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.”

Another abuse death in Michigan: Why doesn’t child protective services want to learn from the past?

Source: The Detroit News

On June 24, a child protective services worker (CPS) accompanied by police officers knocked on the door of a rundown house on Detroit’s west side to conduct a welfare check. Azuradee France answered the door but tried to keep them out. When they entered the house, they found the badly decomposed body of a three-year-old, later identified as Chayse Allen, in a freezer and five more children living in squalor. The media soon learned that Chayse’s mother had been involved with CPS at least seven times as a parent. She had been arrested and convicted for child abuse, serving two years of probation, and her children had been removed but later returned. And yet, there were no procedures in place to protect France’s six children from her lethal violence. And Chayse Allen, described by family members as a sweet, shy and soft-spoken child who had become blind about a year ago, is dead as a result.

There is a common belief that past behavior is the best predictor of future behavior, and that certainly seems to be the case in child maltreatment. Over twenty years ago, Detroit was transfixed when in one week a child was murdered and another suffered irrevocable brain damage, both in the custody of parents who had lost their rights to previous children. This coincidence of horror was enough to spur change–and a new process was created to protect children whose parents had already harmed other children. On September 23, 2000 the directors of the human services and health department agreed to cross-reference the names of parents of newborns with the names of parents who had severely abused their children. The system, which became known as “Birth Match,” is still in effect. This process as designed would not have saved little Chayse, but the story of its imperfect implementation and the state’s declining interest in its application may shed some light on why he too was abandoned by the public officials who were charged with protecting him.

I researched birth match in Michigan while preparing a report on this important tool for child safety, which is being used in only five states. In Michigan, birth match is an automated system that notifies the statewide child abuse hotline when a new child is born to a parent who previously had parental rights terminated in a child protective proceeding, caused the death of a child due to abuse and/or neglect or was manually added to the match list.1 When a birth match report is received, hotline staff must check whether it is accurate and whether there is a pending investigation or open case, and if so, whether the investigative worker is aware of the historical concerns. If there is a pending investigation, the birth match information must be used in assessing the child’s safety.

If the match is accurate and there is not already a pending investigation, the complaint must be assigned for investigation with the allegation of “threatened harm” to the child. “The MDHHS policy manual lays out requirements for assessing threatened harm, including the severity of the past behavior; the length of time since the last incident; the nature of the services received since that incident and whether the parent benefited from those services; a comparison between the historical incident and the current circumstances; and the vulnerability of the child. As in any other investigation in Michigan, if the investigative worker does confirm the allegation of threatened harm, the next step depends on the worker’s assessment of safety and risk. If the child is assessed to be unsafe, the worker must petition the court to remove the child or place the child under supervision at home. If the child is found to be safe but the risk level is considered high or intensive, the worker must open a case to provide services to the family in the home. And if the risk is found to be low or moderate, the worker is directed to refer the family to community–based services.2

At one time Michigan was very proud of its birth match process. Stacey Bladen, the Acting Deputy Director of Michigan’s Children’s Services Administrator gave a presentation about birth match to the Commission to Eliminate Child Abuse and Neglect Fatalities in 2014. She displayed a graph showing an increasing number of birth matches and case openings over time. Three other states had adopted birth match by this time, and CECANF in its final report recommended its adoption by all states as a way to protect vulnerable infants born to parents who have harmed other children. (Only Missouri has adopted birth match since CECANF made this recommendation.)

But even while Bladen was trumpeting the virtues of birth match, the Manager of CPS in Michigan was already concerned that tool was not fulfilling its potential due to imperfect implementation. Based on an internal review of 105 cases conducted in 2011 and 2012, he told a Harvard Law School class that he was disturbed about the small proportion of investigations that found threatened harm (only about a quarter) and the even smaller percentage (6.5 percent) that resulted in a court petition. Given that 4.5 percent of all investigations resulted in a court petition at the time, he would have expected a much higher proportion of birth match cases to go to court, considering the gravity of the behaviors committed by the parents and the fact that a parent’s rights were rarely terminated without a long history of agency attempts to assist a family. Based on these findings, the CPS Manager concluded that investigators were not following agency policy; in particular, he concluded that they often failed to assess the severity of the earlier maltreatment and parents’ response to services they had received since that time.

I asked MDHHS for an update of the data provided by Bladen to CECANF and quickly learned that birth match was no longer a point of pride for the agency. MDHHS was no longer routinely tracking birth match cases: the agency had to generate the tables to respond to my request. Moreover, once received, the data displayed some anomalies. The number of birth match complaints dropped from 1,186 in FY2019 to 873 in FY2020 and 515 in FY2021—a drop of more than half between FY2019 and FY2021. Stranger still, MDHHS administrators appeared to be unaware of this sharp drop in birth match complaints and had no explanation for why it occurred. This is particularly odd because these matches occur automatically; one wonders whether the drop was related to the pandemic, but the continued sharp decline in 2021 casts doubt on that theory.

Throughout the period from FY2009 to FY2021, about half the matched families already had an open investigation or case when the match was generated. But the number and percentage of the remaining matches that resulted in an open case have fallen considerably, from 99 cases, or 9 percent of all matches, in FY2012, to only 30 cases, or three percent of matches, in FY2020. Child removals also dropped from 41 removals, or 3 percent of matches, in FY2012 to 11 removals, or one percent of matches, in FY2020. MDHHS was unwilling to provide any theories about why these changes occurred. Moreover it appeared that agency leaders were not interested in the fate of birth match, as evidenced by their failure to track the data themselves, or to discuss birth match in their published reports or press releases. Furthermore, Michigan’s policies concerning birth match are currently “under review” as part of a “front end redesign” of the state’s child protection system.

