When a child is found to be seriously or fatally abused, the perpetrator is often found to be a male caregiver. But a new study using data from pediatric emergency rooms provides powerful evidence of the correlation between caregiver characteristics and the likelihood of abuse.
The new study is the first to compare caregiver features among children with injuries due to abuse to those with accidental injuries. The article was published in the Journal of Pediatrics, and a summary is available online on the Science Dailywebsite. The authors used data on 1615 children under four who were brought to a pediatric emergency department. Overall, 75% of the injuries were classified as accidents, 24% as abuse and 2% as indeterminate.
The differences between the likelihood of abuse versus accident among different groups of caregivers are striking. Abuse was determined to be the cause of injury to only 10% of the children for whom a female was the only caregiver at the time of injury and fully 58% of children who were with a male caregiver when injured. There was a big difference between fathers and boyfriends however; an “alarmingly high” 94% of the children who were alone with the mother’s boyfriend at the time of injury were determined to be abused, as compared to “only” 49% of injured children who were with their fathers at the time of injury.
Analysis of the 83 cases of severe injury (including fatalities) provided even stronger evidence of the connection between male caregivers and abuse. The authors found that “nearly all cases of severe injury in which fathers and boyfriends were present involved abuse, and for fatalities, the fathers and boyfriends were most commonly present as lone caregivers. Mothers were rarely present alone when severe abusive injuries occurred.”
Among female caregivers, one group was more likely associated with injuries and that was babysitters. Fully 34% of the children left alone with babysitters were found to be victims of abuse
The researchers point to several policy implications of their study. First, they highlight the importance of asking who was caring for the child at the time of injury as part of the investigation to determine whether an injury is the result of abuse. Second, they call for abuse-prevention strategies to focus on male caregivers and female babysitters. (Currently, such programs, like shaken baby education, often focus on mothers.)
But the authors do not mention another policy implication that is equally important. Ensuring that all low-income children have access to high-quality early care and education (ECE) is a logical implication of the study.
As I have written in an earlier post, there are many pathways by which ECE can prevent maltreatment. Free, high quality ECE would provide mothers with an alternative to leaving their children with caregivers who are unsuitable to the task–be it boyfriends, fathers, or babysitters. ECE has other child welfare benefits as well. Staff who are trained as mandatory reporters ensures that more adults will be seeing the child and able to report on any warning signs of maltreatment. Quality ECE programs that involve the parents can also improve child safety by teaching parents about child development, appropriate expectations, and good disciplinary practices. They may also connect parents with needed supports and resources in the community and help them feel less isolated and stressed.
Of course the benefits of ECE extend far beyond child welfare in the narrow sense. We are worried about school readiness for low-income children and we know that much of brain development occurs between the ages of 0 and 3. That’s why quality ECE has been such a priority for the early childhood community. But child welfare policymakers have not yet caught onto the importance of ECE as a means of preventing child maltreatment.
An excellent issue brief from the Administration on Children and Families recommends improving access to ECE for families that are already involved with child welfare. That is a great proposal, but the child welfare field is beginning to focus on prevention rather than only treatment. We must explore ways to provide access to ECE among children who are at risk of child abuse and neglect. Expanding access to subsidized child care among lower-income families, because income is so highly correlated with child maltreatment, would be a good beginning.
Prevention is the word of the day in child welfare. A key part of prevention is making sure children spend their time with caregivers who will not harm them.
Another little boy is dead in Los Angeles County after being left in the hands of his abusers by the Los Angeles County Department of Child and Family Services (DCFS). This time, the victim was four-year-old Noah Cuatro. Noah’s family had been the subject of at least 13 calls to the county’s child abuse hotline. He had been removed from his abusive parents for two years but was returned to him less than two months before he was killed.
Noah’s death is the third since 2013 of child who had been the subject of multiple reports and investigations by child welfare authorities in the remote Antelope Valley of Los Angeles County. In June, 2018, Anthony Avilas was tortured to death by his mother and her boyfriend, who are facing capital murder charges. In 2013, eight-year-old Gabriel Fernandez suffered the same fate. His mother is serving a life sentence and her boyfriend is on death row.
At least 13 calls had been made to the county’s child abuse hotline alleging that Noah’s parents were abusing their children, according to a devastating article in the Los Angeles Times.
Although the case file has not been released, sources revealed some of the contents to the Times reporters. In 2014, DCFS substantiated an allegation that Noah’s mother had fractured the skull of another child. In 2016, Noah was removed from his home and remained in foster care for two years. He was ultimately placed with his great-grandmother, who states that she often told DCPS social workers about concerning behavior her granddaughter displayed at her visits with Noah. She also claims that Noah begged her not to let him go.
Once Noah returned home, reports of abuse continued to be phoned in in February, March, April and May 2019. One report alleged that Noah was brought to the hospital with bruises on his back. A report on May 13 alleged that his father had a drinking problem, was seen kicking his wife and children in public, and sometimes when drinking voiced his doubt that Noah was his child.
At least one DCFS social worker took these reports seriously. On May 14, sources told the Times, she filed a 26-page report to the court requesting an order to remove Noah from his parents. And the judge granted that report the next day. But weeks went by–and the order was not implemented, even after new allegations came in that Noah had been sodomized and had injuries to his rectum. Noah died on July 6, more than seven weeks after the order was granted.
We do not know why Noah was not removed, because state law requires that the agency conduct its own investigation before the case file can be released in child fatality cases. We do know from another Los Angeles Times article that DCFS has already changed its policy on court removal orders to say that such a delay should be an “extreme exception” and must be brought to the director of the agency and approved by his Senior Executive Team.
Why so many tragedies in the Antelope Valley? Given its small population, Antelope Valley has a disproportionate number of deaths caused by a parent or caregiver of children already known to DCFS. according to calculations by the Chronicle of Social Change. Nobody knows if this higher death rate is due to cultural or economic features of the area or to challenges in staffing DCFS. Difficulties in attracting and retaining staff in this remote part of the county have been described in numerous reports, most recently an audit of DCFS and a report on the death of Anthony Avalos.
