The death of David Almond: a perfect storm, or the tip of the iceberg?

Image: WJAR

I have been trying to avoid writing more posts about children failed by state systems that exist to protect them. No matter how many reports are written, these fatalities continue to occur with devastating regularity, and I’m not sure if my posts do any good. But despite my resolution to avoid such stories, I feel compelled to write about David Almond, a fourteen-year-old boy with Autism Spectrum Disorder who died of abuse and neglect on October 21, 2020. I have to write about David for many reasons, including the sheer number of red flags that were disregarded by child welfare, schools and courts in his case; the light his death sheds on risks to children with special needs, and what it shows about the peril posed to abuse victims by the quarantines due to COVID-19.

The Massachusetts Office of Child Advocate (OCA) issued a scathing report in March that revealed “multiple missed opportunities for prevention and intervention prior to the death of David Almond and the discovery of the serious physical and emotional injuries to his brothers.” David’s family was under the supervision or monitoring of the Department of Children and Families (DCF), the juvenile court, the education system and many service providers at the time of David’s death. Reading OCA’s account of the family’s involvement with DCF alone, it is hard to comprehend the many misguided actions and missed opportunities that allowed David to be returned to a family patently unable to care for him and then to deteriorate physically and emotionally over a period of seven months, culminating in his death. The attachment to this blog lays out the sad chronology assembled by OCA, which I summarize more briefly below..

David, Michael and Noah Almond were triplets born in February, 2006 in Syracuse, NY and diagnosed with Autism Spectrum Disorder at the age of about two. Between 2006 and 2013, the triplets were removed from their parents three times by the New York State Office of Children and Family Services (OCFS) due to substance abuse, mental illness, “deplorable living conditions,” medical neglect, inadequate supervision, and “a general lack of basic care.” After working toward termination of the parents’ rights, OCFS inexplicably shifted gears and a New York Family Court awarded full custody of the boys, now aged ten, to Almond, who was living in Massachusetts, in September 2016.

Upon receiving custody, Almond moved the boys to the one-bedroom apartment in Fall River, Massachusetts, which he shared with his partner, Jaclyn Coleman, and his mother, Ann Shadburn. Almond had been removed as a child from Shadburn, whose parental rights to all her children had been terminated due to abuse and neglect. Almond and Coleman were both in DCF custody for part of their childhoods due to abuse and neglect, mental illness, physical violence, and substance abuse. By August 2017, Coleman had a new baby (Aiden) and three reports had already come into Masachusetts’ child abuse hotline concerning the family.

In October 2017, all four children were removed from Almond and Coleman because of abuse and neglect, parental substance abuse, unsanitary home conditions, medical neglect, and the triplets’ excessive absences from school. In the words of OCA, “This was the fourth time in the triplets’ young lives that they were removed from Mr. Almond for the identical pattern of abuse and neglect.” But four strikes was not enough. The parents agreed to a plan requiring them to engage in therapy to address longstanding substance abuse and mental health issues, submit to random drug tests, participate in family therapy with the triplets, complete psychological evaluations, and complete parenting classes. Aiden was placed in foster care and the triplets were eventually placed in a residential facility specializing in autism spectrum disorder and intellectual disability.

While the triplets thrived in their residential facility, Coleman and Almond displayed minimal compliance with their plans, and the children’s permanency goal was changed to adoption in January 2019. But in July 2019, the children’s goal was changed back to reunification based on the parents’ improved compliance with their case plan, and Aiden was returned home the next day. This occurred, as OCA put it, “despite Mr. Almond’s failure to engage with therapy, despite Ms. Coleman’s limited engagement with therapy, and despite the lack of any documentation of any change in Mr. Almond and Ms. Coleman’s ability to parent, specifically their ability to parent children with special needs.” OCA attributes this decision mainly to a parenting evaluation conducted by a contractor that did not adequately assess the caregivers’ ability to care for the children.

In December 2019, DCF Fall River area office management decided to begin the reunification process for the triplets. This decision was made despite concerns raised by the family support provider and the case management team (social worker and supervisor) that the parents were canceling appointments, and more generally regarding their ability to care for the triplets. Management set a target date of January 2020 for the reunification. They disregarded requests for a delay from the case management team, the residential facility and the boys’ school. These requests were based in part on the need of children for a slower transition given the children’s disability, the logic of waiting until June to eliminate an extra change of school, the limited engagement the parents had demonstrated with services, the difficulties inherent in having seven people in a one-bedroom apartment, and the threat of eviction by the landlord if the boys returned home.

As the reunification date grew nearer, Almond and Coleman canceled scheduled visits with the boys, canceled appointments with the parenting support provider, and failed to take steps to secure larger housing. During the first day visit of the boys to the home on January 10, 2020, Coleman stated that reunification was moving too fast and that the family was not yet ready for overnight visits because the apartment was too small. At the first overnight visit on February 7, Almond and Coleman reported that Noah became aggressive, and he was returned to his facility that night. After this home visit, Noah refused to return to the apartment and was allowed to remain at his residential facility. The goal of reunifying him with his parents was dropped. This young autistic boy’s self-advocacy may have saved his life.

On February 11, 2020, the residential care facility took the “extraordinary” step of sending DCF a letter opposing the reunification of David and Michael with Almond and Coleman, citing the inadequate physical environment of the home to meet the children’s therapeutic needs; the fact the parents were facing eviction; and the need for a slower, more appropriate transition plan. The reunification was delayed, but by one month only. The case management team referred the family for Applied Behavioral Analysis (ABA) Services, an evidence-based approach used in both the residential program and school that the boys attended. This service was considered essential for a successful reunification, but there was a waiting list of at least six months for ABA services. Instead of delaying the reunification, DCF chose to secure “continuum services” for the family even though these services targeted one child only (Michael) and were not a substitute for ABA’s services, which are specific to the needs of autistic children.

David and Michael were returned to Almond and Coleman on March 13, 2020, barely two months after their first day visit. Four days after the reunification, the state’s COVID-19 restrictions went into effect. Starting within days of the boys’ return home and continuing until David’s death, OCA states that Almond and Coleman “deliberately avoided contact with the DCF case management team, the Fall River Public Schools, the continuum service provider, and the parenting support service provider.” They often claimed to have phone or internet access issues that prevented them from responding or being on video. When offered help in dealing with these issues, they refused or provided conflicting information.

Between March and September 2020, the case management team conducted monthly virtual visits with the family and received many communications from providers and schools. During this period, the team missed multiple red flags and opportunities to prevent the tragedy that eventually occurred. The team disregarded evidence from their own virtual visits, such as Coleman’s berating of David for his alleged behavior and her coaching of the boys to provide the desired responses to the case manager’s questions. But they never sought to interview David and Michael outside the presence of the adults. Exactly two months before David’s death, DCF received received a new CPS report about conditions in the home and substance abuse by Coleman and Almond. But the case management team accepted Coleman’s attribution of the report to a malicious neighbor and did not request drug tests for Coleman and Almond.

The team ignored concerning reports from providers and schools. These included the termination of services by the parenting services provider due to Coleman and Almond’s failure to engage with services; consistent reports from the continuum services provider that Coleman refused to allow them to speak to Michael, the targeted child for these services, and were resistant to the support and the strategies offered to address the boys’ behaviors; and David was never allowed to see the therapist obtained by DCF. DCF heard from Fall River Public Schools that Coleman and Almond refused the Chromebooks offered by the school in May but never submitted the paper packets they had chosen to complete instead. Instead, DCF learned that that the boys were not logging into school in the fall semester (a report Coleman denied, as she was logging into the schools’ electronic attendance system to falsely mark the boys “present.” ). They learned that David had missed his physical in July and two subsequently scheduled appointments.

