Tag: Child abuse deaths

A jumble of standards: How state and federal authorities have underestimated child maltreatment fatalities

This blog was originally prepared as a report for the project, Lives Cut Short: Children Who Have Died of Abuse and Neglect in the United States Since 2022, which is sponsored by the American Enterprise Institute and the University of North Carolina Chapel Hill. A PDF version appears on the project website.

The annual Child Maltreatment reports, produced by the Children’s Bureau of the U.S. Administration for Children and Families, are based on data that states submit to the National Child Abuse and Neglect (NCANDS) data system. These reports are eagerly anticipated in the child welfare policy community because they provide much of the data commonly used to quantify child maltreatment and the operations of child protective services around the country. The latest report, Child Maltreatment 2022 (CM2022), provides data for Federal Fiscal Year (FFY) 2022, which ended on September 30, 2022. This post discusses the findings on child maltreatment fatalities specifically. A more general discussion of the report is provided in a previous post. In general, this analysis shows the extent to which child maltreatment fatality numbers and rates reported by states reflect how they define and determine child maltreatment fatalities. This diversity makes it impossible to use these data to estimate the total number of fatalities, differences between state maltreatment fatality rates, and differences over time.  More specifically, several key points emerge from the analysis.

  1. States reported a total of approximately 1,990 fatalities to the federal government for Federal Fiscal Year 2022. Yet it is widely recognized that states’ reports to the federal government greatly underestimate the number of child fatalities due to maltreatment by most common definitions. States may use restrictive definitions, fail to consult all available sources, or decide not to investigate or substantiate some maltreatment related deaths. Information from the states’ commentaries to Child Maltreatment 2022 reveals great diversity in how they determine child maltreatment fatalities. In states where child death review (CDR) teams estimate the number of maltreatment deaths, their estimates are always higher than the NCANDS estimates, with some CDR estimates as much as twice, three times, or even ten times higher.
  2. CM2022 shows child fatalities increasing every year between FFY 2018 and FFY2022. But year-to-year changes should be approached with caution. Most states report for each fiscal year the number of maltreatment fatalities identified during that year, not the number that occurred during that year. However, at least two states, including the state with the largest number of children (California), report fatalities based on the year of occurrence and report additional deaths in subsequent years as they are identified. For this reason, even five-year trends shown in CM2022 may change over time. Adjusting for the changes in reports for these two states, reported child maltreatment fatalities have indeed been increasing since 2013. Several states report improvements over time in their ability to capture child maltreatment fatalities for NCANDS reporting. Thus, we do not know the extent to which this increase reflects improved reporting as opposed to increasing deaths from abuse or neglect.
  3. The data reported in CM2022 show that child maltreatment fatalities are concentrated in the youngest children and become less frequent as age increases. Boys are somewhat more likely to die of maltreatment than girls. Black children are much more likely to die of maltreatment than White or Hispanic children—two to three times as likely as White children, depending on the year. The broad category of “neglect,” defined as defined as “neglect or deprivation of necessities” was involved in 76 percent of child maltreatment fatalities while abuse was Involved in 42 percent. Another 8.3 percent of child maltreatment fatalities involved medical neglect.

The Number of Child Fatalities

 There is no standard mandated reporting system for child abuse or neglect deaths in this country. Definitions, investigative procedures, and reporting requirements vary from state to state. Attributing a child’s death to abuse rather than to an accident or natural cause is often extremely difficult. The death of a toddler who drowns in a bathtub, for example, may be classified as an accident in one jurisdiction or as a child neglect death in another.

Committee to Eliminate Child Abuse and Neglect Fatalities, Within Our Reach, 2016, https://www.acf.hhs.gov/sites/default/files/documents/cb/cecanf_final_report.pdf

Child Maltreatment 2022 (CM2022) reports an estimated total of 1,990 child maltreatment fatalities for FFY2022.1 But there is widespread agreement among experts that the annual estimates of child fatalities from NCANDS undercount the true number of deaths that are due to child maltreatment by a factor of two to three.2 The National Center on Child Fatality Review and Prevention lists several reasons why this occurs in a given jurisdiction. Jurisdictions may count only deaths substantiated as abuse or neglect using definitions from child welfare civil or criminal law, which may not be comprehensive. Some jurisdictions count only deaths for which the death certificate lists homicide or child maltreatment. Multiple data sources may not be used to identify possible maltreatment deaths. Accidental deaths that were made possible by egregious neglect are often not included,

To get states to use more data sources, the Child and Family Services Improvement and Innovation Act (P.L. 112-34) requires states to describe in their state plans all the sources used to compile information on child maltreatment deaths. To the extent that information from state vital statistics departments, child death review teams, law enforcement agencies and medical examiners or coroners is not included, states must explain the reason for the exclusion and how they plan to include this information in the future. However, this law is clearly not being enforced, and most states do not report using data from all these sources.

In the commentaries that almost all states provided with their NCANDS submissions (included at the end of CM2022), most report drawing on at least some sources external to the child welfare agency, but usually this information is accepted only as a report to the child protection hotline with an allegation of maltreatment. Only if investigated and substantiated by child protective services (CPS) are these deaths included in the counts provided to NCANDS. A few states report taking special measures to ensure that suspected child fatalities are reported to child welfare agencies. In Missouri, coroners and medical examiners are required by law to report all child fatalities to the child abuse hotline. In its commentary, Missouri suggests that it may appear to have a higher child fatality rate than other states because of this law, and indeed its child fatality rate is higher than that of most states. Indiana requires county coroners to report any “suspicious, unexpected, or unexplained” deaths to the Department of Child Services (DCS).  Idaho’s Division of Vital Statistics refers to CPS all child death cases for which the cause of death is homicide. (Except when a link or reference Is provided, information in this post is drawn from CM2022.)

Some state child welfare agencies have an internal fatality review unit that may add maltreatment fatalities to the state’s counts. Minnesota’s child welfare agency has a Critical Incident Review Team that reviews death certificates and directs local agencies to add fatalities that they find were due to abuse and neglect to the cases that they already substantiated. New Jersey’s Department of Children and Families’ Office of Quality maintains a critical incident review process that may add to NCANDS some deaths that were not substantiated as maltreatment by CPS.

A few states explain that they report to NCANDS fatalities that are determined to be maltreatment-related by agencies other than child welfare:3

  • California reports fatalities determined by medical examiners or coroners, and by law enforcement agencies, in addition to county child welfare agencies, to NCANDS.
  • Washington and New Mexico report to NCANDS child fatalities that were determined to be the result of abuse or neglect by a medical examiner that were not already known to CPS.
  • Alabama, Nebraska, and North Dakota add cases from child fatality review teams that were not already in their databases to their NCANDS reports.
  • South Carolina incorporates into its NCANDS submission additional cases received from the State Law Enforcement Division (SLED), which receives reports of all child deaths that were not the result of natural causes. SLED investigates all “preventable” cases and refers its findings to the Department of Social Services.

Since most states’ child welfare agencies report only fatalities substantiated as maltreatment by CPS to NCANDS, the number that are reported will depend in part on the state’s definition of a child maltreatment fatality. NCANDS defines a child maltreatment death as “the death of a child as a result of abuse or neglect, because either: (a) an injury resulting from the abuse or neglect was the cause of death; or (b) abuse and/or neglect were contributing factors to the cause of death.”4 But not all states use this definition. At least one state, Arizona, includes only fatalities where abuse or neglect was the sole cause of death, as described in more detail below. (Iowa indicated that it did not include fatalities where child maltreatment was only a contributing factor until FFY2015 and there may be other states that do the same.)

A state’s maltreatment fatality numbers will also depend on its tendency to accept child fatality referrals for investigation and to substantiate them. Hotline screening methods and tools differ by state, and states report little about their screening practices around child maltreatment fatalities. Ohio, which has a county-run system, reports that some county agencies will not investigate child fatality reports if there are no other children in the home or the other children are not deemed to be at risk of maltreatment. The likelihood of substantiation of a report once accepted for investigation will depend on a state’s standard of proof and other investigation policies, messages transmitted by agency leadership, and staffing issues.  My commentary about CM 2022 shows how much screening and substantiation rates for maltreatment reports differ by state, and there is no reason to think that fatality reports would be any different from other maltreatment reports. Variations in these rates, as well as the sources states draw from and the definitions they use, ensure that states’ child maltreatment fatality counts reflect much more than the actual number of maltreatment fatalities according to a given definition.

It is instructive to compare states’ maltreatment fatality rates displayed in CM2022 with their rankings on an index of child well-being such as the one used in the Annie E. Casey Foundation’s latest Kids Count Data Book. The 12 states with the highest rates of reported child maltreatment fatalities in CM2022 are Mississippi, South Dakota, Arkansas, Maryland, Alaska, Ohio, Missouri, New Mexico, North Carolina, Illinois, Indiana and South Carolina. Only four of these states are among the 12 states with the lowest rankings for overall child well-being, according to Kids Count. The 12 states with the lowest rankings on child maltreatment fatalities in CM2022 are Vermont, Montana, Nebraska, New Hampshire, Arizona, New Jersey, Rhode Island, Kansas, Kentucky, Utah, Maine, Utah and Hawaii.  Five of these states are also among the 12 states with the best child well-being outcomes, and another seven are not. Clearly a state’s rank on child well-being is not an accurate predictor of its rank in reported child maltreatment fatalities. This suggests that the fatality data may reflect more than actual child maltreatment deaths that meet the state’s definition. Particularly striking are the two states—Arizona and Kentucky—that are among those with the lowest reported child maltreatment rates and worst child outcomes. But it is worth noting that there are no states with top-tier child well-being outcomes that have bottom-tier reported child maltreatment fatality rates. Therefore, this exercise suggests that the state fatality rates may reflect in part the “true” incidence of maltreatment fatalities as defined by the states and in part how maltreatment fatalities are identified.

