddaughter after the third vehicular misuse charge and chronic episodes of running away; or a parent with younger children afraid that an older sibling known to have rages and episodes of violence will harm his siblings, are examples of desperate caregivers I have come across.

In Maryland, the first alarm that child welfare was ill-equipped to care for these youth was sounded in 2002 by local department directors in a memo to the head of the Department of Human Services. Closing detention centers was a good thing, but alternatives weren’t developed for those youth unable to live at home, and no resources were provided to help child welfare accommodate its new clients. As the closure of state psychiatric facilities and detention beds was widely celebrated, the belief that every youth had a family eager and able to provide a home was more than a touch naive, as would soon become clear.

Group home closures

Another domino fell in the early 2000’s, when group homes, many poorly administered with little oversight, became a scandal in Maryland. A series of articles in the Baltimore Sun exposed the flaws of many group care programs, and some were forced to close. With the scandals around bad group homes, the timing was perfect for state leadership, encouraged by a national advocacy group with deep pockets and the laudable dream of a family for every child, to lead a movement to shutter congregate care placements. Funding constraints, too, forced some providers out of business. Reimbursement rates did not keep up with costs, and some programs closed their doors due to inadequate reimbursement. The state lost roughly 450 beds in five or six years, including entire residential treatment center programs. Rate-setting ‘reform’, which began in October of 2021, will not be completed until July of 2026 if it stays on schedule.

At the same time group homes were being closed in Maryland, state agency leadership began to frown on out-of-state placements for youth with highly specialized needs when no placement in Maryland to meet those needs was available. Public officials with little understanding of placement resources pronounced these out-of-state placements to be evil incarnate, and an overwhelming number of bureaucratic obstacles made them nearly impossible.

With the loss of group homes as an option, we were urged to ‘re-imagine’ care for children, yet discouraged from developing individualized plans of care because insufficient flexible funding was allowed to make that happen. We’re fond of slogans in child welfare, as if words will change outcomes, but too many initiatives are about clever slogans and not about substance. If only we would review every child in group care, we were told, we would realize how many had other options. With consultation from the national advocacy group, we spent hours seriously poring over the needs of our children in congregate care and attempting to find matches with kin or foster families. Not at all surprising to our staff, “low hanging fruit” didn’t exist.

We also initiated a rigorous “Family Finding” practice, in hopes of finding kin willing to become providers with services and supports. What we learned is that youth in congregate care had already exhausted family and “kin of the heart” resources. Today it’s not clear that public officials and child welfare leaders grasp that children and youth wouldn’t be in hotels if there were any kin – fictive or otherwise – willing and able to provide care, or if parents could and would be a safe resource.

Youth with intensive, complex needs

As other doors closed, the child welfare system became increasingly tasked with providing residential behavioral health care for children and youth with high-intensity and complex needs for supervision and treatment. The differences between those involved with the juvenile justice system (and may have gone to detention centers in the past) and those who are not are often hard to discern. Both groups tend to engage in behaviors that pose a serious safety hazard to themselves or others. These behaviors may include physical violence; property damage; compulsive self-harm such as cutting or swallowing objects; chronic truancy; frequent runaway episodes; sexual victimization of siblings; aberrant sexual behaviors such as public masturbation; molesting younger siblings; participating in petty crimes; harming family pets; and generally oppositional and dysregulated behavior.

Contrary to the popular notion that the public child welfare system is tearing families apart, these are children whose families are typically frustrated, exhausted, and often eager to place their child. Some even view foster care as a much-needed punishment, imagining that when the youth is ready to “behave,” they can return home. Of course these young people have many strengths to be nurtured, but they need intensive supervision and therapeutic intervention by professionals trained to evaluate and address their special needs and work with families.

The gist of the matter is that we are serving two different out-of-home placement populations with very different needs. One is a younger population in foster care primarily due to maltreatment stemming largely from parental substance abuse and/or untreated mental illness. The other is older youth with complicated behaviors, and behavioral health needs and/or developmental disabilities. The parents and kin of the older group are asking for placement, not objecting to it, and are typically worn out and adamantly opposed to more in-home services. In spite of the stark differences in these two populations, our policymakers and those upon whom they rely have failed to recognize their needs are not the same.

In Maryland and other states, treatment, or ‘therapeutic,’ foster care stepped in to accommodate this new population of older, harder to serve foster youth. To some extent this approach has been effective as an alternative to congregate care, but it’s not the panacea some would like to believe. The desperate need for foster families willing to care for these youth means there’s a certain amount of pressure to lower expectations and even turn a blind eye to foster parents that do a less than stellar job. Tales of locked refrigerators and youth left sitting on the stoop at the end of the school day until the caregiver came home soon proliferated. However, we were told by representatives of a national advocacy group that, “Youth are better off moving from shabby foster home to shabby foster home than in the very best congregate care.” In my own experience, instability begets instability and there’s little more soul-sucking than being rejected from family after family.