David’s school, despite making multiple concerning reports to DCF case management, also missed many chances to save David. In one striking example, a school attendance officer came to drop off Chromebooks for David and Michael only 20 days before David was found dead. Coleman met the officer outside, refusing him entry in the apartment, and the offer did not attempt to see the boys. Apparently he was there solely to drop off the devices and not to see David or discuss with this family his lack of engagement with school since the previous March. If that officer had seen David and noticed his physical state, David might be alive today.

On the morning of October 21, 2020, emergency medical personnel responded to a 911 call regarding David; he was bruised, emaciated, and not breathing. He was transported to Charlton Memorial Hospital and pronounced deceased. Michael was found emaciated but responsive, and Aiden was well nourished and appeared physically unharmed. Substances believed to be heroin and fentanyl were found in the apartment. Michael and Aiden were immediately removed from Almond and Coleman, who are in jail and facing criminal charges.

OCA found that DCF missed multiple opportunities to protect David and his brothers. DCF gathered insufficient information from service providers and failed to analyze the information they did get; underestimated the impact of Almond and Coleman’s substance use; failed to recognize that Almond and Coleman were using access to technology as a tactic to avoid participation in services for themselves and their children; misinterpreted the “successful” reunification of Aiden (a non-disabled child) as a predictor of a successful reunification for the triplets; disregarded the triplets’ need for a gradual transition to the home; failed to secure the recommended essential services for David and Michael to be stable and successful at home; made David responsible for his own physical safety rather than teaching him to distinguish between appropriate and inappropriate interactions how to to communicate concerns to a trusted adult; and failed to adequately identify and adjust to the complications imposed by the COVID-19 pandemic.

OCA found that DCF management failed to understand that the physical environment of the home, a small one-bedroom apartment, did not meet the needs of the triplets. This is despite hearing this concern from the DCF case management team, Almond, Coleman, Almond’s legal counsel, legal counsel for David and Michael, and several provider agencies.  Incredibly, it appears that DCF management interpreted concerns from the various professionals as “an inappropriate consideration of the family’s financial means.” They seem to have disregarded the importance of physical space in the therapeutic management of autistic children and also the fact that Coleman and Almond seemed uninterested in finding a larger apartment and provided multiple excuses for not following up on housing applications.

As OCA states, “It is widely recognized that in times of crisis and economic stress there is an increase in child abuse and neglect.” Yet, OCA found that DCF did not treat the COVID-19 pandemic as a cause for reevaluation of the appropriateness of David and Michael’s reunification and did not consider the implications of the pandemic for the safety or well-being of the children. DCF seemed oblivious of Coleman and Almond’s use of the pandemic to isolate the children. Bizarrely, DCF case management staff urged school staff not to hold Coleman accountable for David and Michael’s complete absence from school, arguing that the problem was lack of technology access in the home. Case management staff also advised Coleman repeatedly to contact the school to explain that technology was the barrier to David and Michael’s participation, in order to prevent the school from filing a child neglect report against her.

Amazingly, DCF did not categorize David and Michael as high-risk children to receive in-person home visits during COVID-19. DCF appeared not to understand that that the boys’ disability, the long history of abuse and neglect in this family, the caregivers’ avoidance of contact with providers, and their reports about David’s behaviors, injuries and illnesses were all signs of children at risk. Moreover, the DCF administration has not issued statewide guidance that provides DCF personnel instructions about how to assess safety and risk during virtual home visits.

And perhaps most shockingly, DCF missed the deterioration in David’s physical and emotional state between March 13, 2020, and his death on October 21. The residential program and school where David lived and studied until March 2020 described him as having good social interaction skills, as being communicative, as having no significant behavioral issues or self-injurious behaviors, as having no aggression toward others and as having the ability to take care of his own activities of daily living. Yet within weeks of reunification Coleman was reporting that David was noncompliant, aggressive, harmed himself, and needed assistance with activities like toileting. During virtual home visits with DCF, David was always quiet and minimally communicative, while Coleman often berated and shamed him for behaviors and defiance. The case management team accepted her account and disregarded the conflict with his observed behavior and past accounts. David was a healthy weight when he left residential care. At his death, David had lost approximately 60 pounds from his last recorded weight in December 2019. It is hard to understand how anyone could have missed such a drastic change, even through a video screen.

OCA found that the Juvenile Court, including the attorney for David and Michael, did not serve as a check on the many egregious decisions of DCF. Instead, perhaps because they all agreed to return the boys home, the court and attorneys relied too heavily on DCF to determine the direction of the case. They accepted DCF’s interpretation of Aiden’s “successful” reunification as an indication of the likelihood of a similar outcome for the triplets, disregarding the differences between Aiden and the autistic triplets; failed to require a submission of a realistic reunification plan despite the judge’s statement that such a plan would be needed; accepted DCF’s narrative of the triplets’ “successful” reunification even though court reports contained information from service providers about the family’s failure to participate in services; disregarded multiple concerns about the small size of the family’s apartment and the stress it caused, based on the apparent belief that it was inappropriate to consider inadequate housing as a barrier to reunification; and never requested an analysis of the effects of the COVID-19 pandemic on the family’s ability to care for these high-needs children.

The education system’s failure of David and Michael was almost as egregious and shocking as that of DCF and the court. OCA found that the state Department of Elementary and Secondary Education (DESE) did not have the resources to monitor the provision of a free and appropriate public education in real time by local school districts during the COVID-19 pandemic. Despite their policy of prioritizing high-risk students for in-person learning, DESE “allowed families to choose the fully remote option for any reason and without a stated reason. In fact, districts were instructed not to counsel families of high risk students to choose in-person learning even if the district felt that remote learning would not be successful for a particular student.” DESE did not set higher standards for monitoring or support for high-risk students, such as those with disabilities and those involved with DFS, regardless of their choice of learning option. DESE issued no guidance to school staff on how to recognize abuse and neglect in a virtual environment. Nor did they address mandatory reporting of attendance issues until January 2021.

In addition to the failures of DESE, Fall River Public Schools (FRPS) missed multiple opportunities to save David. The shift to remote learning, coinciding exactly with the transfer of David and Michael to FRPS, meant that David was never seen by, or spoken to, by any school employee from March 2020 to the time of his death in October 2020. To their credit, school staff made numerous attempts to communicate with the parents and resolve alleged technology problems. Yet, David and Michael’s teachers never attempted to make contact with the boys directly via telephone. While they raised concerns about the boys’ lack of participation to the DCF case management team, school staff never elevated this concern by filing a neglect or truancy report. Moreover, FRPS set no attendance or participation requirements, and David was incredibly promoted to high school after being completely disengaged from his school since being transferred there in March. DESE and FRPS guidance for the fall 2020 concerning attendance tracking, contact, and grading never filtered down to school staff, perhaps preventing an intervention in the last month of David’s life.

There was another entity that could have intervened to raise concerns about the safety of the children, and that was the Massachusetts Probation Service (MPS). Massachusetts children in child welfare cases are assigned a probation officer whose role is to verify compliance with court orders, report to the court on the status of these orders and monitor the well-being of the children. The officer in this case had regular contact with the family and seemed to have a much more clear-eyed view of their problems than did DCF, which did not act on his expressed concerns. However, he did have a worrisome conversation with Coleman only days before David’s death in which she reported on the deterioration of both boys, that they had regressed to wearing adult diapers, that David was picking at his skin causing sores and bleeding, and that Michael had to be hospitalized for self-injury. The officer could have brought these concerns to the attention of the court before the next hearing but did not do so–possibly due to a culture discouraging such communications–and missing the last opportunity to save David.

Several questions remain even after the comprehensive review by OCA. First, what explains the New York Court’s decision to reunify the triplets with their father after taking steps toward terminating his rights? It is very concerning that OCA was not able to obtain this information in its review of court data. A court decision like this would have to be documented and would presumably been based on recommendations from Onondaga County (NY)’s Office of Children and Family Services (OCFS). It is not clear whether OCA requested documents from OCFS, and whether such a request was refused. It is necessary to understand what occasioned this about-face by New York. One cannot help wondering if the agency realized the boys would not be adopted was trying to avoid the expense of caring for the boys into adulthood.