Arizona is one of the states with the lowest reported maltreatment fatality rates despite its low child well-being ranking. Serendipitously, it turns out that Arizona has another estimate of child maltreatment fatalities, thanks to its exceptional Child Maltreatment Fatality Team (CFRT), which is housed in the state’s health department. Arizona’s CFRT analyzes every child death, classifies it by cause and manner, and determines whether the death was caused by abuse or neglect. All child death certificates issued in the state are reviewed, first by the local team in the area where the child lived, and then by the statewide team. For Calendar Year 2022, the team calculated that there were 146 neglect or abuse deaths, or 17 percent of all child fatalities that year. Yet, the Arizona Department of Child Safety (DCS) reported only 14 fatalities to NCANDS for FFY 2022, resulting in its low reported maltreatment fatality rate of 0.88 per 100,000 children.

In its current Child and Family Services Plan, DCS reported that it receives information on all unreported child fatalities from local CFRT’s. But the agency explained that CFRT identifies many more fatalities than it does because CFRT includes deaths where maltreatment was believed to have “contributed” to the death rather than “caused it,” a distinction discussed above, But, as we have seen, the NCANDS Codebook defines a maltreatment death to include cases where abuse and/or neglect were contributing factors to the cause of death.” By not reporting such deaths, DCFS is failing to report all maltreatment fatalities as defined by NCANDS.5 

Arizona’s CFRT clearly has an expansive definition of maltreatment fatalities and probably errs on the side of finding maltreatment. Forty-four of the 146 maltreatment deaths it found (30 percent) were due to suffocation—apparently mainly unsafe sleep deaths. Another 15 (10 percent) were due to drowning. Most of these suffocation and drowning deaths were likely accidental. And as the quote at the top of this post indicates, one jurisdiction (or agency within a jurisdiction) may classify such a death as neglect and another may not.  Another ten percent of the CFRT-identified maltreatment deaths were due to prematurity caused by the mother’s substance abuse or other factors. Fifteen states (including Arizona) and the District of Columbia defined prenatal exposure to harm due to the mother’s abuse of an illegal drug or other substance as neglect as of May 2022. But DCS may not in practice investigate or substantiate such cases.6

The comparison with CFRT provides some insight on why Arizona reports such a low rate of maltreatment fatalities. Leaving out fatalities where maltreatment was a contributing factor and being less likely to find that accidents or premature births involve maltreatment, may help explain the difference between the two estimates. It is also worth noting that Arizona reported a steep drop in maltreatment fatalities from 48 in FFY 2018 to 33 in FFY2019 to 18 in FFY 2020 (followed by no fatalities reported in FFY2021 and 14 in FFY2022). Arizona provided no explanation for these reductions in its commentaries for FFY’s 2019, 2020, and 2022 and did not provide commentary for FFY2021. One cannot help but wonder whether DCS changed its methods or criteria or simply stopped investigating some allegations of child maltreatment fatalities.

In its publication mentioned above, the National Center for Child Fatality Review and Prevention notes that child death review (CDR) teams often identify more maltreatment deaths than states report to NCANDS. Among the reasons are the records from multiple disciplines and agencies are shared, additional information comes to light in the review process, CDR leads to improved investigations, and teams often use broader definitions for maltreatment, as we have seen for Arizona. CDR teams in most states do not review all child fatalities for a given year or identify those that were due to maltreatment, as Arizona does. But a review of the most recent state CDR reports in all states that published statewide reports yielded eight state CDR teams (including Arizona’s) that do such an analysis.  Table 1 shows the differences between the number of maltreatment fatalities identified and reported to NCANDS by child welfare agencies and the number identified by the CDR teams in these eight states in their most recent reports. All the CDR estimates are higher than the NCANDS reports, ranging from 50 percent higher in North Dakota to almost ten times as high in Arizona.

Table 1: Number of Child Maltreatment Fatalities Reported by NCANDS and by CDR
StateNCANDSCDRYear
Arizona141462022
Colorado24432020
Georgia921452021
Indiana62100-1282020
Missouri571982022
Nevada20802019
North Dakota692019
Tennessee43752019

Notes: The number of fatalities reported by the Georgia Child Fatality Review Panel was calculated by multiplying 500 (the number of deaths reviewed) by 28.9 percent, the proportion of reviewed deaths that the panel reported as having “maltreatment identified as causing or contributing to the death or had a reported history of maltreatment.” It was not possible to remove only those children with maltreatment history without losing some of the children who also had maltreatment causing or contributing to the deaths. The Indiana Child Fatality Review Committee did not provide a count of children for whom maltreatment contributed to their death but instead provided separate numbers for exposure to hazards, neglect, abuse, and poor or absent supervision. It was not possible to add these categories as some children may have experienced more than one of these maltreatment types. The committee did report that “poor supervision/exposure to hazards” contributed to the death of 100 children, which means that 100 is a lower-bound estimate of the number of children who died of abuse or neglect according to the committee. It reported that abuse contributed to the deaths of 13 children and neglect to the deaths of 15 children, so the upper-bound estimate is 128.
Table Sources: Arizona Child Fatality Review Team, Thirtieth Annual Report; Colorado Child Fatality Prevention System Data Dashboard; Georgia Child Fatality Review Panel Annual Report; Indiana Statewide Child Fatality Review Committee: 2020 Report on Child Deaths, Preventing Child Deaths in Missouri: The Missouri Child Fatality Review Program Annual Report for 2022; 2019 State of Nevada
Child Death Report, North Dakota Child Fatality Review Panel: Detailed Annual
Report 2017, 2018, & 2019; 2021 Child Fatality Annual Report: Understanding and Preventing Child Deaths in Tennessee.

In contrast to Arizona, Mississippi’s position in the ranking of child maltreatment fatalities is not a surprise. Being 48th in child well-being, the state also has the highest child maltreatment fatality rate—by far—at 10.62 per 100,000 children. But there is an anomaly. Mississippi’s maltreatment fatality rate is almost twice that of the state with the next highest rate. And it almost doubled between 2020 and 2022. Even assuming that Mississippi’s “real” maltreatment fatality rate is closer to the 5.48 per 100,000 it reported in FFY2020 still puts it second from the top of all states. It seems unlikely that Mississippi’s child maltreatment deaths doubled in two years; it is more plausible that something about the way the deaths were defined, identified, or reported changed.

This discussion has illustrated the impossibility of knowing the extent to which state maltreatment fatality numbers reflect real differences in child maltreatment fatalities versus differences in definition or measurement. But if states were consistent over time in their definitions and measures, the difference in fatality numbers over time could still be meaningful. Whether that is the case is discussed below.

Have child fatalities increased?

As mentioned above, CM2022 provides a national estimate of 1,990 children who died of abuse or neglect in FFY 2022 at a rate of 2.73 per 100,000 children in the population. Exhibit 4A from CM2022 shows an increase in reported child maltreatment every year between FFY2018 and FFY2022.7

Source: Child Maltreatment 2022, https://www.acf.hhs.gov/sites/default/files/documents/cb/cm2022.pdf

There are many reasons to be cautious about year-to-year comparisons of child fatalities. Those deaths reported in the 2022 report did not mainly occur in 2022. As CM2022 puts it, the “child fatality count in this report reflects the federal fiscal year (FFY) in which the deaths are determined as due to maltreatment,” rather than the year of death.8 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. States explain in their commentaries that the deaths they reported may have occurred as long as seven years before 2022. Because child fatalities are rare, a year-to-year increase, even in a larger state, may reflect a large fatality event that occurred in one year or a delay in determining several fatalities. For example, Illinois reported that an increase from 70 fatalities in FFY2018 to 106 in FFY 2019 resulted from the delayed completion of 15 death investigations and an incident that claimed the lives of ten children.

However, not all states report fatalities in the way described by CM2022. California, as it describes in its annual commentaries, reports for each federal fiscal year the deaths that occurred in the prior calendar year and were known to the state by December of the calendar year following the death. Because counties will continue to investigate fatalities that occurred in previous years, the state submits revised counts if additional fatalities from that calendar year are later determined to be caused by abuse or neglect. For example, California originally reported 135 fatalities in FFY2021, but that number had increased to 159 by FFY2022. Second-year changes were not as large for fatalities first reported in FFY2020 and FFY2021.

Knowing that at least one state changes its fatality data in the next year’s submission raises an intriguing question.  Even accepting that each state’s fatality count has its own meaning, can we even rely on Exhibit 4A in any given year to at least illustrate the trend in reported fatalities? It does not take long to answer that question. Exhibit 4A of CM2021 does not show maltreatment fatality rates increasing each year between FFY2018 and FFY2022, as does the same table in FFY2022. Instead, it shows a decrease in FFY2020 followed by an increase in FFY2021 to just slightly below the level of FFY2019.

Source: Child Maltreatment, 2021, https://www.acf.hhs.gov/sites/default/files/documents/cb/cm2021.pdf

Since each CM report shows five years of data, each year’s figures will eventually be shown in five different reports, starting as the most recent year displayed and ending as the earliest year. Table 2 shows the numbers of fatalities reported for FFY 2018 to FFY2022 in the CM report for each year. The figures for FFY2018 and FFY2019 changed two or three times in the succeeding years, but never by more than 10 deaths. Oddly, the number of deaths reported sometimes decreased from year to year. But the original numbers for FFY2020 and FFY2021 increased considerably in succeeding years. The total number of deaths reported for FFY2020 increased from 1,750 in that year to 1770 in FFY2021 and 1,850 in FFY2022. The total for FFY2021 increased from 1820 in that year to 1930 in FFY2022. Clearly, the 24 fatalities that California added in FFY2022 for the previous year are part of that increase, and presumably one or more other states did the same.  Inserting the new numbers into the table from CM 2021 now shows an increase every year between FFY2018 and FFY2021.

Table 2: Deaths Reported by Year Reported
Deaths in:Reported In:
 20182019202020212022
201817701780177017651765
2019 1840183018251825
2020  175017701850
2021   18201930
2022    1990
Source: Author’s compilation from Children’s Bureau child maltreatment reports. US Department of Health and Human Services, Administration for Children and Families, Children’s Bureau, “Child Maltreatment,” June 27, 2023, https://www.acf.hhs.gov/cb/data-research/
child-maltreatment.

