This essay was originally published on the website of Lives Cut Short, a project to document child maltreatment deaths in the United States since 2022, for which I serve as Senior Project Associate
Jahmeik Modlin was found in a skeletal condition in a Harlem apartment stocked with food. He died the next day, and his three older siblings were hospitalized with severe malnutrition. The family had been on the radar of the Administration for Children’s Services (ACS) since 2019, before Jahmeik was born. But the agency closed its last case with the family in 2022 after determining that the children were safe, a source told the New York Times. A spokeswoman for ACS declined to offer further information, citing state law designed to protect siblings of fatal abuse victims.
According to data states submit to the federal government, about 1800 children die of abuse and neglect every year, but this figure is widely recognized to be an undercount. Among those deaths, studies suggest that between a third and a half involve families who were already known to the child protection system (CPS) through previous reports. Even in other cases where the family had no prior contact with CPS, other systems may have interacted with the child and perhaps could have intervened. Legislators, advocates and the public must have access to timely information about the circumstances leading up to child maltreatment fatalities so they can identify missed opportunities and policy and practice changes necessary to protect children. For that reason, Congress in 1996 added a provision in federal law that requires all states to provide assurances to the federal Department of Health and Human Services that they have provisions for disclosing findings and information regarding child fatalities and near fatalities from maltreatment.
Lives Cut Short surveyed state laws and policies governing access to information about child maltreatment fatalities and near fatalities. The resulting report, Keeping the Public in the Dark: How Federal and State Laws and Policies Prevent Meaningful Disclosure about Child Maltreatment Fatalities and Near Fatalities, shows that most states have such laws and practices but many of them are vague, and many have provisions that conflict with the purpose of ensuring public access to critical information. Among such provisions are those that prohibit releasing information that might harm surviving children in the families where a child was killed or seriously injured by maltreatment.
New York, at first glance, appears to be more transparent than most states in making information and findings about child maltreatment fatalities available to the public. The New York State Office of Children and Family Services (OCFS), which supervises local agencies such as ACS, is required to review all local investigations of child fatalities reported to the State Central Register and to publish a summary report within six months of the investigation. Disclosure of this information, however, occurs only if the state or local commissioner determines that it is not “contrary to the best interests of the child, the child’s siblings or other children in the household.” While the law does not provide a comprehensive definition of “contrary to the best interests,” the OCFS website does explain that OCFS conducts what it calls a “best interests determination,” sometimes assisted by “experts” from the agency’s Statewide Child Fatality Review Team. The process considers “whether publishing a fatality report is contrary to the best interests of a child’s siblings or other children in the household, what effects publication may have on the privacy of children and family, and any potentially detrimental effects publication may have on reuniting and providing services to a family.”
To understand the impact of the “best interests” determination, one needs to know the proportion of child fatalities for which New York withholds reports. The identifying numbers that the state assigns to its child fatality reports provide a useful clue. All these numbers start with a two-letter abbreviation for the region (AL for Albany, BU for Buffalo, etc.), continue with the last two digits of the year, and end with a three-digit number, starting from 001. For example, the first Albany report for 2022 would be identified as AL-22-001. Assuming that all missing numbers represent reports withheld under the “best interests determination,” about one-quarter of reports on 2022 fatalities in New York State were withheld.
The Child Abuse and Neglect Deaths Integrated Database (CANDID), maintained by Lives Cut Short, allows us to determine which child deaths reported in the media had a corresponding fatality report released by New York OCFS. CANDID combines information on child maltreatment fatalities from media reports, official fatality reviews or reports, and other available sources. New York State’s fatality reports do not include names, but they do include the dates of death as well as details about the circumstances. Therefore, one can attempt to match media coverage with the OCFS review of the same fatality. But very few maltreatment deaths occurring in 2022 and covered by the media had an OCFS review released to the public. It appears that the reviews of high-profile deaths that received media coverage were withheld based on “best interest determinations.”
These cases included:
The death of Bryleigh Klino, a profoundly disabled 17-year-old whose parents have been charged with endangering her welfare. Hospital employees observed numerous signs of abuse and neglect on Bryleigh’s body;
The drowning of six-month-old Dalilah Crespo, whose death was ruled a homicide;
The death from abusive head trauma of four-month-old Cairo Dixon-Sanchez, for which his father pleaded guilty;
The fentanyl poisoning death of 11-month-old Liam Sauve, who ingested 23 times the amount of fentanyl that could kill an adult and whose mother pleaded guilty for his death;
The death of three-month old Genevieve Comager, whose father was charged with shaking her to death;
The beating death of nine-year-old Shalom Guifarro, whose mother has been sentenced to 16 years for her killing;
The death of two-year-old Ermias Taylor-Santiago of a fentanyl overdose, which was ruled a homicide;
The death of blunt force trauma of Xavier Johnson, whose mother’s boyfriend was charged with beating him to death;
The fatal heroin overdose death of six-month-old Denny Robinson, found with a heroin bag in his mouth in a house that was connected with a major drug trafficking operation;
The drug and alcohol poisoning of 14-year-old Hailey Hasbrouck, allegedly by her father and his girlfriend, who allegedly gave her the “toxic cocktail;”
The “suspicious” death of seven-year-old Hunter DeGroat, found unresponsive in his home;
The death of two-year-old Aniyah Wyatt-Wright, allegedly punched to death by her father;
The murder of three-year-old Shaquan Butler, beaten to death in a Queens homeless shelter after being reunified with his parents after being removed from them by ACS.
It is probably not a coincidence that OCFS has elected not to release information on most of the egregious fatalities that were covered in the media. Many of the published state fatality reviews concern deaths due to unsafe sleep factors, accidental drownings, and other fatalities that do not result in criminal charges and are therefore never known to the public. It is possible that OCFS is trying to shield the surviving children in the cases listed above because readers may be able to identify them by putting together the reports and the media coverage—as we did. But these are the very cases for which the information is most urgently needed. The nature of these cases suggests the existence of serious and chronic conditions that might have resulted in previous reports and involvement with CPS. Any harm that public release of the report would cause when the incident has already been covered in the media is dubious. It’s hard to avoid wondering if the exclusion of these cases from disclosure protects the agency more than the children. And to avoid guessing that Jahmeik’s death will join the list of those cases for which reports are never published.
We cannot make progress in the prevention of severe and life-threatening child maltreatment unless legislators, advocates and the public have access to comprehensive information about what led up to these tragic events. Congress tried to provide this access through a provision in federal legislation, but states have couched this requirement in vague language or hedged it with qualifications that prevent the release of critical information—or any information at all in some cases—as in New York. Only Congress can fix the gaps in the federal law, but state legislatures can act in the meantime to ensure their disclosure laws serve the purpose of improving child welfare in their states.
A fourteen-year-old boy and a fifteen-year-old girl are charged as adults, one for a mass shooting and the other for selling a fentanyl tablet that killed an older teenager. These two young people had something in common–a long history of neglect (and sometimes abuse) by their parents and a failure to intervene by child welfare services despite multiple reports that children were in danger. Ignoring chronically maltreated children when they could have been saved and then locking them up for life is both inhumane and costly. We must intervene to help maltreated children before they are irrevocably damaged by years of abuse and neglect.
On September 4, 2024, fourteen-year-old Colt Gray shot and killed two teachers and two students at Apalachee High School in Winder, Georgia with an AR-15 style rifle given to him by his father. He has been charged as an adult and is awaiting trial. It did not take long for the media to uncover that Colt had grown up in a chronically abusive and neglectful home. As the Washington Post put it in a devastating article, “Colt’s parents, each addicted to drugs and alcohol, were perpetually inattentive, often cruel and sometimes entirely absent, according to family members, neighbors, investigators, police reports and court records.” In November 2022, Colt’s mother, Marcee Gray, left his father, Colin Gray, and moved to southern Georgia with her two younger children. It appears that DCFS had opened a case at some point because In October of 2023, a spot drug-test revealed Marcee’s renewed drug use. Colin Gray was ordered to retrieve the other children, or they would be placed in foster care. Shortly thereafter, it appears that the case was closed.
There is no information from media reports about whether DCFS evaluated Colin Gray for his fitness to take care of his three children or to monitor their well-being in his care before closing the child welfare case. Yet, relatives reported to the New York Post that Colin Gray relentlessly bullied his son, calling him names like “sissy” and “bitch.” The Washington Post reported that Colt first came to the attention of authorities at the age of 11, when his school flagged him for searching the internet for ideas on how to kill his father. In Colin Gray’s custody, Colt never attended eighth grade and was not even registered for school until February 2 of that year. That Christmas, Colin Gray gave Colt his own AR-15 style rifle, in an attempt to “toughen him up,” as relatives told the New York Post. By his fourteenth birthday in January, Colt’s grandmother reported that he was searching the internet for what was wrong with him; she offered to pay for therapy and take him there but his father never signed him up. In July of 2023, Marcee returned from rehab and Colin allowed her to move back in. Colt’s mental health deteriorated even further after his mother’s return, and he talked of hurting himself or others. He registered for high school two weeks late and rarely attended. “Colt was like the thrown-away child,” said his grandmother, who tried in vain to get his father and the school to help him. Five days after his father failed to take him to a crisis mental health center despite his grandmother’s plea, Colt brought his rifle to school and took four lives.
Also charged as an adult was 15-year-old Maylia Sotelo of Green Bay, Wisconsin, the subject of a devastating article by Lizzie Presser of Pro Publica. Maylia’s home had been a “hangout for users and dealers.” Her three older sisters had all been kicked out or left due to their mother’s violence. Maylia’s had been referred to child protective services 20 times before she was finally removed from her home at the age of 14. In a pattern typical of chronic maltreatment, the reports concerned multiple types of neglect, sexual abuse, and physical abuse. Before Maylia turned one, CPS documents show that her mother overdosed on cocaine and Adderall with seven children in her home. When she was five years old, a caller reported that her mother was “high as a kite” and her boyfriend was violent. The next year, another report indicated that there was no food in the home and that the mother was using heroin in front of her children.
When Malia was seven, CPS substantiated a report that a man “opened his pants, pulled out his penis and masturbated” in front of one of Maylia’s sisters. That same year, a woman overdosed on crack in the house and Maylia’s mother “would not call rescue or the police because [she] did not want her children removed,” according to a social worker’s notes. And a school employee reported that Maylia missed half the school year. When Maylia was 14 and her mother became psychotic, Maylia and her sister were finally removed from the home and placed with relatives. But they were given no counseling or assistance with school, according to Pro Publica. Maylia had been smoking weed since fifth grade, then began selling it. By the beginning of tenth grade, she was selling “blues,” pills that were billed as percocet but actually contained filler and fentanyl. She sold a pill to an 18-year-old named Jack McDonough. When he died of an overdose, Maylia was arrested for first-degree reckless homicide.
It is obvious that both Colt Gray and Maylia Sotelo were chronically maltreated children who suffered from multiple types of maltreatment over a period of years. It is also obvious that the systems designed to protect them failed both of these young people. Both families clearly required intervention that did not come when it was needed, though we do not have enough details to make an informed critique of the system’s response. When the child welfare system finally intervened in Malia’s case, it may have been hard to change her trajectory, and it appears that she was left with relatives and received monitoring or services to address her traumatic history. In Colt’s case, the intervention may have also come too late to prevent serious psychological damage. And once they became involved, caseworkers appeared to be focused on his mother and ended the case with the placement of all three children with their father, a parent who had been equally neglectful and failed to take action to protect the children from his wife’s abuse.
Perhaps more intensive in-home services provided earlier could have helped Colt’s and Maylia’s parents address the issues that led them to abuse or neglect their children. If not, perhaps Maylia’s earlier removal from her toxic home, and Colin’s removal to a better environment than either of his parents could provide might have saved these children from the sad fate that awaited them. The approach that is currently in fashion – exemplified by the much touted Family First Prevention Services Act (FFPSA) of 2018 – prescribes the avoidance of foster care at almost any cost. It does, however, promise that parents receive support in parenting their children, whether it is mental health, drug treatment, or parenting training. Child welfare systems have long been providing such support to families in the form of in-home services, and FFPSA was supposed to provide the resources to improve these services. Unfortunately, FFPSA did not acknowledge or support the crucial role of frequent home visits to ensure the children are safe and that they can be removed into foster care if the parents do not cooperate with their plans for addressing their issues and improving their parenting.
Sadly, there is no evidence that increases in family support or child safety monitoring are forthcoming. States are proudly citing drops in their foster care caseloads, with no reporting on what is happening to the children left at home. States are not required to release data on the number of cases opened for in-home services, so we have no idea whether the abused and neglected children who are not being removed are getting any supervision or their parents receiving services. But as I have written, data from the states with the largest and third largest foster care caseloads indicates that the number of children receiving in-home services has not increased to make up for the drop in children removed to foster care; instead it has decreased along with foster care placements, resulting in a decline in the number of children being served overall.
Studies have documented the connection between child maltreatment and crime.1 Failing to intervene with at-risk children before they resort to crime and subsequently incarcerating them results in unnecessary human suffering, not to mention greater financial costs, than intervening early. If we do not want to remove more children, we must provide intensive services to parents and close monitoring of their children’s safety–and be ready to remove the children as soon as it becomes clear that parents are not going to change before the children are irreparably harmed. Such monitoring is key, because we really do not know what, if anything, works in preventing future maltreatment among parents who have maltreated their children.
This is not the first time that the failure of CPS has been noted in the wake of a heinous crime. I previously wrote about Lisa Montgomery, who was executed on January 12, 2021. She murdered a pregnant woman, cut out the baby, and took it home. It turned out that Lisa Montgomery had a long and horrific history of physical and sexual abuse throughout her childhood, including beatings and bizarre punishments by her mother, rape by her stepfather, and prostitution by both. Sadly, it seems that we have not made much progress since Lisa’s childhood, and current ideological trends run the risk of leaving even more children unprotected in the future.
The MacArthur Foundation has announced its new class of Fellows, the recipients of what are commonly called the “Genius Awards.” Among the recipients is Dorothy Roberts, the self-styled popularizer of the term “racial disproportionality” and creator of the term “the family policing system.” According to the Director of the Program, “The 2024 MacArthur Fellows pursue rigorous inquiry with aspiration and purpose. They expose biases built into emerging technologies and social systems….” It’s hard to understand how this term can be applied to an author who wrote that the “family-policing system terrorizes Black families because that’s what it is designed to do ” despite also stating that child welfare systems excluded Black children from their inception until the second half of the twentieth century. The choice of Roberts only exposes the bias and lack of rigor–or alternatively the sheer ignorance– of the MacArthur Foundation. As an illustration, I am reposting my 2022 review of Roberts’ most recent book, Torn Apart: How the Child Welfare System Destroys Black Families–and How Abolition Can Build a Safer World.
In her 2009 book, Shattered Bonds: The Color of Child Welfare, Dorothy Roberts drew attention to the disproportional representation of Black children in foster care and child welfare in general and helped make “racial disproportionality” a buzzword in the child welfare world. In her new book, Torn Apart: How the Child Welfare System Destroys Black Families–And How Abolition Can Build a Safer World, Roberts revisits the issues addressed in Shattered Bonds and creates a new buzzword, renaming child welfare as the “family policing system.” Those who liked Shattered Bonds will likely love Torn Apart. But those who value accuracy in history or in data will find it to be sadly misguided, although it does make some valid points about flaws in the U.S. child welfare system.
Roberts starts with a horrific anecdote about a mother, Vanessa Peoples, who was doing everything right–she was married, going to nursing school, about to rent a townhouse and was even a cancer patient. But Peoples attracted the attention of both the police and child welfare and ended up hogtied and carted off to jail by police, placed on the child abuse registry, and subjected to months of monitoring by CPS after she lost sight of her toddler at a family picnic when a cousin was supposed to be watching him. But citing these extreme anecdotes as typical is very misleading. This particular story has been covered in numerous media outlets since it occurred in 2017 and continues to be cited regularly. One can counter every one of these horrific anecdotes with a story of a Black child who would have been saved if social workers had not believed and deferred to the parents. (See my commentary on the abuse homicides of Rashid Bryant and Julissia Batties, for example).
Roberts’ book restates many of the old myths that have been plaguing child welfare discussions as of late and that seem to have a life of their own, impervious to the facts. Perhaps the most common and pernicious is the myth that poverty is synonymous with neglect. Roberts embraces this misconception, suggesting that most neglect findings reflect parents who are too poor to provide adequate housing, clothing and food to their children. But parents who are found to have neglected their children typically have serious, chronic mental illness or substance use disorders that severely affect their parenting, and have refused or are unable to comply with a treatment plan. Many are chronically neglectful, resulting in children with cognitive and social deficits, attachment disorders, and emotional regulation problems. Commentator Dee Wilson argues based on his decades of experience in child welfare that “a large percentage of neglect cases which receive post-investigation services, or which result in foster placement, involve a combination of economic deprivation and psychological affliction…., which often lead to substance abuse as a method of self-medication.” Perhaps the strongest argument against the myth that poverty and neglect are one and the same is that most poor parents do not neglect their children. They find a way to provide safe and consistent care, even without the resources they desperately need and deserve.