On July 23, the Los Angeles County Board of Supervisors unanimously approved a motion requiring DCFS to work with other agencies and educational institutions to develop a staffing plan to alleviate staff shortages and turnover in the Antelope Valley. I It also directs DCFS to immediately develop a Continuous Quality Improvement Section and fill approximately 20 positions which will allow for increased case reviews, initially focused on the Antelope Valley section.
These are good steps that are surely needed, given the staffing problems in Antelope Valley. However, until we know the reason the court order requiring Noah’s removal from the home was disregarded, we don’t know if these steps will address the proximate cause of Noah’s death–the failure to remove him from his home when a social worker clearly recognized the need for it. It appears that this removal order was overriden by someone above the social worker – but we need to know why and by whom. This crucial decision may have little to do with staffing problems and more to do with other factors–such as an ideological preference for parents’ rights or a reluctance to remove children.
Sadly, there is no provision in California or LA County requiring an in-depth case review to be released to the public. This never happened in the cases of Anthony Avalos or Gabriel Fernandez. In order to get to the bottom of these horrendous deaths, Los Angeles County’s Board of Supervisors should pass legislation requiring such a review. Washington’s state’s statute requires a review (by experts with no prior involvement in the case) when the death or near-fatality of a child was suspected to be caused by child abuse or neglect, and the child had any history with the Children’s Administration at the time of death or in the year prior. These reviews must be completed within 180 days and posted on the agency’s website. Florida has a similar requirement, as I have described in an earlier post.
The father and siblings of Anthony Avalos filed a $50 million suit against DCFS and one of its contractors only a few weeks after Noah’s death. They allege that the department “was complicit in the abuse and neglect of Anthony and his half-siblings.” The same attorney is now representing Noah’s grandmother, and a lawsuit is sure to follow. How many more deaths will it take before the county can be relied on to protect its vulnerable children from suffering and death inflicted by their parents?
Illinois’ child welfare services to families that are allowed to keep their children have major systemic flaws that put children at risk. Most importantly, there is extreme reluctance to remove children from their homes and place them in foster care. Those are the findings of a review from Chapin Hall at the University of Chicago that was commissioned by the Governor in the wake of several deaths of children whose families were being supervised by the state.
This report follows an earlier one, discussed in a previous post, by the Inspector General (OIG) for the Illinois Department of Children and Family Services (DCFS) stating that child safety and well-being are no longer priorities for the agency. One problem area identified in that report was Intact Family Services, which are the services provided to families in order to prevent further abuse or neglect without removing the child. OIG’s 2018 annual report included an eight-year retrospective on the deaths of children in Intact Family Services cases, which concluded that in many of these cases the children remained in danger during the life of the case due to violence in their homes, when DCFS should have either removed the children or at least sought court involvement to enforce participation in services,
Increasingly, child welfare systems around the country have been relying on services to intact families (often called in-home or intact family services) in order to avoid placing children into foster care. In 2017, according to federal data, only 15% of children who received services after an investigation or assessment were placed in foster care; the other 85% were provided with services in their homes. These services may become even more predominant with implementation of the Family First Prevention Services Act, which allows federal Title IV-E funds to reimburse jurisdictions for the cost of such services.
It is important for child welfare agencies to be able to work with families that remain intact. This allows the agency to monitor the children’s safety and avoid the trauma of placement in foster care while working to ameliorate the conditions that might lead to a foster care placement. But agencies must be cognizant that not every family can be helped this way, keep a close watch what is going on in the home, and be ready to remove children when necessary to ensure their safety. The deaths of children who have received Intact Family Services in Illinois have raised questions about whether the agency is accomplishing these tasks.
In Illinois, Intact Family Services (referred to below as “Intact”) are provided mostly by private agencies under contract with DCFS. The Chapin Hall report found systemic issues that create barriers to effectively serving intact families.
Avoiding foster care placement: Perhaps the most important issue observed by the researchers was the high priority that Illinois places on avoiding placement of children in foster care. As a result of many years of such efforts, Illinois now has the lowest rate of child removal in the country. Intact staff expressed the belief that “recommendations to remove children based on case complexity, severity, or chronicity will not be heard by the Division of Child Protection (DCP) or the Court.” As a result, Intact supervisors are reluctant to reject referrals of families even when they believe a family cannot be served safely in the home. They are also reluctant to elevate cases for supervisory review when they have not been able to engage a high risk family.
Supervisory Misalignment: In the past, negotiations between DCP and Intact over the appropriateness of a referral occurred on a supervisor-to-supervisor level, allowing Intact to push back against unsuitable referrals. An administrative realignment that placed investigators and Intact under different administrations eliminated this ability of Intact to contest inappropriate referrals. According to the researchers, this resulted in the opening of Intact cases for families with “extensive histories of physical abuse” that Intact staff believed they could not serve effectively.
High Risk Case Closures: Intact service agencies are expected to work with a family for six months and then close the case with no further involvement by DCFS. The researchers learned that there was no clear pathway for intact staff to express concerns when they been unable to engage a family. As a result, some providers told the researcher that they may simply close the case when a family will not engage.
Staffing Issues: Caseload, capacity and turnover. The researchers found that DCP investigators are overwhelmed with their high caseloads and are desperate to make referrals to Intact to get families off their caseload as soon as possible. The prescribed caseload limit of 15 cases per worker is very hard to manage, and some workers carry even more cases. Moreover, DCP workers tend to stop managing safety plans and assessments as soon as a referral is made to Intact, which leaves children in limbo until services begin. For their part, Intact workers’ caseloads are often over the prescribed limits and are not adjusted for travel time or case complexity. Moreover, the difficulty of their clientele makes the current caseload of 10:1 difficult to manage. High turnover among Intact workers, investigators and other staff can also contribute to the information gaps and knowledge deficits mentioned below.
Role Confusion: DCP workers and Intact workers seem to have different views of the role of the DCP worker, according to the researchers. DCP workers view their role as making and justifying the decisions about whether to substantiate the referral and remove the child. However, the Intact Family Services policy calls upon them to engage the family and transmit all necessary information to the Intact staff. Cultural differences between the two sets of workers compound the problems.