A plot of the number of child fatalities reported between FFY2013 and FFY2022, using the most recent versions of each number, is shown below as Figure 1. Assuming the numbers for years before FFY2021 will change little if at all, we can see that reported child maltreatment fatalities have increased annually since FFY2013, aside from a slight decrease in FFY2017. And if the numbers from FFY2021 and FFY2022 will increase, as seems likely, the rise in fatalities in FFY2021 and FFY2022 will get steeper.

Source: Source: Author’s calculations using US Department of Health and Human Services, Administration for Children and Families, Children’s Bureau, “Child
Maltreatment,” June 27, 2023, https://www.acf.hhs.gov/cb/data-research/child-maltreatment

The critical question is whether this increase in reported child maltreatment fatalities reflects increasing maltreatment deaths, better measurement, or even changing definitions. Some states attribute increases in reported fatalities to improvements in the accuracy of their reporting.9

  • Through 2018,  North Carolina reported only child fatalities determined by the Chief Medical Examiner as homicide by a parent or caregiver. According to a Senior Media Relations Manager at the North Carolina Department of Health and Human Services, “Since 2018, Child Welfare has: developed closer working relationships with counterparts at OCME, utilized vital statistics data, and enhanced processes to include more law enforcement information. This work has increased our ability to identify maltreatment deaths, as defined in statute…[W]e have also continued to enhance our ability to track the information – resulting in more robust reporting and accounts for the change in numbers.” The Children’s Bureau noted in CM2022 that North Carolina “resubmitted data from multiple prior years to include additional fatalities.”  North Carolina’s reported child fatalities increased from 64 in FFY2018 to 111 in FFY2019, 99 in FFY 2020, 121 in FFY2021, and 93 in FFY2022.10
  • Mississippi reported that the creation of a special investigation unit for child fatalities in FFY 2014 resulted in an increase in reported child maltreatment fatalities in FFY2013, FFY2014, and FFY2015.  The state also reported that public awareness campaigns about deaths caused by unsafe sleep and deaths from heat stroke of children left in hot cars led to more reporting of such deaths as possible maltreatment starting in 2014.
  • West Virginia reported 20 fatalities in FFY 2016 compared to 9 in FFY2015 and attributed the increase to the fact that the state had begun investigating child fatalities in cases where there were no other children in the home.
  • Virginia attributed its increase from 37 maltreatment fatalities in FFY2014 to 54 in FFY 2015 to a change in the law regarding the timing of investigations. The time spent waiting to obtain documents from outside agencies, like autopsies, would no longer count toward the 45-day deadline for completing an investigation. (It is not clear whether child death investigations previously were terminated before these documents arrived, and therefore the deaths were not reported.)
  • Ohio reported in FFY2022 that it required mandated reporters participating on child fatality review boards to report suspected maltreatment fatalities to the local child welfare agency. Reported child maltreatment fatalities increased from 98 in FFY2021 to 115 in FFY 2022. But the state also attributed the fatality increase to the fact that the overall death rate from violence had been on the rise for the past several years, showing the difficulty of disentangling causes for any increase in maltreatment fatalities.
  • Iowa began reporting child fatalities where maltreatment was a contributing factor rather than the sole cause of the fatality in FFY 2015. Reported fatalities increased from 8 to 12 but those are small numbers, and Iowa attributes the increase to the growing under-18 population.

The increase in reported maltreatment fatalities clearly reflects at least in part improved reporting, as documented by some states. But it may also reflect an underlying increase in actual maltreatment fatalities as defined by the states. Such an increase could be due to several factors. Washington’s commentary in the FFY2022 report suggests that the opioid crisis has contributed to its increase in fatalities from 19 in FFY 2021 to 31 in FFY 2022.11 West Virginia also reported an increase in illegal drug use in its commentary to CM2016, probably referring to opioid abuse as well.12  Ohio mentioned increasing violence in recent years as a possible reason for the increase in reported child maltreatment fatalities.

Demographics, type of maltreatment, and perpetrators

We have already discussed the reasons that the child maltreatment fatality numbers may not be accurate, even given different definitions in different states. These problems affect our ability to draw conclusions about demographics and child maltreatment fatalities. If some of the definition and measurement issues affect different groups differently, it is possible that findings on demographics would be less meaningful.

The data presented in CM2022 shows that Infants under a year old are more than three times more likely to die of maltreatment than one-year-olds, and the fatality rate generally decreases with age. Younger children are more fragile, and there are many reasons to believe that the relationship between age and maltreatment fatality rates is correct, despite problems with the data. The age graph has a similar shape every year, with the percentage of child fatalities dropping as age increases.13  The percentage of victims who are under one year old varied between 22.8 percent and 25.3 percent between FFY2018 and FFY2022. There are bigger differences by year in the older age groups, where smaller numbers make the data less reliable.

Boys were between 57 percent and 60 percent of the fatalities in every year between FFY2018 and FFY2022. In contrast, victims of child maltreatment in general, are slightly more likely to be girls.  It is hard to imagine a reason why data problems would affect boys and girls differently, so it is likely that boys are more likely than girls to die from maltreatment.

Reported child maltreatment fatality rates varied greatly by race and ethnicity, and the differences among the larger groups were fairly stable over the five years since FFY2018. Black children had by far the highest maltreatment fatality rate of all the groups for whom information was available. The fatality maltreatment rate for Black children ranged from 5.06 to 6.37 per 100,000 children over the five-year period. Reported maltreatment fatality rates ranged from 3.27 to 4.40 for children of two or more races. White children reportedly died from maltreatment at a rate between 1.90 and 2.18 per 100,000 children, Hispanic children at a rate from 1.44 to 1.89. (The numbers of Native American, Native Hawaiian, and Asian children were too small to be reliable). The reported maltreatment fatality rate for Black children was two to three times as high as the rate for White children, which was always somewhat higher than the rate for Hispanic children. The rates from CM2022 are shown in Exhibit 4-D, reproduced below.

Source: Child Maltreatment, 2022, https://www.acf.hhs.gov/sites/default/files/documents/cb/cm2022.pdf

The question of bias must be addressed in evaluating racial and ethnic differences in reported child fatality rates. We have seen that fatality numbers reported by states generally reflect the results of a CPS investigation or a determination by a coroner, medical examiner, or fatality review team. It is possible that racial bias could play a role in whether a fatality is substantiated as due to maltreatment. But Drake et al. found that indicators of risk and harm for Black children were usually between two and three times greater than those for White children in 2019, while the Black-White homicide disparity was four times as great as that for White children.14  While we cannot rule out any role for bias, it is unlikely to be the main cause of the Black-White disparities in child maltreatment fatalities. As Drake et al suggest, they are more likely to stem from the legacy of slavery, Jim Crow, and segregation, which includes intergenerational poverty and the relegation of poor Black families to disadvantaged and often dangerous neighborhoods.

For each fatality, NCANDS collects the types of maltreatment that were substantiated. The authors note that “while these maltreatment types likely contributed to the cause of death, NCANDS does not have a field for collecting the official cause of death.” One child can be found to have suffered more than one type of maltreatment. Over three quarters (76.4 percent) of the children who died were found to have suffered from “neglect” (defined as “neglect or deprivation of necessities” in the Codebook), 42.1 percent were found to have endured physical abuse, 8.3 percent were found to have suffered from medical neglect, and 2.4 percent from sexual abuse.

Most of the perpetrators of reported child maltreatment fatalities were parents, according to NCANDS data submitted by 43 states.  A total of 81.8 percent of the maltreatment fatalities involved “one or more parents acting alone, together, or with other individuals. That includes mothers alone in 13.2 percent of the death, fathers alone in 14.5 percent, “two parents of known sex” in 23.2 percent of the fatalities, and mothers with nonparents (such as boyfriends) in 10.3 percent of the cases. Another 13.2 percent of the fatalities involved nonparents only, including relatives (4.7 percent), “child daycare providers” (1.3 percent), unmarried partners of the parent (1.1 percent), and “other” (3.4 percent). A final 4.9 percent of the fatalities involved unknown perpetrators only. (See Table 4-4 of CM 2022 for all the categories, numbers and percentages).

CM 2022 was originally published on the Children’s Bureau website early in January 2024 without a press release; it then disappeared from the website for about three weeks. It is hard to avoid speculating about the reasons for its removal and the gap before it was finally replaced. One might wonder if officials were trying to figure out how to spin the five years of increase in reported fatalities. Strangely, the press release, when it did come out, reported the increase in child maltreatment fatalities without raising the possibility that changes in how fatalities were defined and measured could have contributed to this increase, which might have supported their optimistic narrative.

In summary, this analysis shows how difficult it is to make any conclusions based on the child maltreatment fatality data contained in the Children’s Bureau’s annual Child Maltreatment reports. Single-year numbers cannot be fairly compared between states because they reflect different ways of defining child maltreatment fatalities, learning of fatalities that may involve maltreatment, and determining whether maltreatment was a contributing factor. Trends over time are difficult to assess because states often change these definitions and practices, and because new data from previous years may be entered after each year’s report is published. There is evidence that improved reporting has contributed significantly to the increase in reported fatalities. But until the federal government imposes a uniform set of standards for counting child abuse and neglect fatalities as recommended by the Committee to Eliminate Child Abuse and Neglect Fatalities, it will be impossible to get a handle on actual levels and trends.