Roberts endorses another common myth–that children are worse off in foster care than they would be if they remained in their original homes. She argues that foster care is a “toxic state intervention that inflicts immediate and long-lasting damage on children, producing adverse outcomes for their health, education, income, housing, and relationships.” It is certainly true that foster youth tend to have bad outcomes in multiple domains, including education, health, mental health, education, housing and incarceration. But we also know that child abuse and neglect are associated with similar poor outcomes. Unfortunately, the research is not very helpful for resolving the question of whether these outcomes are caused by the original child maltreatment or by placement in foster care. We cannot, of course, ethically perform a controlled study in which we remove some children and leave a similar set of children at home. We must rely on studies that use various methodologies to disentangle these influences, but all of them have flaws. Roberts cites the study published in 2007 by Joseph Doyle, which compared children who were placed in foster care with children in similar situations who were not. Doyle found that children placed in foster care fared worse on every outcome than children who remained at home. [Update added October 2024: A newer study, reflecting current foster care policy and the more typical state of Michigan, found the opposite result.] But focusing on marginal cases* leaves out the children suffering the most severe and obvious maltreatment. In a recent paper, Doyle, along with Anthony Bald and other co-authors, states that both positive and negative effects have been found for different contexts, subgroups, and study designs.
There is one myth that Roberts does not endorse: the myth that disproportional representation of Black children in child welfare is due to racial bias in the child welfare system, rather than different levels of maltreatment in the two populations. After an extensive review of the debate on this issue, Roberts concludes that it focused on the wrong question. In her current opinion, it doesn’t matter if Black children are more likely to be taken into foster care because they are more often maltreated. “It isn’t enough,” she states, “to argue that Black children are in greater need of help. We should be asking why the government addresses their needs in such a violent way, (referring to the child removal). Roberts was clever to abandon the side that believes in bias rather than different need as the source of disparities. The evidence has become quite clear that Black-White disparities in maltreatment are sufficient to explain the disparity of their involvement in child welfare; for example Black children are three times as likely to die from abuse or neglect as White children. As Roberts suggests and as commentators widely agree, these disparities in abuse and neglect can be explained by the disparities in the rates of poverty and other maltreatment risk factors stemming from our country’s history of slavery and racism. Unfortunately, Roberts’ continued focus on these disparities in child welfare involvement will continue to be used by the many professionals who are working inside and outside child welfare systems all over the country to implement various bias reduction strategies, from implicit bias training to “blind removals.”
In Part III, entitled “Design,” Roberts attempts to trace the current child welfare system to the sale of enslaved children and a system of forced “apprenticeship” of formerly enslaved Black children under Jim Crow, whereby white planters seized custody of Black children from their parents as a source of forced labor.** As she puts it, “[t]hroughout its history US family policy has revolved around the racist belief that Black parents are unfit to raise their children. Beginning with chattel slavery and continuing through the Jim Crow, civil rights, and neoliberal eras, the white power structure has wielded this lie as a rationale to control Black communities, exploit Black labor, and quell Black rebellion by assaulting Black families.” In other passages she adds other groups to the list of victims, adding “Indigenous, immigrant and poor people to the list of communities that are being controlled by the “family policing system.” But most of her statements refer to Black victims only.
Roberts’ attempt to connect slavery and Jim Crow practices with child welfare systems highlights a major flaw of the book. She herself explains that due to racism the child welfare system served only White children when it emerged in the nineteenth century with the creation of child protection charities and the passage of state laws allowing maltreated children to be removed from their homes and placed in orphanages. Foster care was established in the middle of the century and also excluded Black children. The system did not begin serving Black children until after World War II, so it is difficult to understand how it could stem from slavery and Jim Crow practices. It seems much more plausible that the child welfare system arose from basically benevolent concerns about children being maltreated, and that with the rise of the civil rights movement, these concerns were eventually extended to Black children as well.
While Black children’s representation as a share of foster care and child welfare caseloads rose rapidly starting in the 1960’s, and Black children are much more likely to be touched by the system than White children, the system still involves more White than Black children. According to the latest figures, there were 175,870 White non-Hispanic children in foster care (or 44 percent of children in foster care) and 92,237 Black (non-Hispanic) children in foster care, or 23 percent of children in foster care. Moreover, the disparity between Black and White participation in child welfare and foster care as a percentage of the population seems to be decreasing.*** So the idea that this whole system exists to oppress the Black community and maintain white supremacy seems farfetched.
Roberts’ attempt to make Black children the focus of the book results in some awkward juxtapositions, like when she admits that though the Senate investigation of abuses by a for-profit foster care agency called MENTOR “highlighted cases involving white children, we should remember that Black children are more likely to experience these horrors in foster care—not only because Black children are thrown in foster care at higher rates, but also because government officials have historically cared less about their well-being.” A page later she states that the “child welfare system’s treatment of children in its custody is appalling but should come as no surprise. It is the predictable consequence of a system aimed at oppressing Black communities, not protecting Black children.” It is hard to understand how White children being maltreated in bad placements supports this narrative.
Fundamental to Roberts’ critique is her system is “not broken.” “Those in power have no interest in fundamentally changing a system that is benefiting them financially and politically, one that continues to serve their interests in disempowering Black communities, reinforcing a white supremacist power structure, and stifling calls for radical social change.” Even if one believes there is a white supremacist power structure, it is hard to see the direct connection between the abuses Roberts is highlighting and the disempowerment of Black communities; it seems more likely that the more abusive the system, the more protests it would generate. And at a time when the federal government and some of the wealthiest foundations and nongovernmental organizations are echoing much of Robert’s rhetoric, her reasoning seems particularly off-target.
Roberts makes some valid criticisms of the child welfare system. Her outrage at the terrible inadequacies of our foster care system is well-deserved. She is right that “The government should be able to show that foster care puts Black children [I’d say “all children”] on a different trajectory away from poverty, homelessness, juvenile detention, and prison and toward a brighter future.” Any society that removes children from their parents needs to be responsible for providing a nurturing environment that is much, much better than what they are removed from. And we are not doing that. As Roberts states, “The state forces children suffering from painful separations from their families into the hands of substitute caretakers…..who often have unstable connections, lack oversight and may be motivated strictly by the monetary rewards reaped from the arrangement.” As a foster care social worker in the District of Columbia, I was driven to despair at my inability to get my superiors to revoke the licenses of such foster parents; the need for “beds” was too great to exclude anyone was not actually guilty of abuse or severe neglect. Roberts is also right to be concerned the outsourcing of foster care to private for-profit organizations that may be more concerned with making money than protecting children, sometimes resulting in scandals like the one involving MENTOR Inc., which was found to hire unqualified foster parents and fail to remove them even after egregious violations like sexual assault.
Roberts also raises valid concerns about children being sent to residential facilities, often out of state, that resemble prisons rather than therapeutic facilities. But she ignores the need for more high-quality congregate care options for those children who have been so damaged by years of maltreatment that they cannot function in a foster home, no matter how nurturing. Instead, she repeats the usual litany of scandals involving deaths, injuries, fights and restraints, without noting the undersupply of truly therapeutic residential settings, resulting in children sleeping in office, cars, and hotels or remaining in hospital wards after they are ready for discharge. Ironically, she supports defunding the system, even if that would mean even worse situations for these children.
Roberts decries the fact that parents sometimes relinquish custody of their children in order to get needed residential care, arguing that “rather than providing mental health care directly to families, child welfare authorities require families to relinquish custody of children so they can be locked in residential treatment centers run by state and business partnerships.” That statement is completely backwards. The child welfare system does not provide mental health services but, like parents, it often struggles to secure them for its clients. Some parents are forced to turn to the child welfare system because their insurance will not pay for residential care for their children. That is not the fault of child welfare systems, which clearly do not want to take custody of these children. The underlying problem is the lack of adequate mental health care (including both outpatient and residential programs), which has destructive consequences for the foster care system. This is exacerbated by the lack of parity for mental health in health insurance programs. It’s hard to believe Robert is unaware of these well-known facts.
Roberts is correct that parents as well as children are shortchanged by inadequacies in our child welfare program, such as the “cookie cutter” service plans which often contain conflicting obligations that are difficult for struggling parents to meet. But she is wrong when she says that parents need only material support, not therapeutic services. But this error flows logically from her concept of neglect as simply a reflection of poverty. In fact, many of these parents need high-quality behavioral health services and drug treatment, which are often not available because of our nation’s mental health crisis, as well as the unwillingness of taxpayers and governments at all levels to adequately fund these services.
In her final chapter, Roberts concludes that, like the prison system, the child welfare system cannot be repaired because it exists to oppress Black people. “The only way to end the destruction caused by the child welfare system is to dismantle it while at the same time building a safer and more caring society that has no need to tear families apart.” In place of family policing, Roberts favors policies that improve children’s well-being, such as “a living wage and income support for parents, high-quality housing, nutrition, education, child care, health care; freedom from state and private violence; and a clean environment.” I agree with Roberts that aid to children must be expanded. The US is benighted when compared to many other Western countries that invest much more heavily in their children through income support, early childhood and K-12 education, healthcare, and housing. But family dysfunction occurs even if a family’s material needs are met. That is why every other developed nation has a child welfare system with the authority to investigate maltreatment allegations and assume custody of children when there are no other options. Moreover, some of the countries with the strongest safety nets for children also have higher percentages of children living in foster care than the United States.****
Torn Apart is a skewed portrait of the child welfare system. In it Roberts restates the common but easily discredited myths that poverty is synonymous with neglect and that foster care makes children worse off than they would have been if left at home. The underlying flaw in her account is the idea that this system exists to repress the Black community, even though it was established solely for the protection of White children. Roberts makes some valid criticisms of child welfare systems and how they shortchange the children and families they are supposed to help. But when she talks of dismantling child protection, she is proposing the abandonment of abused and neglected Black children in homes that are toxic to them, an abandonment that will perpetuate an intergenerational cycle of abuse and neglect. These children are our future; abandoning their well-being to prioritize that of their parents is a bad bargain with history.
*Doyle’s study included only those cases that would have resulted in foster placement by some investigators and not by others, leaving out the cases in which children were in such danger that all investigative social workers would agree that they should be placed.
**In various places, she also attributes it to different combinations of slavery and apprenticeship of Black children with the transfer of Native American children to boarding schools, the exclusion of Black children from charitable aid and the servitude of impoverished White children.
***A recent paper reports that disparities between Black and White children began to decrease in the twenty-first century in nearly every state, closing entirely in several Southern states.
****Unicef’s report, Children in Alternative Care, shows that Denmark has 982 children in “alternative care” per 100,000 and Sweden has 872 per 100,000, compared to 500 per 100,000 for the United States.
Officials of New Jersey’s Department of Children and Families (DCF) are congratulating themselves on what they call the decline of child abuse and neglect in their state and attributing this ostensible decline to their department’s preventive services. The number of reports of child child maltreatment has actually increased over this period. DCF’s claims are based on a decline in the number of children with substantiated reports–a number which reflects DCF policy and practice much more than it reflects actual abuse and neglect. Whether agency officials are ignorant or attempting to manipulate the data for naive readers, this is no way to keep the public informed about how well New Jersey is protecting its children.
Two DCF officials, Laura Jamey, Director of the Division of Child Protection and Permanencyand Sanford Starr, Director of the Division of Family and Community Partnerships, say they have some good news for New Jerseyans. They announce it in an op-ed titled “Maltreatment of NJ kids is decreasing. Here’s wow [sic] we’re preventing it,” which was published in the Asbury Park Press. “By using evidenced-based [sic] prevention strategies and practically addressing families’ needs, we’re happy to report that over the past decade, there has been a steady decline in the number of confirmed cases of child abuse and neglect in our state. In 2016, there were more than 8,000 substantiated and established cases of Child Abuse and Neglect in New Jersey. Last year, that number was only 2,641.”
Wow! sounds impressive, right? But it turns out the authors took as much care with the substance of their commentary as with their capitalization and spelling. That much is clear to anyone who bothers to look at the data that New Jersey shares with the federal government through the National Child Abuse and Neglect Data System (NCANDS) and which the federal Children’s Bureau shares through its annual Child Maltreatment reports. The data for 2023 have not yet been published by the Bureau, but the figures below represent what New Jersey reported for Federal Fiscal Years (FFY) 2016 to 2022, which ended on September 30, 2022.
Federal Fiscal Year
Referrals
Children Receiving an Investigation or Alternative response
Children receiving a “substantiated” disposition/percent of referrals
Jamey and Starr cited only the number of substantiated cases of maltreatment. But that figure has meaning only in the context of two figures that represent earlier steps in the process, which are always discussed first in the Child Maltreatment reports. “Referrals” is the child welfare system’s term for reports to the state child protective services hotline. As you can see, those reports increased slightly in New Jersey from 56,014 in FFY2016 to 60,934 in FFY2019. There was a significant drop in referrals during the COVID pandemic in FFY2020 and FFY2021, and then a rebound to 57,068 in FFY 2022, just slightly higher than the number in 2016.
The number of children who were the subject of an investigation also dipped during COVID (in response to the drop in referrals) and bounced back up to a level that was slightly higher than that of 2016. But the number of cases that received a disposition of “substantiated” (which means an investigation concluded that a preponderance of the evidence indicated that abuse and neglect occurred) fell every year, with especially large drops in 2017 and during the COVID pandemic. And according to Jamey and Staff, that number fell even further to 2,641 in 2023, which means the number of children with substantiated referrals had dropped by 68 percent since FFY2016. And the number of children receiving a substantiated disposition as a percent of all referrals fell by half–from 11.2 percent to 5.5 percent, in that period.
So what explains this large drop in children with substantiated dispositions during a period of nine years? In its commentary in Child Maltreatment 2017 (CM2017), New Jersey attributed the one-year drop in children with substantiated dispositions from FFY 2016 to FFY2017 to a revised disposition model it adopted in April 2013.1 But after FFY2017, DCF provided no explanations other than regularly repeating its statement in 2018 that “the decrease in the number of substantiated victims “remains consistent with prior years and shows a continued trend in the decrease of victimization rates.” In CM2022, DCF simply acknowledged without explaining that “[d]espite the number of CPS referrals increasing from FFY 2021 to FFY 2022, the number of child victims continues to decrease. The rate in which New Jersey substantiated reports also decreased from FFY 2021 to FFY 2022.”
Research suggests that substantiation decisions are not very accurate and that a report to the hotline predicts future maltreatment reports and developmental outcomes almost as well as a substantiated report.2 So it just does not seem plausible that child maltreatment could have dropped by over half while the number of reports increased. There is one possible explanation for this decline, which I raised in a 2021 blog. New Jersey is one of many states that is increasingly using a practice called “kinship diversion.” Kinship diversion occurs when social workers determine that a child cannot remain safely with the parents or guardians. Instead of taking custody of a child, the agency facilitates placing the child with a relative or family friend. If this occurs in the context of an investigation, kinship diversion may result in a finding of “unsubstantiated” (or in New Jersey, “unfounded” or “not established”) even when abuse or neglect has occurred, on the grounds that the child is now safe with the relative. We have no idea how widespread kinship diversion is in New Jersey or how often it results in an “unfounded” or “not established” finding. However, the system of informal kinship care created by kinship diversion has been called America’s hidden foster care system and nationwide it appears to dwarf the provision of kinship care within the foster care system.
There is no way of knowing how much, if any, of the drop in child maltreatment substantiations is accounted for by kinship diversion. If diversion accounts for a substantial portion of the drop, that points to serious problems with the practice. It means not only that DCF is undercounting incidents of child abuse or neglect but also that a parent who committed serious maltreatment would not show up as having a substantiated report, possibly affecting decisions on future allegations against that parent. I described some of the other problems with kinship diversion, such as the lack of support for the child and relatives, the possibility that the caregiver will return the child to the an unsafe home, the possible placement of children with inadequately-vetted relatives, and the lack of due process and services for the parents, in another post.
Despite their lack of explanation in their annual commentaries designed for federal employees and child welfare specialists to read, DCF officials have offered the public an optimistic explanation for the drop in maltreatment substantiations. “We’ve worked to transform New Jersey’s child welfare system to support and strengthen families who are struggling to meet their basic needs rather than separating them. A family unable to provide clean clothes may need a supportive neighbor who can offer a ride to the local laundromat. A family struggling to put food on the table may need to be connected with a local food bank.” We have already shown that this decline does not indicate a decline in actual maltreatment, but this attempt to tie it to simple casework like finding a family a ride to a laundromat is simply not believable.
The problem is not just an op-ed that few will read. As quoted in NJ Spotlight News, the Commissioner of DCF told a legislative committee that “Working together, we have achieved so much for New Jersey’s families, including the lowest rate of family separations in the country, one of the lowest rates of child maltreatment and repeat maltreatment in the country.” This was quoted as part of a congratulatory article about how New Jersey has become a “national leader in child welfare.” it is unfortunate that this public media outlet simply echoed the Department’s rosy view, making no attempt to verify their claims by consulting the data.
The misuse of data by high officials of New Jersey’s child welfare agency raises an uncomfortable question. Is it really possible that these leaders believe that child maltreatment has declined by 68 percent since 2016? All I can say is that their statement reflects either ignorance or a cynical disregard for the truth. Neither of these options reflects well on the leadership’s moral or intellectual capacity to serve their state’s most vulnerable children and families.