Birth match started in an atmosphere of hope. In a heartfelt essay, a blogger named Donna Pendergast expressed her feeling that “As horrific as the murder of Miracle Jackson was, it can be said that something good came of it,” citing the new practice of birth match. “May [Miracle’s] legacy be that other children are spared her horrific fate.” Unfortunately, Miracle’s legacy appears to be fading.

Even as it was envisioned, Miracle’s legacy of birth match was not broad enough to save Chayse Allen. His birth would not have been matched because his mother’s parental rights were never terminated, she was not found to have caused a child’s death, and she probably would not have been added manually to the birth match list. But the failure to learn from the past which has hampered the implementation of birth match is on full display in the agency’s dealings with Chayse’s mother. As media outlets have revealed, Azudee France had a history of child welfare involvement including at least seven separate episodes. Court records obtained by WXYZ, Detroit’s ABC affiliate, and the Detroit News showed three CPS contacts in 2016 and two in 2017 due to “physical abuse, improper supervision, sexual abuse, failure to protect, and physical neglect.” The records also show that at least the allegations received in November 2017 were substantiated for physical abuse and improper supervision. In 2018, France admitted to assaulting her two year old nephew, who was staying with her temporarily, leaving him with “swollen lips, a black eye, a contusion on the forehead, and bruises to his rib cage and both ankles,” described as “severe physical abuse” in a court document. She was charged with felony child abuse and pleaded guilty to a misdemeanor charge, serving two years of probation.

In April, 2020, MDHHS filed a petition requesting court approval to take custody of France’s newborn son, who was born on April 7, 2020. France’s other four children were already in foster care, apparently due to her conviction for abusing her nephew. The petition stated that France “has not yet rectified the conditions that brought her other children into care” and that she “continues to have untreated mental health concerns.” It also stated that France had a history of postpartum depression and threatened to harm her newborn son.

It appears that the MDHHS petition to take custody of the baby was granted, but three months later following a hearing on August 24, 2020, all five children were returned to France. The court referee3 stated that “Mother has completed parenting classes. … mother is currently in therapy…. mother’s home is suitable.” France’s sister Azunte Sauls told Detroit News reporter George Hunter that she could not imagine how France’s home was deemed suitable as it was filthy and “not suitable for any adult.” And It’s hard to understand how the serious and deep-seated issues outlined in the petition could have been resolved in three months.

Sauls told Hunter that CPS workers came to her sister’s home again last year, to investigate a report of a burn to Chayse. But apparently the investigators, unfazed by France’s history, accepted her explanation that he had burned his hand on some noodles. Sauls and her mother also reported that they and other relatives called CPS many times after incidents of suspected abuse, but to no avail. France subsequently gave birth to a sixth child, who was two months old at the time of Chayse’s death.

When is enough enough? When does an agency accept that it is time to stop waiting for a parent to change and place the children in a safe environment, preferably with loving extended family members? Chayse’s aunt told WXYZ that she had custody of Chayse and his siblings when he was two months old and all of the children were removed from their their mother after her conviction for child abuse. “She should have never gotten her kids back after that,” another aunt told reporter Kimberly Craig of WXYZ. Michigan law allows a parent’s rights to a child to be terminated if “there is a reasonable likelihood, based on the conduct or capacity of the child’s parent, that the child will be harmed if he or she is returned to the home of the parent.” That argument could certainly have been made for any of France’s children long before Chayse was killed.

The desire to let parents start anew with each new child or report is one reason why birth match has been adopted by only four states and appears to be so unpopular among the current DHHS leadership. Moreover, the current child welfare climate is exacerbating the failure to protect children, especially children of Black or Indigenous origin. The concern about racial disparities in child welfare involvement may be discouraging agencies from protecting vulnerable children like Chayse and his siblings.

Azudee France has been charged with with felony murder, first-degree child abuse, torture, and concealing the death of an individual in the death of Chayse, and the children are now with relatives. Maybe by his suffering and death, Chayse was able to save the lives of one or more of his siblings. But they have endured experiences that will leave scars for a lifetime. And it’s all because CPS was unable or unwilling to learn from the past, as its imperfect and waning implementation of birth match illustrates so well.

Notes

  1. The provision for manual additions allowed the inclusion of adults who committed an egregious act of maltreatment but did not have their rights terminated, or who harmed a child that was not their own child.
  2. It is not totally clear how “threatened harm” can be found and yet the risk level can be determined to be low or moderate.
  3. A referee is an attorney who holds hearings, examines witnesses, and makes recommendations to a judge. 

When ideology can kill: the death of Noah Cuatro

Image: KTLA.com

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Bias accusations

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

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

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

Strength-based practice

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

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

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

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

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

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

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

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

The Trials of Gabriel Fernandez: an all-too familiar story

TrialsofGabrielFernandez
Image: Facebook.com

On February 26, Netflix released a heartbreaking series, The Trials of Gabriel Fernandez.  Directed by Ben Knappenberger, the series centers on  the horrific death of an eight-year-old boy in the Antelope Value of California on May 24, 2013. Gabriel Fernandez died after eight months of torture by his mother and her boyfriend. Despite repeated reports to the child abuse hotline and the Sheriff’s Office, multiple investigations, and even an open family services case, there was no rescue for Gabriel. It was only after his death that the story of his last eight months and the inexplicable failure of the police and social services were revealed.