Notes

  1. This estimate is based on the reports of 51 jurisdictions including the District of Columbia, Puerto Rico, and all states but Massachusetts. The maltreatment fatality rate for the reporting jurisdictions was multiplied by the population of all 50 states, the District of Columbia, and Puerto Rico, to obtain the estimate of 1,990.
  2. US Government Accounting Office (2011). Child Maltreatment: Strengthening National Data on Child Fatalities Could Aid in Prevention. Washington, DC; Schnitzer P, Covington T, Wirtz J, Verhoek-Oftedahl W, Palusci V. (2007). Public Health Surveillance of Fatal Child Maltreatment: Analysis of 3 State Programs. American Journal of Public Health. 97:7; Herman-Giddens ME, Brown G, Verbiest S, et al. (199() Underascertainment of child abuse mortality in the United States. JAMA. 282:463–467; Crume TL, DiGuiseppi C, Byers T, Sirotnak AP, Garrett CJ. (2002). Underascertainment of child maltreatment fatalities by death certificates, 1990–1998. Pediatrics. 110(2 pt 1):18.
  3. In contrast to those states that augment their own data with that of other agencies, Alaska delegates the entire process of determining whether a fatality involves maltreatment to medical examiners or coroners.
  4. CAPTA defines maltreatment in part as “an act or failure to act on the part of a parent or caretaker,” but it does not define “caretaker.” There may be some differences among states on who they define as a caretaker, but these are unlikely to affect many cases and cause big differences between states.
  5. DCS also says that CFRT’s fatality count is higher because it counts fatalities caused by a person other than the parent, caregiver, or custodian (which would not normally be counted). Based on CFRT’s tabulations regarding caregivers, this does not seem to be a large issue.  DCS also state that the CFRT counts deaths that occur outside the state’s jurisdiction, such as on an Indian reservations. It is true that CFRT includes any death that occurs in Arizona, even if the child is not a state resident. However out-of-state residents were only three percent of the total number of fatalities in 2022, according to its most recent report, Ten percent of the children who died of all causes were American Indians but they do not report on how many lived on reservations.
  6. The remaining deaths that CFRT identified were due to motor vehicle and other transport (14), poisoning (13), other medical causes (12), blunt force injury (10), undetermined (9) causes, firearm injury (8), and other injury (6). Many of these deaths could also be due to accidents that DCS was reluctant to investigate or find neglectful.
  7. Exhibit 4A counts the District of Columbia and Puerto Rico as states, resulting in up to 52 “reporting states” per year.
  8. Child Maltreatment 2022, p.  52.
  9. Other states report improvements in their data collection, but their data do not suggest that they had a long-term beyond one year on fatality numbers. In FFY 2020, New York reported that it began reporting all fatalities, regardless of date of death, as long as the investigation ended during the reporting period and the fatality had not been reported during a prior year. Before that time, New York reported only those deaths that occurred and were reported in the applicable FFY. New York attributed the increase in the number of fatalities from 69 in FFY 2019 to 105 in FFY 2020 to this change. Perhaps the increase came from reporting an extra “batch” of fatalities in FFY2020. However, the state had reported 118 fatalities in 2018. And it then reported 126 in FFY2021 and 105 in FFY2022, so it is hard to understand how the change resulted in an increase in fatalities reported, except as compared to a year with abnormally few of them. When fatalities rose sharply in Mississippi from 49  in FFY2021 to 72 in FFY2022; the state again used the creation of the special unit in FFY 2014 to explain the increase, but that seems unlikely. I have asked West Virginia to speculate about reasons for the increase but have not yet heard from the state. In FYF2019 or perhaps FFY2018 (when the state did not submit commentary), South Carolina created a special unit to receive and investigate reports of child fatalities. The number of fatalities reported jumped from 39 in FFY2018 to 60 in FFY2019. But it then fell to 36 in FFY 2020, 41 in FFY2021, and 38 in FFY2022. So it is does not appear that the creation of the special unit had a long term effect on maltreatment fatality counts.
  10. North Carolina provided revised numbers for FFY2018 and FFY2019 to NCANDS and provided them to me through their press office
  11. Washington reports that between FFY 2021 and FFY 2022 the percentage of child fatalities in the state that were due to opioid ingestion or overdose rose from less than one percent to 23 percent of child fatalities. Of the deaths and near-fatalities that qualified for a review because they occurred in families touched by the system in the previous year, that percentage jumped from 28 to 44 percent. 
  12. In its Commentary, West Virginia stated that only one of the 13 fatalities reviewed by its critical incident team did not involve substance abuse as a factor either in the death or the family’s history.
  13. However, it must be reported Exhibit 4-B, Child Fatalities by Age, appears to be inaccurate. It looks very different from every other year, with much higher rates for older children. There is no way that the fatality rate per 100,000 17 year olds would increase from 0.42 to 3.3, from 0.57 to 5.0, for example. It looks almost, but not exactly, like Exhibit 3-D, which shows child maltreatment victims (not deaths) by age. The Children’s Bureau referred my inquiry of March 21 to the “appropriate team,” which has not yet responded.
  14. Brett Drake et al., “Racial/Ethnic Differences in Child Protective Services Reporting, Substantiation, and Placement, With Comparison to Non-CPS Risks and Outcomes: 2005-2019. Child Maltreatment 2023, Vol 0(0) 1-17.

Where is the outrage at the death of Chase Allen in Detroit?

Source: The Mirror

On June 24, the decomposing body of Chase (also spelled Chayse or Chayce) Allen was discovered in a freezer in the basement of a rundown house in Detroit. It did not take long for the media to learn that Chase’s mother had a history of child abuse, including a conviction in court, resulting in the removal of all six of her children by Children’s Protective Services (CPS). Nevertheless the children were returned over the objections of their grandmother and aunts, whose continued calls to the hotline to report suspected incidents of abuse were to no avail. The last time CPS came out in response to one of their calls, it was too late to save Chase. Shockingly, media interest in this story dropped off after a few days, and legislators and community activists have been totally silent. There have been no demonstrations, no vigils, nobody demanding justice for Chase. One doesn’t have to look far for the reason for this appalling lack of concern. Chase’s story does not fit into the prevailing narrative, which features CPS wresting Black children from their loving parents simply because they are poor.

The discovery of Chase’s body was first reported by media outlets including the Detroit News on June 24. On June 26, Channel 7 and others reported that Chase’s mother, Azuradee France, was charged with first-degree murder, child abuse and torture and concealing the death of an individual, and was jailed. In the next few days, the Detroit News reported that France had a history with the Children’s Services Division of MDHHS dating back at least to 2017 and had been involved with the agency at least seven times as a parent. She had been arrested and convicted for child abuse of a nephew for whom she was caring temporarily, serving two years of probation, and her children had been removed from her. When she gave birth to a fifth child in 2020, MDHHS obtained a court order to take custody of that child, citing her failure to address the conditions (including untreated mental illness) that brought her children into care. Nevertheless, all five children were inexplicably returned to her only three months later, and she apparently gave birth to a sixth child about two months ago. Relatives reported making multiple calls to the child abuse hotline since the return of the children. One visit, due to a burn to Chase, resulted in no action by CPS; the next visit in response to a CPS call resulted in the finding of Chase’s body.

The last bit of media coverage appeared on July 3, when Karen Drew of Channel 4 reported on Chase’s grandmother’s belief that CPS could have prevented his death if he had not been returned to his mother. But since July 3, Chase’s story appears to have totally disappeared. Shockingly, there is no mention of Chase on the website of the city’s paper of record, the Detroit Free Press and the Metro Desk did not respond to a tip from this writer. And amazingly there has been no coverage anywhere of the preliminary court hearings on the case. Even worse, there has been no response to the tragedy from the Detroit City Council, the Michigan Legislature, or community activists.

Is Chase’s story an outlier? Not likely. Several families and attorneys told Kara Berg of the Lansing State Journal earlier this year that Michigan children are often left in abusive households due to inadequate investigations and a failure to act by state employees. An audit of CPS investigations in Michigan published in 2018 by the Michigan Auditor General found that MDHHS’s efforts to ensure “the appropriate and consistent application of selected investigation requirements” such as starting investigations in a timely manner, conducting required child abuse and criminal history checks of adults in the home, and assessing the risk of harm to children were “not sufficient” and that ineffective supervisory review of investigations contributed to the deficiencies they found. Such an inadequate response to children’s suffering almost invariably results in lifelong damage to children, but can also result in severe injury or death as in Chase’s case. Michigan reported 43 children died of abuse or neglect in 2020 (undoubtedly a gross underestimate1) but was not able to report how many of these children were known to CPS. Nationally, the Commission to Eliminate Child Abuse and Neglect Fatalities estimated that one-third-to one half of children killed by maltreatment were known to CPS.2

So what is the explanation for this lack of outrage about Chase’s death, given that evidence of problems already exists? In the wake of George Floyd’s murder, the ensuing “racial reckoning,” and the movement to defund the police, a parallel narrative and associated movement has sprung up in child welfare. Funded by deep-pocketed foundations led by Casey Family Programs and embraced by the US Administration for Children and Families, this narrative portrays CPS as a “family policing system“ that wrests helpless children from parents only because they are poor. Perpetrators of this narrative have devoted obsessive attention to the disparities in the proportion of Black and White children who are involved with the child welfare system at every stage–reporting, investigation, case opening and child removal. There is a problem with this analysis. The evidence suggests that Black children’s higher likelihood of being reported, investigated and removed reflects their higher tendency to be abused and neglected. Reducing their involvement in the system to a rate comparable to that of White children would mean to establish separate, lower standards for the safety of Black children.

But nowadays there appears to be little concern about Black children who are killed by their parents. B As one Black woman told reporter Kara Berg of the Lansing State Journal about her failure to interest CPS on the neglect and sexual abuse of her nephew, “They think this is how Black children are supposed to live.” What could be more racist than disregarding Black children’s suffering and deaths at the hands of their parents, when such suffering and death would be cause for massive protest if it happened to White children? Do Black lives matter only when taken by a White police officer, and not by a Black parent?

If Black lives matter, then surely Black children’s lives matter. More than twice as many Black children are killed by their parents every year as the total number of Black people of all ages killed by police. in 2020, 504 Black children were killed by parental or caregiver abuse or neglect, according to annual child maltreatment report of the US Children’s Bureau, which is widely considered to be an understatement of the actual number of child fatalities.3 That is more than twice the number (243) of Black people of all ages who were killed by police in the same year, according to the Washington Post‘s police shootings database.