Information Gaps: Because of the role ambiguity mentioned above, investigators often fail to pass on crucial information to Intact workers. Yet, these workers often cannot access investigators notes or key features of the case history. Moreover Chapin Hall’s reviews of the two recent deaths of toddlers in intact cases found that much of the family’s history was inaccessible because cases were expunged or purged. DCFS expunges most unsubstantiated reports and shreds investigators files and appears to be more aggressive about such expungements than most other states, according to a previous DCFS Director, George Sheldon.
Service Gaps: The researchers also mentioned gaps in service availability, especially long waiting lists for substance abuse prevention, which make it very difficult to engage families as well as providers.
The authors made a number of recommendations for addressing these problems they identified. These include:
Work with courts and State’s attorneys to refine the criteria for child removal in complex and chronic family cases;
Develop and refine protocol for closing Intact cases;
Direct attention to cases at greatest risk for severe harm; revisit the use of predictive models which should be transparent, based on broad input and be supported by ethical safeguards’
Clarify goals and expectations across staff roles;
Utilize evidence-based approaches to preventive case work;
Improve the quality of supervision;
Adjust the preventive services offered through Intact to meet the needs of the population;
Restructure Intact Services to address the supervisory mismatch with DCP; and
Redesign the assessment and intake process to reduce redundant information, improve accuracy or assessments to support decision-making and improve communication across child serving systems.
We would have liked to see a recommendation to modify Illinois’ policy of expunging and purging all unsubstantiated investigations. At a hearing in May, 2017, the DCFS Director, George Sheldon, expressed his support for allowing DCFS to keep records of all investigations, even if they are unsubstantiated. Research suggests that it is very difficult to make accurate decisions about whether maltreatment has occurred; moreover, unsubstantiated reports are as good as substantiated ones in predicting future maltreatment. Examples of children killed after families have had multiple unsubstantiated reports have been observed all over the country.
This report should be a must-read for all child welfare agencies. Children in many states have died of abuse or neglect after intact cases have been opened for their families. (Think about Zymere Perkins in New York or Anthony Avalos and Gabriel Fernandez in Los Angeles.) Many of the issues identified by the Chapin-Hall report may have contributed to these deaths as well, particularly the extreme avoidance of child removals that has condemned so many innocent children to death ever since the widespread push to reduce the foster care rolls, supported by a coalition of wealthy and powerful foundations and advocacy groups.
The 21st National Conference on Child abuse and Neglect (NCCAN) sponsored by the Children’s Bureau of the U.S. Department of Human Services (HHS) took place in Washington DC from April 24-26, 2019, and there could be no better window onto the child welfare zeitgeist. NCCAN’s defining spirit was perfectly embodied in the conference theme, Strong and Thriving Families. But the main takeaway for this blogger was how far the field has strayed from its central and defining mission–protecting children.
From the first words booming out of the speaker in the hotel ballroom, the conference plenary sessions focused relentlessly on a two-part message. First, the worst thing to do for abused and neglected children is to remove them from their families and we should stop doing it right now. Second, child welfare should focus on primary prevention–preventing child maltreatment before it occurs.
Removing abused and neglected children from their families is the worst thing you can do to them. That was the main message delivered by plenary speaker Amelia Franck Meyer, one of PEOPLE Magazine’s 25 Women Changing the World. Meyer made extensive use of the animal kingdom to make her points about the mother-child relationship. She started with baby ducks imprinting onto their mothers and went on to mother bears. When one of own children is not having their needs met at school, Meyer says she will stop at nothing to ensure that the little one’s needs are met. And that’s why all kids need their mother, she explained, because your mother “always has your back.”
“Mama bear” would not be the best term to describe many of the mothers I saw as a foster care social worker, or the ones whose children’s deaths I have been reviewing as part of the District of Columbia’s Child Fatality Review Committee. The moms who expose their babies to brain-damaging substances in utero, sleep through the night aided by drugs or alcohol while their infants die, can’t be bothered to bring their children to school for 30 days in a semester, leave them in the care of volatile boyfriends, or inflict bruises and cuts are hardly mama bears. And, despite what we may want to believe, some children need to be rescued from such mothers.
Meyer also told us that we should not think of children as individuals but as part of families, which sounds a bit like a return to an earlier century. And of course she did not forget to the modern trope that child welfare is not about saving children from their families but rather about helping families protect their children.
In his closing plenary session, Children’s Bureau Chief Jerry Milner urged us to stop using the term “birth parent,” “which undermines the singular parent-child relationship.” That term helps separate the idea of procreation from that of nurturing–something that Milner clearly does not want to do. We also can’t talk about “dysfunctional” families, according to Milner. If only not talking about them would make them function well!
Milner urged participants to picture a different type of child welfare system, where “families are given what they need to thrive, not just survive.” In an interview with the Chronicle of Social Change, Milner suggested that what families need to prevent maltreatment includes “parenting education and support, community-based substance abuse prevention and treatment services, ready access to needed medical and mental health services and trauma-informed services to help parents heal from their adverse experiences.”
Milner did not mention child care, housing, or increased cash assistance–services that many would argue poor families need to thrive. But that’s not surprising given that he’s a member of the Trump Administration. Even expanding access to parenting classes, drug treatment and mental health services does not sound like an administration priority–unless the funds come from reprogramming current spending, which seems to be what Milner has in mind. By his own report, he tells child welfare officials who are afraid of adding a new set of primary prevention functions to their current overwhelming mandate that they should do it instead of what they are already doing, not in addition to it! Apparently he believes that cutting funds for CPS investigations and foster care would provide ample funding for primary prevention.
So what’s wrong with all this? Isn’t primary prevention the most logical approach to any social ill? Unfortunately, there are a few problems with making it the only approach:
We don’t know much about what works to prevent child abuse and neglect. The most touted programs involve home visiting, and we don’t have a lot of evidence that they work to prevent child abuse and neglect. The California Evidence Based Clearinghouse for Child Welfare (CEBC) has rated only one home visiting program as “well-supported” by the research evidence as a means of preventing child maltreatment, and that program (Nurse Family Partnership) is limited to first-time low-income mothers. CEBC rates only one program (SafeCare) as “supported by the research evidence” as a program to prevent child maltreatment. And all of these programs have been strictly voluntary–which leaves out the families that are most dangerous to their children.