Notes
Before the new framework, New Jersey had only two investigation dispositions: unfounded and substantiated. The new model added two new dispositions: established and not established, which fall on a continuum between “substantiated” and “unfounded.” DCF explains that the cases that receive the “established” disposition are coded as “substantiated” in NCANDS, so it is possible that finding some children who would have been substantiated as “not established” instead contributed to the drop in substantiations. ↩︎
Theodore Cross and Cecilia Casanueva, “Caseworker Judgments and Substantiation,” Child Maltreatment, 14, 1 (2009): 38-52; Desmond K. Runyan et al, “Describing Maltreatment: Do child protective services reports and research definitions agree?” Child Abuse and Neglect 29 (2005): 461-477; Brett Drake, “Unraveling ‘Unsubstantiated,’” Child Maltreatment, August 1996; and Amy M. Smith Slep and Richard E. Heyman, “Creating and Field-Testing Child Maltreatment Definitions: Improving the Reliability of Substantiation Determinations,” Child Maltreatment, 11, 3 (August 2006): 217-236. Brett Drake, Melissa Jonson-Reid, Ineke Wy and Silke Chung, “Substantiation and Recidivism,” Child Maltreatment 8,4 (2003): 248-260; Jon M. Hussey et al., “Defining maltreatment according to substantiation: Distinction without a difference?” Child Abuse and Neglect 29 (2005): 479-492; Patricia L. Kohl, Melissa Jonson-Reid, and Brett Drake, “Time to Leave Substantiation Behind: Findings from a National Probability Study,” Child Maltreatment, 14 (2009), 17-26; Jeffrey Leiter, Kristen A. Myers, and Matthew T. Zingraff, “Substantiated and unsubstantiated cases of child maltreatment: do their consequences differ?” Social Work Research 18 (1994): 67-82; and Diana J. English et al, “Causes and Consequences of the Substantiation Decision in Washington State Child Protective Services,” Children and Youth Services Review, 24, 11 (2002): 817-851. ↩︎
Greetings to my faithful readers! I’m trying out a different format for Child Welfare Monitor–a monthly newsletter format that highlights events and information that catch my eye. I’m not ruling out a single-issue piece now and then, particularly when there is a major new report or data source to discuss and analyze. Please let me know what you think of the new format. If you can think of a more exciting title than “Child Welfare Update,” let me know. And if you do find this to be a useful resource, please share it with your colleagues.
Adam Montgomery convicted of Harmony Montgomery’s death
In December 2021, Manchester, New Hampshire Police announced the disappearance of Harmony Montgomery, who would have been six years old if she were alive. We learned that Harmony’s noncustodial mother, Crystal Sorey, had called the police a month earlier to say that she had not seen or heard from her daughter since April 2019, two-and-a-half years earlier. The country was rapidly transfixed by the search for Harmony. We soon learned that the little girl, who was blind in one eye, had first been removed from Sorey at the age of two months by the Massachusetts Department of Children and Families (DCF) due to Sorey’s substance abuse. Harmony’s father, Adam Montgomery, was in jail at the time. Harmony was returned to her mother at seven months, and removed again at ten months. At almost three years old, and after two straight years in foster care with the same family that fostered her from the start and wanted to adopt her, Harmony was returned to her mother for the second time. At age three-and-a-half, Harmony was removed from her mother for the third time. Since Harmony was first removed, Adam Montgomery had been released from prison and begun visiting her. In February, 2018, a judge awarded Montgomery immediate custody of Harmony, without waiting for an assessment of his wife or a study of his living situation in New Hampshire.
A shattering report by the Massachusetts Child Advocate revealed the many missteps by all the professionals tasked with keeping Harmony safe. The OCA concluded that “Harmony’s individual needs, wellbeing, and safety were not prioritized or considered on an equal footing with the assertion of her parents’ rights to care for her in any aspect of the decision making by any state entity.”
Two years after the search for Harmony began, Adam Montgomery has been convicted of her death, thanks to the testimony of his wife. She told prosecutors that after Harmony soiled her bed at night he beat her viciously on the head in the morning of December 9, 2019 and again that afternoon in the car when she soiled herself once more. He then injected opioids and ate fast food as Harmony died of her injuries in the back of the car. He concealed Harmony’s body for months until renting a U-Haul and dumping her remains somewhere outside Boston. Her body has never been found. Montgomery is already serving 32 1/2 years in prison for another case and I hope he will never see the light of day, but what about all the professionals who failed to prioritize Harmony’s needs? And what has Massachusetts done to ensure that there will be no more Harmonies? The adoptive parents of Harmony’s brother have been speaking out; I assume Harmony’s foster parents are too devastated to do so, but their hearts must be broken.
Race trumps child welfare I: Black children don’t get attached?
Harmony Montgomery’s case illustrates, among other things, what happens when the importance of attachment for young children is disregarded. Attachment theory, which is widely accepted and taught in classes on psychology, social work and human development, posits that a strong attachment is central to the development of infants and affects their brain development and their ability to form relationships throughout life. The critical role of attachment in human development, which has been confirmed in mammals as well as humans, is the reason that the Adoption and Safe Families Act (ASFA) set a timeline requiring states to file for termination of parental rights after a child had spent 15 of the last 22 months in foster care. That is the deadline that Harmony’s team disregarded when they returned her to her mother after two years in foster care and continued to work with both parents after her return to foster care at the age of three-and-a-half. The continued disruptions were so devastating for Harmony that her foster parents, according to the OCA, could no longer meet her needs when she was placed with them for the third time, and asked that she be transferred to a specialized therapeutic home.
But some lawyers that counsel parents in child protection cases are being told that attachment theory does not apply to Black children. In Race Trumps Child Welfare, Naomi Schaefer Riley calls attention to a paper called “The Weaponization of Whiteness in Child Welfare,” originally published by the National Association of Counsel for Children. The paper calls attachment theory a “tool to justify the separation of families” and a manifestation of “racism in psychology.” The authors take aim at professionals who utilize attachment theory to argue for the adoption of Black children by White foster families who have raised them from infancy rather than returning them to their parents or placing them with kin. They argue that a Black child who has lived with a White foster family for the entire two-and-a-half years of his life should be placed with a relative who has never even seen the child. Black families, they say, belong to a collective culture, which emphasizes the needs of the group as a whole over the needs of an individual. Thus, any suffering to an individual child, they imply, is justified by the gain to the group–though it is hard to understand how Black people as a whole gain from the traumatization of young Black children.
Race Trumps Child Welfare II: ABA “addressing bias in medical mandated reporting” in Michigan
The American Bar Association (ABA) has announced that its Center for Children and the Law is piloting a new initiative in Michigan “to address overreporting by medical professionals of Black, Indigenous and Latino/a children to the child welfare system.” Without a footnote, the ABA reports that “injuries in Black children are 9 times more likely than those in White children to be reported as abuse despite evidence that child abuse and neglect occur at equal rates across races.” (Italics are mine.) Equal across races? I wonder what data they are using. While I am the first to acknowledge that maltreatment substantiation rates may not reflect actual incidence of abuse or neglect, evidence suggests that the two-to-one Blsck-White difference in child maltreatment substantiation rates is likely an understatement, not an overstatement. Moreover, Latino children nationwide are not reported to CPS disproportionately to their share of the population.
The pilots, funded by the Children’s Bureau, will use a “multisystem approach developed by the ABA’s Stop Overreporting Our People (STOP) project” to “address each decision made from the time a medical provider has a concern about maltreatment through child welfare hotline report and investigation to the decision of the judicial officer to remove the child from the home.” In Michigan, according to Child Maltreatment2022, of the 174,000 referrals to the hotline in Federal Fiscal Year 2022, about 68,000 were screened in, about 139,000 children received an investigation or alternative response (down 12 percent from the previous year), and 23,500 were substantiated as victims of abuse or neglect–a whopping 37.7 percent drop over the previous year. Of those “victims,” a total of 2,760 or 11 percent were placed in foster care–along with an additional 956 children who were not substantiated as victims but may have been siblings who were deemed to be equally endangered. Despite the precipitous drops in investigations and substantiations and the very low proportion of children substantiated as victims that were placed in foster care, the ABA isn’t satisfied…or doesn’t bother to look at data. The Michigan pilots will also focus on how doctors are trained to report maltreatment, according to the ABA. Discouraging doctors from reporting the signs that they are uniquely trained to spot may not strike all readers as a good idea.
Where was CPS?
Utah:Abuse in plain sight: Ruby Franke, a parenting influencer who achieved fame by promoting her strict parenting style, was sentenced to up to thirty years after pleading guilty to aggravated child abuse of two of her children. Franke rose to prominence with a youtube channel called 8 Passengers (now taken down) that documented her life with her husband and six children and was criticized for promoting abusive discipline methods. She eventually formed a business partnership with another woman named Jodi Hildebrandt, who encouraged and participated in the abuse of Franke’s children. Both women were arrested in August 2023, after one of Franke’s children escaped the home and ran to a neighbor’s house asking for food and water. The neighbor noticed the child’s open wounds, duct tape around his ankles and wrists and emaciation and called the police. After the arrest, the oldest daughter posted on social media that: “We’ve been trying to tell the police and CPS for years about this, and so glad they finally decided to step up.” “Several of us tried to help,” one neighbor told the Salt Lake Tribune. “I know people left food on doorsteps knowing the kids might not be eating; I know people were making phone calls to DCFS, to the police — people really did try and care. No one was looking the other way.”
New Mexico: $5.5 million settlement reached in eight-year-old girl’s brutal death: The Santa Fe New Mexicanreports that the New Mexico Children Youth and Families Department (CFYD) has agreed to pay $5.5 million to the brother and half-siblings of Samantha Rubino, acknowledging that it placed Samantha and her brother in the care of a man (Juan Lerma) with a history of child abuse and domestic violence, who had been investigated once before for abusing her and had not seen either Samantha or her brother for two years. Samantha died of blunt force trauma to the head, and Lerma placed her body in the trash. This is the latest in a series of big-money settlements by CYFD, funded by the taxpayers. New Mexico’s system is in crisis, with a backlog of 2,000 investigations of abuse and neglect. Is it too much to hope that the legislature will decide it is better to spend money up front to keep children safe than to pay massive settlements to their survivors?
The march continues to remove protections for homeschooled children
The powerful homeschool lobby continues its crusade to eliminate the few regulations that still exist to protect homeschooled children. In Nebraska, LB 1027 would eliminate two of the three minimal documents required for homeschool enrollments. It would bar school districts and Health and Human Services from investigating educational neglect in a homeschool setting. And it would give one parent the power to make homeschooling decisions without input from the other parent. The unicameral legislature’s Education Committee heard testimony from the Nebraska Christian Home Educators Association, the president of a Christian homeschoolers’ co-op, and another homeschooling parent. There was no testimony against the bill. The Education Committee has recommended the bill, and it is headed for a floor vote.
In West Virginia, legislators have tried to bar abusive parents from homeschooling ever since an eight-year-old girl named Raylee Browning died of sepsis, possibly caused by drinking toilet water, in 2018. Teachers had called CPS multiple times because Raylee was constantly hungry and covered in bruises. To avoid further problems, her guardians removed her from school for the ostensible purpose of homeschooling, thus enabling them to torture ber to death without interference. Every year since 2019, legislators have introduced Raylee’s Law, which would prohibit homeschooling if the parent or home educator had a pending investigation for child abuse or neglect or had been convicted of abuse, neglect or domestic violence. This very modest bill, which probably wouldn’t even have saved Raylee because her guardians did not have a pending investigation when they withdrew her from school, nor were they convicted of abuse, has never gotten through the legislature. This year it was voted down in the Education Committee by 15-5 after several legislators outlined their concerns–such as the fear that it would force children to enter public school before an investigation could be completed!
This year, the sponsors of Raylee’s Law managed to get a version of the legislation included in a bill that removes certain testing requirements for homeschooled children, and it passed by a voice vote. Unfortunately the amendment that passed was watered down further from the original bill, which itself was very weak The amendment that passed requires that a parent cannot withdraw a child for homeschooling if there is a pending child abuse or neglect investigation. But if the complaint is not substantiated within 14 days, the superintendent must authorize homeschooling. And the bill to which it was attached (HB 5180) reduces protection of homeschooled children by removing the requirement that parents submit academic assessments for homeschooled children in certain grades, as well as the requirement that the parent or home educator submit evidence that they have a high school or post-secondary degree.
Readers who care about the protection of homeschooled children and the drastic disproportion of power between homeschooling parents and advocates for their children should give to one of my favorite organizations, the Coalition for Responsible Home Education. They are doing their best on a shoestring budget, but they can’t afford to go to every state where protective legislation is threatened.
From the “Are you kidding me?” department
“Safe Haven laws” are a way for new parents who are not ready to raise a child to surrender their newborns safely without any questions or legal consequences. The laws exist in all 50 states. The Committee to Eliminate Child Abuse and Neglect Fatalities has endorsed these laws as a way to protect vulnerable infants and recommended that they be amended to extend the age of protected infants to age 1 and to expand the types of safe havens allowed. And it turns out that this option has existed in Europe since Pope Innocent III required churches to install “Foundling Wheels” in 1198!
In New Mexico, mothers are told they can anonymously surrender their infants through “safe haven baby boxes” located around the state. But recent media coverage from local stations KRQE and KOB4 has revealed the state’s Children Youth and Families Department (CYFD) has been investigating these surrenders–because they are required to do so by the state’s safe haven law. CYFD Secretary Teresa Casados told KRQE that “state law requires CYFD to investigate to ensure the mother was not forced to give up her baby, to make sure she is safe, and to inform the father of the child as well.” (She was apparently not asked what would happen if the father had raped or abused the mother.) She also explained that the Indian Child Welfare Act (ICWA) requires CYFD to look into each case and notify “all the tribes and pueblos” to ensure they are following the Act’s requirement that placement with a Native family be preferred. It is not clear that any other state has interpreted ICWA this way. New Mexico legislators rushed to draft legislation to retain the right of mothers to surrender their infants safely and anonymously, but the short session ended before a bill could be passed.
Never underestimate a persistent child advocate
John Hill, the Investigative Editor at Civil Beat, a nonprofit news outlet in Honolulu, Hawaii, has never given up on his quest to find out how a six-year-old girl named Ariel Sellers was placed with Lehua and Isaac Kalua, the adoptive parents who tortured her, culminating in her murder two-and-a-half years ago. The Kaluas have been charged with murder and abuse of both Ariel and her then 12-year-old sister, among other charges. The prosecution alleges that Ariel was kept in a dog cage and denied food, and that Lehua Kalua caused her death by duct-taping her mouth and nose. For more than two years, according to Hill, the Hawaii Department of Human Services has stonewalled in accounting for its actions in the adoption of Ariel, who was renamed “Isabella Kalua” by her adoptive parents. But Hawaii’s Public First Law Center, motivated by a series of columns written by Hill, has filed a motion to receive the foster and adoption records for Ariel and her siblings. Now Hill is asking uncomfortable questions about the January 2024 death of 10-year-old Geanna Bradley, who was also allegedly tortured and starved to death by her adoptive parents.
In a bizarre twist, the Honolulu Star Advertiser has reported that the Kaluas have retained custody over Isabella’s three sisters, who were removed from the home in September 2021. But apparently the state of Hawaii hasn’t moved to terminate the parental rights of the Kaluas. A special master appointed to oversee the interests of Ariel’s sisters is concerned that the failure to terminate the rights of the Kaluas will interfere with efforts to find permanent families and educational opportunities for the girls. (And already has, I would think!)
The guaranteed income craze continues
At its February oversight hearing, the Director of the District of Columbia Child and Family Services Agency announced a forthcoming grant from the Doris Duke Foundation to a guaranteed income for some low-income families. The announcement was greeted with congratulations from the Council Chair who referenced the great results from the recent Strong Families, Strong Futures pilot, which provided 132 new and expecting mothers with $10,800 in the course of a year. I don’t know where she got her information. An article in the Washington Post reported on interviews with three of the mothers participating in the pilot. One of the mothers took the money as a lump sum. Setting aside about $5,000 for essential expenses, she used the remaining money on a $6,000 trip to Miami preceded by the purchase of new clothes, shoes, gadgets and toys for all of her three children and a $180 hair and nails treatment for herself. Another mother decided to spend $525 on a birthday party for her one-year-old, who clearly couldn’t appreciate it. Program coordinators said that the mothers reported spending most of their funds on needs such as housing, food and transportation. But I’m not sure how I feel as a DC taxpayer to see my money spent in ways that I personally find wasteful, nor am I sure that allowing such spending provides appropriate training in how to budget scarce resources. Such no-strings-attached money giveaways might not be the best use of taxpayer money, even if foundations choose to support it.
And the prize for cynical use of data goes to….
Kentucky! The State’s Cabinet for Health and Family Services (CHFS) is crowing about Kentucky’s drop from the highest rate of child maltreatment “victimization” to number 13 among the 50 states and the District of Columbia. In a statement reported by Spectrum News1, CHFS said this improvement “demonstrates the efforts made by the Department for Community Based Services and its many partners to increase the provision of child welfare prevention services and reduce child abuse and neglect within the Commonwealth.” But child advocates and family court judges are not convinced, citing a longstanding problem with hotline workers screening out cases that should be investigated–exacerbated by the adoption of an actuarial screening tool at the hotline in April 2022. The report quotes two family court judges and a CASA program director who linked child deaths to the failure to investigate prior reports involving the same families. According to one judge, “The alarm has to be sounded because I’m not joking when I say children are perishing in the state of Kentucky because of this ‘Structured Decision Making’ tool….'” The judges are right. One has only to look at Kentucky’s commentary in the Children’s Bureau’s report, Child Maltreatment 2022.