The lack of public outrage at the death of yet another Black child means there is no pressure on MDHHS to release information on Chase’s family’s history with its children’s services division. A public information officer for MDHHS has told WXYZ (Channel 7) Detroit, that “The department, by law, cannot release specifics about Children’s Protection Services (CPS) investigations or confirm whether or not CPS has received complaints about a specific family or individual.” The exact opposite is true. The agency is actually required to release certain information in a child abuse or neglect case in which a child who was a part of the case has died.” That information includes anything in the case record related specifically to the department’s actions in responding to a complaint of child abuse or child neglect.”3

The public needs access to the case files in order to understand what went wrong and what policies and practices need to be changed. In addition, the case files are necessary to ensure that public officials, including investigators, supervisors, and court personnel, are held accountable for their decisions. Some of the many questions that need answers include the following:

  • What caused Chase to go blind? (Relatives indicated he lost his sight “over a year ago.”) Was this the result of some sort of maltreatment? Was he targeted for abuse because he was disabled? Did CPS ever ask these questions?
  • Why were the children returned to their mother three months after MDHHS filed a petition to take custody of the newest baby she was deemed to be far from ready to parent them? And did the juvenile court referee named by Channel 7 and the Detroit News make this decision at the behest of MDHHS or against its recommendation?
  • The children were returned to their mother “under the supervision of the department,” according to the court record cited by the Detroit News. Exactly what did this supervision consist of? How long did it last? Who agreed to the end of supervision and why? What does the record state about the mother’s improvement and readiness to parent? What “intensive reunification supports” were provided?.
  • Why did CPS take no action after the most recent report, when the grandmother reported that three CPS investigators came to the home?
  • How many calls from Chase’s family were screened out and did not even receive an investigation?

Receiving no response to my emails to local reporters urging them to request the the files on MDHHS’s involvement with Chase and his family, I contacted the agency’s public information office on July 11 to make the request. On July 25, I received a denial of my request based in part on the fact that the investigation of Chase’s death is not complete. It is unclear why the fact of an incomplete investigation is a reason for the denial of my request; the agency could send me the records of all previous investigations now and I would be happy to wait for the latest one. It’s a shame that several media outlets, who have attorneys who can appeal decisions by agencies to withhold information, did not choose to seek this information. Readers can help by sharing this post with their contacts in Michigan and asking them to urge their state and local legislators to demand answers.

The reaction, or lack thereof, to the death of Chase Allen shows a blatant disregard for Black children’s suffering and death at the hands of parents or caregivers, in large part because it does not fit within the prevailing narrative of CPS snatching children from loving Black parents. Anyone who believes Black lives matter should be asking why CPS and the courts left this vulnerable child unprotected in such a dangerous home. We’ve already let Chase die. Let us at least learn from his death how to save children in similar situations.

Endnotes

  1. This is almost certainly an understatement for several reasons. As Michigan describes in its notes for the 2020 Child Maltreatment report, only deaths that are found to be due to maltreatment by a CPS investigation are counted. Second, the count of 43 is considerably lower than the estimates for previous years (63 in 2019, for example), suggesting that the Covid pandemic delayed completion of child death investigations by CPS.
  2. See footnote 14 on page 35 of Within Our Reach: A National Strategy to Eliminate Child Abuse and Neglect Fatalities.
  3. As reported by the Commission to Eliminate Child Abuse and Neglect Fatalities in its final report, this number is considered to be an understatement because not all states currently report on fatalities and in some states the death is not reported to the federal system if the child was not known to the CPS agency.
  4. MCLS Section 722.627c states that “The director shall release specified information in a child abuse or neglect case in which a child who was a part of the case has died.” “Specified information” is defined in Section 722.622bb  as “information in a children’s protective services case record related specifically to the department’s actions in responding to a complaint of child abuse or child neglect.”

The murder of Thomas Valva: Another innocent child betrayed by Family Court and CPS

Thomas Valva funeralIt’s happened again. Another child is dead after being removed from a loving mother and placed with an abusive father. Another child is dead after more than 20 reports from school officials concerned about his treatment at home. Another child is dead after a judge and child protection workers made the wrong decisions over and over again.

On January 17, as reported by Newsday and other media outlets, police responded to a 911 call at the home of NYPD Officer Michael Valva and his fiancee Angela Pollina in East Moriches, Long Island. The caller stated that eight-year-old Thomas Valva, who had autism, had fallen in the driveway. Police soon learned that there was no fall in the driveway. The night before he died, Thomas and his brother were forced to sleep on the concrete floor of their family’s unheated garage, while outside temperatures fell to 19 degrees, Thomas’ body temperature was 76 degrees at the time of his death in the hospital. A chilling recording obtained by the police records the father mocking his dying son, who repeatedly fell when trying to walk, jeering that he was”cold, boo-[expletive]-hoo.” Valva and Pollina were arrested and charged with second-degree murder, among other crimes. They have pleaded not guilty and are being held without bail.

The facts stated above are clear, but the chronology below had to be pieced together from multiple articles in the media, each containing part of the puzzle. Many questions still remain.

The Family Court Places Thomas in Harm’s Way

A decision by Nassau County Supreme Court Judge Hope Schwartz Zimmerman in the divorce case between Thomas’ parents set the stage for the tragedy. On September 17, 2017, she took Thomas and his two brothers away from their mother, Justyna Zubko-Valva, and placed them with their abusive father and his fiancee, Angela Pollina, who also had three girls. Based on court records obtained by Eyewitness News reporter Kristin Thorne, the judge had ordered forensic evaluations of both parents, a normal procedure in a custody case. But Justina Zubko-Valva, Thomas’ mother, refused to be interviewed by the psychologist without being able to tape the session. Due to the “sensitive nature of the testing materials,” the evaluator refused this request and the evaluation was not done.

It is not clear why Zubka-Valva insisted on a videotape of the interview, but she has indicated on Twitter and elsewhere her conviction that there was a conspiracy against her. She and her children paid a high price for her choice. The judge told the court, according to the court papers obtained by Eyewitness News, that “There’s certain things that have to be done in terms of preparing this case for trial … and until that happens I can’t have the trial. So I’m awarding temporary, temporary custody of the children to the father.” The Judge’s reasoning is unclear from the quotes provided by Eyewitness News, but the most plausible explanation is that she gave custody to Valva in order to pressure Zubko-Valva to submit to the evaluation. If that was her goal, it was certainly improper (as children should never be treated as tools to gain a parent’s compliance), and it certainly did not achieve its intended effect.

Ms. Zubko-Valva was by most accounts a devoted mother.  She trekked daily to Manhattan to bring her autistic sons to a special school. Struggling to provide for her children with minimal support from Mr. Valva after their separation, she had taken a job as a correctional officer to make ends meet and keep them on the same health insurance plan as they had before.  Dr. Kim Berens, a behavioral psychologist who worked with the boys told the Daily Beast that Ms. Valva “one of the one of the most loving, caring, devoted mothers I’ve ever met.” The children’s pediatrician and the neuropsychiatrist who examined both boys also praised Ms. Valva. Judge Zimmerman never got to hear from them thanks to Ms. Zubko-Valva’s own refusal to submit to the court-ordered evaluation.

CPS Seals Thomas’ Fate

The decision to place Thomas with his father opened the door to his murder, But it was the egregious failure of Nassau County Child Protective Services (CPS) over the succeeding two years that sealed Thomas’ fate.  After Valva and Pollina gained custody of the boys, they were apparently able to coach them to accuse their mother of abuse. By October 2017, Zubko-Valva was being investigated for child abuse. It appears that CPS actually substantiated the trumped-up charges and brought her to “trial”1 for abuse. The charges were dismissed in April 2018. Thus, the “temporary, temporary” custody stretched to become a long-term arrangement as Ms Zubko-Valva was apparently denied even visitation with her children once the abuse charges were filed or substantiated by CPS.

In the meantime, calls began streaming in from the boys’ school public school, where Valva had moved them from their special program in Manhattan immediately upon gaining custody. The New York Daily News obtained records of “some 20 calls” from Thomas’s teachers while he was living with Valva and Pollina. The calls reported that Thomas and his brother Anthony, who is also autistic, missed school for two or three days at a time, showed signs of physical abuse, and often arrived in school hungry and dirty.

The Daily News found that at least one abuse allegation (that Thomas had a black eye) was substantiated against Valva and Pollina but that CPS concluded that it did “not rise to the level of immediate or impending danger of serious harm. No controlling interventions are necessary at this time.” Another report alleged that Anthony had been coming to school with his backpack soaked in urine. “As a result of the child being soaked in urine, he has a foul odor and he is extremely cold,” the report continued.

Another call reported that Thomas had a welt on his forehead caused when Michael Valva threw a backpack at him. The report continues that Valva “refused to let the two boys be interviewed at school, where they might have felt freer to speak, or to allow the other children in the home to be interviewed.” However, the New York State Child Protective Services Manual states that if CPS is refused access to the home or to any child in the household “the CPS worker, in consultation with a CPS supervisor, must assess within 24 hours of the refusal whether it is necessary to seek a court order to obtain access.” Allowing an abusive parent to deny access to his children effectively neutralizes CPS’s ability to investigate. Why did CPS fail to follow its own procedures?

At least one allegation apparently resulted in CPS monitoring Valva  for a year under a court order that also required him to take parenting classes and “refrain from harmful activities,” according to Newsday. This order was apparently imposed by Suffolk County family court judge, Bernard Cheng, who was also presiding over the child abuse trial of Zubko-Valva, according to the Daily News. (The divorce case with Judge Zimmerman was in Nassau County Supreme Court). But the case closed and the children were left to their fate. It appears that Judge Cheng sensed that something was badly wrong in the Valva household but felt his hands were tied. The Daily News cites the Judge expressing concern in February 2019 about several issues:

  • Anthony arrived at an interview walking bent over at the waist and complaining his backside was sore. His school reported that he arrived with injuries so severe from beatings that officials needed to ice down his buttocks and upper thighs. Judge Cheng indicated that Anthony said that  “his father told him to say he does not get hit at his house.”
  • Ten-year-old Anthony had lost six pounds in one month, and Thomas gained just four pounds in the 12 months of 2018.
  • Teachers at the boys’ school told investigators that the children could not concentrate due to hunger and were looking for food in garbage cans or off the floor.
  • In his April 12 decision dismissing the charges against Ms. Zubko-Valva, the Judge stated that he found the father’s denials of abuse “less than credible,” since his testimony changed when he was asked for more detailed accounts.