OCA was also unable to explain the DCF area management’s unwillingness to reconsider the appropriateness of the reunification plan in the face of objections from their case management team and almost everyone else involved. OCA states that there was no pressure from the Juvenile Court, Almond, Coleman, their attorneys, nor the children’s attorney to rush a transition home. DCF administration also confirmed during this investigation that there were adequate funds in the Fall River Area Office’s budget to continue the triplets residential placement. Once again, as in New York, one has to wonder whether, despite the existence of “adequate funds” for the boys’ placement, there was in fact pressure on the local DCF office to return the boys due to the financial costs of their placement. Such budget concerns might have explained the unseemly rush to reunify despite the unavailability of a crucial service and adequate housing and the clear logic of waiting until the triplets completed their educational program in June 2020.

It is hard to avoid speculating about whether Almond and his paramour actually wanted custody of David and Michael. It appears that Almond and Coleman wanted Aiden back (not surprising as he was Coleman’s son and not disabled) and that is why they began to cooperate somewhat with services after an initial period of total noncompliance. There is no evidence that the couple were pushing for the return of the triplets and many indications that they tried to delay it as long as possible. Canceling visits to the boys and appointments with providers and failing to take steps to find a larger apartment could all be taken as signs of reluctance to receive the boys at home. Caring for triplets with autism plus a baby is not easy for anyone, it is hard to imagine a troubled couple like this one doing it, especially without the help that was recommended by the expert.

There is no excuse for the sheer inhumanity displayed in this household. Nevertheless, the case does call to mind the reports that are coming from all parts of the country regarding our national failure to help parents care for their mentally ill or developmentally disabled children–a crisis that is leading good parents to consider relinquishing custody of their children in order to obtain the services they need. It is possible that Almond and Coleman (not being good parents in the least) were trying hard to relinquish custody but were unsuccessful in unloading their unwanted triplets onto New York and Massachusetts. The eagerness of agency management to shed this burden and the reluctance of Almond and Coleman to take it on made for a toxic mix that killed David Almond, and left both of his brothers with lifelong wounds.

The OCA report contains many pages of recommendations for DCF, which include improving supervision, reviewing and revamping agency policies on contacts with collaterals, clients with disabilities, reunification; revamping the safety assessment process; setting standards for when and how virtual visits can be conducted, establishing a robust quality assurance system with additional monitoring at critical decision-points in a case and for higher-risk cases, and creating a “culture of continuous learning” where the “identification and correction of errors, miscalculations, or misinterpretations is encouraged and commended.” Many more recommendations targeted the juvenile court, the Probation Services, and the public schools.

While this report is unique due in its exploration of the complications due to the COVID-19 pandemic, we have seen too many similar reports from all of the country over many years. Most recently, Maine’s child welfare ombudsman found that the system continues to struggle with making an informed decision about whether to send a child home from foster care and whether to end agency supervision of reunified children. In a review of 82 cases closed in the past year, they found 20 cases where reunification practices were at issue.

Commonwealth Magazine notes that OCA conducted comprehensive investigations in 2013 and 2015, following three high-profile child deaths. Since 2015, the Legislature and Gov. Charlie Baker’s administration have increased funding for DCF by more than $200 million, added more than 650 positions, reduced caseloads, and introduced numerous reforms. Yet, Fall River State Representative Carole Fiola pointed out that many of the same patterns of agency malfunction were found in the earlier reports. This is indeed discouraging. Perhaps stronger measures are required.

A “three strikes law” for abuse and neglect might be one such stronger measure. Perhaps parents should not be given another chance after three or more removals. And this question brings up the role of ideology, especially as it might be expressed by managers who are unfamiliar with the actual details of the case. In the current child welfare climate, it often seems that parents can do no wrong. As noted repeatedly in the this case, there was too little focus on the problems that brought the children into care, and too little assessment of whether these problems were truly solved before the children were returned. This may not be atypical or surprising, given the current emphasis on family preservation and “strength-based” approaches to working with families, which ask social workers to minimize problems and find strengths wherever they can. There is certainly value in this perspective as a corrective to an earlier focus exclusively on problems, but taken too far it can be deadly.

The reluctance of the agency, lawyers and court personnel to consider housing adequacy as a prerequisite to reunification was another dysfunctional intrusion by ideology into case practice. Today’s dominant narrative asserts that children are being removed from families due to poverty that is being couched as neglect by intrusive child protective services systems. Poverty should not be a reason for removal nor should it be a barrier to reunification. But this case was not so simple. Almond and Coleman took no steps to apply for larger housing, despite being offered many opportunities to do so. It is possible that their reluctance to apply stemmed to their hope that they would not be saddled with the three boys. But the reigning narrative may have blinded agency management, court and lawyers to this concerning lack of action by the boys’ father and his paramour.

David’s case warns us to beware of the blanket statements often pushed by the child welfare establishment. It is often accepted as common knowledge that children do best with their family of origin, that in rare cases where children cannot remain at home the best placement is a relative (like Ann Shadburn?), and that congregate care is always the worst placement for children. None of these “truths” were correct for David and his brothers. Perhaps David’s story will lead some leaders and commentators to ask themselves what a home really is, and to understand that it is the presence of love, not the type of setting, that matters to a child.

“It is tempting to characterize this case as resulting from a ‘perfect storm,'” says the OCA, while not expressing an opinion on whether that is an apt characterization. The “perfect storm” explanation is often used by governments to argue against placing significant weight on individual cases, no matter how egregious. “A system should not be judged by one case, no matter how sad or sensational,” said Joette Katz, Commissioner of Connecticut Department of Children and Families (DCF) as reported by the Hartford Courant. Katz was talking about the death of Matthew Tirado, an autistic 17-year-old, on February 14, 2017 from prolonged abuse and neglect by his mother. Matthew had been known to Connecticut’s Department of Children and Families since the age of five, as revealed by a heartbreaking  report from Connecticut’s Office of the Child Advocate. Yes, A System Should be Judged by One Case was my answer to Katz. If David’s death was the outcome of a perfect storm, it was also the tip of the iceberg. If professionals are capable of making the kind of mistakes they made over and over again in this case, similar mistakes are obviously occurring in other cases. For every David Almond or Matthew Tirado, there must be many other children left in abusive and neglectful homes who never come to our attention because they are not actually killed albeit suffer lifetime damage. But the cost in current suffering and future damage is incalculable.

Certainly the COVID-19 pandemic was a large part of the “perfect storm” leading to David’s death. Thankfully, the pandemic appears to be easing and schools should be open full time next fall. However many jurisdictions plan to retain a virtual option next fall. OCA expressed concern that even though an in-person option was offered to the boys in Fall 2020, parents were allowed to choose virtual education without any stated reason and even if the district felt that remote learning would not be successful for a particular student. OCA made many recommendations for improving the oversight of children in virtual education but did not make a recommendation that addressed this finding. It is my view that jurisdictions should establish guidelines for approval of virtual education for each student and require a waiver for any student whose guardians request virtual education for reasons that are not included in these guidelines. Many advocates for children and domestic violence victims, such as Andrew Campbell, have warned from the outset of the pandemic of the dangers facing people who locked in with abusers. David’s case showed how right they were and that planning for future emergencies needs to include better provisions for such vulnerable people, including school-aged children.

COVID-19 will end, but I will continue to write about the Davids, the Matthews and all of the children who are failed by the agencies that exist to protect them. I will continue to write about them until we learn to value our children more than money or ideology, and until we decide as a nation that children will no longer be collateral damage in the pursuit of other goals, whether pandemic containment, “family preservation,” or budget savings.