Many primary prevention programs don’t belong in the child welfare agency. Mental health and drug treatment serve a broader clientele than parents involved in child welfare and are generally provided by different agencies. And while Milner was careful not to mention housing, child care, or cash welfare, these don’t belong under the jurisdiction of child welfare agencies either.
Even if we had a better idea about what worked, we might reduce maltreatment but not eliminate it. We would need a method of investigating possible occurrences and protecting (even sometimes rescuing) the children at risk. It’s like saying we need to shut down hospitals. Of course we want to prevent gun violence, car accidents, cancer, and outbreaks of preventable infections diseases. But we certainly need to have hospitals available in case we fail.
Given NCCAN’s focus on primary prevention, it is not surprising that the Family First and Prevention Services Act received almost no mention throughout the conference, even though it is the biggest change to federal child welfare legislation in two decades and takes effect in October–and federal guidance is woefully lacking. Jerry Milner has already said that Family First is only the first step toward transforming child welfare. What he really wants is a block grant that would allow states to shift funding from CPS, foster care, and family preservation to primary prevention. And that could result in further starvation of CPS, foster care and in-home services (which need more funding, not less) in the name of a mission that should be carried out by other agencies.
On Monday, conference participants returned to the real world, where media outlets in Illinois and nationwide were reporting on five-year-old AJ Freund, who was beaten to death on April 15. His parents, who reported his disappearance three days later and tearfully attended a vigil shortly thereafter, have been charged with his murder. As the Chicago Tribune put it,
Witnesses in all corners of AJ’s life saw signs of abuse or neglect. A doctor, neighbors, police and others knew or suspected that much was amiss over the years. Many of them sounded alarms that were recorded by the courts and the Illinois Department of Children and Family Services, which once again finds itself struggling to explain why a child on its watch is now dead….Yet AJ, who was born with opioids in his system, was left to live in a filthy house of horrors where it appears he was hurt again and again.
And if Jerry Milner and Amelia Franck Meyer have their way, many more AJ’s will suffer and die without anyone to rescue them. Because they believe that child welfare agencies should not be in the business of rescuing children.
An unproven–and mostly discredited–theory is encouraging family court judges to award custody–against children’s wishes–to the parent that has been accused of harming them. Moreover, this theory of “parental alienation” has “spawned a cottage industry of so-called family reunification camps that are making big profits from broken families.” That’s the message of a stunning report by the Center for Investigative Journalism aired on public radio’s Reveal program.
The Reveal broadcast focused on two custody cases in which the judge ordered children placed against their will with the parent that they claimed was abusive. In one case, the judge sent a teenage boy to juvenile detention because he was not making sufficient efforts to get along with his mother. He and his sister were then sent to live with their father and allowed no contact with their mother for a period of three years. In the other case, a fourteen-year old girl who said her mother was emotionally abuse and wanted to live with her father was sent to a “reunification camp” for ten months at her parents’ expense. Her mother was given full custody and the teen was separated from her father father for four years. The judges in both cases based their decisions on a theory called “parental alienation.”
“Parental alienation,” originally “Parental alienation syndrome (PAS),” was the brainchild of Richard Gardner, a child psychiatrist who developed it to help fathers fight abuse claims in custody disputes. In its current iteration, parental alienation describes a parent’s attempt to turn the children against another parent in a custody dispute. A charge of parental alienation is often deployed by a parent who has been accused of abuse, allowing that parent to turn the tables and accuses the other parent of brainwashing the children. The theory encourages judges to remove children from the parent with whom they are bonded because that parent is believed to have alienated them against the other parent.
According to Joan Meier, a leading researcher in the field of domestic violence and custody cases, there is little evidence to support the idea that “parental alienation” due to manipulation by one parent is a common occurrence. However, invoking parental alienation allows an abusive parent to portray a protective parent as a vengeful liar who is manipulating the children by implanting false memories of abuse. The theory creates a “paradoxically disastrous dynamic“: if an abuser can convince a court that the children’s attitudes reflect parental alienation, he can actually benefit from his abuse.
The Reveal story was misleading in one respect. While acknowledging that the charge of alienation is overwhelmingly used by fathers against mothers, the story focused on two families in which the mothers used the charge to take custody from the fathers. Much more common are stories like the following:
In August 2018, six-year-old twin boys were ordered removed from the sole custody of their mother (with whom they had lived for five years) and placed with their father, who was alleged to have physically and sexually abused them for years. The father, an Air Force colonel with a traumatic brain injury, had acknowledged problems with controlling his anger and sexual impulses. Yet a family court judge in Montgomery County, Maryland gave sole custody to the father, voicing the belief that the boys’ mother had manipulated them into making five allegations of abuse–even though such fabricated abuse allegations from young children are rare.
The divorce case of Omer Tsimhoni and his ex-wife, Maya Eibschitz-Tsimhoni of Bloomfield Hills, Michigan, drew international attention in 2015 when the judged locked up their three children, ages 9, 11, and 14, because they refused to have lunch with their father. The children spent more than two weeks in juvenile detention before the judge released them after public outcry. The mother had claimed the children were estranged from their father because he physically and verbally abused them, and the father accused her of alienating the children. Later, the father was given temporary custody and the children did not see their mother for almost nine months. The mother was finally given primary custody by a new judge in June 2016.
How do judges make these decisions, which often seem cruel and contrary to common sense? According to Meier, many lack understanding of domestic violence and child abuse. Moreover, they often rely on neutral evaluators who also also lack “meaningful knowledge or expertise in domestic violence and abuse. Adding to this ignorance is the emphasis in family courts and mental health training on the importance of children retaining relationships with noncustodial parents after divorce and a consequent emphasis on “co-parenting,” which often reinforces the parental alienation hypothesis.