But, despite expressing all of these serious concerns, the judge took no action to protect the boys. The attorney for CPS argued at the February hearing that the concerns brought up were “non-issues.” Judge Cheng disagreed with him, stating that the concerns were valid. He also stated, with more knowledge of child development than CPS, that “deterioration in [Anthony’s] level of functioning suggests that his needs are not being met.” But he said he had to rely on the opinions of CPS investigators. This statement is confusing to this former social worker who has more than once been overruled by a Family Court judge. It is hard to say what is more astonishing: that Judge Cheng was aware of so much credible evidence of abuse and did not order the removal of the children despite CPS’s opinion, or that CPS thought the children should be left in this lethal home.

Justyna Zubka-Valva has custody of her surviving two sons now. She was granted that custody by another judge at an emergency hearing following Thomas’ death. But it was too late for Thomas. Inquiries are underway into Judge Zimmerman’s conduct in the case as well as the actions of CPS.

Why were Thomas and his brothers not protected?

More information is necessary to make conclusions about why the system failed. The factors that affected the court case–Ms. Zubko-Valva’s intransigence and the Judge’s inappropriate response–may be specific to this one case.  But widely-known systemic issues with CPS appear to have played into this tragedy.

High CPS Caseloads: As in many jurisdictions, Suffolk County CPS caseloads are too high, with the average caseload at 17.9 per worker at the beginning of 2019, declining to 12.4 by the end of the year, and several caseworker handling more than 30 cases a month. The Child Welfare League of America recommends that CPS workers carry no more than 12 cases at a time.  In addition, Nassau County CPS workers complain that they spend too much time on paperwork instead of investigating allegations–a complaint that this former social worker heartily endorses.

Making it difficult to substantiate abuse: But the overwhelmed CPS explanation can only take us so far. The head of the union representing social workers told CBS-New York that workers did what they were supposed to do in Thomas’s case but their hands were tied. “You can’t remove a child from a parent without having clear cut evidence as supported by the law that will be upheld by the judicial system,” he said.  It is hard to believe that CPS did not consider it had such evidence–and that makes one wonder if a policy of quelling such findings was being imposed from on high. A chilling comment by Jeanette Feingold, director of Suffolk County Child Protective Services illustrates the issue. At an emotional legislative hearing covered by Newsday, she said “We don’t want to take these children. We want to build these families…. We’re not there to rip families apart.” I’ve written before about the exaggerated emphasis on family preservation that has taken hold in most child welfare systems. But with the mother being the primary parent for most of her older children’s lives, it is hard to understand the preference by CPS for Mr. Valva over his wife. 

The need for an independent review

Multiple reviews of judicial and agency conduct are underway, but they may never be available to the public. Or they may end up whitewashing official conduct, like the recent review of child welfare agency responsibility for  the death of Noah Cuatro in Los Angeles. Needed is an independent agency such as the Inspector General for the Department of Children and Family Services in Illinois, which reviews such cases and publishes detailed summaries that are redacted to preserve the confidentiality of living children and innocent adults.

Some analysts say the focus on fatalities is not useful because they are atypical. I disagree. Fatalities and other extreme cases are the tip of the iceberg that is the total universe of abused children. For every fatality, we have no idea how many other children are living with pain and fear even though child welfare agencies or courts have been alerted. These same judges and social workers operating under the same laws and policies hold the fates of hundreds of other children in their hands every year.

A repeating story in New York

Moreover, this cases are not as atypical as one might think. Within two weeks of Thomas’ death, the deaths of two other little boys from abuse after being abandoned by the state made it to the pages of the New York Times. In New York City, Teshawn Watkins was arrested late in January for murdering his six-week old son, Kaseem, after video was found showing him smothering the infant with a pillow. Now New York City’s Administration on Children’s Services (ACS) is facing questions about why the infant was not protected despite his father’s known history of abuse. It turns out that not only was Watkins arrested twice for assaulting the baby’s mother, but he has been investigated four times for child abuse, including a broken leg suffered by one of his two other sons. The two older brothers (now ages 3 and 4) were actually placed in foster care until the police found no evidence of the infant’s abuse. Watkins is being held without bail on Riker’s Island, where ironically Justina Zubka-Valva is a correctional officer.

In the same week, the ACS’ failure to protect another little boy was on display: Rysheim Smith was convicted for the murder of six-year-old Zymere Perkins after ACS disregarded numerous reports that the little boy was repeatedly injured and in constant danger from his mother’s violent boyfriend.  The case shocked the city in 2016 and led to a raft of reforms that apparently failed to protect tiny Kaseem. The New York Times reported on Smith’s conviction for killing Zymere on January 15, Thomas’ death on January 24, and baby Kaseem’s death on February 7. All of the articles were by different reporters. Nobody at the paper seems to be putting the pieces together to expose what appears to be a crisis of children abandoned by the state.

We need to pay attention to these egregious cases for at least two reasons. Only by finding out what went wrong in these cases  can we know how to change policy and practice to prevent future tragedies. But we also need accountability. I’m tired of hearing that we don’t want to punish people or create a climate of fear. It’s not about punishment. It’s about removing people who should not have custody over children’s lives.

This post was updated on February 13, 2020.

 

 

  1. The term “trial” connotes what is called a “neglect trial,” not a criminal trial. ↩

When will they ever learn? Another little boy dead on DCFS’ watch in Antelope Valley

NoahCuatro
Image: losangeles.cbslocal.com

Another little boy is dead in Los Angeles County after being left in the hands of his abusers by the Los Angeles County Department of Child and Family Services (DCFS). This time, the victim was four-year-old Noah Cuatro. Noah’s family had been the subject of at least 13 calls to the county’s child abuse hotline. He had been removed from his abusive parents for two years but was returned to him less than two months before he was killed.

Noah’s death is the third since 2013 of child who had been the subject of multiple reports and investigations by child welfare authorities in the remote Antelope Valley of Los Angeles County. In June, 2018, Anthony Avilas was tortured to death by his mother and her boyfriend, who are facing capital murder charges. In 2013, eight-year-old Gabriel Fernandez suffered the same fate. His mother is serving a life sentence and her boyfriend is on death row.

At least 13 calls had been made to the county’s child abuse hotline alleging that Noah’s parents were abusing their children, according to a devastating article in the Los Angeles Times.

Although the case file has not been released, sources revealed some of the contents to the Times reporters. In 2014, DCFS substantiated an allegation that Noah’s mother had fractured the skull of another child. In 2016, Noah was removed from his home and remained in foster care for two years. He was ultimately placed with his great-grandmother, who states that she often told DCPS social workers about concerning behavior her granddaughter displayed at her visits with Noah. She also claims that Noah begged her not to let him go.

Once Noah returned home, reports of abuse continued to be phoned in in February, March, April and May 2019. One report alleged that Noah was brought to the hospital with bruises on his back. A report on May 13 alleged that his father had a drinking problem, was seen kicking his wife and children in public, and sometimes when drinking voiced his doubt that Noah was his child.

At least one DCFS social worker took these reports seriously. On May 14, sources told the Times, she filed a 26-page report to the court requesting an order to remove Noah from his parents. And the judge granted that report the next day. But weeks went by–and the order was not implemented, even after new allegations came in that Noah had been sodomized and had injuries to his rectum. Noah died on July 6, more than seven weeks after the order was granted.

We do not know why Noah was not removed, because state law requires that the agency conduct its own investigation before the case file can be released in child fatality cases. We do know from another Los Angeles Times article that DCFS has already changed its policy on court removal orders to say that such a delay should be an “extreme exception” and must be brought to the director of the agency and approved by his Senior Executive Team.

Why so many tragedies in the Antelope Valley? Given its small population, Antelope Valley has a disproportionate number of deaths caused by a parent or caregiver of children already known to DCFS. according to calculations by the Chronicle of Social Change. Nobody knows if this higher death rate is due to cultural or economic features of the area or to challenges in staffing DCFS. Difficulties in attracting and retaining staff in this remote part of the county have been described in numerous reports, most recently an audit of DCFS and a report on the death of Anthony Avalos.

On July 23, the Los Angeles County Board of Supervisors unanimously approved a motion requiring DCFS to work with other agencies and educational institutions to develop a staffing plan to alleviate staff shortages and turnover in the Antelope Valley. I It also directs DCFS to immediately develop a Continuous Quality Improvement Section and fill approximately 20 positions which will allow for increased case reviews, initially focused on the Antelope Valley section. 

These are good steps that are surely needed, given the staffing problems in Antelope Valley. However, until we know the reason the court order requiring Noah’s removal from the home was disregarded, we don’t know if these steps will address the proximate cause of Noah’s death–the failure to remove him from his home when a social worker clearly recognized the need for it. It appears that this removal order was overriden by someone above the social worker – but we need to know why and by whom. This crucial decision may have little to do with staffing problems and more to do with other factors–such as an ideological preference for parents’ rights or a reluctance to remove children.

Sadly, there is no provision in California or LA County requiring an in-depth case review to be released to the public. This never happened in the cases of Anthony Avalos or Gabriel Fernandez. In order to get to the bottom of these horrendous deaths, Los Angeles County’s Board of Supervisors should pass legislation requiring such a review. Washington’s state’s statute requires a review (by experts with no prior involvement in the case) when the death or near-fatality of a child was suspected to be caused by child abuse or neglect, and the child had any history with the Children’s Administration at the time of death or in the year prior. These reviews must be completed within 180 days and posted on the agency’s website. Florida has a similar requirement, as I have described in an earlier post.