Attachment: Chronology of the case of David Almond, from the Office of the Child Advocate Report

February, 2006: David, Michael and Noah Almond were born in Syracuse, NY to Sarah and John Almond, as described in OCA’ s devastating report. The triplets were all diagnosed with Autism Spectrum Disorder at the age of about two.

2006 to 2013: the triplets were removed from their parents three times by the New York State Office of Children and Family Services (OCFS) due to substance abuse, mental illness, “deplorable living conditions,” medical neglect, inadequate supervision, and “a general lack of basic care.” Their mother had no contact with them after the final removal, and their father moved to Massachusetts. OCFS began steps to terminate the parents’ rights to the boys, but never completed the process.

September 2016: A New York Family Court awarded full custody of the boys to Almond, who was living in Massachusetts, in September 2016, after years of minimal or no contact. Almond moved the boys to the one-bedroom apartment in Fall River, Massachusetts, which he shared with his partner, Jaclyn Coleman, and his mother, Ann Shadburn. All three had a history of abuse and neglect as a victim or perpetrator. Shadburn’s parental rights to all of her children, including John Almond, had been terminated. Almond and Coleman were both in DCF custody for part of their childhoods due to abuse and neglect, mental illness, physical violence, and substance abuse.

June 2017: The first two abuse or neglect reports were called into the Massachusetts hotline concerning the children. Another report came in that August, citing Coleman’s substance abuse and questions about the parents’ ability to meet the needs of their newborn son, Aiden, as well as of the triplets.

October 2017: All four children were removed from Almond and Coleman because of abuse and neglect, parental substance abuse, unsanitary home conditions, medical neglect, and the triplets’ excessive absences from school. In the words of OCA, “This was the fourth time in the triplets’ young lives that they were removed from Mr. Almond for the identical pattern of abuse and neglect.” But four strikes was not enough. The parents agreed to a plan requiring them to engage in therapy to address longstanding substance abuse and mental health issues, submit to random drug tests, participate in family therapy with the triplets, complete psychological evaluations, and complete parenting classes. Aiden was placed in foster care and the triplets were eventually placed in a residential facility specializing in autism spectrum disorder and intellectual disability.

January 2019: While the triplets thrived in their residential facility, Coleman and Almond displayed minimal compliance with their plans, and the children’s permanency goal was changed to adoption.

July 2019; the goal for all of the children was changed back to reunification after reports that Coleman and Almond’s compliance with their plans had improved, and Aiden was returned home the next day. This occurred, as OCA put it, “despite Mr. Almond’s failure to engage with therapy, despite Ms. Coleman’s limited engagement with therapy, and despite the lack of any documentation of any change in Mr. Almond and Ms. Coleman’s ability to parent, specifically their ability to parent children with special needs.” OCA attributes this decision mainly to a parenting evaluation conducted by a contractor that did not adequately assess the caregivers’ ability to care for the children.

December 2019: DCF management decided to begin the reunification process for the triplets. This decision was made despite concerns raised by the family support provider and the case management team (social worker and supervisor). DCF management set a target date of January 2020 for the reunification. They disregarded independent requests for a delay from the case management team, the residential facility and the boys’ school.

January 10, 2020. The boys had their first day visit to the home and Coleman stated that reunification was moving too fast and that the family was not yet ready for overnight visits because the apartment was too small.

February 7, 2020: At the first overnight visit on February 7, Almond and Coleman reported that Noah became aggressive, resulting in a physical altercation. As a result, Noah was returned to his facility that night. After this home visit, Noah refused to return to the apartment and was allowed to remain at his residential facility. The goal of reunifying him with his parents was dropped.

February 11, 2020: The congregate care provider took the “extraordinary” step of sending DCF a letter opposing the reunification of David and Michael with Almond and Coleman, citing the inadequate physical environment of the home to meet the children’s therapeutic needs; the fact the parents were facing eviction; and the need for a slower, more appropriate transition plan. The reunification was delayed, but by one month only.

March 13, 2020: David and Michael were returned to Almond and Coleman, barely two months after their first day visit, while remaining in the legal custody of DCF. Four days after the reunification, the state’s COVID-19 restrictions went into effect.

April 2020: At the monthly virtual DCF visit Ms. Coleman reported that there were no concerns regarding the children’s behaviors and the children had access to a laptop for the purposes of schooling. The DCF case management team did not recognize that Ms. Coleman provided contradictory information to the continuum service provider. 

May, 2020: Ms. Coleman rescheduled a DCF virtual home visit supposedly due to technology access issues. During this phone call, Ms. Coleman reported to the DCF case management team that David was vomiting from having too many snacks and was lying in his own vomit. The DCF case management team did not follow up with Ms. Coleman about how David was feeling or the possibility that David could be sick another reason. When the virtual home visit happened ten days later, Coleman took a “strong and controlling role in the communication between the DCF case management team and the children.” She prompted the children to provide specific answers to the DCF case management team questions. In the same month, the parenting support service provider cancelled the service with Almond and Coleman due to their lack of engagement with the service. Also in May, the school offered Chromebooks to David and Michael. This offer was turned down by Coleman in favor of having the boys complete paper packets. But paper packets were never submitted for either of the boys, and the school took no action.

June 2020, the continuum service provider shared with DCF Coleman’s report that Almond physically restrained David due to David’s aggression and that David was completing his chores, which included scrubbing the floor with a toothbrush. Later in the month, the continuum service provider informed DCF that Ms. Coleman reported being fearful that David and Michael would both attack her at the same time and that David refused to take his medication. The provider reported that Coleman refused an outdoor visit and was not using the provider’s emergency service line that they repeatedly urged her to use.

June 2020: In the monthly virtual DCF visit, Coleman tried to stop the boys from answering a question about whether they wanted to visit with their brother Noah, whom they had not seen since March. OCA believes that “Ms. Coleman intentionally prevented David and Michael from virtually visiting with Noah to isolate them from Noah and isolate them from the congregate care program staff that knew them well and might have identified concerns.”

June 17, 2020: A foster care review panel was held and reviewers found that “Mr. Almond and Ms. Coleman were meeting the needs of the children and participating in the continuum services. According to OCA, “It is unclear if the foster care review panel was aware that the parenting support service provider closed the case in May due to a lack of responsiveness from Mr. Almond and Ms. Coleman, and it was unclear also if the panel knew of the continuum service provider’s description of the challenges facing the family.” 

July 17, 2020: The Court returned legal custody to Almond despite the lack of improvement in his and Coleman’s participation in services and no change in Coleman’s description of the boys’ behavioral challenges . Almond was not present at the hearing. On the same day Coleman refused both an outdoor and an indoor visit. According to OCA, “The DCF case management team did not observe the children, the home, or Mr. Almond or Ms. Coleman between June 19, 2020 and July 17, 2020 when David and Michael were legally returned to Mr. Almond’s care.” 

July 22, 2020: At the monthly DCF virtual visit, Coleman berated David in front of the case management team for his behavior. When Michael contradicted Coleman’ account of David’s behavior, she said he was “making her look like a liar.” But at no point did the case managers seek to interview David or Michael outside Ms. Coleman’s presence.

August 2020: The continuum service provider informed the DCF case management team that Ms. Coleman had reported David scratched his collar bone until it had become raw. The DCF case management team did not follow-up with Almond or Coleman about this injury. The continuum service provider also expressed that the family was not fully engaging with the service and that the children needed Applied Behavioral Analysis (ABA) services. 

August 21, 2020: DCF received a report about conditions in the home and substance abuse by Coleman and Almond. The case management team conducted a virtual home visit three days later. Coleman attributed the report to a malicious neighbor and denied the substance abuse. The team accepted her self-report and did not request drug tests for Coleman and Almond. Coleman attributed a bandage on David’s nose to self-injury and when David was asked, he followed Coleman’s prompting to corroborate her account. As OCA points out, the team neither considered the significance of self-injury as a sign of distress nor considered the possibility of parental violence as the cause of the injury.