Unfortunately, there is no data to indicate how often parental alienation plays a part in child custody decisions. But according to Joan Meier, “parental alienation remains a dominant issue in many, if not most, custody cases in which a mother has alleged that a father was abusive.”According to Meier, the increasing use of parental alienation theory is part of a broader “trend toward reversal of custody from protective mothers to allegedly abusive fathers…”
Thankfully, it appears that due to media coverage and the work of scholars and activists, awareness about the use of parental alienation theory is growing among the public, child advocates, and policymakers. After eight years of advocacy, the House passed a Concurrent Resolution last fall that states that “child safety is the first priority of custody and parenting adjudications, and courts should resolve safety risks and claims of family violence before assessing other best interest factors.” The resolution also calls for higher standards for evidence and for the “experts” who testify in court and calls on Congress to schedule hearings on family court practices with regard to children’s safety and civil rights. According to Joan Meier, this resolution is “the perfect springboard” for local activists to take to their legislators and ask for similar changes at the local level, where the family courts actually operate.
DV LEAP, an advocacy organization founded by Joan Meier, and other organizations are also fighting for the rights of protective parents and abused children in court. On March 22, DV LEAP and many other organizations filed a groundbreaking brief with the New York State Court of Appeals that is the first documented collaboration between domestic violence and child maltreatment professionals on parental alienation theory. According to Meier, this brief has the potential to be a catalyst for national change.
This post is a departure for Child Welfare Monitor. We have not touched on many issues outside the arena of public child welfare. But parental alienation theory is yet another example of powerful adults ignoring the best interests and expressed wishes of children, and putting them at risk due to ignorance or mistaken beliefs. Those of us who care about abused and neglected children need to expand our awareness and activity to include all children whom our institutions fail to protect from maltreatment.
DCFS has lost focus on ensuring the safety and well-being of children as a priority. This is evidenced by several recent cases and the clear lack of attention to assuring children and families receive adequate, thorough, and timely responses and needed services. Investigators, caseworkers and supervisors are unmanaged, and unsupported. Children are dying, children are being left lingering in care, children are being left in in psychiatric hospitals beyond medical necessity causing them to lose hope. This is not just unacceptable it is HARMFUL
That startling statement was made by the Acting Inspector General (IG) for Illinois Department of Children and Families to News Channel 20 about its most recent annual report. During FY 2018, the Office of Inspector General (OIG) reviewed 97 deaths and one serious injury of children whose families were involved in the child welfare system within the preceding 12 months. Of the 98 families involved, at least 52 were the subject of of a completed child abuse or neglect investigation during the previous 12 months; fully 37 of these investigations failed to find any abuse or neglect and were closed without any action to protect the child. Twelve of the 98 families were the subject of an open investigation when the child died, eight were involved in an open family service case, and three had had a family case closed within a year of the death. (See the full count of deaths by case status at the bottom of this article.)
Not all of the deaths or serious injuries can be attributed to DCFS failure to protect a child. Twenty-seven deaths were ruled natural; most of the children involved had serious medical issues. Some of the deaths (including most the 16 youths in foster care)1 were sadly due to violence, car accidents, drug abuse by older youths and other circumstances not under the Department’s control. Heartbreakingly, two older teens in foster care died of abuse that was inflicted on them as infants and left them medically compromised.
However, many of the case reviews suggest DCFS missed danger signs and opportunities to save vulnerable children. Thirteen children were killed by a parent, step parent, parent’s paramour, another relative or unknown perpetrator within a year of an open investigation or service case. These children were beaten, starved, stabbed, and shot to death. The cause of 23 deaths of children in families that recently interacted with DCFS is still undetermined; many are currently being investigated. Most of these children were infants; many of the deaths appeared to be linked to unsafe sleep practices and at least four raised concerns of abuse. The deaths of 24 children with an open or recently open case were classified as accidental. Fourteen of these deaths were attributed to asphyxia, suffocation, or sleep related causes; there were also two accidental drownings, an accidental hanging, and an accidental shooting of a three-year-old by an 11-year-old, as described below.
The OIG completed “full investigations” of four cases that have drawn extensive media attention:
Seventeen-month-old Semaj Crosby was found dead under a couch in her home 30 hours after being reported missing. There was both an open in-home case and a pending child protection investigation of the family at the time Semaj was reported missing. The family had been the subject of 11 investigations during the two years before her death. The mother received SSI for cognitive delays but was never assessed to determine her ability to keep her children safe. Semaj’s seven-year-old brother was psychiatrically hospitalized three times for threatening to kill himself during the time the family’s case was open. A family service caseworker visited the home the day before the toddler was reported missing, and a child protection investigator had been to the house the day the report was made. No immediate safety concerns were reported by this investigator, even though the health department deemed the apartment uninhabitable after the body was found. Criminal and child neglect investigations are pending.
Four-year-old Manual Aguilar was killed, apparently starved to death, and his body was burned post-mortem. Four years before his death, Manual and his three siblings were removed from their mother’s custody after she left the three older children in a car overnight at temperatures hovering around freezing, while Manual was left in a stranger’s care. The children were returned home a year before Manual’s death despite the mother’s failure to progress in therapy and an unfounded investigation stemming from bruises to one child that his older siblings reported were inflicted by the mother during an overnight visit. Five months before Manual’s death, the two older siblings texted to their former foster parent that their mother was beating them, but the investigation was unfounded when they recanted. The mother has been charged with murder.
A daycare center reported that a two-and-a-half-year-old appeared to have cigarette burns on both hands. The reporter also said the child’s face had been swollen on two prior occasions, and an unknown male accompanying the mother was seen to hit the child across the face a week before. The investigator closed the case without investigating adequately either the child’s burns or the family’s allegation that they occurred at the daycare. Two days following the investigation’s closure, the child experienced cardiac arrest and died four days later. The autopsy concluded that the manner of death was undetermined and suspicious, but a child protection investigation did not find evidence to find anyone responsible for the death.