An overall decrease for child victims was observed between FFY 2021 and FFY 2022. Kentucky has worked diligently over the past several years to implement a safety model which includes the implementation of SDM® Intake Assessment Tool and a thorough review and modification of the state’s acceptance criteria to ensure a focus upon children and families with true safety threats versus risk factors. This shift in the approach to the work may have contributed to the decrease in child victims this year.
Children’s Bureau, Child Maltreatment 2022, p. 13
In other words, they changed the screening criteria to screen out more cases and voilà! Fewer child victims! Amazing! The percentage of referrals that was screened in decreased from 45.5 percent in 2021 to 39.9 percent in 2022, and the maltreatment substantiation rate decreased from 14.9 to 12.3 per thousand children during the same period. But both of these rates have been decreasing since FFY 2018, so more factors than the new screening tool are likely responsible. It’s unlikely that a decrease in actual maltreatment is among them.
The placement and workforce crises continue
Every month brings another crop of articles on the intertwined placement and workforce shortages plaguing child welfare. February’s news on the placement crisis included a story from Texas Public Radio reporting on the release of hundreds of incident reports about “Children Without Placements” in the state from 2021 to 2023. They include stories of children squaring off to fight each other in the hallway of a Houston hotel that resulted in the hospitalization of one youth. These incidents, occurring at a rate of about two a day, often involved injured staff, injured youth, and calls to police.
In a state that requires some social workers to supervise youths in hotels and other unlicensed placements, its not surprising that about one in four caseworkers left the job in January, according to the head of the Department of Family and Protective Services (DFPS). And even workers who don’t have to supervise unruly youths are dealing with untenable caseloads and terrible working conditions. Some states are taking action to attract and retain workers. The Governor of Maine announced a series of three one-time lump-sum payments of $1,000 to recruit and retain child welfare workers. Let us hope it is enough to reduce the state’s high caseloads.
And now for some good news: efforts to keep siblings together
It’s always nice to read about people who see a need and create a program to meet it. February brought news of two new “foster care villages” to house larger sibling groups, an idea I have promoted in the past. In California, the actor Christian Bale achieved a dream he has nurtured for 16 years–breaking ground on Together California, a new foster home community in Palmdale, Los Angeles County. The project will include a dozen foster homes built to accommodate up to six siblings and staffed by full time, professional foster parents. A 7,000-square foot community center will offer academic, therapeutic, social, and recreational activities for young people in the foster homes and the surrounding community, which is very short on such resources.
In South Carolina, a new foster care “village” called Thornwell is transforming old houses built about 100 years ago to house foster families and large sibling groups. Two homes are in use, a third is under renovation and more homes await renovation provided the funds and parents can be found. Foster parents will pay one dollar of rent per month and receive free utilities. Children will be eligible for Thornwell’s early learning center, charter school, and recreational facilities. Here’s hoping for more programs like Together California and Thornwell!
“Child Maltreatment Victims Have Decreased for the Past Five Years to a New Low,” proclaimed the Administration for Children and Families (ACF) as it released Child Maltreatment 2022, its long-awaited annual compendium of child maltreatment data shared by the states. Contrary to the headline, the report says nothing about the actual incidence of child abuse and neglect. It does show that in Federal Fiscal Year 2022, calls to child protective services hotlines almost rebounded to pre-pandemic levels. But the number of investigations and assessments that CPS undertook in response to these calls did not bounce back as much as calls, and states are confirming even fewer allegations of maltreatment as they did in FFY 2021 and 2022. Moreover, child fatalities are up for the fifth year in a row. Some of the most striking and interesting results are discussed below, though this is not an exhaustive summary of the report’s contents.
Referrals and Reports
The annual Child Maltreatment reports, produced by the Children’s Bureau of ACF are based on data that states submit to the National Child Abuse and Neglect (NCANDS) data system, and this latest report concerns Federal Fiscal Year (FFY) 2022, which ended on September 30, 2022. NCANDS uses the term “referrals” to connote contacts to child protective services (CPS) hotlines. In 2020, the number of referrals dropped sharply as schools closed and children vanished into their homes. In FY 2021, with some opening of schools and society, the referral rate rose slightly but was still much less than in FFY 2019. But in FFY 2022, the referral rate bounced back to 58.6 per 1,000 children, bringing it close to the rate of 59.7 per 1,000 in FFY 2019. Some states mentioned in their commentaries that the pandemic continued to suppress referrals somewhat in FFY 2022, which began in October 2021. That fall and winter in particular, there were still temporary school building closures and increases in absenteeism due to big waves of infection. This continued pandemic effect may help explain the failure of referrals to reach their 2019 level.
Source: Child Maltreatment 2022
As usual, the state-by-state tables document huge differences in referral rates, from 21.1 per 1,000 children in Hawaii to 180.7 per 1,000 in Vermont. Vermont reports in its commentary that its very high referral rate reflects that the state counts all calls to the hotline as referrals, suggesting that most states do not do so. And indeed, Connecticut and Alabama report that none of the calls that are assigned to alternative response are included in NCANDS, resulting in a far lower number of calls than the number they actually receive. Louisiana reports that some referrals are neither screened out nor accepted; these are calls related to open investigations or in-home or out-of-home service cases; it appears that these are not counted as referrals at all. These inconsistencies between states make it difficult to interpret state-by-state differences in referral rates.
Once a state agency receives a referral, it will be screened in or out by hotline staff. In general, referrals are screened out if they are deemed not to contain an allegation of child abuse or neglect, contain too little information to act on, are more appropriately assigned to another agency, or for some other reason do not fall under the mandate of the child welfare agency. In NCANDS, a referral becomes a “report” once it is screened in, and it then is assigned for an investigation or alternative response. The 47 jurisdictions that reported both screened-in and screened-out referrals collectively reported screening in 49.5 percent of referrals and screening out 50.5 percent. The national screened-in referral rate was 29.0 per 1,000 children, an increase of one percentage point from the rate in FFY 2021. In that year, as shown in Child Maltreatment 2021, the 46 states reporting screened in 51.5 percent of referrals and screened out 48.5 percent. So as the number of referrals increased, it appears that the states screened in a lower percentage of them.
State by state differences in the percentage of referrals that are screened in were vast; ranging from 16.9 percent of referrals to 98.7 percent in Alabama. But as discussed above, differences in which calls are reported in NCANDS will affect these percentages, making the data hard to interpret. Some of the very high rates reported, such as the 98.7 percent for Alabama, and Texas’s reported 84.5 percent, are hard to understand.
Indiana’s commentary provides an example of how a state can purposely reduce its screen-in rate. The state reported that the Department of Children’s Services “partnered with the Capacity Building Center for States as well as ran internal events targeted at reducing our screen-in rate.” Added to the types of allegations to be screened out during FFY 2021 were “sexting concerns among adolescents,” “pre-adolescent children exhibiting potentially sexually maladaptive behaviors,” and “educational neglect.” Some child advocates might be concerned about excluding these types of allegations, as all of them could indicate serious problems in the home, and the exclusion of educational neglect is particularly surprising. Perhaps the changed screening guidelines are one reason the number of Indiana children receiving an investigation or alternative response fell from 139,343 in 2020 to to 123,644 in 2022, a decrease of 11.6 percent.
Screened-in Referrals by Referral Source
Before the pandemic, teachers were the most common source of screened-in referrals, submitting 21 percent of all referrals that were screened in in FFY 2019. They lost that position in FFY 2020 with the pandemic school closures, while legal and law enforcement personnel increased their share of reports. It is not surprising that teachers did not recoup their leading role in 2021, since many students were still attending school virtually for some part of the year. But even in 2022, legal and law enforcement personnel still submitted slightly more screened-in referrals than education personnel–21.2 percent of screened-in referrals compared to 20.7 percent for education personnel. Medical personnel submitted 11.2 percent of referrals and social services personnel 9.8 percent. Because these data are available only for referrals that are screened in, they reflect both the number of referrals each group submits and the extent to which they are screened in. It seems likely that teachers submit more referrals than law enforcement but that their referrals are more likely to be screened out.
Source: Child Maltreatment 2022
Child Disposition Rates: The “Footprint” of CPS
In every state, screened-in reports may receive an investigation, which results in a determination (or disposition) about whether or not maltreatment has taken place. Some states assign some reports (often those deemed to be lower risk) to an alternative track (often called “alternative response” or “family assessment”) that does not result in a formal disposition as to whether maltreatment occurred and who was the perpetrator. ACF calls the proportion of children receiving either an investigation or an alternative response the “child disposition rate.” This is an important indicator, because it can be seen as a measure of the “footprint” of CPS–the number of children it actually touches.
For FFY 2022, an estimated 3,096,101 children, or 42.4 per 1,000 children, received an investigation or alternative response, as shown in Exhibit S-1 of the report, reproduced above. That rate has dropped 12.7 percent since FFY 2018. Not surprisingly, the biggest drop was during the pandemic, but it dropped again in 2021 and rose by only one percentage point from 41.4 in FFY 2022, remaining significantly lower than before the pandemic.
The diversity in child disposition rates across states is striking. Disregarding the 15.0 in Pennsylvania, which excludes most neglect cases from NCANDS,1 this rate ranges from a low of 17.1 per 1,000 children in Maryland to a chilling 131.3 in West Virginia (over one out of 10 children!). The opioid crisis and its catastrophic effects on children in West Virginia has received considerable media attention. It is worth noting that West Virginia’s child disposition rate has decreased from 143.2 in FFY 2018. Below West Virginia, Arkansas and Indiana have similar child disposition rates of 79.9 and 78.8 respectively, far above the next group of states at about 66. The five states with the lowest child welfare “footprint,” (other than Pennsylvania) are Maryland, Hawaii, South Dakota, Connecticut and Louisiana.
Some states or jurisdictions, including Alaska, Arizona, the District of Columbia, Indiana, Kentucky, Maryland, Montana, North Dakota, Rhode Island, and South Carolina, had very large decreases in their disposition rates between FFY 2021 and FFY 2022. These may reflect purposeful policy changes to reduce the role of child welfare (such as Indiana’s addition of categories to be screened out), but it may also affect other factors such as the workforce crisis that is affecting child welfare in most states.
CPS Workforce Data and Child Disposition Rates
Child Maltreatment 2022 also provides interesting data on state child welfare workforces although the quality of the data is impossible to assess. Table 2-4 of the report provides the CPS caseload, which is obtained by dividing the number of intake, screening, investigation and alternative response workers by the number of “completed reports,” meaning reports with a disposition. That is not a very meaningful number, because it leaves out all the alternative response cases, while the workers who handle these cases are included in the numerator. In order to get a better sense of the number of children seen by each worker, I divided the number of children receiving an investigation or alternative response by the number of workers in the 20 states with the highest populations, minus the four states that did not provide workforce numbers–Florida, Georgia, New York and Ohio, as well as Pennsylvania.1
Among the 15 states in the table below, there is a staggering variation in the number of children per worker, which ranged from 21.1 in Wisconsin to 199.4 in Indiana. As child welfare commentator Dee Wilson explains in an unpublished analysis, “Differences of this magnitude develop over time when policymakers do not staff child welfare systems in accordance with workload standards.” We must also keep in mind that we do not know if the data are truly comparable between states.
Children Per Worker, FFY 2022
Source: Child Maltreatment 2022
“Victimization”
An investigation can result in a variety of dispositions, depending on the state. Most states use the term “substantiated” to indicate that the allegation was verified, but some states use another term, usually “indicated.” In NCANDS, a “victim” is defined as “a child for whom the state determined at least one maltreatment was substantiated or indicated; and a disposition of substantiated or indicated was assigned for a child in a report.” A reader might think the terms “victim” and “victimization” reflect the true number of children who experienced abuse or neglect. But there are many reasons they do not provide such a true count. Many cases of child maltreatment go unreported. Children assigned to alternative response will not be found to be victims unless their case is reassigned to the investigation track. And finally, substantiation is not an accurate reflection of whether maltreatment occurred. Adults can lie, children can lie, perhaps when coached by adults, the youngest children are nonverbal or not sufficiently articulate to explain what happened or didn’t, and making a determination of whether maltreatment occurred is difficult. So it is not surprising that research suggests that substantiation decisions are inaccurate2 and a report to the hotline predicts future maltreatment reports and developmental outcomes almost as well as a substantiated report.3 For all of these reasons, it is widely recognized that the number of children estimated to be victims of maltreatment is likely an underestimate. And over time, events such as the coronavirus pandemic or changes in state policies can be confounded (innocently or cynically) with actual changes in child maltreatment victimization. For that reason I generally put quotes around “victimization” or replace it with “substantiation,” and use the terms “substantiated victims” or “children found to be victims of maltreatment” instead of “victims.”
The 2022 report provides an estimate of 558,899 substantiated victims of maltreatment, or 7.7 per 1,000 children, down from 8.2 in FFY 2021. States differed greatly in the “victimization rates” that they found in FFY 2022. Of course these differences can stem from the factors mentioned above, as well as from actual maltreatment. The number of substantiated victims per 1,000 children ranged from 1.6 in New Jersey to 16.5 in Massachusetts. We know that New Jersey has been intent on reducing CPS involvement in the lives of families, no doubt encouraged by its effort to exit a class action suit monitored by the Center for the Study of Social Policy, one of the founders of the upEND movement to abolish child welfare. So its low victimization rate is not surprising (An article by Sarah Font and Naomi Schaefer Riley discusses the New Jersey experience in more detail.) New Jersey’s “victimization” rate has dropped by more than half since FFY 2018.
The number of children found to be victims of maltreatment has declined every year since FFY 2018. The change in state “victimization rates” between FFY 2018 and FFY 2022 ranged from a 48 percent decrease in Kentucky to a 14.5 percent increase in Nevada over those five years. Many things could explain these changes other than an actual change in maltreatment, including policy changes made by state legislatures or agencies. Two of the largest states made it more difficult to substantiate maltreatment in FFY 2022, and both found a decline in the number of maltreatment victims. In Texas, the legislature narrowed the definition of neglect, requiring the existence of both “blatant disregard” for the consequences of a parent’s action or inaction and either a “resulting harm or immediate danger.” Perhaps this helps account for the drop in the number of substantiated victims from 65,253 to 54,207. In New York, the level of evidence required to substantiate an allegation of abuse or neglect was changed from “some credible evidence” to “a fair preponderance of the evidence.” The number of victims found in New York dropped from 56,760 to 50,056. States reported other reasons for changes in their rates of “victimization,” including changes in the use of alternative response, new screening and intake tools, reduction in investigation backlogs, and the continued effects of the pandemic.
It is instructive to look at the changes in the number of referrals, screened-in referrals, child disposition rates, and child “victimization rates” between FFY 2021 and FFY 2022, as the nation came out of the pandemic. Thinking about the process as a funnel starting with referrals and ending with victims, we can see that the effect of the increased referrals is further attenuated at each stage. While the number of referrals increased from 4,010,000 to 4,276,000, an increase of 6.6 percent, the number of screened in referrals increased only 3.3 percent. The number of children receiving an investigation or alternative response increased by only 2.0 percent. And the number of children substantiated as victims decreased by a whopping 7.2 percent. It’s just another way of describing what we have already seen–that the child welfare system’s response is not keeping up with the public’s renewed reporting activity.
Source: Child Maltreatment 2022 and author’s calculations
Demographics and “Victimization”
Younger children are more likely to be substantiated as maltreatment victims. The likelihood of being a substantiated victim of maltreatment is is more than twice as high for an infant younger than one than for a two-year-old, and drops a bit with every one-year increase in age. Girls are more likely to be substantiated as victims than boys, with a rate of 8.2 per 1,000 children, compared to 7.1 for boys. This is probably related to sexual abuse; girls are the overwhelming majority of victims of substantiated sexual abuse, as shown in Exhibit 7-F of the report.
In terms of race and ethnicity, American Indiana and Alaska Native children had the highest rate of substantiation as a victims, at 14.3 per 100,000 children, followed by Black or African-American children with a rate of 12.1 per 100,000 children. The rate for Hispanic children was 7.0 per 100,000 and for White children it was 6.6 per 100,000. Again, the number of substantiated victims is not equal to the number of actual victims. These rates reflect the extent to which these children are reported to CPS, the referrals are screened in, and they are substantiated. If, as many assert, there is systematic bias affecting referral, screening, and investigation, then the total number substantiated will also reflect that bias.
Victimization Rate per 1,000 children by Race and Ethnicity, FFY 2022
American Indian/Alaska Native: 14.3
Asian: 1.3
Black or African-American:12.1
Hispanic: 7.0
Native Hawaiian/Pacific Islander: 9.3
Two or more races: 9.4
White: 6.6
The claim that these rates are biased has resulted in a movement to eliminate racial disproportionality in child welfare or even to eliminate child welfare itself, as promulgated by the upEND Movement. However, evidence confirms that the Black-White difference in substantiation rates is actually less than the disparities in other indicators of child risk and adversity. A group of prominent child welfare researchers led by Brett Drake estimated the “expected rate” of being reported to CPS, using several categories of risk and harm that are known to be highly correlated with the risk of child abuse and neglect, such as poverty, single-parent families, teen birth rate, very low birth weight, and homicide. Drake et al. reported that the disparity in all the measures of risk, and in all of the measures of harm except accidental deaths, were greater than the disparity for CPS reports, as measured by NCANDS. In other words, there was a greater disparity in risk and harm to Black children compared with White children than there was in CPS reporting. Thus, given their likelihood of being abused or neglected, Black children appear to be reported to CPS less than White children, not more. And even when adjusted to account for confounding factors, Black children are less likely to be substantiated (and placed in foster care) than White children. So if anything, the “victimization rates” provided in CM 2022 may underestimate the true disparities in child maltreatment substantiation of Black and White children.