September 14, 2020: On September 14, 2020, Michael was brought to an out-of-state hospital emergency department for an injury that Coleman reported was self-inflicted. Michael was admitted for overnight observation and discharged home the next day. This injury was not reported to DCF.

September 25, 2020: The DCF case management team had its last virtual home visit with the family. Ms. Coleman described David as having behavioral issues, and David refused to speak. Between September 20, 2020 and October 3, 2020, the family canceled or did not attend all their scheduled appointments with the continuum service provider. 

On October 1, 2020, a school attendance officer came to drop off Chromebooks for David and Michael. Coleman met the officer outside and he did not attempt to see the boys as he was there solely to drop off the devices and not to see David or discuss with this family his lack of engagement with school since the previous March. If that person had seen David and noticed his physical state, David might be alive today. Twice in October, a teacher contacted DCF to report that the boys were not logging into school. The OCF team contacted Coleman, who denied that report.

October: The DCF case management team was made aware that David’s individual therapist had only been successful in contacting the family one time since August. Ms. Coleman told the case management team why that therapist was not appropriate for David. 

October 5 and October 14, 2020: A teacher from Fall River Public Schools contacted the DCF case management team and reported that David and Michael were not logging into school virtually. The DCF case management team contacted Ms. Coleman, who denied this report and reported both David and Michael were attending school virtually 

On October 7, 2020, the team learned that David had missed his physical in July and two subsequently scheduled appointments. A case review was held on October 14, 2020. Almond and Coleman did not attend. The review panel “inexplicably found that Mr. Almond and Ms. Coleman were meeting all the children’s needs in the home. This determination was made despite concerns regarding the family’s lack of consistent engagement and utilization of services, that David and Michael had not attended school or received any special education services since their reunification in March, and despite Ms. Coleman’s reports of David engaging in serious self-injurious behaviors.”

October 14, 2020: Another foster care review meeting was held in the absence of Almond and Coleman. In OCA’s words, “The foster care review panel inexplicably found that Mr. Almond and Ms. Coleman were meeting all the children’s needs in the home. This determination was made despite concerns regarding the family’s lack of consistent engagement and utilization of services, that David and Michael had not attended school or received any special education services since their reunification in March, and despite Ms. Coleman’s reports of David engaging in serious self-injurious behaviors.” 

October 21, 2020: Emergency medical personnel responded to a 911 call regarding David; he was bruised, emaciated, and not breathing. He was transported to Charlton Memorial Hospital and pronounced deceased. Michael was found emaciated but responsive, and Aiden was well nourished and appeared physically unharmed. Substances believed to be heroin and fentanyl were found in the apartment. Michael and Aiden were immediately removed from Almond and Coleman, who are in jail and facing criminal charges.

The Noah Cuatro Report: Another whitewash by the Los Angeles Office of Child Protection

NoahCuatro
Image: Losangeles.cbslocal.com

On July 5, the parents of four-year-old Noah Cuatro called 911, saying their son had drowned in the pool at their apartment complex. But Noah did not look like a drowning victim, and the sheriff is investigating his death. Noah’s family had been under the supervision of the Department of Children and Family Services (DCFS). The eagerly awaited report on the Noah Cuatro investigation has appeared after a long delay, and OCP in the person of Judge Michael Nash (Ret.) has exonerated DCFS from responsibility for Noah’s death. This is not surprising given the similar results of OCP’s Anthony Avalos investigation, which Child Welfare Monitor addressed in our last post.

The flaws in this latest report are so glaring that they are evident even to readers without access to Noah’s case file. The report describes a child who may have been wrongly sent back to his parents, and an agency that failed to protect him after he was sent home. But Nash limited the scope of the investigation to DCFS’s failure to carry out an order to remove Noah from his parents. “Given what is currently known, the primary issue in this case from a systemic perspective focuses on the removal order,” Nash states. He defines three questions, all of which involve the removal order. Was it appropriate? Should it have been issued? Should it have been executed? Nash concludes that the order was inappropriate, the judge was correct (nevertheless in issuing it), and the decision not to execute it was correct. End of story.

But the decision to confine his conclusions to the removal order disregards a much larger issue. Here is a family that was under DCFS supervision since the reunification of Noah and his parents in November 2018.  A child under supervision by DCFS died in unexplained circumstances in the Antelope Valley of Los Angeles County. Sound familiar? Think of Gabriel Fernandez in 2013. Think of Anthony Avalos, who had been under court supervision for years but was left unprotected for over a year until he died in 2018.  Had there been no removal order at all, this case would have raised serious questions.

A Story of a Troubled Family

Let us step back and look at the history, as summarized by Nash. In August 2014, shortly after Noah’s birth, he and his sister were placed in foster care with their maternal great-grandmother as a result of DCFS finding that their mother had fractured the skull of her own infant sibling, and that their father was abusing marijuana. They were returned to their parents in May 2015 based on dismissal of the allegations in the original petition for removal.

Noah and his sister were removed again in November 2016 (although his sister was returned over the objections of DCFS) due to DCFS finding that Noah had been diagnosed with “failure to thrive,” developmental delay, and congenital hypertonia, and that he was medically neglected by his parents, who failed to take him to eight scheduled appointments. Noah was originally placed in an unrelated foster home and was then placed with his maternal great grandparents in August 2017.

In November 2018, the court ordered Noah returned home to his parents over the objections of DCFS. As is common practice in Los Angeles and around the country, Noah was placed under court supervision after being reunified with his parents.  The court ordered DCFS to make unannounced visits and set up a visitation schedule for Noah’s maternal great-grandparents and also ordered that Noah and his parents participate in Parent Child Interaction Therapy (PCIT) to help improve their bond. The next judicial review was scheduled for May 9.

Between Noah’s return to his parents in November 2018 and his death in July 2019 the following occurred:

  • The parents did not enroll in PCIT or put Noah in preschool–which would have been another set of eyes on the child. Noah had only one visit with his maternal grandmother.
  • On her February 28 visit the caseworker supervising the family’s case (referred to as a “CS-CSW” without clarification by Nash) described Noah as lethargic and advised his parents to take him to the doctor. They did not follow his advice, waiting for Noah’s well-child visit on March 7, where Noah was diagnosed with an ear infection and prescribed medication.
  • On April 17, 2019, the hotline received a call (almost certainly from Noah’s maternal great-grandmother) stating that he appeared “thinner, intimidated, and scared.” The caller alleged that Noah suffered from night terrors and said his “butt hurt” and that his father hits and curses at him. The family’s caseworker was informed of the report and went to see Noah. She noted a bruise on his back and a scab on his forearm. He denied all the allegations and agreed with his mother that he had fallen off a bunkbed. The caseworker suspected he had been coached.
  • On April 18, the caseworker made a report to the hotline and an investigative worker met with the family. She took Noah for a forensic exam on April 19. Noah denied any abuse and the examiner concluded that the injury could have occurred as Noah and his mother reported. On May 9, the investigator met with the family’s prior caseworker. The latter said she “always had concerns for Noah, was opposed to his return home, and felt that the parents are habitual liars who present well.” She also expressed doubts about the bonding between Noah and his parents and concerns that he was targeted by them for abuse among their other children. Nevertheless, the referral was closed on May 9 or shortly thereafter with a finding of “inconclusive.”
  • On May 13, the investigative worker advised the current caseworker that the allegations could not be verified, but the caseworker indicated that she was working on a petition to the court for permission to remove Noah due to concerns about the compliance and honesty of the parents. On May 15, the caseworker submitted the removal petition to the court and it was signed the same day.
  • On May 15, the maternal grandmother called the hotline alleging that Noah’s maternal aunt reported his father beat his mother in front of the children and sometimes threw them in the street. She also reported that Noah spent the night at an aunt’s home and woke up screaming in the middle of the night. He also told the maternal uncle that his “butt hurt” and the uncle told the aunt that Noah was being sexually abused. This referral was assigned to the same investigative worker. When the investigator saw the family on May 20, the parents and Noah denied all the allegations and Noah even denied staying over with his aunt. The mother also denied being pregnant–a fact that becomes significant later.
  • On May 22, a case conference including the Assistant Regional Administrator agreed not to execute the removal order while the investigation was underway. They agreed to facilitate a meeting with the family. “Unsuccessful attempts were made through July 5” to schedule this meeting, according to Nash.
  • On June 6, the mother, who had denied pregnancy on May 20, gave birth. At the hospital she initially denied the baby was hers, claimed she was artificially inseminated as a surrogate, but that she did not know she was pregnant. Hospital staff reported that the mother had no prenatal care and they were concerned about her mental health. Nevertheless the baby was discharged with her parents.
  • On June 13, the investigator, in consultation with her supervisor, decided to add Noah’s three siblings to the family’s case because of “concerns for Mother’s mental health and her ability to comply with court orders.”
  • On June 18, according to redacted documents that have since disappeared from the internet, an automated assessment found the risk to Noah to be “very high” and the caseworker noted “current concerns for the mother’s mental health,” as cited by the Chronicle of Social Change.
  • On June 19, the investigation begun on May 15 was closed. The allegation of general neglect by the mother was substantiated and the allegation of abuse by the father was found inconclusive.
  • On June 28 the investigative worker saw all the children and reported Noah to be in good spirits. (Note: It is unusual for an investigative worker to visit 9 days after an investigation is closed. Perhaps this is an error and the visit was by the caseworker).
  • On July 5, Noah was hospitalized after his parents said they found him in the pool at their apartment complex. The county sheriff stated that Noah had signs of trauma that were not consistent with drowning, and an investigation is ongoing.  Noah died on July 6.

Critical Questions

This history raises serious questions aside from the question of why the removal order was not implemented, which is all that Nash addressed. This family was under supervision by the the court, with DCFS responsible for monitoring the family. The family’s caseworker was concerned enough about Noah’s safety to file a 26-page request for a removal order from court. If the agency later decided to shelve the order, what was done to ensure Noah’s safety?  Between the decision not to carry out the court order on May 22 and Noah’s hospitalization on July 5, Nash does not list any visits to Noah by the caseworker who was supposed to be supervising the case. Unusually, the investigative worker was recorded as visiting them one more time on June 28, after the investigation was closed. If that was the only visit to Noah in six weeks, this is evidence of serious negligence, especially in light of the fact that the family’s caseworker thought his situation was bad enough to require a removal. Moreover, the investigator had added the other children to the case on June 13 due to concerns about the mother. Other than gross negligence, the only possible explanation for the lack of visits noted is that there were visits but Nash was not given access to the notes. That possibility is concerning; also concerning is the fact that Nash apparently did not notice the gap and ask for any missing notes.

More questions abound. Information from the hospital after the birth of the new baby was very concerning as to the mother’s lack of veracity and her mental health. Yet, this did not seem to change the outcome of the still-open investigation or result in more intensive supervision of the family. Why not? Why is there no report on the court hearing that was supposed to take place on May 9? Moreover, how could an agency make “unsuccessful attempts” to schedule a family meeting for six weeks without raising the stakes? The agency had recently had a removal order for Noah. Did they try to involve the court? Why is the family’s former caseworker now a “Human Services Aide,” which appears to be a demotion?

Perhaps Nash is right in his narrow conclusion that a removal was not warranted on May 15 when the order was granted. But it is impossible to assess this conclusion without seeing the text of the removal petition or the judge’s order. Note that DCFS was against returning Noah to his parents in the first place and was overruled by the judge in the case. Nash’s report does not provide any of the reasons why DCFS opposed the reunification. (It would be interesting to see these reasons and also learn whether they were restated in the petition requesting the removal order.) One would think that if the same team was in place when new concerns were raised, they would have been very happy to implement the removal order when they finally received it. We need to know if the team was the same and if so, why it changed.

We will have to wait for the release of the full case file to know the answers to these questions. It is not clear why Judge Nash authored such a faulty report. Perhaps it was a deliberate attempt to whitewash DCFS; perhaps DCFS administrators provided incomplete or misleading information; or maybe Judge Nash simply failed to appreciate the questions raised by the information he received. It is ironic that OCP exonerated the agency for Anthony Avilas‘s death because unlike the family of Gabriel Fernandez, Anthony’s family was not under agency supervision at the time of his death. But in addressing Noah Cuatro’s death while under agency supervision and in light of numerous red flags, OCP has exonerated DCFS, giving the agency a free pass for losing a child it was supposed to protect. It seems that the agency cannot go wrong in the eyes of Judge Nash.

 

Inspector General: Child safety and well-being no longer priorities for Illinois Department of Child and Family Services

SemajCrosby
Semaj Crosby: wtvr.com

DCFS has lost focus on ensuring the safety and well-being of children as a priority. This is evidenced by several recent cases and the clear lack of attention to assuring children and families receive adequate, thorough, and timely responses and needed services. Investigators, caseworkers and supervisors are unmanaged, and unsupported. Children are dying, children are being left lingering in care, children are being left in in psychiatric hospitals beyond medical necessity causing them to lose hope. This is not just unacceptable it is HARMFUL

That startling statement was made by the Acting Inspector General (IG) for Illinois Department of Children and Families to News Channel 20 about its most recent annual report. During FY 2018, the Office of Inspector General (OIG) reviewed 97 deaths and one serious injury of children whose families were involved in the child welfare system within the preceding 12 months. Of the 98 families involved, at least 52 were the subject of of a completed child abuse or neglect investigation during the previous 12 months; fully 37 of these investigations failed to find any abuse or neglect and were closed without any action to protect the child. Twelve of the 98 families were the subject of an open investigation when the child died, eight were involved in an open family service case, and three had had a family case closed within a year of the death. (See the full count of deaths by case status at the bottom of this article.)

Not all of the deaths or serious injuries can be attributed to DCFS failure to protect a child. Twenty-seven deaths were ruled natural; most of the children involved had serious medical issues. Some of the deaths (including most the 16 youths in foster care)1 were sadly due to violence, car accidents, drug abuse by older youths and other circumstances not under the Department’s control. Heartbreakingly, two older teens in foster care died of abuse that was inflicted on them as infants and left them medically compromised.

However, many of the case reviews suggest DCFS missed danger signs and opportunities to save vulnerable children. Thirteen children were killed by a parent, step parent, parent’s paramour, another relative or unknown perpetrator within a year of an open investigation or service case.  These children were beaten, starved, stabbed, and shot to death. The cause of 23 deaths of children in families that recently interacted with DCFS is still undetermined; many are currently being investigated. Most of these children were infants; many of the deaths appeared to be linked to unsafe sleep practices and at least four raised concerns of abuse. The deaths of 24 children with an open or recently open case were classified as accidental. Fourteen of these deaths were attributed to asphyxia, suffocation, or sleep related causes; there were also two accidental drownings, an accidental hanging, and an accidental shooting of a three-year-old by an 11-year-old, as described below.