An eleven-year-old girl accidentally shot her three-year-old brother in the head while playing at home. This child survived and and this appears to be the only non-fatal case reviewed. The parents had left four of their children, of which the eleven-year-old was the oldest, at home alone. The father had eight drug convictions and had been arrested multiple times for physically assaulting the mother. The investigation of the shooting was the eleventh investigation of this family since 2008. One investigation had occurred when the father barricaded himself in the home with the mother, who was eight months pregnant, and the screaming and crying children. The children’s eight-year-old sibling was in residential care in the custody of DCFS at the time of the shooting and the agency was required to monitor the at-home siblings as well. Nevertheless no visits by case managers to the home were documented in the 45 months before the shooting with one exception. A case manager attempted to visit the home 21 days before the shooting but was not allowed in. .
The acting Inspector General told a reporter that understaffing may have contributed to the state’s inability to prevent child deaths. Following the death of Semaj Crosby, the OIG investigated a media report that child protection workers in the local office were offered incentives for early case closure. The IG found that while Semaj’s family was involved with DCFS, the entire region was understaffed (at times as low as 66% of staff needed), resulting in excessive caseloads for investigators. In December 2016, the field office administrator offered a $100 gift card to the investigator who could close the most cases in January. The IG found similar incentive programs for early case closure around the state.
The OIG also found that “a large contributing factor to the caseload problem was that the previous director had several management initiatives that seemed to take priority” over any attempt to redistribute caseloads. One of these initiatives, Rapid Safety Feedback, received some media attention last year. DCFS awarded a multimillion-dollar contract to two out-of-state firms using a “propriety algorithm to identify cases most likely to result in death or serious injury.” There were concerns that this contract was one of several no-bid contracts given to a circle of former associates of the previous director, as described by the Chicago Tribune. The contract was terminated after 25 to 50 percent of cases were flagged as having a a greater than 90% probability of death or serious injury in the next two years, alarming and overwhelming social workers. At the same time, the algorithm failed to predict the death of Semaj Crosby and other children who were killed while under supervision by DCFS.
The OIG report identified two areas of “chronic misfeasance,” or conduct that is lawful but inappropriate or incorrect. One of these areas is “intact family services,” which is DCFS-speak for the services provided to families to prevent further abuse or neglect without removing the child. OIG’s 2018 annual report included an eight-year retrospective on the deaths of children in intact family services cases. The OIG concluded that in many of these cases the children remained in danger during the life of the case due to violence in their homes, when DCFS should have either removed the children or at least sought court involvement to enforce participation in services.
A second area of “chronic misfeasance” identified in the 2019 report which has also drawn media coverage is the practice of leaving foster children in psychiatric hospitals “beyond medical necessity,” or after they are stable enough to be cared for outside that setting because there is no appropriate placement. OIG reported that the number of such episodes increased from 273 in FY 2017 to 329 in 2018. “The availability of community-based services and resources for youth with significant mental and behavioral needs continues to be at crisis levels.”
The OIG’s overall conclusion–that child safety and well-being are no longer priorities for DCFS–is sobering. But even more alarming is the fact that this description could be applied to many or even most other states. Although we don’t have numbers for most states, every year brings stories from around the country of children killed after long histories of contact with child welfare authorities. Twenty-seven percent of the fatality cases analyzed by the Administration on Children and Families for its Child Maltreatment report had at least one Child Protective Services contact within the past three years. State child welfare agencies tend to hide behind strict privacy protections in order to avoid releasing information on child protection failures, even though the case information could be released without including the names of the families involved. As a member of the District of Columbia’s Child Fatality Review Commission, I hear at almost every monthly meeting about one or more children who died after the family was called to the attention of CPS multiple times. And yet, I am not allowed to share any information about these cases with anyone, including legislators.
At least in Illinois, thanks to the DCFS Inspector General, the public and its elected representatives are given the opportunity to learn about failures to protect children while in the custody of their parents as well as those the custody of DCFS. This information helps make the case for change. The OIG report was the subject of a hearing in Springfield. The Governor has already requested an increase of more than $70 million for 126 new staff and technology upgrades.
Unfortunately, most states do not have an independent agency like the Illinois OIG to look out for children who are served by the agency both at home and in care. In a report issued on April 4, 2018, the National Council of State Legislators found that only 11 states have “an independent and autonomous agencies with oversight specific to child welfare,” although they seem to have missed Illinois. All states need such an autonomous agency. Somebody needs to reveal the truth about how we fail our most vulnerable children–and what it would take to do better.
Number of Child Deaths by Case Status from OIG Report
Case Status*Number of deaths or serious injuries
Pending Investigation at time of child’s death………………………………………………………12
Unfounded Investigation** within a year of child’s death……………………………………37
“Indicated” Investigation*** within a year of child’s death…………………………………..15
Youth in care………………………………………………………………………………………………………………16
Open Placement/Split custody****……………………………………………………………………………..3
Open Intact Case*****………………………………………………………………………………………………….8
Closed Intact Case within a year of child’s death……………………………………………………….3
Child of Youth in Care……………………………………………………………………………………………………1
Child Welfare Services Referral (no allegation of abuse or neglect)………………………….2
Preventive services to assist family but not as result of indicated investigation………1
*When more than one reason existed for the OIG investigation, the death was categorized based on “primary reason.”
**An investigation in which the agency was unable to verify that abuse or neglect occurred.
***An investigation in which abuse or neglect by the parent was found to have occurred.
****Child was in home with siblings in foster care
****A case in which the family was receiving services while the child remained in the home.
Of the 16 children who died while in foster care, a 14-year-old and an 18-year-old died of gunshots by unrelated perpetrators, two died as a consequence of abuse by their parents in infancy, three were infants in care of relatives and cause of death was undetermined for two and suffocation for one, two died of methadone or opioid intoxication, one 18-year-old died in a car accident and five died of natural causes. ↩
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:.
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.
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.
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.”
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.
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.
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:
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.
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.
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.
On May 18, 2018, a little girl named Heaven Watkins was found brutally beaten to death in her home in Norfolk Virginia. Three months earlier, Heaven was hospitalized with third-degree burns that kept her in the hospital for six days and required skin grafts. Child Protective Services in Norfolk was reportedly called but they decided not to intervene to protect Heaven.