CM 2022 also provides information on the number of substantiated victims with different maltreatment types. Three-quarters of the substantiated victims, or 74.3 percent, were found to have experienced neglect, 17 percent physical abuse, 10.6 percent sexual abuse, 0.2 percent sex trafficking, and another 3.4 percent another type of maltreatment. (These percentages add up to more than 100 because some children were found to be victims of more than one type of maltreatment during the year.) As shown in Table 3-9 of the report, some states diverged from the pattern that substantiated allegations are for neglect–and instead found more (or almost as many) children to be physically abused than neglected. These states include West Virginia, where 76.2 percent of substantiated victims were found to have suffered physical abuse; Vermont, (58.6 percent); Tennessee (51.8 percent), Alabama (53.5 percent), South Carolina (47.5 percent), and Ohio, with 46.6 percent.5 Corporal punishment often opens the door to physical abuse, some of these states are in regions where corporal punishment is known to be more prevalent. But the absence of Mississippi on this list (with only 16.0 percent of victims substantiated for abuse) and the presence of Vermont are surprising. Perhaps liberal Vermont is simply reluctant to find neglect in cases associated with poverty; only three percent of its victims were found to be neglected. And perhaps in Mississippi, a state that allows corporal punishment in the schools, the standard for finding abuse is may be high.
Substantiation by Reporting Source
Chapter 7 of CM 2022 contains an interesting table plotting the number of substantiations for each reporting source. We have seen that legal and law enforcement personnel made only slightly more screened-in reports than education personnel in FFY 2022: Table 7-3 of the report shows that each group made approximately 21 percent of the reports that were screened in. Yet the reports made by law enforcement personnel accounted for 38 percent of the substantiated victims, and the reports of educators accounted for only 11 percent of the substantiated victims. So reports from law enforcement personnel were over three times more likely to be substantiated than reports from teachers. Medical personnel did better but not quite as well as the police: they made 11 percent of screened-in reports, which accounted for 13 percent of substantiated victims. An analysis by The Imprint shows that social services personnel have a slightly higher share of substantiated reports than of total reports, while nonprofessionals have a substantially lower share. The data align with increasing criticisms of teachers as making too many reports that do not rise to the level or abuse or neglect. Whether that is true, or whether reports from teachers are automatically devalued because of their source, cannot be ascertained from this information.
Fatalities Continued to Increase
CM 2022 reports an estimated increase in child maltreatment fatalities for the fifth consecutive year. The report provides a national estimate of 1,990 children who died of abuse or neglect in FFY 2022 at a rate of 2.73 per 100,000 children in the population. That number has increased every year since 2018, and the 2022 estimate is a 12.7 percent increase over the estimate from 2018. The increase in child fatalities started before 2018; Child Maltreatment 2017 reported an 11 percent increase in child fatalities from 1,550 in FFY 2013 to 1,720 in FFY 2017. That amounts to a 28 percent increase between FFY 2013 and FFY 2022.
Source: Child Maltreatment, 2022
There are many caveats to be made about year-to-year comparisons of child fatalities. First, there is nearly universal agreement among experts that the annual estimates of child fatalities from NCANDS dramatically undercount the true number of deaths that are due to child maltreatment. As CM 2022 states, some child deaths may not come to the attention of CPS at all. That can happen if nobody makes a report, perhaps because there are no surviving children in the family, or if the family is not already involved with CPS. For this reason the Child and Family Services Improvement and Innovation Act (P.L. 112-34) requires states to describe in their state plans all the sources used to compile information on child maltreatment deaths, and to the extent that information from state vital statistics departments, child death review teams, law enforcement agencies and medical examiners or coroners is not included in that description, to explain why that information is not included and how it will be included. Most states that comment on fatalities report using at least some of these sources, but the extent to which they are capturing actual fatalities is unclear. Only Virginia reports that it does not collect child fatality data from external sources.
Second, the fatalities reported in the 2022 report did not all occur in 2022. The report explains that child fatalities reported in CM 2022 are generally those that were determined to be due to maltreatment in 2022, not those that actually occurred during 2022. That is because It may take more than a year to find out about a fatality, gather the evidence (such as autopsy results and police investigations) to determine whether it was due to maltreatment, and then make the detrmination. Some states report that the deaths they reported may have occurred as long as five years before 2022. However, each state has its own way of determining which fatalities to report. California, for example, explains that the fatalities reported in the 2022 report were actually fatalities that occurred in FFY 2021 and were known to the state by December 2021, meaning that the estimate is truncated.
The meaning of the increasing fatalities is not obvious. Just like “victimization,” the classification of a death as a maltreatment fatality depends upon whether the fatality was even reported to the child welfare agency as well as whether the correct decision was made to substantiate the fatality as due to maltreatment. As mentioned above, states are supposed to gather the information about fatalities from other sources like medical examiners, but the extent to which they are receiving this information, and the extent to which these other sources are identifying maltreatment, is unclear.6
From the explanations that some states provided in their commentaries, it appears that annual maltreatment fatality counts can reflect a variety of factors. Year-to-year changes are often attributed to random fluctuations due to small numbers or timing issues. In their commentaries, states often explained a year-to-year jump by explaining that many children in one family died, or or that a large group of fatalities that occurred the previous year were reported in the current year.
Some states reported on societal issues that have contributed to increasing child fatalities over time. For example, Washington’s commentary suggests that the opioid crisis has contributed to its increase in fatalities from 19 in FFY 2021 to 31 in FFY 2022. The state reports that between FFY 2021 and FFY 202 the percentage of child fatalities in the state that were due to opioid ingestion or overdose rose from less than one percent to 23 percent of child fatalities. Of the deaths and near-fatalities that qualified for a review because they occurred in families touched by the system in the previous year, that percentage jumped from 28 to 44 percent. Ohio reported that it attributes the increase in child fatalities to an increase in the overall death rate due to violence. Other states commented on the type of deaths that have increased, such as unsafe sleep coexisting with substance abuse.
Changes in how maltreatment fatalities are defined can also affect fatality counts, and in the case of Texas, the change resulted in a decrease in child fatalities from 206 in FFY 2021 to 176 in FFY 2022. Specifically, Texas attributes this decrease to the new law that makes the definition of neglect more stringent. Considering that the new law requires both “reckless disregard” of the consequences of parental action or inaction and actual harm, and given that death is certainly harm, this suggests that those investigating the deaths did not consider that the parents or caregivers exhibited such reckless disregard. Texas reports that deaths from unsafe sleep, drowning, and vehicle-related fatalities declined in FFY 2022 under the new definition of neglect.
Some states attribute increases in reported fatalities to improvements in the accuracy with which they report child fatalities. Commentaries from states that experienced an increase in child maltreatment fatalities in recent CM reports include accounts of their improvements in their ability to identify such deaths. These included several states that reported an increased awareness of unsafe sleep practices and hot car deaths resulting in more reports involving these cases, the creation of a Special Investigation Unit that investigates child fatalities to determine whether they are due to maltreatment (Mississippi); requiring mandated reporters participating on child fatality review boards to report suspected maltreatment fatalities to the local child welfare agency (Ohio); the development of capability to track fatalities at report, during investigation, or in care (Maine); ensuring that documentation of deaths is included in the states CCWIS system (Maryland); increased training of staff and partners on reporting child fatalities (Texas); and implementation of death review panels (Arkansas). Therefore, it is not possible to determine the extent to which the increase in reported child maltreatment fatalities reflects better identification, more maltreatment deaths, or a combination of the two.
Demographics and child maltreatment fatalities
Infants under a year old are more than three times more likely to die of maltreatment than one-year-olds, and the fatality rate generally decreases with age. In contrast to the different rates of substantiated abuse or neglect, boys have a higher maltreatment fatality rate (3.26 per 100,000 boys) than girls (2.25 per 100,000). Black children have by far the highest fatality rate of all the groups for whom information was available; 6.37 per 100,000 black children died of substantiated maltreatment, compared to 3.37 for American Indian or Native American children, 1.99 for White children, and 1.68 for Hispanic children. The maltreatment fatality rate for Black children is over three times as high than the rate for White children, a difference that is even more stark than the difference in the “victimization rate,: which is twice as high for Black children than for White children.
Source: Child Maltreatment 2022
The question of bias has to be addressed again when talking about fatalities from maltreatment. It is theoretically possible that racial bias could play a role in whether a fatality is substantiated as maltreatment. But it is likely that there is less opportunity for bias when it comes to fatalities, as the fact that harm was done cannot be disputed even if the parent’s role may be unclear. Drake et al. found that in 2019 indicators of risk and harm for Black children are usually between two and three times greater than those for White children, while the Black-White homicide disparity was four times as great as that for White children. So while we cannot rule out any role for bias, it is unlikely to be the main cause of the disparities in child maltreatment fatalities.
The data showed that most of the perpetrators of child fatalities were caregivers; more than 80 percent of child fatalities involved “one or more parents acting alone, together, or with other individuals.” NCANDS does not collect the official cause of death, but it does ask for the type of maltreatment that was substantiated in each fatality. Thus, one child can be found to have suffered more than one type of maltreatment, though it is not clear that each maltreatment type that was substantiated must have contributed to the fatality. Over three quarters (76.4 percent) of the children who died were found to have suffered from neglect, and 42.1 percent were found to have endured physical abuse.
It is worth noting that CM 2022 was originally released on or about January 8 without a press release and then disappeared from the internet for about three weeks. It is hard to avoid speculating about the reasons for the removal of CM 2022 and then its publication several weeks later. Could it be that officials were trying to figure out how to spin the five years of increase in fatalities? When the press release finally appeared along with the restored report, ACF had elected to basically recycle last years headline, New Child Maltreatment Report Finds Child Abuse and Neglect Decreased to a Five-Year Low. Once again, the press release failed to explain that victimization is not actual maltreatment. It did mention the increase in child maltreatment fatalities and, surprisingly, did not raise the possibility that better measurement contributed to this increase, which might have helped their case.
In the press release, Children’s Bureau Associate Commissioner Aysha Schomberg is quoted as encouraging “agencies to pay particular attention to data in this report that is disaggregated by race.” There is something perplexing about this suggestion. Paying attention to race means observing the stark disparities in child maltreatment “victimization” and fatal child maltreatment, between White children and Black and Native American children. ACF and its allies at Casey Family Programs, the Center for the Study of Social Policy and other like-minded organizations typically argue that these disparities are not due to different rates of maltreatment but to racial bias built into the system. But ACF’s press release accepts these “victimization” rates as a true indicator of child maltreatment, which suggests that the racial disparities in child maltreatment are real. And if that is indeed the case, as I believe it is, isn’t the right answer to protect Black and Native American children through a stronger and better-functioning CPS, rather than trying to weaken or abolish it?
ACF’s Communications team’s misuse of the term “victimization” to suggest that maltreatment is declining is disappointing in a government agency with a responsibility to inform the public. We will never get an accurate measure of child maltreatment because so much of it occurs behind closed doors. So what is the real meaning of CM 2022? The failure of the child disposition rate to keep up with the increase in reports suggests a decreasing response by child welfare to reports of maltreatment, with the slight uptick after the pandemic disguising a downward secular trend over the entire period. The continuing decline in substantiations despite the increase in referrals, while not indicative of declining maltreatment, shows even more clearly how child welfare systems are seeking to reduce their involvement with families. Could the increase in child fatalities be the consequence of this reduced involvement? It is possible, but the improvement of fatality reporting in some states makes it impossible to answer this question definitively.
Notes
In Pennsylvania, referrals that involve non-serious injuries or neglect are assigned to General Protective Services (GPS), and information on these cases is not reported in NCANDS.
Theodore Cross and Cecilia Casanueva, “Caseworker Judgments and Substantiation,” Child Maltreatment, 14, 1 (2009): 38-52; Desmond K. Runyan et al, “Describing Maltreatment: Do child protective services reports and research definitions agree?” Child Abuse and Neglect 29 (2005): 461-477; Brett Drake, “Unraveling ‘Unsubstantiated,'” Child Maltreatment, August 1996; and Amy M. Smith Slep and Richard E. Heyman, “Creating and Field-Testing Child Maltreatment Definitions: Improving the Reliability of Substantiation Determinations,” Child Maltreatment, 11, 3 (August 2006): 217-236.
Brett Drake, Melissa Jonson-Reid, Ineke Wy and Silke Chung, “Substantiation and Recidivism,” Child Maltreatment 8,4 (2003): 248-260; Jon M. Hussey et al., “Defining maltreatment according to substantiation: Distinction without a difference?” Child Abuse and Neglect 29 (2005): 479-492; Patricia L. Kohl, Melissa Jonson-Reid, and Brett Drake, “Time to Leave Substantiation Behind: Findings from a National Probability Study,” Child Maltreatment, 14 (2009), 17-26; Jeffrey Leiter, Kristen A. Myers, and Matthew T. Zingraff, “Substantiated and unsubstantiated cases of child maltreatment: do their consequences differ?” Social Work Research 18 (1994): 67-82; and Diana J. English et al, “Causes and Consequences of the Substantiation Decision in Washington State Child Protective Services,” Children and Youth Services Review, 24, 11 (2002): 817-851.
The ideal numerator would be the duplicated count of children who received and investigation or alternative response, because even if one child is investigated five times, each investigation needs to be counted. But CM 2022 does not provide that number, and I am assuming that there won’t be enormous differences in repeat responses by state.
Pennsylvania also has a high percentage of abuse findings but that reflects the fact that it does not report General Protective Services cases in NCANDS.
Each state submits both a child and an agency file. The Child File contains case-level data on reports that resulted in a disposition in the reporting year. The Agency File contains data that are not reportable at the child-specific level and often gathered from agencies external to CPS, like medical examiners vital statistics departments and child fatality review teams. Child fatalities can be included in the Child File, which means the entire record of the case from report to disposition is included (as well as any previous cases) or it can be included only as part of the aggregate total in the agency file. States must report as part of the Agency File the total number of victims who were not reported in the Child File, so that those that were reported are not double-counted.
To my readers: This blog summarizes a report that is the culmination of nine months of work. It is part of my advocacy for children in the District of Columbia, which I share in my blog, Child Welfare Monitor DC. But I think this post and the underlying report will be of interest to child advocates, policymakers and researchers around the country because the findings and issues discussedare widely applicable.
“We are not here to save children.” That is what I was told on the first day of my training as a child protective services worker at the District of Columbia’s Child and Family Services Agency (CFSA). And indeed, the District is on the cutting edge of the current movement in child welfare around the country that considers child protective services as a “family policing system” that unnecessarily harasses and separates families, especially families of color. The problem with this perspective is that some families do not provide a safe environment for children to grow and develop. In some of these families, children die. That is what happened to the 16 children whose cases are discussed in a new report, which is summarized in this post. And indeed, analysis of the limited information provided suggests that CFSA did not take advantage of the opportunities it had to protect children even after long histories of CFSA involvement in their families. As a result, three children were beaten to death, three more were poisoned by opioids, and others died of burns, a car accident, and unknown causes when the deaths might have been preventable if the agency had been more protective.
When a child dies of abuse or neglect after that child’s family has been on the radar of the agency designed to protect children, it is important for the public to know whether and how this death could have been avoided. The essential question is whether the agency could have prevented the death by doing something differently. Did staff miss any red flags, and therefore fail to take action when necessary? If the death was preventable, what factors must be remedied in order to prevent such failures in the future? It is not enough for the agency itself to have access to this information, or to have an internal team review it. Agencies can fail to learn from their mistakes when they are blinded by ideology, self-interest or just inertia.
For those reasons, federal law requires every state to have a law or program that includes “provisions which allow for public disclosure of the findings or information about the case of child abuse or neglect which has resulted in a child fatality or near fatality.” In compliance with this requirement, DC Code requires the Mayor or the Director of CFSA, upon written request or on their own initiative, to provide findings and information related to “[t]he death of a child where the Chief Medical Examiner cannot rule out child abuse, neglect, or maltreatment as contributing to the cause of death.” In March 2023, we requested such findings and information for all the fatalities that met the criteria and were reviewed by CFSA’s internal fatality review team between 2019 and 2021. It took more than six months of meetings and emails to receive the information that is presented in this report. We agreed to restrict our request to cases reviewed in 2019, 2020 and 2021 and to withdraw our request for information on near-fatalities, which CFSA only began tracking in October, 2022.