 The OIG completed “full investigations” of four cases  that have drawn extensive media attention:

  • Seventeen-month-old Semaj Crosby was found dead under a couch in her home 30 hours after being reported missing. There was both an open in-home case and a pending child protection investigation of the family at the time Semaj was reported missing. The family had been the subject of 11 investigations during the two years before her death. The mother received SSI for cognitive delays but was never assessed to determine her ability to keep her children safe. Semaj’s seven-year-old brother was psychiatrically hospitalized three times for threatening to kill himself during the time the family’s case was open. A family service caseworker visited the home the day before the toddler was reported missing, and a child protection investigator had been to the house the day the report was made. No immediate safety concerns were reported by this investigator, even though the health department deemed the apartment uninhabitable after the body was found. Criminal and child neglect investigations are pending.
  • Four-year-old Manual Aguilar was killed, apparently  starved to death, and his body was burned post-mortem. Four years before his death, Manual and his three siblings were removed  from their mother’s custody after she left the three older children in a car overnight at temperatures hovering around freezing, while Manual was left in a stranger’s care. The children were returned home a year before Manual’s death despite the mother’s failure to progress in therapy and an unfounded investigation stemming from bruises to one child that his older siblings reported were inflicted by the mother during an overnight visit. Five months before Manual’s death, the two older siblings texted to their former foster parent that their mother was beating them, but the investigation was unfounded when they recanted. The mother has been charged with murder.
  • A daycare center reported that a two-and-a-half-year-old appeared to have cigarette burns on both hands. The reporter also said the child’s face had been swollen on two prior occasions, and an unknown male accompanying the mother was seen to hit the child across the face a week before. The investigator closed the case without investigating adequately either the child’s burns or the family’s allegation that they occurred at the daycare. Two days following the investigation’s closure, the child experienced cardiac arrest and died four days later. The autopsy concluded that the manner of death was undetermined and suspicious, but a child protection investigation did not find evidence to find anyone responsible for the death.
  • An eleven-year-old girl accidentally shot her three-year-old brother in the head while playing at home. This child survived and and this appears to be the only non-fatal case reviewed. The parents had left four of their children, of which the eleven-year-old was the oldest, at home alone.  The father had eight drug convictions and had been arrested multiple times for physically assaulting the mother. The investigation of the shooting was the eleventh investigation of this family since 2008. One investigation had occurred when the father barricaded himself in the home with the mother, who was eight months pregnant, and the screaming and crying children. The children’s eight-year-old sibling was in residential care in the custody of DCFS at the time of the shooting and the agency was required to monitor the at-home siblings as well. Nevertheless no visits by case managers to the home were documented in the 45 months before the shooting with one exception. A case manager attempted to visit the home 21 days before the shooting but was not allowed in. . 

The acting Inspector General told a reporter that understaffing may have contributed to the state’s inability to prevent child deaths. Following the death of Semaj Crosby, the OIG investigated a media report that child protection workers in the local office were offered incentives for early case closure. The IG found that while Semaj’s family was involved with DCFS, the entire region was understaffed (at times as low as 66% of staff needed), resulting in excessive caseloads for investigators. In December 2016, the field office administrator offered a $100 gift card to the investigator who could close the most cases in January. The IG found similar incentive programs for early case closure around the state.

The OIG also found that “a large contributing factor to the caseload problem was that the previous director had several management initiatives that seemed to take priority” over any attempt to redistribute caseloads. One of these initiatives, Rapid Safety Feedback, received some media attention last year. DCFS awarded a multimillion-dollar contract to two out-of-state firms using a “propriety algorithm to identify cases most likely to result in death or serious injury.” There were concerns that this contract was one of several no-bid contracts given to a circle of former associates of the previous director, as described by the Chicago Tribune. The contract was terminated after 25 to 50 percent of cases were flagged as having a a greater than 90% probability of death or serious injury in the next two years, alarming and overwhelming social workers. At the same time, the algorithm failed to predict the death of Semaj Crosby and other children who were killed while under supervision by DCFS. 

The OIG report identified two areas of “chronic misfeasance,” or conduct that is lawful but inappropriate or incorrect. One of these areas is “intact family services,” which is DCFS-speak for the services provided to families to prevent further abuse or neglect without removing the child. OIG’s 2018 annual report included an eight-year retrospective on the deaths of children in intact family services cases. The OIG concluded that in many of these cases the children remained in danger during the life of the case due to violence in their homes, when DCFS should have either removed the children or at least sought court involvement to enforce participation in services.

A second area of “chronic misfeasance” identified in the 2019 report which has also drawn media coverage is the practice of leaving foster children in psychiatric hospitals “beyond medical necessity,” or after they are stable enough to be cared for outside that setting because there is no appropriate placement. OIG reported that the number of such episodes increased from 273 in FY 2017 to 329 in 2018. “The availability of community-based services and resources for youth with significant mental and behavioral needs continues to be at crisis levels.”

The OIG’s overall conclusion–that child safety and well-being are no longer priorities for DCFS–is sobering. But even more alarming is the fact that this description could be applied to many or even most other states.  Although we don’t have numbers for most states, every year brings stories from around the country of children killed after long histories of contact with child welfare authorities. Twenty-seven percent of the fatality cases analyzed by the Administration on Children and Families for its Child Maltreatment report had at least one Child Protective Services contact within the past three years.  State child welfare agencies tend to hide behind strict privacy protections in order to avoid releasing information on child protection failures, even though the case information could be released without including the names of the families involved. As a member of the District of Columbia’s Child Fatality Review Commission, I hear at almost every monthly meeting about one or more children who died after the family was called to the attention of CPS multiple times. And yet, I am not allowed to share any information about these cases with anyone, including legislators.

At least in Illinois, thanks to the DCFS Inspector General, the public and its elected representatives are given the opportunity to learn about failures to protect children while in the custody of their parents as well as those the custody of DCFS. This information helps make the case for change. The OIG report was the subject of a hearing in Springfield. The Governor has already requested an increase of more than $70 million for 126 new staff and technology upgrades.

Unfortunately, most states do not have an independent agency like the Illinois OIG to look out for children who are served by the agency both at home and in care. In a report issued on April 4, 2018, the National Council of State Legislators found that only 11 states have “an independent and autonomous agencies with oversight specific to child welfare,” although they seem to have missed Illinois. All states need such an autonomous agency. Somebody needs to reveal the truth about how we fail our most vulnerable children–and what it would take to do better.

Number of Child Deaths by Case Status from OIG Report

Case Status*                                                    Number of deaths or serious injuries

Pending Investigation at time of child’s death………………………………………………………12

Unfounded Investigation** within a year of child’s death……………………………………37

“Indicated” Investigation*** within a year of child’s death…………………………………..15

Youth in care………………………………………………………………………………………………………………16

Open Placement/Split custody****……………………………………………………………………………..3

Open Intact Case*****………………………………………………………………………………………………….8

Closed Intact Case within a year of child’s death……………………………………………………….3

Child of Youth in Care……………………………………………………………………………………………………1

Child Welfare Services Referral (no allegation of abuse or neglect)………………………….2

Preventive services to assist family but not as result of indicated investigation………1

Total……………………………………………………………………………………………………………………………….98

*When more than one reason existed for the OIG investigation, the death was categorized based on “primary reason.”

**An investigation in which the agency was unable to verify that abuse or neglect occurred. 

***An investigation in which abuse or neglect by the parent was found to have occurred.

****Child was in home with siblings in foster care

****A case in which the family was receiving services while the child remained in the home. 


  1. Of the 16 children who died while in foster care, a 14-year-old and an 18-year-old died of gunshots by unrelated perpetrators, two died as a consequence of abuse by their parents in infancy, three were infants in care of relatives and cause of death was undetermined for two and suffocation for one, two died of methadone or opioid intoxication, one 18-year-old died in a car accident and five died of natural causes. 

 

Why America needs an Interstate Child Abuse and Neglect Registry

HeavenWatkinsOn May 18, 2018, a little girl named Heaven Watkins was found brutally beaten to death in her  home in Norfolk Virginia. Three months earlier, Heaven was hospitalized with third-degree burns that kept her in the hospital for six days and required skin grafts. Child Protective Services in Norfolk was reportedly called but they decided not to intervene to protect Heaven.