Investigations from KARE 11 in Minneapolis and 13News Now in Norfolk revealed that Heaven was removed from her parents four years before in Minnesota due to concerns about physical punishment, sexual abuse, drug sales and guns in the home. Virginia DSS has refused to tell reporters whether its workers knew of the family’s history in Minnesota. The haunting question is whether Virginia would have done more to protect Heaven had they known of her history in Minnesota.
Heaven was not the only child in the care of a parent who was known to Child Protective Services in another state. A 2012 report by The Oregonian discussed several other children who died of abuse after investigation that did not unearth their family history in other states. Heaven’s story has triggered renewed calls for an interstate registry of child abuse and neglect. Had a registry existed, Virginia would have known the troubled history of this family and might have opted at least to provide supervision if not to remove the children.
The establishment of an interstate registry of child abuse and neglect was actually mandated more than a decade ago by the same legislation that mandated the national registry of sex offenders. Section 633 of the Adam Walsh Child Safety and Protection Act of 2006 required the Secretary of Health and Human Services to create a national registry of substantiated cases of child abuse and neglect. Yet this registry was never created.
Congress never appropriated funds to establish the registry but it did designate funds for a feasibility study that was also mandated under the act. A Research Report on the feasibility study and a report to Congress based on the results were published in 2012–six years after passage of the Act. The conclusions of the report were somewhat discouraging as to the potential benefits of a national registry. But interestingly, the underlying research reports had a much more positive view of the feasibility and potential benefits of the registry.
In the report to Congress, HHS emphasized the barriers to developing a functional registry. These include the Adam Walsh Act’s prohibition on including any information other than the perpetrator’s name, the need for stronger due process requirements in some states if the database were to be used for employment checks (which is not the purpose envisioned by the statute), the need to provide funding or other incentives for states to participate, and the need for legislative changes in many or most states. These are serious barriers indeed but could be addressed, albeit with new legislation and funding that would not be trivial to obtain.
Unlike HHS, the authors of the feasibility study addressed the barriers but gave first billing to the conditions that allow for the development of a registry. In the final paragraph of the research report states that “The foundations for a national registry already exist in the child protective services field given that nearly all States maintain the necessary data on child abuse and neglect perpetrators. The technical capacity of the States also supports the feasibility of a national registry.” The authors go on to discuss the barriers, but give first billing to the conditions that support the registry.
In its report to Congress, HHS concluded that even if the barriers to an interstate registry could be resolved, the registry would provided limited information “beyond what is already available from existing single state registries” and therefore “the added safety benefit of a national registry of child maltreatment perpetrators would be quite limited.” HHS concluded that a decision on whether to implement the registry should “consider whether this or alternative child safety investments would be most effective in promoting the well-being of vulnerable children.” The clear implication was that alternative investments would be advisable.
HHS drew its conclusion about the limited safety benefit of a registry from the prevalence study mentioned above. The researchers used the numbers of perpetrators with incidents in more than one state to estimate how many interstate perpetrators would be identified by a registry. Using information from 22 states with about 54% of the U.S. population, the researchers estimated that 7,852 perpetrators of child maltreatment in 2009 (or 1.5% of all substantiated perpetrators) had any substantiated maltreatment incidents in another state within the preceding five years.
HHS described 7,852 as a small number, and therefore concluded that there was “no evidence of a widespread phenomenon of child maltreatment perpetrators who offend in multiple states.” Moreover, HHS added that most of these perpetrators had “a single additional substantiation for child neglect (rather than for physical or sexual abuse) in a single additional state.” Moreover, just half of one percent of child maltreatment deaths in states participating in the study was attributed to a perpetrator who had a substantiated maltreatment report in another state (4 in total).”
HHS’ interpretations suggest a low valuation of children’s lives and freedom from suffering. Almost 8,000 interstate perpetrators in a year could be considered a large number, even if most of them were substantiated for neglect and not abuse. The downplaying of neglect is a common trope among critics of CPS intervention, but neglect can be equally dangerous and often coexists with abuse that may not be substantiated. “Just” four deaths in one year is a hard description to stomach while wondering if even one of these deaths could have been prevented with an interstate registry. Moreover, each death implies an unknown but larger number of injuries, and even more children living in pain and fear.
While dismissing the prevalence study’s estimates as “small,” HHS failed to mention the conclusion in a separate report on the prevalence study that the number of positive matches from states’ use of a fully functioning national registry would be much larger than the estimates above would indicate. That’s because the registry would be most commonly used during an investigation before a substantiation decision has been made, and the investigators would be looking for a substantiation in just one state. Therefore, the researchers concluded that the registry would likely yield “several times the number of matches” that the study found for interstate predators.
HHS also downplayed the benefits found by the Key Informants Survey–the other part of the feasibility study. Of the 36 states participating in the Key Informants Survey, 25 states said participating in a national registry would save time, and 22 states thought it would “provide more timely knowledge that would be useful in assessing child safety.” The authors of the research report concluded that “There appears to be significant interest in a national registry, primarily because States already have to inquire about possible prior perpetrator status from multiple States.” In the report to Congress, on the other hand, HHS did not report that there was significant interest by states’ in a registry. Instead, the agency reported that survey results indicated that the primary benefit of the registry would be to save time, and then cautioned that this time-saving benefit might not occur.
Similar to the key respondents, the authors of the feasibility study concluded that an interstate registry might be most useful in saving staff time and resources “resulting from the speed and efficiency of making all interstate inquiries, the vast majority of which will not find a match.” The authors added that this could enhance child safety due to faster processing of maltreatment cases. This conclusion was not included in the report to Congress.
Of course an interstate registry could not be produced quickly or on the cheap. Creating and activating it would be a multiyear effort that would have to begin with the amending of the authorizing legislation to include at least sex and date of birth in addition to perpetrator’s name. Many states would need to change their legislation as well in order to eliminate statutory barriers to participation. As the authors of the feasibility study indicated, convincing a “critical mass of states” to participate quickly might require incentives, such as funds to offset costs for initiating a registry. Clearly, an infusion of federal funds for this purpose would be a necessary incentive. Perhaps Congress could make participation in the registry mandatory in order to receive federal child welfare funds under CAPTA or better still the Social Security Act.