I wrote about Gabriel’s story in November 2018 in a post entitled, Why No One Saved Gabriel Fernandez. But The Trials of Gabriel Fernandez uses the power of video to bring the case alive in a way that is difficult to do in writing. The unusually calm voice of a mother tells a 911 operator her son is not breathing. An ambulance flies through the late-night streets, carrying an eight-year-old who had been resuscitated by the EMT’s and again in the ambulance and will stop breathing twice more in the ER. A little boy with injuries to almost every part of his small body, which will, in spite of all the heroic efforts by doctors and nurses to save him, finally shut down.

So begins The Trials of Gabriel Fernandez. In six excruciating but riveting episodes, The Trials tells the story of the Los Angeles Times investigation into Gabriel’s life and death, the trials of his murderers, and the unsuccessful attempt to hold accountable those professionals who failed him. Times reporter Garrett Therolf recounts learning of the eight-year-old’s death in a crime blog and wondering about the circumstances, being faced with self-protective wall secrecy and stonewalling imposed by the Los Angeles County Department of Children and Family Services (DCFS) and hearing from  a whistleblower who risked his job to reveal the truth. The prosecutor wheels into court the shockingly small cabinet where Gabriel spent his nights bound and gagged. Isaurro Aguirre sits impassive as a parade of witnesses describe the sweetness of Gabriel and the unspeakable nature of his injuries. Gabriel’s teacher fights back tears as she tells how she contacted CPS every time Gabriel arrived in school with increasingly bizarre and severe injuries. The partner of Gabriel’s uncle tells of the three-day-old infant they took home from the hospital because his mother did not want him, his growth into a joyful four-year-old, who was then raised by his grandparents for the next four years until he was returned to his mother for the welfare money. A bewildered social worker sheds tears of fear for her own future, claiming she had no idea anything was wrong in Gabriel’s home.

I identified two major systemic issues that could have been behind DCFS’ failure to rescue Gabriel. One of these issues–the focus on family preservation at all costs–was addressed in the documentary. The other issue–that of resources–was not. As Garrett Therolf put it in a brilliant article in The Atlantic, child welfare requires a balancing act between child safety and family preservation. Finding this difficult balance requires a highly trained workforce with the resources to carry out a thorough investigation in every case.” Overworked, undertrained, and underpaid social workers simply cannot do it.

Gabriel’s case was far from unique, as the documentary made clear. Two weeks after Isaurro Aguirre was sentenced to death for his murder of Gabriel, and Pearl Hernandez was sentenced to life without parole after taking a plea deal to avoid the death penalty, another little boy was dead of abuse in the Antelope Valley. Ten-year-old Anthony Avilas was allegedly killed by his mother and her boyfriend. His torture and abuse appeared to be motivated at least in part by homophobia, as in Gabriel’s case. And there was a long history of interactions with authorities with no help forthcoming for Anthony. Soon enough news arrived that a four year old named Noah Cuatro had died under similar circumstances in the Antelope Valley. Around California, over 150 children who were known to DCFS have died of abuse or neglect since Gabriel died, as reported in the documentary.

But this is not a California story alone. These cases happen all over the country. The Commission on Child Abuse and Neglect Fatalities estimated that a third to a half of the child maltreatment fatalities around the country involved families known to Child Protective Services. I write have written about some of these children whose cases made it to the mass media: Zymere Perkins in New York City,;Matthew Tirado in Connecticut; Adrian Jones and Evan Brewer in Kansas; the six Hart children in Minnesota, Oregon and Washington; Jordan Belliveau in Florida; and most recently Thomas Valva in New York. All were the subject of reports and investigations, and sometimes service cases, but all were allowed to die at the hands of murderous caretakers.

The power of video to bring about public awareness is truly awe-inspiring. Normally my posts are read mainly by academics, child advocates, and child welfare professionals. On February 27, I started to notice some unusual traffic on my blog. Between February 27 and the early morning of March, my posts on Gabriel, Anthony, Noah and other children failed by the state had been viewed over 2000 times. If only the public could keep up this level of interest –perhaps even follow my blog–and insist on adequate funding and an end to the wall of secrecy around child welfare services, we might be able to save the next Gabriel Fernandez.

 

Los Angeles County missed many chances to save Anthony Avalos

Anthony Avalos
Anthony Avalos: Los Angeles Times

In July 2018, ten-year-old Anthony Avalos arrived at the Emergency Room with fatal bleeding in his brain. His emaciated and battered body succumbed the next day to years of deprivation and abuse. For four years, the Los Angeles Department of Children and Family Services (DCFS) had received 13 reports on suspected abuse of Anthony and his siblings. For part of that period, his family was actually under the supervision of DCFS.

Many commentators saw parallels between Anthony’s death and that of Gabriel Fernandez in 2013 in the same town of Palmdale, in the Antelope Valley section of Los Angeles County. Gabriel was tortured to death by his mother and stepfather after multiple reports to DCFS failed to result in his rescue from this lethal home.

But based on its review of the family’s case file, Los Angeles County’s Office of Child Protection (OCP) concluded that Anthony’s case was “very different” from Gabriel’s. OCP concluded that it could not say that Anthony might still be alive today if the agency had done things differently. In justifying this conclusion, OCP stressed that the family was not under DCFS supervision at the time of Anthony’s death and that it had been over a year since the last report was made to the child abuse hotline concerning the family.