Not surprisingly, CFSA interpreted the disclosure requirements in a way that restricted the information provided as much as possible. If a medical examiner did not rule the manner of death to be an abuse or neglect homicide or “undetermined,” no information was provided. Therefore, the agency did not release any information on cases where the manner of death was labeled as accidental, even if it found a parent responsible for the death or removed the children. The “accidental” deaths for which information was not provided included one child who died after he was left in a baby swing for two hours, which most ordinary people would consider to be neglect. The death of seven-week-old Kyon Jones, whose mother told police that she threw his body in a dumpster after she rolled over him while high on PCP, was not included because his body was never found and therefore it did not meet the criteria for release of the information–even though CFSA removed the surviving children from their mother.*
In addition to omitting some cases in which neglect or abuse played a role, CFSA heavily redacted the information it did provide, with many pages and large portions of others blacked out. CFSA refused to provide the names of the children, parents and caregivers, providing a rather convoluted interpretation of DC Code, which clearly requires the release of this information. (See the full report for more information about their reasoning). In three cases, the child’s identity was clear from media coverage of the case, and we used the child’s name. A major source of redactions was the exclusion of “personal or private information unrelated to the child fatality.” It appears that CFSA’s legal team interpreted this term much more broadly than a social worker or researcher would, because they redacted almost all information about parents’ history of criminal activity, substance abuse, mental illness, and domestic violence–which are obviously relevant to many of the fatalities we are discussing.
On investigations, it is unfortunate that DC Code requires that the agency release only ”a description of the conduct of the most recent investigation or assessment” rather than all investigations regarding the family in question. It appears that the agency interpreted “the most recent investigation” as the fatality investigation itself rather than the most recent investigation before the fatality, but the law ought to require a description of all previous investigations. The agency also disregarded language that requires it to provide “the basis for any finding of either abuse or neglect.”
For most cases, we received very little information aside from a list of the previous referrals (reports to the CPS hotline) including only the date of the report, the allegation category and the disposition; an account of in-home and foster care case activities for the families that had such cases; and an account of the investigation of the fatality itself. The information about the parents was heavily redacted, and almost the entire history of agency involvement was blacked out in most cases. Despite the limited information provided, the redacted summaries included some new information, some of which was startling and disturbing. The report is based on the 16 case summaries provided by CFSA, occasionally supplemented with information from the agency’s annual fatality reports, which are available to the public. These cases affected 15 families, as one family had two fatalities in one year. Unless otherwise noted, the information is based on the case summaries. The full report, from which this blog is excerpted, contains summaries of each case.
Cause and Manner of Death
CFSA classifies child deaths by cause and manner. “Cause of death” is the specific disease or injury that led to the death. Manner of death refers to the circumstances that caused the death, and falls into five categories: natural, accidental, suicide, homicide, and undetermined. Of the 16 cases for which information was provided by CFSA, three (19 percent) were abuse homicides, six (37 percent) were neglect homicides, and seven (44 percent) were undetermined in manner. The latter were the cases for which CFSA provided information because the Medical Examiner was unable to rule out child abuse or neglect homicide as the manner of death.
The most common causes of death were blunt-force trauma and opioid poisoning, each claiming the lives of three children, as shown in figure below. The remaining children died from a variety of causes, including drowning, asphyxia, thermal and scald injuries, injuries from a car accident, and unknown causes.
Abuse deaths: Blunt Force Trauma
Three of the children died of blunt force trauma–one of the two most common causes of death in the sample. The murders of two of these children – Makenzie Anderson and Gabriel Eason – – became known to the horrified public through press coverage of their deaths in February and April of 2020. Each of them died from head trauma inflicted by a parent or stepparent. Makenzie suffered from multiple contusions to the face and head, skull fractures, and other injuries, and her mother pleaded guilty to manslaughter, receiving a ten-year prison term with seven years suspended on the condition that she obtain mental health treatment and have no unsupervised contact with children. Gabriel’s autopsy found abrasions and contusions to the head, face and torso; contusions to the heart and thymus gland; liver and kidney laceration; new and healing fractured ribs; and a brain hematoma. His stepfather was sentenced to 12 years and eight months in prison and his mother, who did not seek medical help for Gabriel or his critically-injured three-year-old brother, was sentenced to four years of probation and three years of supervised release.
But there was a third homicide by blunt force trauma. A three-year-old girl died of trauma to the abdomen in the home of an aunt where she was placed by CFSA after being removed from her drug-addicted mother. Her injuries included contusions to the forehead and abdomen, a lacerated liver, and blood in the abdominal cavity. No charges were filed against either the aunt or her boyfriend, and the case received almost no public attention.
Neglect deaths: Opioid Poisoning and other causes
Three children (a three-year-old girl, a three-year-old boy, and a three-month-old girl) died of synthetic opioid toxicity, with fentanyl implicated in all three deaths. (One of the children had also ingested a controlled substance called eutylone.) There is no information about how the children might have ingested the drugs, but all lived with parents who were known or alleged to abuse substances. These deaths never became known to the public, which is not surprising since it appears that none of the parents were arrested or charged.
A 17-month-old boy died of “complications of thermal and scald injuries,” and his mother told the investigator that she had no idea how it happened or how he ended up face-down in the bathtub several hours later. A seven-year-old died of injuries from a car accident. His mother was a long-time substance abuser and was arrested for Driving Under the Influence (DUI) in the accident. She was driving from Florida to Washington and her children were not sitting in car seats or belted in. A five-month-old boy died of asphyxia by drowning after being left alone in the bathtub with a one-year-old sibling while their mother searched for her car keys.
Deaths for Which the Manner was Undetermined
Two deaths has known causes but the manner – whether abuse or neglect or something else – was not determined. A twelve-year-old girl with asthma died of an untreated bacterial infection and pneumonia but also had enough bruising from two separate beatings in the previous two days to support a CFSA substantiation of the mother for physical abuse. It is unclear why this was not considered a medical neglect homicide. A ten-month-old girl died of asphyxia but the manner of death was undetermined. Her mother had left her in the care of her father and returned to find her unresponsive.
The cause as well as the manner of death was unknown or undetermined in five cases. These included an 18-month-old boy with a subdural hematoma, which could have been caused by abuse or a fall, an 11-month-old girl whose mother reported leaving her unsupervised on her stomach with a bottle in her mouth for about 40 minutes, a nine-month-old boy put to bed with a bottle and found face-down on a pillow; a two-month-old girl who died while sleeping with her mother, and a three-month-old girl found unresponsive by her parents one morning. Unsafe sleep practices may have contributed to some of these deaths, but other unsafe sleep fatalities were categorized as accidents, for which case summaries were not provided.
Demographics
A quarter of the children who died were younger than six months old and half of them were one-year-old or younger. Another quarter were two or three. This is not surprising as young children are more vulnerable and similar results are found nationally. But older children were not invulnerable to abuse or neglect, including the seven-year-old who died in a car accident and the 12-year-old who died of an untreated bacterial infection and pneumonia.
Fifteen of the decedents were African American and one was classified as “African-biracial.” According to the latest data from Kids Count, 54 percent of children in the District of Columbia are Black. So Black children were overrepresented among the children who died of maltreatment or possible maltreatment. The overrepresentation of Black children among children who died points to Black children’s particular need for protection. And it suggests that current emphasis in the District and around the country on reducing the involvement of Black families in child welfare may cause more suffering and more deaths among Black children.
The prevalence of large families among those that lost a child due to abuse or neglect is striking. More than two thirds of the mothers of children who died by maltreatment had four or more children. The average mother in the group had 4.6 children, often with more than one father.
Histories of System Involvement
All the families had been the subject of at least one report to the CFSA hotline before the fatality, or else they would not be included in this report. But many of the families that lost a child had experienced a large number of reports prior to the fatality. Among the 16 fatalities included in this report, only six occurred in families that were the subject of five reports or fewer in the last five years. Five occurred in families that had between six and 10 reports, three occurred in families with 10 to 15 reports, and one family had 24 reports. Three of the families had actually experienced a previous child fatality–a shocking statistic considering the rarity of child fatalities overall.
The families of the two children – Makenzie Anderson and Gabriel Eason – whose abuse homicides shocked the District of Columbia in February and April 2020 were both known to CFSA before the deaths, and the last report to the hotline came five months before the fatalities of both children. Makenzie Anderson’s family was reported to the hotline eight times within five years of her death. The last report alleged exposure to unsafe living conditions, inadequate supervision, and substance abuse by a parent, caregiver, or guardian. All those allegations were unfounded (not confirmed) by CFSA. Gabriel Eason’s family was the subject of 17 prior calls to the hotline since 2012, including 12 in the five years preceding Gabriel’s death. The most recent report was for unexplained physical injury in October 2019 and was also unfounded by CFSA.
Substance abuse by the parent or caregiver was the most frequent allegation CFSA received regarding the families in the five years before the deaths, with 30 substance abuse allegations collectively accumulated by the families of the 16 dead children during that period. Another eight reports concerned positive toxicity of a newborn, a reflection of parental substance abuse. Substance abuse by the parents was observed or alleged in the families of all but four of the victims included in this report. Inadequate supervision was the second most common allegation, with 25 allegations concerning the 15 families. Almost as common was educational neglect, referring to children with excessive school absences, with 24 allegations received in the five years preceding the fatality. Ten of the 15 families had at least one report for educational neglect before the child’s death. Another major theme was exposure to domestic violence, with 17 allegations received by the families. Domestic violence was mentioned in nine of the 16 case histories as the subject of an allegation or in notes from social workers or police.
Most of these families could be described as “chronically neglectful.” According to the Child Welfare Information Gateway, “Chronic child neglect occurs when a caregiver repeatedly fails to meet a child’s basic physical, developmental, and/or emotional needs. Chronic neglect can have long-term, negative consequences for child health and well-being.” Working with chronically neglectful families is especially difficult and requires special training and skills, which many CFSA social workers may lack. Perhaps that is one reason why they struggled so hard to engage some of these families. Four of the children died while an in-home case was open. Three out of four of the in-home case narratives from CFSA portray caregivers who evaded offers of help from CFSA and other providers and refused to cooperate with efforts to monitor conditions in their homes.
System Failures
The information received suggests several areas where failures in policy and practice by CFSA and other agencies may have allowed these deaths to happen. These areas include:
Screened out and unsubstantiated reports: Research points to the difficulty of determining correctly whether a child has been maltreated, as well as the absence of significant differences in subsequent outcomes between children with a substantiated allegation of maltreatment and those with an unfounded allegation. Without information on how hotline and investigation decisions were made, we cannot assess the agency’s performance in these areas. But the fact that most previous reports for families with a subsequent death were screened out or unfounded is concerning.
Flawed management of in-home cases: Four of the deaths reviewed here happened while an in-home case was open for the family. In three of these cases, workers struggled to complete face-to-face visits with the families because parents evaded these visits. Social workers and supervisors could have filed a petition to involve the court, an option known as “community papering.” But they did not exercise this option–or they started too late, as in the case of the child who died after a meeting was finally scheduled to discuss community papering the case. The meeting was cancelled after the agency received word of the child’s death.
Too many chances: The mother of the seven-year-old killed in the 2020 car accident had been given numerous chances to recover from drug addiction and had relapsed many times over 18 years of involvement with CSFA. The family of the 17-month-old who died of complications of thermal and scald injuries had 24 referrals to CFSA between 2016 and 2021. Three in-home cases were opened and closed, but the children were not removed until the little boy died.
A fragmented health care system: In its findings on Gabriel Eason’s death, CFSA pointed out that Gabriel was taken to different medical providers for his various injuries. Because they use different information systems, the providers could not see records of the earlier injuries.
The reaction of CFSA and the criminal justice system after the fatalities obviously did not contribute to the fatalities themselves but may illustrate a pattern that contributes to future deaths. Specifically, CFSA’s tendency to place siblings informally after fatalities and the police and US District Attorney’s failure to charge parents raise concerns.
Informal placements after fatalities: CFSA, and child welfare agencies around the country, have been criticized for relying on informal placements with family members, rather than formally removing the children, placing them with the relatives, and opening a case to monitor their safety and well-being. In at least four of the 16 cases reviewed here, CFSA did not officially remove the siblings of the children who died but instead relied on informal placements with fathers or other relatives to keep them safe. Nothing was done to assure that the children were not returned to the home from which they had been removed as soon as the investigations closed, or to verify that the parents or caregivers had rectified the conditions leading to the child deaths.
Failures by the criminal justice system: The failure to bring charges against some of the parents and caregivers described here is quite concerning, particularly in the case of the three-year-old who died of blunt-force trauma and the infant and two three-year-olds who died of opioid poisoning. There has been considerable criticism of the US Attorney’s office in the District (which handles adult criminal prosecutions) for its low rate of opting to charge people for crimes. We do not know if the problem is the Metropolitan Police Department’s failure to bring the cases to the US Attorney or the latter’s failure to pursue them.
Recommendations
Without seeing the full case studies that were available to CFSA’s internal review committee, we cannot make detailed recommendations about how to avoid child maltreatment fatalities for children known to CFSA. The minimal recommendations that CFSA’s internal review team made show the need for the City Council, advocates and the public to have access to these complete case studies: in its 2021 report the agency made no recommendations other than those dealing with the fatality review process! Therefore, our first recommendation is to the City Council, urging it to require that CFSA release comprehensive case histories on all proven or suspected child maltreatment fatalities. Our next blog post will discuss the legislative changes that are needed.
The lack of information on how screening and investigation decisions in particular were made precludes specific recommendations. Perhaps a new audit of the hotline is in order. Some changes to hotline screening policy might be advisable, especially around educational neglect. School absences should be investigated regardless of the age of the child (requiring a change in the law) and their academic performance. And perhaps investigative workers could benefit from better training in forensic interviewing techniques that might help them better evaluate parents’ and childrens’ statements for veracity and perceive more subtle signs of abuse or neglect.
The case narratives make clear that in-home social workers struggled to complete home visits to the families of the children who later died. The agency must change its policy to encourage “community papering,” making court involvement routine after a certain number of missed visits or other instances of noncooperation. CFSA might also want to consider strengthening its in-home practice, perhaps by reinstating the Chronic Neglect Units, which were eliminated barely a year after they were implemented. These units would employ specially-trained social workers with lower caseloads and longer time periods to work with families.
Despite the current ideology favoring family preservation and reunification at all costs, the agency must also recognize that sometimes it must give up on a parent and find a safe, permanent alternative for the children. Giving parents multiple chances with successive children over many years belies the true purpose of child welfare services – to protect children.
Not all needed changes fall in CFSA’s bailiwick. Reforms in the criminal justice system are also necessary to ensure that parents who killed one child cannot harm more children. Couples who refuse to cooperate with prosecutors, and parents who expose children to opioids due to their own abuse or drug dealing must also be charged. Other jurisdictions do it, and the District must do it as well.
DC Health and medical providers also have a crucial role to play in making children safer. Encouraging the adoption of a comprehensive medical information platform across the region to prevent families from using different doctors to hide abuse and neglect would be a welcome step. A campaign by DC Health to educate young women on how an early pregnancy, especially when followed quickly by others, compromises their future and that of their children, is a crucial necessity. It must be accompanied by improved access to long-acting reversible contraceptive methods.
In summary, even with the very minimal information we received, some conclusions emerge. CFSA’s extreme deference to parents and guardians emerges clearly through the redactions in these narratives. This is in direct contrast to the picture that is being painted by the foundations, advocacy groups and public agencies dominating the child welfare conversation. Their accounts portray interventionist child welfare agencies that remove children rather than giving their families the help they need and want. We are seeing the opposite here: families who evade offers of help from the agency and providers and refuse to cooperate with efforts to monitor conditions in the home. The goal of such parents often appears to be to avoid surveillance by outsiders rather than to improve their ability to care for their children. And CFSA workers often seem unwilling or unable to intervene in a way that will protect these children.
‘The tragic deaths of children whose families are known to CFSA are the tip of a much larger iceberg. For every child who dies of abuse or neglect, an unknown number of others are living in fear or pain from abuse, suffering chronic neglect that will cause lifelong intellectual an emotional damage, or lacking the loving attention necessary for optimal mental, emotional and physical development. Sadly, it is only the children who die whose cases can be used to learn lessons to prevent similar tragedies in the future. This information must be public, so that the public can push for a system that protects all children who are not receiving the parental care they need to survive and thrive.
*The case, which received media coverage, was included and easily identifiable in
After its premiere on June 2 on Amazon Prime Video, Shiny Happy People: Duggar Family Secrets, reached more viewers in its first nine days than any other Amazon docuseries. The series exposes the fundamental moral corruption underlying the Duggar family, the subject of TLC’s long-running reality series, 19 Kids and Counting, as well a spinoff entitled Counting On. The Amazon series reveals the Duggar family involvement with a fundamentalist Christian movement that endorsed physical child abuse, sanctioned educational neglect, and created a culture of sexual abuse of women and girls. One issue that was not discussed in the series is the key role that unregulated homeschooling plays in allowing the abuse and exploitation of children like the Duggars to occur and persist.
For someone who was hardly aware of the Duggars and their reality-shows empire, Shiny Happy People was a revelation. I learned that the Duggers were the poster children for an organization called the Institute in Basic Life Principles (IBLP), which was formed in the 1960s by a minister named Bill Gothard in reaction to the civil rights, women’s rights, and student protest movements, and to the cultural changes of the period. The first principle of IBLP was “Authority.” Just as God was the ultimate authority over mankind, so did IBLP preach the father’s ultimate authority over his family. Girls remained under the authority of their fathers until they transitioned by arranged marriage to the authority of their husbands.