Setting aside the question of quality, foster care, whether treatment or not, has great challenges recruiting homes for youth with weapons charges, those with a history of drug dealing, or whose parents have refused to pick them up from the police after another runaway episode. “Cutters” and “swallowers” need 24/7 supervision to keep them safe and in general, kin have already tried to provide care long before the child’s entry into state custody. With the closure of group homes and residential treatment centers in Maryland and the prohibition on out-of-state placements, finding placements willing to accept youth with high-intensity needs became literally impossible. As a result, for years now children have been left in psychiatric hospitals (sometimes for months) after “ready” for discharge, and others are ‘boarding’ in emergency rooms for weeks or months.

A failure to recognize reality

Instead of recognizing the lack of capacity to serve those youth with nowhere to go after being hospitalized, hospital representatives, public officials, and legislators blamed caseworkers for not ‘picking children up’, as though they were simply lazy and incompetent. “Advocates” proposed legislation imposing more caseworker accountability as the solution, as though if caseworkers worked harder and filled out more forms, placements that didn’t exist would magically appear. Fortunately, none of the legislation passed, but being a lonely voice trying to explain the source of the problem wasn’t lazy caseworkers or enough forms was painful. Public officials, leaders and advocates also clamored for more “prevention” services, not recognizing the acute needs of older youth developed over many years and that new services authorized today are not going to keep them safely at home.

During my 20 years as the director for my county’s foster care and adoptions program, I can’t count the nail-biting times we came close to not finding a placement for a child – but we were always able to pull something together. The state made funding available for a 1:1 staff person (or sometimes 2:1) we could offer existing providers, allowing us to use that as a bargaining chip. Of course, increasing reimbursement rates and staff salaries would have been far less expensive than millions for extra staff to support ill-equipped placements, but that change in fiscal allocation has yet to happen.

Five years have now passed since I retired, and hotel placements have become not a rarity but a regular necessity. At the rate of $30,000 to $60,000 per child each month (not including damages to hotels) to warehouse children in hotel rooms supervised by an untrained aide – one can only imagine what that kind of money could be doing productively for children. Caseworkers are overseeing the most precarious and risky “placements,” and being ‘hotel reservation clerks’ isn’t the reason competent social workers choose to do the work. We’ve all heard the tales of youth stealing their 1:1’s car; or youth locking themselves in their rooms doing what we don’t know; a youth who overdosed on his medication; parties taking place with the acquiescence of the 1:1; youth harassing guests; and the youth who leaped over the reservation desk to try to steal cash.

Over the years there have been many, many meetings among high ranking state officials and others; ironically, these meetings didn’t include the experienced and knowledgeable child welfare staff responsible for the children. Lots of strategies, goals, and plans too – a personal favorite was the goal of instructing local department staff on hospital discharge planning, as if they weren’t already experts. Despite all the meetings and all the hand-wringing, progress meeting the needs of the children in our care, or soon to be in our care when parents abandon them at the hospital or elsewhere, has been negligible. Years that could have been spent on developing and promoting new model programs have been wasted. In the meantime, Congress saw fit based on testimony from well-heeled advocacy groups to pass the Family First Prevention Services Act, which limited congregate care even more by restricting funding to approvable options based on criteria seemingly pulled out of a hat.

Today, the deepening and pervasive placement crisis is affecting nearly every state and attracting media attention around the country. Given the financial resources dedicated to keeping children in hotels, finances clearly aren’t the issue. And it certainly isn’t about quality of care, since hotel rooms, overstays in hospitals, and boarding in emergency rooms rank far below a quality congregate care program as a suitable home for a child.

What is to be done?

In the short run, Maryland and other states need respite programs for young people awaiting placements in hospitals, emergency rooms, and hotels. In the long run, we must acknowledge child welfare’s responsibility not only for maltreated children, but also those with high-intensity needs for supervision and treatment once served by other child-serving organizations. We need to bring the finest minds together to reimagine how residential care is provided, and its role in the continuum of child welfare resources to meet the needs of older youth entering foster care because of needs related to behavioral health and/or developmental disabilities. That process should include some of the scholars who have been studying the use of congregate care in other countries where it is more highly valued as a treatment and a professional field. Exploring the development of real alternatives to congregate care is also a worthy investment. Finally, the unintended consequences of the Family First Prevention Services Act that disincentivized needed placements without a credible replacement must be remedied.