But in his devastating article,  The horrific death of Anthony Avalos and the many missed chances to save him, investigative reporter Garrett Therolf shows that DCFS had many opportunities to save Anthony. It also reveals striking connections between Anthony’s case and Gabriel’s. The same private agency counselor had worked with both boys, and had been questioned in court about Gabriel. A caseworker who had been disciplined for his errors in the Fernandez case actually supervised the social worker who managed Anthony’s case.

Garrett Therolf was kind enough to share the DCFS case file with Child Welfare Monitor. In reviewing the file, we were struck by the many red flags that DCFS ignored and the crucial points where the agency could have intensified the surveillance of the family or removed the children to safety. In this post, we highlight our own observations from the case file, complemented by key information obtained from other sources (such as interviews and grand jury transcripts) by Therolf.

The First Calls: 2013 and 2014

Anthony Avalos first came to the attention of DCFS in February 2013, when he was only four years old and reported that his grandfather sexually abused him. The agency substantiated the abuse but did not set up any ongoing monitoring, relying on his mother, Heather Barron, to keep his grandfather away from him.

In May 2014 the family came to the attention of DCFS again when a caller alleged that Barron, who had four children at the time,  was  hitting the children with hoses and belts and locking them in their rooms for hours. An allegation of neglect (but not abuse) was substantiated.  Barron agreed to the opening of a voluntary case, which was open from May 20, 2014 to December 4, 2014. A social worker named Mark Millman was assigned to manage the case. 

Under DCFS Supervision: June-December 2014

In June, 2014 a PhD. psychologist who evaluated Barron concluded that she  “appeared to have poor parenting skills as shown by her lack of patience towards her two children that displayed energetic behavior….At this time…. the assessor believes that her capacity to provide suitable care for her children is severely limited by her poor parenting skills, poor judgment, and denial and lack of awareness of her mental health issues.”  The evaluator recommended a variety of services for Barron. She refused to participate in individual therapy–probably the most essential. But there is no indication that case manager Millman even read the report, let alone followed up to see if the services were provided or successfully completed. Barron did participate in in-home services to improve her parenting skills, which were provided by an agency called the Children’s Center of the Antelope Valley. 

Once services got under way, reports from the provider were not encouraging. A July 2014 progress report from the Children’s Center indicated that Barron was “having a difficult time maintaining her composure when the children misbehave.” In its August 2014 report, the agency reported that Barron was overwhelmed. The agency case manager recommended therapy for Ms. Barron but she again refused saying she was not interested in talking about the past. 

On October 9, 2014, a counselor at the Children’s Center called the hotline with concerns about the family.  The counselor had tried to discuss her concerns with Millman but he seemed to “blow it off.”  She reported that Barron, who had recently given birth to a fifth child, was “ very aggressive and angry and showed no nurturing to any of her children, even the infant.” She reported that she observed Barron yanking one child by the arm, yanking her daughter’s hair while brushing it, and calling the children names like “punk” and “bitch.” 

The social worker assigned to investigate the new allegations was not concerned.  He observed  that Barron and her children were ”interacting positively” and “that mother and children had secure attachment as seen by their interaction.” Barron’s admission that she hit the children with a belt and used hot sauce to punish them for talking back did not seem to bother him.  It appears that he was influenced heavily by Millman, who expressed no concern for the family. He reported that Ms. Barron “has her hands full and is doing her best….…She does cuss and yell but [is] doing all she can to provide appropriate care.”

The automated risk assessment performed as part of every investigation showed a high risk of abuse and neglect and recommended promotion to a court case. The investigator overrode this recommendation,  stating that the children were already involved in a voluntary case and getting services. And somehow, despite the mother’s own admission, the investigator closed the referral as “inconclusive” for physical abuse, as well as emotional abuse and general neglect.

Another Children’s Center therapist called DCFS on November 5, 2014, alleging she overheard one child say “She’s bad because she whips our ass.” The caller said that Barron continued to get frustrated easily. She quoted Barron as telling one of the children, ‘Don’t think, because she is here, I won’t whip your ass.’” This referral was “evaluated out” with no explanation.

Case Closed: December 2014

The voluntary case was closed on December 4, 2014 with the following comments: “The mother has been compliant with services and receptive to outside resources. Although the family has received two new referrals, the allegations were assessed unfounded/ inconclusive. Mother has agreed to continuing counseling for the children.” The agency arranged for the family to receive this counseling through a new agency,  Hathaway Sycamores Counseling.  There  was no indication that the mother had made any progress in addressing her parenting issues.  Nor was there a rationale given for directing the counseling toward the children rather than the mother.

Hathaway-Sycamores was the same agency that worked with Gabriel Fernandez, as mentioned above. As Therolf reveals, Anthony was even assigned to the same counselor, Barbara Dixon, who worked with Gabriel. Dixon testified in court that she had observed extensive injuries to Gabriel but did not report them to the hotline, despite being a mandatory reporter. The fact that she still had her job is mind-boggling. According to Therolf, “her case notes show that she counseled [Gabriel] to listen to his mother more attentively and to finish his homework.”

Kareen Leiva Enters the Picture: 2015

As Therolf describes, Barron met Kareem Leiva in 2015 and began a relationship that would last several years and result in Barron’s seventh child. Within months, the father of Anthony’s two-year-old brother reported to police that Leiva was abusing his son. There was no DCFS investigation but DCFS did open a court case involving that child and his parents, resulting in regular visits to the home by a social worker, Mindy Wrasse.