To reinforce its authority, IBLP preached (and the Duggars used) physical punishment starting from infancy. As babies, the Duggar children were subjected to “blanket training,” promoted by the book To Train Up a Child, which is popular in Christian homeschooling circles. Babies are shown a desirable object, told not to touch it, and hit every time they reach for it. The point is to teach obedience. The survivors interviewed for the series spoke of receiving physical punishment for just about any transgression, no matter how minor.
In 1984, IBLP published a home-schooling curriculum consisting of “wisdom booklets” based on the Bible, which was marketed as an academic curriculum but according to survivors contained little if any actual education. Children learned that all fossils were created by God at the same time and that the rhythm of rock music could be traced to satanic ritual; girls were taught to identify what items of female clothing are provocative and should be avoided. It’s not surprising that many survivors spoke of struggling financially after leaving home without preparation for further education or work beyond the minimum wage level.
The children of IBLP families were brought up with frightening visions of hell and taught to constantly examine their own thoughts for evidence of sin, especially the sin of lust. This practice may have backfired. Survivors interviewed for the series reported that IBLP families were rife with sexual abuse. It was eldest son Josh Duggar’s admitted abuse of his sisters among other girls that put an end to the long running series, 19 Children and Counting. It was replaced by a new series called Counting On, which focused on some of the family’s daughters, but that show in turn was suspended after Josh Duggar was arrested for receipt and possession of child pornography. He is now serving 12.5 years in prison.
IBLP is not the only Christian home schooling movement that promotes physical punishment and educational neglect. The Revolt of the Christian Home-Schoolers, a brilliant article by Peter Jamison in the Washington Post, tells the story of Christina and Aaron Beall, who were brought up in families that were both active in a religious community led by Gary Cox, an evangelical pastor and pioneer of Maryland’s home-schooling movement. (Cox’s son later ran for Governor of Maryland and lost in a landslide to Wes Moore.) Christina and Aaron could not bear to watch their children grow up the way they did – in fear of being beaten several times a week. They rejected corporal punishment for their four children and eventually decided to send them to public school.
Christina and Aaron’s children were lucky. But states’ policies toward homeschooling provide little protection for those who need it, like the Duggar children. The Amazon series did not address the policy context of the abuses suffered by the Duggars and all the other children brought up in IBLP and similar movements, or how future children in these environments could be protected. As Eve Ettinger, the oldest of nine children homeschooled in a fundamentalist Christian home, explains in Salon Magazine, it is the failure of states to meaningfully regulate homeschooling that allows abuse and neglect to take place in these homes.
Before continuing, it is important to note that It is not just fundamentalist Christians who homeschool. Homeschoolers include Black parents who wish to avoid racism in the public schools, parents of elite athletes or musicians whose schedule does not allow for attendance at regular schools, and other parents who simply want to have more input into their children’s education than the public schools allow. And most of these parents are no doubt well-meaning and provide an excellent education. But when homeschooling parents abuse or neglect their children, the protections provided to other students are not available.
According to the Coalition for Responsible Home Education (CRHE), an advocacy group started by homeschool alumni, 11 states require nothing of homeschooling parents, not even notification to the school district when they begin homeschooling. Another 16 states require only that parents who intend to homeschool give notice to state or local officials. The remaining states have some combination of requirements for subjects covered, hours of schooling, academic assessments, parent qualifications, or other provisions. Only nine states require academic assessments that are meaningful because they must be submitted to the government or require a certain level of achievement. Only 11 states require any qualifications (usually a high school degree or GED) for parents who want to homeschool their children, and only two states conduct background checks for parents who want to homeschool their children. Of those two states, Pennsylvania prohibits homeschooling if a parent or other adult in the household has been convicted of any of a range of offenses. Arkansas prohibits homeschooling if a registered sex offender lives in the household, but parents may petition the sentencing court to have this restriction waived. No state provides for monitoring of parents who begin to homeschool during or after a child protective services investigation, or for those with histories of child welfare involvement. Such provisions have been introduced in several states but have failed to become law due to opposition from the homeschool lobby. Shockingly, no state requires that a state employee or contractor ever set eyes on the child once homeschooling is approved.1
The lack of meaningful standards and monitoring of home education opens the door for educational neglect by parents who reject the importance of anything but a biblical education. Such educational neglect was described eloquently by many survivors in the Amazon series, who reported that their learning outside of religious principles was minimal and that they spent most of their time doing chores and caring for their younger siblings. Such children “graduate” from home schools without the knowledge and skills necessary to thrive in American society. A 2013 article in the Washington Post described one Virginia student’s struggle to fill the gaps in his home education. This determined young man needed several years of remedial education and other courses at the local community college before he could fulfill his dream of attending a four-year-college.
Even worse, the lack of contact with educational staff isolates homeschooled children from adults outside their families, churches, and fundamentalist homeschooling circles, leaving them particularly vulnerable to long-term maltreatment. Teachers and other school staff have traditionally been the most common reporters of child abuse and neglect.2 When a child is being abused or neglected at home, it is teachers and others at school who see the bruises or the hunger. If the child does not go to school, that extra set of eyes is missing; there remains only the hope that a doctor or other professional (if the child is lucky enough to see one) will notice something is wrong. The importance of educators as mandatory reporters was illustrated in a chilling manner by the Connecticut Office of the Child Advocate, which found that of children withdrawn from public schools to be homeschooled between 2013 and 2016, 36 percent had at least one prior accepted report for suspected abuse or neglect to the Department of Children’s Services, and the majority of these families had multiple prior reports for suspected maltreatment. So it is not surprising that a disproportionate number of the horrific abuse deaths that make the news (such as the Hart children, Natalie Finn in Iowa, Matthew Tirado in Connecticut and Adrian Jones in Kansas), involved parents who hid their abuse behind the guise of homeschooling, even though schooling rarely took place in these homes.
Before the 1980’s, homeschooling was not even addressed in state laws. The first achievement of the new homeschooling movement was the legalization of homeschooling in the 1980s and early 1990s in every state, as described by Milton Gaither in his history of American homeschooling. This came about thanks to the work of the Home School Legal Defense Association (HSLADA) and allied groups. Since that time, HSLADA and state-level homeschool lobbies have often been successful in getting legislatures to strike requirements that were included in the original legislation. For example In Virginia, homeschool groups succeeded in removing the requirement that homeschooling parents have a bachelor’s degree, replacing it with the lower requirement of a high school degree or GED. In Arizona, the requirements that parents pass a proficiency exam and that students take annual standardized tests were both removed, and the new requirement that parents have a high school diploma or GED was later removed. In Iowa, homeschooling was completely deregulated in 2013.
Homeschool lobbies have also been successful at thwarting attempts to add regulations to protect children, some of which were inspired by egregious instances of abuse. After the 13 Turpin children and young adults were found imprisoned (some chained to their beds) and emaciated in their home in California, a horrified public learned that their parents had elected to homeschool as an individual private school, an option available in that state. California Assemblyman Jose Medina introduced a bill that would require a fire inspection for all private schools, regardless of size.3 Due to a massive outcry from the homeschooling community, the inspection requirement was eliminated, leaving a bill that required nothing but identification of homeschooling families by name and address. When the eviscerated bill was scheduled for a hearing, hundreds or perhaps thousands of homeschooling families poured into the capitol building, testifying for three hours. No committee member even moved to approve the bill, and it died that day.
The Covid-19 pandemic resulted in a jump in homeschooling enrollment which has not yet subsided. There has been an estimated 30 percent rise in homeschooling enrollment since the beginning of the 2019 school year. This increasing trend makes the need for regulation of homeschooling more urgent. CRHE’s recommendations for protection of at-risk children include prohibiting homeschooling by parents who have committed offenses that would disqualify them from teaching school, requiring that students be assessed annually by trained mandatory reporters, and flagging certain at-risk children (such as those in families with a history of child protective services involvement) for additional protections and support. CRHE also recommends requiring a high school degree or GED for the primary homeschooling parent, instruction in the same subjects as public schools, maintenance of academic records, and assessments of annual progress with interventions in case of inadequate progress, among other recommendations.
With Shiny Happy People, Amazon Prime exposed the abuse and neglect hiding behind the happy facade that the Duggar family presented through its reality shows. But unfortunately the series did not let watchers know how we can protect today’s homeschooled children from such maltreatment by increasing regulation and oversight. I wish the series had ended by urging viewers to contact their state legislators and urge them to mandate reasonable regulation and oversight for homeschooling, so that no more children will be victimized.
In Federal Fiscal Years 2020 and 2021, teachers lost their top ranking as maltreatment reporters to legal and law enforcement personnel due to Covid-19 school closures. It is my guess that they will gain it back in 2022.
There actually already was a fire inspection requirement for schools with 6 or more children, but there was no record that the Turpin home had been inspected.
A shattering new report from a Minnesota child advocacy group demonstrates that many of the more than 160 deaths of children from abuse and neglect over an eight-year period ending last May were preventable. These deaths, the report concludes, can be attributed to “a child welfare philosophy which gave such a high priority to the interests of parents and other adults in households, as well as to the goals of family preservation and reunification, that child safety and well-being were regularly compromised.” This report is essential reading for child advocates everywhere, because this philosophy reigns around the country, and the troubling factors identified exist in states where most of the child population resides.
Produced by the child advocacy group Safe Passage for Children of Minnesota, and authored by Safe Passage Executive Director Richard Gehrman and Maya Karrow, a fellow from a local law school, the project collected information about 88 children who were killed between 2014 and 2022. The Minnesota Department of Human Services (DHS) told project staff that it was aware of 161 child maltreatment deaths during a period that mostly coincides with the period studied.1 But DHS refused to provide information on any of these deaths (in violation of state and federal law), so the staff had to rely on news reports, online court records, and information provided by counties for the 88 cases it had identified.
Like child maltreatment fatality victims nationwide, the dead children were young, with 42 percent under a year old and 36 percent between one and three years old. Children under four were 78.4 percent of the Minnesota deaths very similar to the 76.3 percent for child maltreatment fatality victims nationwide. Black children accounted for 26.1 percent of all the fatalities reviewed. In contrast, Black children were 17.8 percent of children involved with child welfare and 10.6 percent of the state’s child population in 2021.2 Based on the statistics and case file reviews, the report’s authors expressed concern that chld welfare agencies in Minnesota “may have tended to leave Black children in more high-risk situations for longer periods of time than children of other races and ethnicities.” The report’s authors are not the first to have asked whether fears of being accused of racism may be leading agencies to leave Black children in harm’s way even more than children of other races.
The most common causes of death among the cases reviewed were blunt force trauma to the head (33 percent) and body (19.3 percent). The other major causes of death were asphyxiation (17.0 percent) and gunshot wounds (8.0 percent). Other causes included drowing, sepsis, poisoning from drugs, stabbing, hypothermia/hyperthermia, fire, and undetermined causes.
The most common perpetrators of child fatalities were mothers (27.3 percent), mothers’ significant others (23.9 percent), and fathers (22.7 percent). In 65.9 percent of the cases, one or more of the perpetrators had a history of substance abuse. Shockingly, there were seven deaths in foster care, of which six were in kinship foster care. In another appalling finding, there were seven cases in which a child was killed along with the mother or while attempting to intervene in an assault on the mother.
A concerning pattern was the evidence of child torture in a surprisingly large number of cases. The project’s reviewers identified 14 cases (or 15.9 percent) that displayed signs of torture, according to criteria outlined by experts. The authors used the case of Autumn Hallow, who was killed at the age of eight, as an illustration. Investigators found that Autumn’s father and stepmother frequently bound her in a sleeping bag as punishment, sometimes with her hands tied behind her back or overnight, and starved her for six months so that she weighed only 45 pounds when she died. A particularly appalling feature of her case was the “chilling indifference by all the authorities involved to the screams of a child [reported repeatedly by neighbors] and the pleas of an increasingly distraught mother.” Autumn’s cause of death was declared to be asphyxia and blunt force trauma. Her father and stepmother were convicted of second-degree unintentional murder in her death.
The project uncovered numerous systemic flaws that contributed to the 88 deaths reviewed. These included inappropriate assignment of reports to a “family assessment” rather than a factfinding investigation; the failure to respond adequately to repeated reports suggesting chronic maltreatment; seemingly endless chances given to parents to address chronic problems; the return of children from foster care to homes where safety had not improved;the placement of children with kin without appropriate vetting; leaving children with mothers who repeatedly failed to protect them from violent partners; and the lack of integration between child welfare and child custody cases.
The repeated inappropriate assignment of cases to the “Family Assessment” (FA) track, which is intended for low-risk cases, was a major recurring theme in the case reviews. Minnesota is one of 34 states that initially adopted a two-track model, often known as differential response, for responding to reports of suspected maltreatment. (Some states have since terminated the practice). The idea was that a less-adversarial response than an investigation would be a better way to engage families with lower-risk cases. But with its practices like informing parents of visits beforehand, interviewing children in front of their parents, and making no finding as to whether maltreatment occurred, the report explains that FA is not appropriate when the risk to children is high. Yet, by 2020, 62 percent of CPS reports in Minnesota were assigned to Family Assessment. The researchers found that 31 of the 59 families with Minnesota child protection history had at least one and as many as six Family Assessment cases prior to the fatality. As the authors point out, “it is self evident that the repeated use of FA in chronically referred families is inconsistent with the policy that FA be used only in low-risk cases.”
Among the examples cited by the authors for the inappropriate use of FA was one that occurred following a report that a mother and her boyfriend were hitting their children with objects and dragging them by their hair. This family was the subject of six previous reports that included allegations of “physical abuse, sexual abuse, and unhygienic and unsafe conditions, including rotten food, garbage, drugs, alcohol, and sharp objects accessible to children throughout the home.” Twenty days after that last FA, two-year-old Lyla Koob was dead. Her mother’s boyfriend admitted to shaking her in frustration after she vomited. Her autopsy revealed bleeding on the brain and injuries behind both eyes.
Based on analysis of court records, the researchers found that 71.6 percent of the dead children’s families had previous involvement with child protection. The 61 families included 59 with prior history in Minnesota and two with prior history in another state. In view of these percentages, it is not surprising that the project staff found that Minnesota child welfare had a pattern of failure to respond adequately to chronic maltreatment.
In some cases, the researchers noted a pattern of inaction by child welfare agencies in the face of chronic multitype maltreatment, or maltreatment that includes neglect as well as abuse. The case of Tayvion Davis, who died in 2018 at the age of eight, was used to illustrate this type of negligence. Before he was born, Tayvion’s mother was convicted of malicious punishment of a child after she and two adult relatives held down and beat one of her children. From that time until Tayvion’s death, the family was the subject of at least ten reports of physical abuse, sexual abuse, or neglect. According to court records, the children were hit with a hammer and a metal rod, whipped with a belt, burned with boiling water or chemicals, deprived of food and sleep as punishment, and threatened with death if they talked about the abuse. There were multiple reports of sexual abuse of Tayvion or a sibling by the oldest sibling, juvenile and adult relatives, and an unrelated adult.
Tayvion Davis froze to death in 2018 after his mother locked him in the garage overnight in subzero temperatures. The autopsy found numerous scars that suggested years of abuse that may have escalated into torture. Unbelievably, Tavion’s siblings were returned to their mother after being removed in the wake of Tavion’s death. They remained with her for another five months, during which she was the subject of several additional reports. It was not until they were removed again that they told their foster parents that Tavion was deliberately locked in the garage, resulting in murder charges against the mother.
The researchers also found that counties gave parents multiple chances to address chronic problems, while failing to execute effective safety plans for children remaining at home. One example of this tendency was the case of Aaliya Goodwin, who died at the age of five months. There had been eight reports for two older siblings regarding the parents’ substance abuse. Between 2015 and 2021, four safety plans were mentioned in court records, the oldest sibling was placed in foster care and returned home twice, the mother was charged with nine drug-related offenses and convicted of five, and the father was charged seven times with two convictions. The county opened a new FA in January 2022 due to a report of domestic violence and the mother agreed to a substance abuse assessment. Three days later she was found passed out on the couch after using drugs and alcohol. Aaliyah, squashed between her mother and the couch, was dead of positional asphyxia.
Another pattern cited in the report was counties’ tendency to return children from foster care to a home that was still unsafe. The project revealed that 26 percent of the children who died had been previously removed from their parents and then returned. The case of Khamari Golston was provided as an illustration of this pattern. Multiple abuse injuries to four-month-old Khamari resulted in his and his twin sister’s removal and placement in foster care. Their mother was charged with felony malicious punishment and assault. But only two months after adjudicating these children to be in need of protection, the judge sent them home for a “trial visit.” The mother was said to be cooperating with her case plan but there was no documentation of this in the court record. Eight weeks later, Khamari was dead of suffocation or smothering. He also had multiple injuries consistent with physical abuse. Khamari’s ten-year-old sister reported that their mother frequently choked him and covered him up when he cried.
Some children were returned from foster care to parents with serious mental illness. The report cites six-year-old Eli Hart, whose mother killed him with multiple shotgun blasts to the head and torso nine days after he was returned home. Eli was returned home without evidence that his mother’s mental illness was under control. Instead, her mental health remained a concern throughout the year that he was in foster care and during a trial home visit. She received eight traffic-related convictions (including for speeding and reckless driving) and was also charged with theft of pharmaceutical drugs during the time he was in foster care.