How many more years until we wake up? And how many children will have to be harmed? A colleague had a quote in her office that stays with me always, “when we are doing something with somebody else’s child we wouldn’t do with our own, we need to stop and ask ourselves why.” Who among us would consent to our own children boarding in emergency rooms, on overstay at hospitals, or ‘placed’ in hotel rooms? If that’s not okay for our own children, it shouldn’t be okay for the children in our state’s custody either.

Residential care in child welfare: An international perspective

In my last post, Family First at five: Not much to celebrate, I discussed how the Family First Prevention Services Act (FFPSA) made it more difficult to provide residential care (often pejoratively called “congregate care” by the Act’s supporters) for the most troubled foster youth while doing little to ensure the development of alternatives. The result has not been surprising–an exacerbated placement crisis, with foster youth around the nation sleeping in hotels, offices, jails and other inappropriate settings. An important new book provides an international perspective on residential care. It shows that the U.S. ranks very low in the percentage of foster youth that are in residential care, casting doubt on the advisability of trying to further reduce residential placements. The obvious conclusion is that we would do better to increase the quality of residential care by raising standards for staff.

The new book, Revitalizing Residential Care for Children and Youth, is a compilation of research on residential care in 16 high and middle-income countries, edited by James K. Whittaker, Lisa Holmes, Jorge F. Del Valle, and Sigrid James, who are professors at universities in the US, England, Spain, and Germany, respectively.¹ The editors define “residential care” as “any group setting where children spend the night,” encompassing settings that vary in size and function and that operate under the auspices of child welfare, juvenile corrections, or mental health. The 16 countries are viewed through a common template, making comparisons possible. However, there are problems with such comparisons. As explained in the second chapter, countries differ in the terms they use for different types of care and how they define these terms, among other things. The editors’ definition of “residential care” does not ensure that the same facilities are being counted across nations. A small group home with paid staff might be classed as “foster care” in some countries, and some facilities (like those for youth offenders) might be counted in the residential totals for some countries and not others.

Keeping in mind the impossibility of obtaining data that is totally comparable across countries, there appears to be a striking variation between nations in the utilization of residential care for youths who are in out-of-home placements. The editors defined the residential care utilization rate as the proportion of out-of-home care dedicated to residential care rather than family foster care or other types of out-of-home placements. This percentage ranged from seven percent in Ireland and Australia to 97 percent in Portugal, as shown in Figure 29.1, which is reproduced below. The United States had the third lowest residential care utilization rate, with ten percent of children in out-of-home placements being in residential settings. Moreover, the number of children in U.S. residential care fell by about 25 percent between 2015 and 2019. According to the editors, it appears that countries in the low-utilization category have made legislative changes (like FFPSA and California’s Continuum of Care Reform in the US) that have led to drastic reductions in residential care. But the countries with medium utilization rates (between 30 and 55 percent) seem to be focused on improving residential care by strengthening the elements believed to be associated with quality care rather than reducing the utilization of residential care.²

Source: James Whittaker et al, *Revitalizing Residential Care for Children and Youth*, page 430.

The authors also found great variability in the education and training requirements for residential care staff. These range from no minimum qualification in the United States, Canada and Australia, to high school level (Israel, Argentina and Portugal), to rigorous multiyear vocational training and/or university education in the other countries. A number of countries use both vocationally trained and university educated staff. For example, in Germany, about 70 percent of residential care staff hold a 3.5 to five-year vocational degree as educators (or in fewer cases two years as assistants) and 30 percent have Bachelors’ degrees in social work or “social pedagogy.”³

The editors found that it is countries with lower educational requirements for staff that have turned against residential care and have sought a drastic reduction of its use. Among those countries was, no surprise, the United States, along with Australia and England. In contrast, countries with a high qualification requirement have higher utilization of residential care. This correlation is not surprising. There is no doubt, say the volume’s editors, that “the quality of the services is directly related, in any field, to the qualifications, training and experience of the professionals who provide them.” In child welfare, they argue, “[I]t is difficult to carry out the work without a qualification based on the learning of very diverse theories related to child development, the clinical expressions of trauma, listening and helping techniques, the framework of family relationships, and ecological theories.” The editors suggest the existence of a vicious cycle, where low staff qualifications may led to poor quality and outcomes, which in turn lead to reduced funding, making it harder to recruit well-qualified staff.