On June 12, 2015, the same father went to the police again after an agency-supervised visit with his son, reporting that his son had bruises on his arm and face. The social worker observing the visit had confirmed the bruising and reported that the child repeatedly said “Mommy is mean” during the visit. The father reported that the child seemed to have bruises at every visit. Ms. Barron reported the two-year-old fell in the shower, and the toddler reportedly confirmed the report. A two-year-old’s ability to confirm this verbally–and to take a shower on his own–shows suspicious precocity for his age. Despite the other siblings giving two different accounts of the bruising, the referral was ruled unfounded on the grounds that all of the children had similar stories. Additionally, the risk of maltreatment was found to be high and the recommendation was to promote to a case. But this recommendation was overriden because there was already an open case involving the two-year-old and his mother. That case closed in October 2016, leaving no DCFS personnel in contact with the family.

The Children Beg for Help: September 2015

On September 18, 2015, the hotline received a call, revealed by Therolf to be from the principal of Anthony’s school, recounting disturbing reports by Anthony of his treatment at home. A similar call came in from a sheriff’s deputy the next day. According to Therolf’s investigation, the children were visiting their uncle, David Barron, and told him about the horrific treatment they received from Barron and her boyfriend, Karim Leiva. David Barron refused to allow his sister to pick up the children and called the police instead. Anthony and his two oldest siblings described to the deputy who responded a litany of horrific punishments by Barron and Leiva.  They reported Barron made them. squat against the wall for long periods of time, a torture she called the “Captain’s Chair.” They also described beatings,  food deprivation, being locked in their rooms, and Leiva’s hanging Anthony’s brother from the stairs.  

When the DCFS investigator met with Anthony, he told her  “Heather is my old mom. This is my new house. I am part of the Barron family now. I’m never going to see Heather again. She locks us up in our rooms and makes us starving.”

But sadly, the agency that was responsible for Anthony’s safety did not allow him to stay in his safe “new home.”  The investigator spoke with three staff members of Hathaway-Sycamores, the agency providing home-based services to the mother. The three reported that they were “constantly in the home” and that the mother did not hit the children.  They said the children did not seem frightened, never talked of abuse, and there were no locks on the doors. The contrast with the reports of the Children’s Center a year earlier is striking. Given what came out after Anthony’s death, it is clear that the providers from the Children’s Center were much more discerning. Or perhaps Hathaway-Sycamores was in the grips of an ideology that values family preservation over child safety–a belief system that has led to many other children being abandoned to a horrible fate. In any case, it is incredible that DCFS was still using this agency after its role in Gabriel’s death.

Heartbreakingly, Ms. Barron was allowed to take the children home from her brother’s house. Not surprisingly, they recanted all the allegations once deprived of the protection of their aunt and uncle. Instead, they said their aunt and uncle told them to make these allegations. The wholesale retraction is suspicious because of the similarity and unusual nature of the allegations and the young age of the children, as well as the number of previous reports of abuse. It doesn’t take a genius to realize that the children may have been frightened into recanting their allegations. But the investigator decided that the aunt and uncle were manipulating the children and had instigated the allegations. (Therolf reports that she was new to the job and testified in court that she was unaware that survivors of abuse often retract their accounts.). The allegations were found to be “inconclusive “and the referral was closed with a disposition of “situation stabilized.” 

One last chance of rescue missed: April 2016

 On April 28, 2016, DCFS received another report, which Therolf learned came from a domestic violence center staffer who was working with Barron. Two of Anthony’s brothers had bruises on their faces. Barron said they had been in a fight, but the boys told the reporter that Karim Leiva made them fight each other. They also reported being locked in their rooms and deprived of food for long periods of time. Barron stated that Leiva had not been in the home since the previous September. In interviews with the investigator, Anthony, his sister, and the five year-old brother all denied the allegations. Anthony and his sister denied that Leiva was in the house or even that they knew him–a denial which should have raised serious concerns to the investigator. Wrasse, the social worker who was monitoring the open case involving Anthony’s brother, said the children definitely knew who Leiva was–and she thought he was coming regularly to the house. The investigator of the previous report also declared definitely that the children knew Leiva.

Despite all these inconsistencies, the allegations were all judged “unfounded” or “inconclusive,” and the disposition was “situation stabilized.” The risk assessment showed a high risk of abuse or neglect and a recommendation to “promote” the case. But the recommendation was disregarded because there was already a social worker on the scene–the same worker who was sure Leiva was coming into the home regularly. Her involvement ended in October 16, and then the children were totally on their own.

There were no more allegations until it was too late for Anthony. At some point, Ms. Barron cut ties with her brother and sister-in–law and moved Anthony to a school that did not know his history. Nobody was left to protect him. It is nevertheless surprising that no  reports came from the children’s schools–a fact that deserves further investigation. According to Therolf, Anthony’s teacher noticed that he was “often nervous about something.” Such nervousness is not normal and should have triggered a response. But that is an issue for another post.

June 2018: Anthony’s suffering ends

Anthony’s fate was sealed when he told his his mother that he liked boys and girls. Leiva overheard this conversation.  The following night, his siblings later reported, Leiva picked up Anthony by his feet and slammed his head on the floor repeatedly. The next morning, Barron called 911, saying Anthony  had fallen. He was taken to the hospital and died the next day.

Anthony’s siblings initially denied any abuse, but as soon as they were questioned by an expert forensic interviewer, they revealed all the horrors that were occurring in the home. As punishment for minor transgressions, they were made to kneel on rice with weights in their hands, were kept awake all night (with water thrown into their faces by Barron or Leiva if they fell asleep), and were whipped with a belt or extension cord on the buttocks or soles of their feet. Anthony was singled out of special punishment. Leiva would pick him up by the feet and slam him on the floor head-first, as he did the night before Anthony died. By dying, Anthony saved his siblings from this nightmare home. They were removed from the home Barron and Leiva , who have been charged with first-degree murder for Anthony’s death.