The father and siblings of Anthony Avalos filed a $50 million suit against DCFS and one of its contractors only a few weeks after Noah’s death. They allege that the department “was complicit in the abuse and neglect of Anthony and his half-siblings.” The same attorney is now representing Noah’s grandmother, and a lawsuit is sure to follow. How many more deaths will it take before the county can be relied on to protect its vulnerable children from suffering and death inflicted by their parents?

 

Why No One Saved Gabriel Fernandez

Gabriel Fernandez
Image: LATimes.com

On September 13, 2018, a Los Angeles County judge denied a motion to dismiss felony child abuse and falsification of records charges against four former child welfare caseworkers in the 2013 death of eight-year-old Gabriel Fernandez.  The charges, filed in 2016, marked the first time Los Angeles caseworkers were criminally charged for misconduct connected with their work, and is one of only a few similar cases nationwide.

If Gabriel’s case is one of the few child deaths to result in prosecution of state workers, the egregious nature of the state’s failure explains why. A brilliant article by investigative reporter Garret Therolf shows that for seventh months, evidence of Gabriel’s abuse steadily accumulated. Yet again and again, the Los Angeles Department of Child and Family Services (DCFS) failed to intervene. Some of the worst errors are listed below.

  • Gabriel’s mother had been the subject of at least four calls to the child abuse hotline, had abandoned one child, and had lost custody of a son a year older than Gabriel. Yet, this record was never reviewed by workers investigating multiple reports of suspicious injuries to Gabriel.
  • Each time investigators came to the home, they interviewed Gabriel and his siblings with his mother in the room, against agency policy and common sense. And each time they did so, he recanted his previous statements. Even after he came to school with his face full of bruises from being shot by his mother with a BB gun, he recanted and told the investigator the injuries were from playing tag with his siblings. In the face of visible evidence, the investigators repeatedly chose to believe the repeated recantations
  • Investigators never spoke with neighbors or school personnel (other than the teacher who reported the abuse) but according to Therolf the abuse was known widely among school staff.
  • A computer program had found Gabriel to be at “very high risk” of abuse, requiring that the case be “promoted,” usually involving asking a court to require services or foster care. But the investigator, backed up by her supervisor, referred Gabriel’s mother to voluntary family services. Gabriel’s mother Pearl Fernandez withdrew from these services after three visits.
  • During the brief period of voluntary services, Gabriel wrote several notes saying he wanted to kill himself. Gabriel’s therapist informed the caseworker and supervisor, but they took no action.
  • The therapist had grown concerned that Gabriel was being abused, but her supervisor told her not to call the hotline so as not to jeopardize the mother’s participation in the voluntary case.
  • After three visits, Pearl Fernandez asked for her voluntary case to be closed. The caseworker accepted her decision, stating that there were no safety or risk factors for the children. Contrary to policy, her supervisor signed off on the case closure without reading the file.
  • After the case was closed, a security guard at the welfare office saw Gabriel covered with cigarette burns and other marks and being yelled at by his mother. The called DCFS twice and got lost in the automated system. The 911 operator gave him the non emergency line, which he called. He was later told that a sheriff’s deputy had gone to the home and seen nothing wrong.
  • Gabriel’s teacher, who had lost hope of any rescue from DCFS, called the DCFS investigator one more time late in April when Gabriel showed up looking worse than she had ever seen him. One eye was blood-red, skin was peeling off his forehead, and other marks were on his face, neck and ear. Her call was never returned. Gabriel had only about a month left to live.

Investigators later learned that during the weeks before his death, Gabriel  was spending days and nights locked in a cabinet with a sock in his mouth, hands tied, a bandanna over his face, and handcuffs on his ankles. His solitude was interrupted by vicious beatings and torture sessions in which his siblings were required to participate. On May 22, Pearl and Aguirre tortured Gabriel a final time with a BB gun, pepper spray, coat hangers and a baseball bat. When they finally called 911, paramedics found two skull fractures, broken ribs, several teeth knocked out, BB gun pellet marks, cigarette burns on his feet and genitals, a skinned neck, and cat feces in his throat.

Therolf poses a key question regarding Gabriel’s death: “Was [the] failure …to protect Gabriel an isolated one—the fault of four employees so careless and neglectful that they allowed a child to suffer despite a series of glaring warning signs? Or was it a systemic one, the result of a department so ill-equipped to safeguard children that tragedies were bound to happen?”

While Therolf does not actually answer the question, his report offers a number of key findings and insights that point strongly in the direction of systemic factors as the prime contributors to the failure to protect Gabriel. Therolf found that many of the errors made by investigators, such as failure to interview children alone or to speak with witnesses outside the family, were prevalent in Los Angeles County. Sadly, many of the same failures were evident in the very recent case of Anthony Avalos, also in Los Angeles. And we also see similar failures , and in cases around the country, including Kansas, New York, and Oregon.

The systemic factors that cause these failures fall into two major categories–resource constraints and ideological factors.

Resource Constraints

Child welfare involves a balancing act between too much intervention  or “erring on the side of child safety” as Therolf puts it and too little or “erring on the side of family preservation.”  Striking this critical balance requires a combination of  knowledge, skill, and time. In other words, as Therolf puts it, “it requires a highly trained workforce with the resources to carry out a thorough investigation in every case.” Therolf rightly contends that most agencies don’t have these resources. One has only to read the constant stream of news reports of overwhelming caseloads and poor training of child welfare workers around the country. All of this reflects the unwillingness of taxpayers and legislatures to provide what is needed to protect children. Inadequate funds mean caseloads are too high and salaries are too low, both resulting in low standards for caseworkers.

More funding and could buy both lower caseloads and higher salaries, which are necessary to obtain more qualified investigative workers. After reading so many similar stories, and recalling my own rudimentary training as a Child Protective Services (CPS) worker I am beginning to think that ultimately CPS Investigation should be a specialty in Masters in Social Work Programs. Students would learn advanced interviewing skills and how to assess the truthfulness of children and adults rather than, for example, believing children when they recant allegations with their parents in the room.  Alternatively, CPS Investigations could be folded into the growing field of Forensic Social Work. In any case, a Masters-level specialization could be required in order to be a CPS worker, also adding a needed level of prestige to an important, difficult and hard-to-fill  job.

Ideological Constraints

Inadequate resources might result in a random distribution of agency errors between those that involve too much intervention and those that involve too little. But the dominance of a particular ideology may skew the errors in one direction or another. And Garrett Therolf alludes to the rise of an ideology prioritizing family preservation nationwide and particularly in California during the years preceding Gabriel’s death. This ideology contributed to the decline in foster care numbers around the nation and particularly in Los Angeles, where Therolf reports the number of children in foster care fell from about 50,000 in 1998 to 19,000 in 2013. Much of this decline occurred during the tenure of DCFS administrator David Sanders, who later went on to lead Casey Family Programs, a foundation worth over two billion that has played an outsize role in national child welfare policy. The same year that Sanders took over at Casey, it declared a new goal to reduce the number of children in foster care by half by 2020.

Therolf was right to point a finger at Casey Family Programs. In my post about the death of two children by child abuse in Kansas, I wrote about how Casey leverages its massive wealth to affect policy directly, bypassing the voting public. It provides financial and technical assistance to state and local agencies, conducts research, develops publications, and provides testimony to promote its views to public officials around the country. Through its wealth in an underfunded field, Casey has been able to directly influence policy at the federal, state, and local levels.

Therolf points out that opinions on child welfare often cut across traditional political groupings. While Casey tends to support progressive causes, its emphasis on family preservation is often shared by conservatives who desire to reduce the government’s incursions on parental authority and at the same time to reduce spending. Working together, Casey and the George W.  Bush administration created a waiver policy that allowed child welfare agencies to direct unused foster care funds toward family preservation services–a policy change which created an incentive to reduce the use of foster care. Therolf links this incentive to the drastic decline in the Los Angeles County foster care rolls between 1998 and 2013, stating that “When Gabriel came to the attention of DCFS, the chances of an abused child being placed in foster care were “lower than they’d been in many years.”

Perhaps all of the factors that led up to Gabriel’s death can be summed up by a striking statement by the supervisor on Gabriel’s case, who is currently standing trial in Gabriel’s death. He told Therolf that he had  “concluded long ago that some of the children who depended on the department would inevitably be injured, if not killed.” He expressed frustration that administration and the public expected him to prevent all such deaths. This is not an acceptable attitude. It is true that a child welfare agency cannot prevent deaths among children who are unknown to the agency. But to expect that children will die under the agency’s watch–that is a low expectation indeed. We must do better by our most vulnerable children.

How to prevent more Hart cases

Hart family
Image: katu.com

In my last post, I discussed the tragic case of the six children adopted by Jennifer and Sarah Hart. The entire family perished in the crash of their SUV off a cliff in California on March 26. Multiple system gaps resulted in the failure to rescue these children before their tragic death. Below are some suggestions for filling these gaps so that children do not continue to suffer and die in abusive homes.