It is concerning that HHS under the last Administration produced such a distorted view of the Congressionally-mandated feasibility study of an interstate child abuse and neglect registry. It is my hope that this issue can be revived in the current Congress, perhaps as part of the reauthorization of CAPTA. Our children deserve no less.
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 ten-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.
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.
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.
I recently read a book that should be a must-read for all involved in child welfare policy. In Etched in Sand, Regina Calcaterra tells of being left at the age of eleven to care for her two younger siblings while her mother disappeared for weeks at a time. When she was home, her mother savagely beat the children. Chronically malnourished and living in fear, Calcaterra was responsible for feeding, clothing, and protecting her younger siblings–and making sure they looked clean and well-fed so as not to draw the attention of the authorities who might place them in foster care.
Despite her horrific childhood, the goal of Regina and her older siblings, as she said in an interview for Youtube TV, “was to never to be picked up by the authorities because when the authorities found out how we were living, they would separate us.” When Regina was finally unable to satisfactorily explain the results of a savage beating, the children were indeed taken into care and separated.
No maltreated children should have to hide their plight in order to avoid separation from each other. Yet, this is undoubtedly the situation facing many children even while you read this. I myself know two girls who, for fear of being separated, remained for two years with an uncaring guardian who diverted her guardianship stipend to her own needs. The girls only recently broke the silence, and were removed from this toxic home.
Sibling relationships are known to be critically important in emotional development in childhood and beyond, as documented in a useful publication from the Child Welfare Information Gateway. In abusive and neglectful families, sibling relationships can be even more important as siblings support each other through adverse circumstances.
Keeping siblings together in foster care provides an important element of continuity for children who have already suffered a traumatic removal from the home they had known. As the the brief cited above puts it, “For children entering care, being with their brothers and sisters promotes a sense of safety and well-being, and being separated from them can trigger grief and anxiety.” Some studies have reported poorer outcomes for children separated from their siblings in foster care.
We don’t know how many siblings are separated in foster care. Older studies indicate that a large proportion of foster children were separated from at least some of their siblings, but the proportions varied by location. Current, national data are not available.
In most cases siblings are separated for no other reason than the lack of foster homes that can accommodate siblings, especially larger sibling groups. There is a nationwide shortage of foster parents, but foster parents who are able to take more than two siblings are even more scarce.
In some states, like North Carolina and Florida, family-style group homes have been an important vehicle for keeping siblings together. Many of these homes, such as Crossnore School and Children’s Home in North Carolina and A Kid’s Place in Florida provide highly enriched services to their residents with the help of public and private philanthropic funding. These homes often use a family-style model based on houseparents that mimics a family home. Group homes are serving sibling groups in many other states, including California, Texas and New York.
Unfortunately, the recently passed Family First Prevention Services Act (FFPSA) threatens these important havens for sibling groups and may result in mass separations of siblings. That’s because FFPSA eliminates federal funding for placement of children in congregate-care settings such as group homes beyond two weeks, unless an assessment shows that a child’s needs cannot be met with family members or in a foster family home. Moreover, group facilities must meet criteria as “Qualified Residential Treatment Programs” designed to meet the needs of “children with serious emotional or behavioral disorders.”
FFPSA is based on the widely-held belief in child welfare circles that most children do better in a family than in another type of setting. However, experts such as Dave Bundy, President and CEO of the Children’s Home Society of America, believe that it is better to keep siblings together in congregate care than to split them up among separate foster homes.
Moreover, many legislators and executives pressing for closing group homes have much more than children’s best interests at heart. The greater cost of congregate care has clearly contributed to its growing unpopularity and to the bipartisan support of FFPSA. But these comparisons are often deceptive. Facilities like Crossnore and the Florida Sheriffs Youth Ranches provide therapists, case managers, after-school activities, and other services, such as therapeutic riding. Moreover, they bring in substantial private funding in addition to state support. And no matter how expensive they are, they cannot cost more than keeping children in hotels and offices when there are no homes for them, which is happening around the country.
Siblings have already been separated due to the policies against congregate care that have already taken hold in some states. From 2006 to 2015, Sonoma County Children’s Village was a haven for 24 foster children, including sibling groups, who lived in four homes staffed by “village parents,” with surrogate grandparents living in onsite apartments. But after California began to limit group home placements for children requiring high levels of care, the village had to close. Sixteen children, including a group of seven siblings, had to leave. The children were devastated. They sent out appeals to the likes of Barack Obama and Taylor Swift, but to no avail.
There is another approach to housing large sibling groups which in practice looks very similar to family-style group homes. Some child welfare agencies contract with private agencies, such as Neighbor to Family in Florida and Georgia, that provide homes where siblings can live together in foster care. Some of these programs actually provide larger houses in clusters or “neighborhoods” to foster parents willing to care for large sibling groups but who don’t have the space. This clustering provides the added benefit of community support and shared facilities for recreation and other activities. Such programs include the SOS Children’s Villages in Illinois and Florida. New homes are currently being built in locations around the country including Oklahoma, and Southwest Florida. However these programs are too few and far between to make a dent on the national problem of sibling separation in foster care.
Perhaps all the group homes that keep siblings together could eventually be replaced by family foster homes with housing provided by public and private agencies. The feasibility of this approach would have to be investigated; it might be even harder to find good foster parents than it is to find good houseparents, because the latter generally have a schedule that allows time off to return to their own residences, while being replaced by a substitute couple. In any case, such a transition would take years to accomplish and could not occur in the short period preceding the implementation of the FFPSA provisions, which go into effect on October 1, 2019. States can apply for a two-year delay in implementing these provisions but then they must forego the opportunity to received federal matching funds for services to prevent foster care placements. (For a detailed explanation, see the “Cliffs’ Notes on Family First” from the Chronicle of Social Change.)
The sponsors and supporters of FFPSA likely had no idea that sibling separation might be a consequence of their legislation. Once they understand what they have done, I hope they will consider amending FFPSA to make congregate care allowable for sibling groups and provide a new funding stream to encourage jurisdictions to build foster home communities where siblings can thrive together.