DCFS had many chances to save Anthony but it wasted them all. This gifted, sensitive, and loving child was condemned to years of suffering ending only with his death. OCP was set up to protect children in the wake of Gabriel Fernandez’s death. It’s sad that this office ended up basically whitewashing Anthony’s. Now we are waiting for their report on why four-year-old Noah Cuatro was killed when DCFS disregarded an order to remove him from his home. Based on the Avalos report, the chances of a thorough investigation by OCP are slim.

Yet another child abandoned by another state: Two-year-old Jordan Belliveau dead at his mother’s hands in Florida

Juliet Warren (left) with her foster child, Jordan Belliveau. The 2-year-old toddler went missing for more than two days and was then found dead late Tuesday. His 21-year-old mother, Charisse Stinson, now faces a charge of first-degree murder in the death of her child. [Photo Courtesy the Warren Family]
Jordan Belliveau, Jr. with his foster mother: Tampa Bay Times
On September 4, 2018, the body of two-year-old Jordan Belliveau was found in a wooded area in Largo, Florida. Two days before, his mother Charisse Stinson told police she was assaulted by a stranger and that her son was missing when she recovered consciousness. She later admitted that she had fabricated this account and in fact had caused the injuries that caused Jordan’s death.

Jordan had been removed from his parents in October 2016 and reunited with Stinson in May 2018. At the time of his death, Jordan was under court-ordered “protective supervision” by a nonprofit agency under subcontract with the Florida Department of Children and Families (DCF). There was also an open investigation of allegations of ongoing domestic violence between Stinson and Jordan’s father, Jordan Belliveau, Sr. DCF convened a special review team to determine why Jordan killed despite being under supervision by the system that was supposed to protect him. The team’s report was issued earlier this month.

To understand the case, one must grasp the particularly fragmented nature of child welfare in Pinellas County, Florida, in which three crucial functions usually vested in one agency are split between three different agencies. The Sheriff’s Department handles child abuse investigations, a private agency called Directions for Living manages in-home service cases under contract with Eckerd Connects, which in turn has a contract with DCF, and the State Attorney’s Office represents DCF in court.

The first call concerning Jordan and his parents came in to the child abuse hotline on October 2016, when Jordan was three months old. Jordan and his parents were living in the home of his paternal grandmother, and the caller was concerned about drugs, gang activity and firearms in the home. The allegations were verified and an emergency hearing was called. Ms. Stinson was ordered to relocate immediately and was referred to a program providing housing and support services to young mothers. However, she  refused to cooperate with the program and was rejected. A second hearing was convened on the same day (November 1, 2016) and Jordan was placed in foster care. In order to get Jordan back, the parents had to comply with a case plan which required each of them to obtain stable housing and income, comply with a “biopsychosocial assessment,” and follow the recommendations of the assessment. Ms. Stinson was also required to obtain counseling.

In January 2017, Jordan was placed with the foster family that would keep him until he was returned to his mother 16 months later. It was in this home, as his foster mother reported in a heartbreaking statement after his death, Jordan learned to roll, crawl, walk and talk and flourished in a supportive community of church members, foster families, and Coast Guard families.

While Jordan was thriving in foster care, an escalating series of violent incidents was reported between his parents. Each parent was in turn arrested for violence against the other but each case was dropped because the other parent did not press charges. Despite these incidents, Ms. Stinson was granted unsupervised visits with her son starting June 18, 2017. During the first unsupervised visit, Ms. Stinson allowed Mr. Belliveau to attend despite the fact that his visits were still required to be supervised. At this visit, which took place at a Burger King, members of a rival gang arrived and a fight ensued. Holding Jordan in her arms, Ms. Stinson struck at a woman who was fighting with Mr.Belliveau. Attempting to hit back, the woman hit Jordan in the mouth, inflicting lacerations. This incident was reported to the child abuse hotline, along with allegations that Mr. Belliveau was selling cocaine and marijuana from their home and that both parents used these drugs. Both parents refused to be tested for drugs. The investigation concluded with a finding of inadequate supervision and failure to protect Jordan by both parents.

In the next court hearing on the family case, the magistrate in charge of the case was not informed that this was a gang-related incident, that Ms. Stinson was involved, or that Jordan was injured. There was no mention of the  need to screen both parents for drug use.

According to Florida statute, DCF was required to file a petition for termination of parental rights within 60 days of November 1, 2017, when Jordan had been in foster care for 12 months. Yet no such petition was filed. At the hearing on January 8, 2018, the court found “compelling reason not to consider termination” because Ms.  Stinson was “partially compliant” with her case plan tasks because she had completed an assessment and was wrongly reported to be in counseling.

During a court hearing on April 23, 2018, Ms. Stinson’s attorney reported that she had completed the counseling mandated by her case plan, but no documentation was provided. As a matter of fact, Ms. Stinson had been terminated from counseling for the second time a week before the hearing. The Guardian ad Litem (GAL appointed to represent Jordan’s interests in court) objected to reunification because there was no documentation that Stinson was going to counseling and it appears that the case management agency objected as well. Without requiring documentation,  Magistrate Jennifer Sue Paullin ordered reunification and gave all parties 20 days to object based on new information. No objection was filed.

The court order, obtained by the Tampa Bay Times, states: “No evidence was presented to show that the circumstances that caused the out-of-home placement have not been remedied to the extent that the return of the child to the mother’s care with an in-home safety plan … will not be detrimental to the child’s safety.”.