  1. Improve Vetting of Potential Adoptive Families. The second set of Hart children were adopted despite the fact that the parents were investigated for abuse of one of the first set of children. Moreover, Minnesota staff told Oregon DHS staff that Texas arranged many adoptions through a particular agency, even when not supported by Minnesota’s child welfare agency. We need to know more about how adoptions could be organized against the wishes of the child welfare agency in the adoptive child’s state, and whether such adoptions continue to occur.
  2. Monitor adoption subsidy recipients. The Harts received almost $2,000 a month in adoption subsidies–money that clearly enabled them to live. All agencies paying adoption subsidies should verify periodically that the children are alive and well and still living in the adoptive home.  Submission of an annual doctor visit report, and/or an annual visit by a social worker could be used for such verification.
  3. Regulate homeschooling. The Harts removed all their children from school after their child abuse case was closed in Minnesota. The Coalition for Responsible Home Education (CRHE), an advocacy group for homeschooled children, recommends barring from homeschooling parents convicted of child abuse, sexual offenses, or other crimes that would disqualify them from employment as a school teacher. CRHE also recommends flagging other at-risk children (such as those with a history of CPS involvement) for additional monitoring and support and requiring an annual assessment of each homeschooled child by a mandatory reporter.
  4. Adopt universal mandatory reporting and educate the public about reporting child maltreatment. The Harts’ neighbors in Washington witnessed clear indicators of maltreatment months before the family went off a cliff. If they had reported their observations earlier, the children might have been saved. However, Minnesota and Oregon reporters were more conscientious, and the children were failed by CPS; hence the next recommendation.
  5. Revamp the investigative process. We have seen that social workers in Minnesota and Oregon had a very clear idea of the dynamics of the Hart household, and how the parents manipulated professionals to shift all blame to the children. Nevertheless they were not able to act on this knowledge to protect the children. There are several reasons that arise from the characteristics of child protective services in most or all states. First, action such as opening an in-home case or removing a child is contingent on the abuse allegation being confirmed. But that is very difficult to do, especially when children deny the abuse, as abused children often do. It is likely that many actual cases of abuse are not substantiated. Research has found little or no difference in future reports of maltreatment of children who were the subject of substantiated or unsubstantiated reports.  We need to move away from substantiation as a trigger for action to protect children.  Another problem is the bizarre distinction between risk and safety which is made in most or all CPS systems. That children could be labeled “safe” even when  at risk, as happened in Oregon, is obviously ridiculous. This false distinction has contributed to the deaths of Adrian Jones in Kansas, Yonatan Aguilar in California, and doubtless hundreds of other children around the country.
  6. Establish stricter criteria for case closure. In Minnesota, one or two cases were opened and the Harts were required to participate in services. We know in retrospect that none of the services worked to change the Harts’ parenting style. It appears that the parents continued their pattern of abuse and food deprivation while the services were being provided. State and local agencies need to revise their criteria for case closure to make sure that they are not leaving the children in the same unsafe situation they were in before the case opened. Agencies must be required to do a rigorous assessment of the children’s safety, which includes checking in with all service providers as well as the children and other professionals who have contact with them.
  7. Encourage doctors to err in the direction of protecting children. The similar response from doctors in Minnesota and Oregon to these malnourished children (saying that they don’t know if there is a reason for concern because lack of historical data) suggests a pattern of reluctance by medical professionals even to express concern that abuse or neglect may be occurring. For a doctor to say that he or she has no concerns because of the lack of information is backwards. Pediatricians need to express concern until given reason to believe otherwise. The American Academy of Pediatrics should issue guidance to this effect, but this needs to be followed up by consequences for doctors who fail to protect their patients.

The Hart children can be seen as victims of a “perfect storm”–adoption by unqualified parents, home schooling, neighbors who failed to report, history not shared between states, and inadequate investigations.  But it only takes one system failure to kill a child or scar one for life. All of these systemic gaps must be addressed, so that all children can have a real childhood and grow to be happy, productive adults.

This post was updated based on new records from Minnesota discussed in a later post on April 27, 2018

Why Kansas let Adrian and Evan die

 

Image: kansascity.com
Image: cbsnews.com

Dianne Keech, a former Kansas child welfare official and currently a child safety consultant, was asked by the Wichita Eagle and Fox News to analyze case files regarding the highly-publicized deaths of Adrian Jones and Evan Brewer.  I asked Ms. Keech to prepare a guest blog post about the factors contributing to the deaths of Evan and Adrian. She prepared a ten-page document, which you can access here. Below, I highlight some of her conclusions. 

Calls to the Kansas child abuse hotline began when Adrian Jones was only a few months old. There were 15 screened-in reports for Adrian before he was six years old. Out of 15 reports in total that KCF investigated, Keech found that there was only one substantiated allegation of abuse, and that was based on an investigation by law enforcement.  After Adrian was removed from his mother’s custody due to lack of supervision and placed with his father and stepmother, calls alleged that there were guns all over the house, that the stepmother was high on drugs, that Adrian had numerous physical injuries, that he was being choked by his father and stepmother, and that he was beaten until he bled.  Adrian’s father and stepmother consistently denied every allegation and the agency did nothing to verify their stories.  Adrian’s body was found in a livestock pen on November 20, 2015. It had been fed to pigs that were bought for this purpose. It was later found that Adrian’s father and stepmother had meticulously documented his abuse through photos and videos. They are serving life terms for his murder.

DCF received six separate reports of abuse of little Evan Brewer between July 2016 (when he was two years old) and May 2017. These reports involved methamphetamine abuse by the mother, domestic violence, and physical abuse of Evan. Only three of these reports were assigned for investigation and none were substantiated.  In the last two months of Evan’s life, the agency received two reports of near-fatal abuse, one alleging that he hit his head and became unconscious in the bathtub and the other alleging that his mother’s boyfriend choked Evan and then revived him. The first of these reports received no response for six days and the investigator apparently accepted the mother’s claim that the child was out of state. The investigator of the second report also never laid eyes on Evan.  On September 22, a landlord found Evan’s body encased in concrete on his property. Horrific photos and videos documented Evan’s months of torture by his mother and her boyfriend. His mother and her boyfriend have been charged with first-degree murder. 

Looking at Root Problems

Keech believes that there are three root problems that led to Adrian and Evan’s deaths: a dangerous ideology, the pernicious influence of a well-heeled foundation, and faulty outcome measures used by the federal government. These are discussed in order below.

Dangerous Ideology: Signs of Safety is a child protection practice framework that was never officially adopted by Kansas. But Keech alleges that its philosophy has permeated all aspects of child welfare practice in the state. The Signs of Safety framework, according to its manual, seeks to avoid “paternalism,” which “occurs whenever the professional adopts the position that they know what is wrong in the lives of client families and they know what the solutions are to those problems.” Signs of safety links paternalism with the concept of subjective truth, citing  “the paternalistic impulse to establish the truth of any given situation.” According to Keech, this implication that all truth is subjective  means that investigating “facts” is a worthless task.  Workers are encouraged to “engage” parents, not investigate them.  Keech gives numerous examples of how this practice approach left Evan and Adrian vulnerable to further abuse. When Adrian’s younger sister was brought to the hospital with seizures, she was diagnosed with a subdural head trauma that was non-accidental. But when Adrian’s stepmother insisted that Adrian inflicted the injury with a curtain rod, DCF believed her and did not substantiate the allegation–not even finding her neglectful for letting the child be hurt. When DCF received a report that Evan’s mother was using methamphetamine and blowing marijuana in his face, they accepted her denials and closed the case with no drug test required.

Along with a new practice framework, Kansas adopted a new definition of safety. As in many other states, safety in Kansas has been redefined as the absence of “imminent danger.” This is in contrast to “risk,” which connotes future danger to the child. As a result, children can be paradoxically found to be at high risk of future harm but safe–which happened twice with Adrian. (He was found to be at “moderate” risk three times.) As long as a child is deemed “safe,” the child cannot be removed from home. The decoupling of risk from safety explains why both Adrian and Evan were found to be “safe” 18 times in total, when they were anything but. This is a common situation in many other states. “Risk,” on the other hand, triggers an offer of services, which can be refused, which is what Adrian’s father and stepmother did when he was found to be at risk. I’ve written about the case of Yonatan Aguilar in California, who was found four times to be at high risk of future maltreatment but “safe.” His parents refused services. He spent the last three years of his life locked in a closet until he died.

Pernicious Influence: Casey Family Programs is a financial behemoth with total assets of $2.2 billion. Its mission is to “provide and improve, and ultimately prevent the need for, foster care.'”Over a decade ago, Casey set a goal of reducing foster care by 50% by the year 2020.  Casey works in all 50 states, the District of Columbia, two territories and more than a dozen tribal nations.  It provides financial and technical assistance to state and local agencies to support its vision. It conducts research, develops publications, provides testimony to promote its views to public officials around the country.  As Keech puts it, “There is not a corner of child welfare in the United States where Casey is not a highly influential presence.” Keech has experienced firsthand Casey’s efforts to pressure Kansas to reduce its foster care rolls.  At a meeting in that Keech attended in 2015, Casey used “peer pressure” to “shame one region for having a higher foster care placement rate.  Casey adopted and promoted the Signs of Safety approach discussed above.

Faulty Federal Outcome Measures: The Child and Family Services Review (CFSR) is an intense federal review of the entire child welfare system.  If a state does not pass the review (and no state has passed, to date) then the state must agree with the federal government on a Program Improvement Plan (PIP) or lose funding. Keech feels that the federal reviews can be manipulated by states to improve their outcomes at a cost to child safety.  For example, one of the two measures of child safety is timely initiation of investigations. When a hotline screens out a report (as was done three times with Evan)  or a case manager fails to report a new allegation (which was done three times while Adrian had an open services case) the agency does not need to worry about timely initiation of an investigation. Another CFSR outcome is “reduce recurrence of child abuse and neglect, ” which is measured by calculating the percentage of children with a substantiated finding of maltreatment who have another substantiated finding within 12 months of the initial finding. This outcome can be improved by failing to investigate reports, or investigating them but failing to substantiate. Only one of the allegations involving Adrian was substantiated; three of the allegations involving Evan were not even investigated and the other three were not substantiated. By not substantiating allegations, Kansas reduces its recurrence rate. 

The factors that Keech discusses are not unique to Kansas and are occurring around the country, in states including most of America’s children. All of these states should consider Keech’s recommendations for protecting Kansas’ children from the fate of Adrian and Evan.  Most importantly, states need to prioritize the safety of children over and above any other consideration.   The primary goal of child welfare must be the protection of children, not reducing entries to foster care. The artificial division between risk and safety should be eliminated and risk should be allowed to inform safety decisions. States must treat substance abuse, domestic violence, criminal activity, mental health issues, and parental history of maltreatment, as real  threats to child safety. Workers must be empowered and required to gather all of the information needed to determine the truth of allegations, not rely on adults’ self-serving denials. And they must be allowed–and required–to request out of home placement when there is no other way to protect a child.