The occurrence of seven deaths of children in foster care, of which six were in kinship care, was a startling revelation of this study. There have been concerns raised around the country that the growing focus on kinship placements may be leading to the placement of children with family members who have not been adequately screened and are not appropriate caregivers. And indeed, the project staff found a “lack of due diligence in deciding whether a kinship placement would ensure the safety and well-being of the child.” To illustrate this pattern, the report offers the history of Leila Jackson, a 17-month-old who was killed by her foster father in 2018. Her autopsy showed “extensive subdural hemorrhages and severe brain injury, as well as extensive bruising on her buttocks.” Layla and her brother were placed in the kinship home after their mother’s parental rights were terminated. The foster parents denied having criminal records or substance abuse histories, but a background check (which was never conducted) would have revealed convictions for DWI, theft, possession of drug paraphernalia, and disorderly conduct.
The pressure to keep children with mothers who were victims of domestic violence, even when these mothers showed they were unable to protect their children, was another systemic problem noted by the project team. The authors found that 28.4 percent of the cases involved domestic violence–not surprising in view of the co-occurrence of child maltreatment with domestic violence. But that seven children were killed along with their mothers, or in an attempt to protect them, was shocking indeed. This is a difficult issue, and removals of children from domestic violence victims by CWS have been harshly criticized. But as the report put it, “at a certain point a line is crossed and it becomes imperative to move children to a safe place.”
In Minnesota, public child welfare cases are heard in juvenile court and custody cases in family court, which means that the same family can have two different court cases with different judges. The findings of the report suggest that the failure to consolidate these cases can place children at risk. In the case of Eli Hart, who was killed by his mentally ill mother, the custody case filed by his father was put on hold pending a resolution of the juvenile court case surrounding his mother. This is despite the fact that the mother’s mental health remained a concern and that all reports indicated that the father was a good and safe parent for Eli.
In sum, the report concludes that “the professional norms currently guiding child protection and foster care are out of alignment with those of the broader community.” As a first step, the report recommends that DHS release more information about child maltreatment fatalities, including making public the fatality and near-fatality reports that counties are required to submit to the state; such reports include information about previous reports and investigations on these families. This recommendation is particularly important because if the public knew about the types of egregious failures described in this report, there might be more public support for changes.
The report contains many specific recommendations to correct the systemic flaws found in the case studies. This year, Safe Passages will be distributing the report to legislators and briefing them on its findings and recommendations. Rick Gehrman, Executive Director Rick Gehrman reports that he will be working with legislators to translate some of these recommendations into legislation to be introduced in the next session, addressing at a minimum some of the Family Assessment practices that endanger children. The ultimate goal, Gehrman says, is to “raise public and legislative awareness of the child welfare practices that endanger children and to bring about a change in the overall philosophy of child welfare services in Minnesota.”
In effect, Safe Passages for Children has unofficially implemented the first recommendation of the Committee to Eliminate Child Abuse and Neglect Fatalities in its 2016 final report, Within Our Reach. That report recommended that each state, with federal funding and assistance, identify and analyze all of their child abuse and neglect fatalities from the previous five years in order to identify factors associated with maltreatment fatalities and agency policies and practices that need improvement to prevent fatalities. Based on this report, every state would develop a fatality prevention plan. Unfortunately, legislation supporting this proposal stalled in Congress and no state has elected to do this on their own. Maryland’s Council on Child Abuse and Neglect and its Child Fatality Review Board, inspired by this recommendation, formed a joint subcommittee that produced an excellent review of child maltreatment fatalities in Baltimore between 2012 and 2015 which identified systemic flaws and made recommendations to correct them.3 Other than that report, I am not aware of any other similar project by a state or local government agency. Let us hope that this report encourages other child advocacy groups and community boards to act where governments have not.
The final words of the report deserve to be repeated. “The erosion in professional norms that has gradually caused human services entities to tolerate the current level of neglect and physical abuse of children has developed over the course of decades. A concerted effort by a community of professionals will be required to restore standards that were once taken for granted, and to place appropriate limits on the ability of adults in a child’s life to harm them.”
Notes
The actual number was likely two to three times as high because the manners of so many maltreatment deaths are misclassified.
See Child Maltreatment 2021. Table C-2, Child Population 2017 to 2021 shows the state’s child population rose from 1,300,061 in 2017 to 1,317,567 in 2021. Table C-3, Child Population Demographics, shows that there were 140,129 Black children in Minnesota in 2021. That figure, divided by 1,317,567 gives the Black percentage of all children in Minnesota as 10.6 percent in 2021.
City of Baltimore Health Department, Eliminating Child Abuse and Neglect Fatalities in Baltimore City. January 2017. This report appears to be no longer available online. Please email marie@childwelfaremonitor.org for a copy.
The federal government’s annual maltreatment report for 2021 was released on February 9, 2023, and the child welfare establishment is celebrating. New Child Maltreatment Report Finds Child Abuse and Neglect Decreased to a Five-Year Low, crowed the Administration on Children and Families (ACF). “Number of Abuse and Neglect Victims Declines Again,” trumpeted The Imprint, a journal that typically reflects the prevailing voices in child welfare today. Left for the body of the ACF press release (and totally omitted by The Imprint) was the fact that in 2021 the nation was still in a pandemic that kept many schools closed for much of the year, and that child maltreatment “victimization” reflects jurisdictions’ policy and practice much more than it reflects actual maltreatment. Thus, there is no reason to celebrate a decrease in child maltreatment based on this report.
Child Maltreatment 2021 , the latest edition in the annual series from the ACF, combines data from the 50 states, the District of Columbia and Puerto Rico about the number of reports or children involved in each stage of the child welfare system in Federal Fiscal Year (FFY) 2021, which ran from October 1, 2020 to September 30, 2021. The data are obtained from the National Child Abuse and Neglect Data System (NCANDS), a national data collection program run by the Children’s Bureau under ACF. Arizona did not submit data in time to have its data included in this report, so only 49 states are included in this year’s report, along with the District of Columbia and Puerto Rico. Commentaries from most of the states regarding policies and conditions that may affect their data are attached in an appendix. The report’s findings are summarized in Exhibit S-2. All of the figures in this post are taken from the report.
A family’s journey through the child welfare system starts with an initial report, known as a “referral.” Figure 2-D below shows that the total number of referrals (the purple line) rose between 2017 and 2019, dropped sharply in the wake of the Covid pandemic in 2020, as schools closed and many families isolated at home, and increased only slightly in FFY 2021. It is important to remember that in FFY 2021, which began in October 2020, many schools were still closed. Most schools opened over the course of FFY 2021, but some remained closed the entire year. Thus, reporting from school personnel was suppressed for the federal fiscal year.
The rate of referrals as a portion of the child population varied greatly by state. Table 2-1 of the report shows that the total referral rate per 1,000 children in 2021 ranged from a low of 17.8 in Hawaii to a high of 137.0 in Vermont in 2021. Such differences exist every year and reflect factors such as public opinion and knowledge of child maltreatment reporting, as well as state practices. Some states do not even report most referrals to NCANDS, as described in the state commentaries. Pennsylvania has a unique system in which most reports that are not for abuse are classified as “General Protective Services” and not reported to NCANDS. Similarly, Connecticut does not report referrals receiving an alternative (non investigation) to NCANDS. In 2021, state-to-state differences may also reflect how soon in-person schooling resumed in the state after the pandemic. Vermont reported in its commentary that it has been receiving more referrals for concerns that do not reflect maltreatment. Vermont also included several reasons for its high referral rate, including the fact that reports on multiple children in the same family are counted separately. Kansas reported a decrease in reports due to “engaging communities to focus on prevention.”
Once a referral is received, it can be screened in or out by agency hotline or intake units. In general, agencies screen out referrals that do not meet agency criteria, which vary by jurisdiction. Reasons for screening out a referral may include that it does not meet the definition of child abuse or neglect, that not enough information is provided, that another agency should more appropriately respond, or that the children being referred are over 18. Despite receiving slightly more referrals than the previous year, child welfare agencies screened out a larger proportion of them in FY 2021, resulting in a slight decrease in screened in referrals (known as “reports“), from 2020 to 2021 – the blue line in Exhibit 2-D. In the 46 states that provided both data points, 51.5 percent of referrals were screened in and 48.5 percent were screened out.
There is great diversity in the proportion of referrals accepted by states. The percentage of referrals that was screened-in ranged from 15.3 in South Dakota to 98.5 percent in Alabama.1 There are many reasons for these variations, mostly associated with differing policies and practices between jurisdictions. For example, Georgia mentioned in its commentary that after hotline calls increased in 2021, it adjusted screening criteria to screen out more of them. Indiana tried to reduce its screen-in rate by changing criteria related to sexual behavior among teens and preteens, marijuana use by children, and educational neglect. Kansas reported a decrease in reports due to a change in the screening process for educational neglect. Missouri, on the other hand, changed screening criteria to screen in more referrals out of concern for children isolated because of the pandemic.
In FFY 2019, teachers were the most common source of referrals, submitting 21 percent of all referrals. They lost that position in FFY 2020 with the pandemic school closures, while legal and law enforcement personnel increased their share of reports. Perhaps it is not surprising that teachers did not recoup their leading role in 2021, since many students were still attending school virtually for some part of the year. Teachers actually submitted a smaller proportion of referrals in 2021 (15.4 percent) than in 2020 (17.2 percent). It is possible that teachers were making more calls but that more of these calls were being screened out than in the year before. But since ACF does not show the distribution of all referrals by reporting source, one cannot use this data to test that hypothesis.
Investigations
In Chapter 3 of Child Maltreatment 2021 the focus shifts from the referral or report to the child. ACF estimates that 3.016 million children or 40.7 children per 1,000 in the population received an investigation or alternative response2 in 2021. This was a slight decrease over 2020, when 42.0 per 1,000 children received an investigation or alternative response. These rates varied greatly by state, from a low of 12.8 per 1,000 in Pennsylvania to a high of 129.8 in West Virginia. The low in Pennsylvania is not surprising due to its unique system in which most neglect referrals are not reported to NCANDS. But Maryland and Hawaii also investigated small proportions of children– 15.7 and 15.9 per 1,000. These investigation rates reflect the number of referrals and how many were screened in, as well as the number of children per referral.
ACF found that of the children who received an investigation or alternative response, 16.7 percent were found to be victims of child abuse or neglect, as shown in Exhibit 3-B.3 The remaining children were not determined to be victims or received an alternative response. Estimating for missing data from Arizona, ACF calculated a national “victimization rate” of 8.1 per 1,000 children. As Exhibit 3-C shows, this rate has been decreasing since 2018 but the greatest decrease was in 2020 with the arrival of the pandemic.
ACF’s use of the term “victimization” can be misleading. An investigator’s decision about the truth of an allegation is based on limited information and is constrained by available time and staff, and evidence indicates that many referrals are unsubstantiated when maltreatment actually exists. Moreover, these rates are dependent on state policies and practices. Because of the misleading nature of the term “victimization,” the term “substantiation” is used for the rest of this commentary. State substantiation rates per 1,000 children ranged from 1.6 in New Jersey (even lower than Pennsylvania’s 1.8) to 17.0 in West Virginia, suggesting that these rates reflect much more than the prevalence of child abuse and neglect.
Among the many factors that can influence state substantiation rates are:
Differences in referral rates and screening practices, as decribed above;
Different policies about what is considered child maltreatment and different levels of evidence required to substantiate an abuse allegation;
Whether and how much a state uses an alternative (non-investigation response);
Natural and social disasters that may vary in their impact between states. Some states went back to in-person schooling for the entirety of 2021, others opened midyear, and others were virtual almost all year. West Virginia, with the highest substantiation rate, has been particularly hard-hit by the opioid epidemic. The state has the highest overdose mortality rate in the nation;
Differences in the messages coming from an agency’s leadership about the relative importance of child safety versus family preservation;
Variations in the use of kinship diversion, the practice of placing children with a relative without court involvement or case opening. If this happens before the investigation is completed, it may result in an “unsubstantiated finding.
All of these factors can change over time, affecting substantiation rate trends from year to year. It is clear that nationwide, the COVID-19 pandemic continued to suppress reports to CPS hotlines, and therefore investigations and maltreatment findings, in 2021. But the effect of the pandemic differed greatly between states: it appears that some states had more in-person days of school in 2021 than in 2020, and others had less. Additionally, several states described changes in their screening practices in 2021, usually to screen in fewer referrals. Delaware and Washington mentioned an increase in reports diverted to differential response as a reason for declining substantiation numbers in FFY 2021. The emphasis on prevention as an alternative to intervention has been increasing in most states, perhaps affecting the likelihood of substantiation. It is possible also that increases in kinship diversion may have reduced substantiation rates: there is no data to prove or disprove this, but concern over this practice is certainly growing.
To state that maltreatment decreased between 2020 and 2021 is to ignore that “maltreatment victimization” is not a measure of actual abuse and neglect. It is the result of a winnowing process that starts even before a referral arrives. At each stage, the numbers remaining may depend on a wide variety of factors, including policy, practice, natural and man-made disasters and more. The vast differences between state data on referrals, reports, investigations and substantiations shows how unlikely it is that the total number of children found to be victims of maltreatment reflects the actual number of maltreated children, and how irresponsible it is to suggest this might be the case.
A note onChild Fatalities
Last year, ACF used a decline in fatalities due to child maltreatment to headline its press release, Child Fatalities Due to Abuse and Neglect Decreased in FY 2020, Report Finds. This year, the number of child abuse and neglect fatalities reported by states increased slightly, a rise that was not the subject of a headline by ACF. Whether there is a small increase like this year or a decrease like last year means very little, for several reasons. As ACF explains, these child fatality counts reflect the federal fiscal years in which the children were determined to have died of maltreatment, which may be different from the year the child actually died. Such determinations may come much later due to the time it takes to complete a death investigation. For example Alabama reported that for the fatalities reported in FFY 2021, the actual dates of death were between FFY’s 2016 and 2021. Michigan even reported that its child fatality data included the child abuse death of twins in 2003 which was revealed by a cold case investigation.
A second problem with the fatality estimates is that they are widely believed to be too low. One reason is that many states report only on fatalities that came to the attention of child protective services agencies. As the report’s authors point out, many child maltreatment fatalities do not become known to agencies when there are no siblings or the family was not involved with the child welfare agency. Moreover, some fatalities resulting from abuse or neglect are labeled as due to accident, “sudden infant death syndrome,” or undetermined or unknown causes because insufficient evidence was found. Irecently reviewed the child fatality review report produced by the District of Columbia’s Child and Family Services agency (CFSA). CFSA relied on the decisions of the medical examiner, which chose not to classify as maltreatment deaths an infant who died after a mother who was high on PCP rolled on top of him when sleeping with him in the same bed (counted as “unknown); a baby left on his stomach with a bottle in his mouth when his mother left the apartment (counted as “undertermined); a child who was shot to death by gunmen trying to kill her father, involved in the violent drug trade, outside a liquor store at 11:00 PM (“non-abuse homicide”), and a child who died of an untreated bacterial infection and had beating injuries diagnosed by doctors as due to abuse (“undetermined”). The total number of maltreatment fatalities was estimated at only three for the District in CY 2021, not including those four deaths. Some researchers suggest that the actual number of abuse and neglect fatalities may be as much as twice or three times that given in the Child Maltreatment reports,4 and the District of Columbia data suggest this may well be the case.
Notes
This leaves out three states that are listed as screening in 100 percent of referrals: Illinois, New Jersey and North Dakota. Both Illinois and New Jersey explained in their state commentaries that reports must meet certain criteria to be accepted for investigation, so it is not clear why they responded that they screen in 100 percent of referrals. North Dakota actually screens in all referrals, but that is more semantic than real. Reports that do not meet agency criteria for a report of suspected chlid abuse or neglect are categorized as receiving an “administrative assessment,” and are not investigated. North Dakota does not report the number of referrals receiving an “adminnistrative assessment;” hence the reports that 100 percent of cases are screened in. It is unclear why New Jersey and Ilinois provided this figure of 100 percent but the reason may be similar.
Alternative response is, as defined in NCANDS, the “provision of a response other than an investigation that determines if a child or family needs services. A determination of maltreatment is not made and a perpetrator is not determined.”
NCANDS defines a “victim” as “a child for whom the state determined at least one maltreatment was substantiated or indicated, and a disposition of substantiated or indicated was assigned for a child in a report.” “Indicated” is defined as a disposition that concludes that maltreatment could not be substantiated under state law or policy, but there is a reason to suspect that at least one child may have been maltreated or is at risk of maltreatment.”
Herman-Giddens, M. E., et al. (1999). Underascertainment of child abuse mortality in the United States. JAMA , 282(5), 463-467. Available from http://jama.jamanetwork.com/article.aspx?articleid=190980. Also, Cotton, E. E. (2006). Administrative case review project, Clark County, Nevada: Report of data analysis, findings and recommendations. Crume, T. L., DiGuiseppi, C., Byers, T., Sirotnak, A. P., & Garrett, C. J. (2002). Underascertainment of child maltreatment fatalities by death certificates, 1990-1998. Pediatrics, 110(2). Abstract available from https://pubmed.ncbi.nlm.nih.gov/12165617/. Herman-Giddens et al. estimate actual child abuse and neglect deaths to be as high as three times the national reported amount; Cotton et al. and Crume et al. found the actual number of deaths to be twice that reported.
Child Welfare Monitor 