On April 25, 2018, in anticipation of Jordan’s return to Ms. Stinson, the latter was referred to an in-home reunification program that provided twice-weekly visits from a licensed clinician. Ms. Stinson missed three or her five scheduled visits prior to reunification, which went ahead as scheduled on May 21, 2018. She missed seven of 11 visits following reunification and was unsuccessfully discharged from the program due to failure to participate

In a court hearing on June 11, 2018,  the court granted reunification to Mr. Belliveau, allowing him to join the family. Ms. Stinson had already missed several appointments with the clinician but the case management agency and government attorney reported that both parents were compliant with services.

On July 14, 2018, police responded to the parents’ residence to find Ms. Stinson bleeding and bruised and reporting that she had been punched by Belliveau. Mr. Belliveau was arrested after threatening to kill Ms. Stinson and “a lot of ….cops.” The child abuse hotline was not notified of this incident until three weeks later, on August 4. Despite the escalating violence and threats, the ensuing investigation did not find Jordan to be in danger warranting removal, but it was still open at the time of Jordan’s death.

On August 17, 2018, the agency filed an amended case plan with the court, including domestic violence services for Belliveau (as a perpetrator) and Ms. Stinson (as a victim). On August 24, Ms. Stinson refused to allow the GAL into the house. The investigator contacted the case manager for the first time on August 29, more than three weeks after the investigation began. The case manager said she normally visited once a week but admitted that he sometimes had trouble  reaching Ms. Stinson. On August 31, the case manager completed a home visit and explained to the parents that they needed to participate in services in order to retain custody of Jordan. Less than 24 hours later, Ms. Stinson reported Jordan missing.

Charisse Stinson has been charged with first degree murder for hitting Jordan, causing him to hit his head and have a seizure. Police report she did not seek medical treatment immediately and Jordan died. She then allegedly dumped his body in a wooded area and lied to police about a stranger kidnapping him, resulting in an Amber Alert and days of searching before Jordan’s body was found.

The special review team made six findings about the system’s  failures to save Jordan:.

  1. The decision to reunify Jordan with his parents was apparently driven by the parents’ perceived compliance to case plan tasks rather than behavioral change. Case decisions were solely based on addressing the reasons Jordan came into care. which related to gang and drug activity in the home where he was living. Although other concerns came to light during the life of the case, like substance abuse, domestic violence and mental health issues among the parents, these factors were not added to the case plan or considered in the decision to reunify Jordan with his parents. Ms. Stinson herself requested anger management training during a meeting in 2016 but this was never included in her case plan or provided. Moreover the court was kept in the dark about many of these concerns. “On multiple occasions, Ms. Stinson provided false information to the court,” which the case management agency and government attorney did not correct.
  2. Following Jordan’s reunification with his parents, staff failed to follow policy and procedures to ensure child well-being, such as making weekly visits. Moreover, they did not notify the court or take any action based on the mother’s lack of compliance with post-reunification services.
  3. When a new report was made to CPS, the investigator “failed to identify the active …threats occurring within the household that were significant, immediate, and clearly observable.” These included: ongoing and escalating violence between the parents, the father’s threat to kill the mother, and his gang membership and access to weapons, among others. In a major understatement, the Special Review Team opined that “Given the circumstances, a modification of Justin’s placement should have been considered.”
  4. There was a “noted lack of communication and collaboration” between investigative staff located in the Sheriff’s Department and case management staff during the August 2018 child abuse investigation. The investigator did not talk to the case manager for over three weeks after opening the investigation.
  5. There was a failure of communication and collaboration between all of the different entities involved in the case. There was a “lack of diligence in conducting multidisciplinary staffings at critical junctures of the case.” Neither the case management agency nor the state attorney provided accurate information to counter the false information provided by the mother to the court. Unbelievably, the case manager attended court hearings with no information about the mother’s participation in counseling, which was provided by the same agency.
  6. Assessments of both parents failed to consider the history and information provided by the parents and resulted in treatment plans that were ineffective to address behavioral change.

The review team did a good job of isolating the specific system failures that occurred in Jordan’s case but was not as successful identifying the systemic problems behind these failures. In this writer’s opinion, three major systemic factors contributed to the failure to protect Jordan:

  1. Lack of coordination and communication between agencies. This was the factor emphasized by the review team, which suggested that this issue was limited to Pinellas County. State Senator Lauren Book castigated the team for for this implication, arguing in a statement that the issue of “siloed communication” goes beyond the county and even beyond child welfare itself, citing the errors that predated the shooting at Marjorie Stoneman Douglas High School.
  2. Inadequate funding of child welfare services, leading to high caseloads and staff turnover.  The review team gave an offhand mention to the difficulty caused by high caseloads and turnover, both of which can be traced to inadequate funding but treated it as a given, rather than a problem to be rectified.
  3. The overemphasis on family reunification. In Florida and around the country, family reunification has been emphasized to the degree that children are often placed at risk. The Tampa Bay Times highlighted this  problem in its editorial entitled, Another child dead, another state failure. The death of a child following reunification is not a new story in Florida or around the country. If Florida law had been followed, Jordan’s parents’ rights should have been terminated before he was ever returned to them. A case manager who left Directions for Living shortly before Justin’s death told Florida’s News Channel 8 that the system “puts far too much weight on reuniting kids with unfit parents and makes it nearly impossible for caseworkers to terminate parental rights.” When asked why workers did not remove Jordan, she replied, “We are on quotas and we are told, ‘If there is any way to keep this kid in home do it.”