Unfortunately, available data do not tell us what proportion of children and youth in residential care in each country are there for time-limited treatment for behavioral issues with a plan to “step down” to a family setting. Available data suggest that a majority or large minority of children and youth in residential care in the middle-utilization countries have a mental health diagnosis, which does necessarily mean that they are in a time-limited therapeutic setting. Most likely, the residential care population in the middle-utilization countries is a combination of youths with issues that require treatment in residential care and those who could be in family foster care if available As one of the editors notes in the introductory chapter, “residential care across the globe …does not seem to be limited to the narrow treatment-oriented and time-limited setting it is generally reduced to in several Anglo-American nations. In fact, in many countries,…., children and youth still spend years in residential care programs.”

The assumption that family foster care is always the better choice unless a child cannot function in such a setting may be unique to the English-speaking countries. Small, family style group homes, whether freestanding or part of a campus of such homes, may be difficult to distinguish from foster homes, especially if they use a house-parent model. In fact, the authors say, some countries classify “a small “family group” home, staffed by paid staff” as a foster home. I have argued in the past that high-quality family-like group homes may be better for children than mediocre or poor-quality foster homes and are especially appropriate for siblings. Indeed, as discussed in the book, France has 28 children’s villages, which are family-like units especially for siblings.

The evidence shared by Whittaker et al. has important implications for the United States. Given our low position on the scale of residential care utilization, one might logically conclude that further lowering the number of children in residential care would be unrealistic. In the two countries with lower residential utilization rates than the United States, Ireland and Australia, news accounts document an urgent need for more foster parents, with young people being separated from siblings, moving from one emergency placement to another for lack of a suitable home, and spending nights at hotels. Instead of trying to bring the residential share of foster care even lower, the U.S. might be better advised to follow the example of countries like Germany and Finland, which are focusing on improving residential care programs rather than eliminating them.

Cross-national comparisons are valuable in many policy areas, and the absence of such comparisons in child welfare debates is particularly unfortunate. Reading this book brings home the lack of international comparisons informing Congress when it passed the FFPSA. As far as I know, the supporters of FFPSA’s drastic restrictions on residential care never referred to other countries’ use of residential options; that’s not surprising as such comparisons may have led to uncomfortable questions about the premise that too many foster children and youth were in residential care.

Some members of Congress who supported the residential restrictions in FFPSA may have been more concerned about budgets than ideological objections to residential care. Improving residential care costs money, while cutting it may appear to help balance budgets. FFPSA was designed to be budget-neutral, so that restrictions for funding of residential care were required in order to offset the increase in spending for services to families. And it apparently did not matter to Congress if those costs were by necessity picked up by states that had no other options: the federal government would see the savings.

Perhaps the federal coffers have benefited from the restrictions on federal funding for residential care, especially because federal spending for the “prevention services” side of Family First has been negligible. But it is hard to believe that states have gained financially from the new law. Spending as much as $2,000 a night for a hotel room complete with staffing and security for foster youth, as Washington State is reportedly doing, cannot possibly be a better use of funds than improving and expanding residential care. And the effects on children and youth are disastrous. One can only hope that state leaders will be brave and smart enough to take the first steps in the direction of revitalizing residential care to be a nurturing and therapeutic environment for children and youth and a field that is a source of pride for its practitioners.

Revitalizing Residential Care for Children and Youth should be required reading for anyone involved in making policy or drafting legislation regarding foster care. But it is probably too much to hope that the anti-residential crusaders will choose to read this important book. They find it more comfortable to continue believing that cutting funds for these programs without providing an alternative will save money and help children at the same time.

Notes

The countries studied include Argentina, Australia, Canada, Denmark, England, Finland, France, Germany, Ireland, Israel, Italy, the Netherlands, Portugal, Scotlad, Spain, and the United States.
Portugal, with 97 percent of its out-of-home youth in residential care, is in violation of its own law establishing residential care as the last option for out-of-home care. It appears that the country has not developed the supply of foster parents needed to shift the system toward home-based care. Argentina, with 86 percent of children separated from their families living in residential care, is only in the early stages of developing family-based foster care. In Israel, a system of residential facilities or “youth villages” developed as a means of social integration of immigrant groups, starting with survivors of the Holocaust. This system of residential care operates under the MInistry of Education. A separate child welfare system developed later under the Ministry of Labor, Social Affairs and Social Services, to serve the needs of maltreated children, and 63 percent of the children in this system are also in youth villages.
According to the editors, “[s]ocial pedagogy is grounded in a holistic understanding of the person and espouses participation, democratic processes, self-determination, and social and moral education within the context of everyday life as guiding values and principles for practice. Individualization (n contrast to standardization) and professional decision-making are further hallmarks of this approach.”