What is to be done to prevent future deaths like Jordan’s? It must begin, as the Tampa Bay Times editorial board asserts, with holding those involved accountable. This applies particularly to the magistrate on the case, who should have given the child rather than the parents the benefit of the doubt and held up reunification until she heard from the mother’s counselor. Second, child welfare must be funded adequately so that its staff are well-qualified and able to devote the time to handle cases correctly. Third, the silos must be broken down through improved policies and procedures that mandate data sharing and collaboration, but only adequate funding to enable reasonable caseloads will allow this to happen.

Finally, Florida and other states must rectify the balance between a child’s safety and the value of family reunification. Agencies must recognize that some parents who are suffering from the consequences of intergenerational trauma and dysfunction cannot change–at least within a timeline that is appropriate for a developing child.  This decision must be made early, with the input of qualified staff, high-quality evaluations, and laws and policies that put the child first.

As Justin’s foster parents put it, “Ultimately, we hope that our painful loss will result (in) a fundamental re-examination of the entire system, of how foster care works, of the reunification process. Jordan deserves that, and the other children in the system deserve that.”

Charisse Stinson is awaiting trial on charges of first degree murder and lying to police. She gave birth to another child in December and Belliveau has been determined to be the father. Both parents have filed court documents requesting the child be handed over to Belliveau, who has been arrested twice since Jordan’s death.

 

 

 

 

Abuse death of Anthony Avalos after 16 reports: the public needs to know why

Anthony Avalos
Image: Los Angeles Times

On June 21, the suffering ended for ten-year-old Anthony Avalos when his tortured body finally succumbed to years of abuse. The ten year old had severe head injuries and cigarette burns all over his body when his mother found him unresponsive and called 911. Anthony died the next morning. Despite sixteen reports to the Los Angeles Department of Child and Family Services (DCFS) or the police, the agencies tasked with protecting Anthony never rescued him from the adults that had abused him for years. Without a new law requiring public disclosure of the details of such cases, the public will never know how Anthony’s peril was missed or what changes are needed to protect future children from his horrible fate.

School administrators, a teacher, a counselor, family members and others called police or the child abuse hotline at least 16 times since 2013 to report abuse of Anthony or one of his six siblings, as revealed in a devastating article by respected investigative reporter Garrett Therolf published by the Los Angeles Times. DCFS received twelve reports between 2013 and 2015, according to its director, Bobby Cagle.

According to these reports, “Anthony or his six siblings were denied food and water, sexually abused, beaten and bruised, dangled upside-down from a staircase, forced to crouch for hours, locked in small spaces with no access to the bathroom, forced to fight each other, and forced to eat from the trash.”

Most of the allegations concerned Anthony. Among the alleged abusers were his mother, Heather Barron, her boyfriend, Karim Leiva, and another family member who was left in charge of the children and was accused of sexual abuse.

According to the sources, only some of the investigations resulted in a finding of child abuse. And even when abuse was found, the children were only once placed with an uncle and aunt, from whom they were soon removed and brought back to their mother over protests from the relatives, according to the aunt. She reports that she started making calls to DCFS in 2015 when she noticed injuries the children said were inflicted by Leiva.

Anthony’s father, a Mexican citizen, reported that Anthony asked to live with him but his mother refused. Aware that Anthony was being treated badly, he repeatedly gave case workers his contact information in Mexico. But he never heard back.

Instead of placing Anthony with his father or aunt and uncle, DCFS workers opened at least two cases to help Anthony’s mother improve her parenting while the children remained in the home. But these cases where closed without any resolution of the safety threat to these vulnerable children.

These horror stories of deaths of children after multiple serious allegations to police and child welfare agencies never seem to end.   The first step in preventing more tragedies is to conduct a detailed case review to identify the critical decision points where an opportunity was missed. It is likely that DCFS has already begun such an internal review. But it will be shared only with the county Board of Supervisors, which will hold it close.

This state secrecy is not unique to Los Angeles. Only a few states provide for the release of information about agency interactions with children who died of abuse or neglect. Texas’ Office of Child Safety posts reviews of fatalities but only when a child died of abuse or neglect during an open case. Florida requires an immediate investigation of a child’s death if the family was involved with CPS in the past year and posts the review if the child was found to have died of abuse or neglect.  In Washington, the Children’s Administration (CA) conducts 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 CA 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.

The Washington legislation is the broadest and most useful requirement. However, the universe of cases covered should be increased to include families that had contact with the child welfare agency within the past five years at a minimum. The last report on Anthony’s family was made in April 2016, more than two years before Anthony’s death, according to a statement by Bobby Cagle, the DCFS Director.  After the sixth abuse report concerning Yonatan Aguilar (also in Los Angeles County), Yonatan was locked in a closed for over four years until he was found dead in 2016.

Reviews should also be required for cases of children who suffer severe injuries due to abuse or neglect as well as cases of chronic severe maltreatment that was allowed to continue despite reports to CPS. These would include another Los Angeles County case recently in the news when a jury awarded $45 billion to a girl who suffered two years of sexual abuse after child welfare workers left her in a home with an a accused molester. We need to know how these errors happen as well.

A requirement that all states conduct and post such reviews of children who died should also be added as an amendment to the Child Abuse Prevention and Treatment Act, which is expected to be reauthorized in 2018. When an agency egregiously abdicates its responsibility to protect children, the public must know how and why it happened. Only then can they hold their government accountable for making the changes necessary to prevent such tragedies in the future.

This post was updated on July 27, 2018.