Investigations from KARE 11 in Minneapolis and 13News Now in Norfolk revealed that Heaven  was removed from her parents four years before in Minnesota due to concerns about physical punishment, sexual abuse, drug sales and guns in the home. Virginia DSS has refused to tell reporters whether its workers knew of the family’s history in Minnesota. The haunting question is whether Virginia would have done more to protect Heaven had they known of her history in Minnesota.

Heaven was not the only child in the care of a parent who was known to Child Protective Services in another state. A 2012 report by The Oregonian  discussed several other children who died of abuse after investigation that did not unearth their family history in other states. Heaven’s story has triggered renewed calls for an interstate registry of child abuse and neglect. Had a registry existed, Virginia would have known the troubled history of this family and might have opted at least to provide supervision if not to remove the children.

The establishment of an interstate registry of child abuse and neglect was actually mandated more than a decade ago by the same legislation that mandated the national registry of sex offenders. Section 633 of the Adam Walsh Child Safety and Protection Act of 2006 required the Secretary of Health and Human Services to create a national registry of substantiated cases of child abuse and neglect. Yet this registry was never created.

Congress never appropriated funds to establish the registry but it did designate funds for a feasibility study that was also mandated under the act. A Research Report on the feasibility study and a report to Congress based on the results were published in 2012–six years after passage of the Act. The conclusions of the report were somewhat discouraging as to the potential benefits of a national registry. But interestingly, the underlying research reports had a much more positive view of the feasibility and potential benefits of the registry.

In the report to Congress, HHS  emphasized the barriers to developing a functional registry. These include the Adam Walsh Act’s prohibition on including any information other than the perpetrator’s name, the need for stronger due process requirements in some states if the database were to be used for employment checks (which is not the purpose envisioned by the statute), the need to provide funding or other incentives for states to participate, and the need for legislative changes in many or most states. These are serious barriers indeed but could be addressed, albeit with new legislation and funding that would not be trivial to obtain.

Unlike HHS, the authors of the feasibility study addressed the barriers but gave first billing to the conditions that allow for the development of a registry. In the final paragraph of the research report states that “The foundations for a national registry already exist in the child protective services field given that nearly all States maintain the necessary data on child abuse and neglect perpetrators. The technical capacity of the States also supports the feasibility of a national registry.” The authors go on to discuss the barriers, but give first billing to the conditions that support the registry.

In its report to Congress, HHS concluded that even if the barriers to an interstate registry could be resolved, the registry would provided limited information “beyond what is already available from existing single state registries” and therefore “the added safety benefit of a national registry of child maltreatment perpetrators would be quite limited.” HHS concluded that a decision on whether to implement the registry should “consider whether this or alternative child safety investments would be most effective in promoting the well-being of vulnerable children.” The clear implication was that alternative investments would be advisable.

HHS drew its conclusion about the limited safety benefit of a registry from the prevalence study mentioned above. The researchers used the numbers of perpetrators with incidents in more than one state to estimate how many interstate perpetrators would be identified by a registry.  Using information from 22 states with about 54% of the U.S. population, the researchers estimated that 7,852 perpetrators of child maltreatment in 2009 (or 1.5% of all substantiated perpetrators) had any substantiated maltreatment incidents in another state within the preceding five years.

HHS  described 7,852 as a small number, and therefore concluded that there was  “no evidence of a widespread phenomenon of child maltreatment perpetrators who offend in multiple states.” Moreover, HHS added that most of these perpetrators had “a single additional substantiation for child neglect (rather than for physical or sexual abuse) in a single additional state.” Moreover,  just half of one percent of child maltreatment deaths in states participating in the study was attributed to a perpetrator who had a substantiated maltreatment report in another state (4 in total).”

HHS’ interpretations suggest a low valuation of children’s lives and freedom from suffering. Almost 8,000 interstate perpetrators in a year could be considered a large number, even if most of them were substantiated for neglect and not abuse. The downplaying of neglect is a common trope among critics of CPS intervention, but neglect can be equally dangerous and often coexists with abuse that may not be substantiated.  “Just” four deaths in one year is a hard description to stomach while wondering if even one of these deaths could have been prevented with an interstate registry. Moreover, each death implies an unknown but larger number of injuries, and even more children living in pain and fear.

While dismissing the prevalence study’s estimates as “small,” HHS failed to mention the conclusion in a separate report on the prevalence study that the number of positive matches from states’ use of a fully functioning national registry would be much larger than the estimates above would indicate. That’s because the registry would be most commonly used during an investigation before a substantiation decision has been made, and the investigators would be  looking for a substantiation in just one state. Therefore, the researchers concluded that the registry would likely yield “several times the number of matches” that the study found for interstate predators.

HHS also downplayed the benefits found by the Key Informants Survey–the other part of the feasibility study. Of the 36 states participating in the Key Informants Survey, 25 states said participating in a national registry would save time, and 22 states thought it would “provide more timely knowledge that would be useful in assessing child safety.”  The authors of the research report concluded that “There appears to be significant interest in a national registry, primarily because States already have to inquire about possible prior perpetrator status from multiple States.” In the report to Congress, on the other hand, HHS did not report that there was significant interest by states’ in a registry. Instead, the agency reported that survey results indicated that the primary benefit of the registry would be to save time, and then cautioned that this time-saving benefit might not occur.

Similar to the key respondents, the authors of the feasibility study concluded that an interstate registry might be most useful in saving staff time and resources “resulting from the speed and efficiency of making all interstate inquiries, the vast majority of which will not find a match.” The authors added that this could enhance child safety due to faster processing of maltreatment cases. This conclusion was not included in the report to Congress.

Of course an interstate registry could not be produced quickly or on the cheap. Creating and activating it would be a multiyear effort that would have to begin with the amending of the authorizing legislation to include at least sex and date of birth in addition to perpetrator’s name. Many states would need to change their legislation as well in order to eliminate statutory barriers to participation. As the authors of the feasibility study indicated, convincing a “critical mass of states” to participate quickly might require incentives, such as funds to offset costs for initiating a registry. Clearly, an infusion of federal funds for this purpose would be a necessary incentive.  Perhaps Congress could make participation in the registry mandatory in order to receive federal child welfare funds under CAPTA or better still the Social Security Act.

It is concerning that HHS under the last Administration produced such a distorted view of the Congressionally-mandated feasibility study of an interstate child abuse and neglect registry.  It is my hope that this issue can be revived in the current Congress, perhaps as part of the reauthorization of CAPTA. Our children deserve no less.

 

 

Why No One Saved Gabriel Fernandez

Gabriel Fernandez
Image: LATimes.com

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

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

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

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

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

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

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

Resource Constraints

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

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

Ideological Constraints

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

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

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

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

“Steady March Toward Child Fatality Prevention” leaves Many Endangered Children Unprotected

sad child
Image: socialworkhelper.com

In an April 26 Opinion piece in the Chronicle of Social Change, Teri Covington congratulated the child welfare establishment for a “steady march toward child fatality prevention,” citing new developments on the federal, state and local levels. Earlier that week, new details came out about a case involving six child abuse fatalities that had transfixed the nation. But any mention of the Hart case–or how we can address fatalities and near-fatalities from chronic and severe child abuse–was conspicuously missing from the article and the briefing conducted by Covington’s group on the same day.

On April 23, newspapers across the country carried new headlines about Jennifer and Sarah Hart and their six adoptive children, who drove off a California cliff to their deaths in March. The new information, released by the State of Oregon Department of Human Services (DHS), revealed that DHS knew of the Hart parents’ extensive CPS history in Minnesota and had convincing evidence of maltreatment in Oregon but was still unable to determine that abuse had occurred.

The Hart case may have been unusual in the sheer number of system failures involved, but none of the specific features of the case is unusual. In January, the 13 Turpin children who were saved from death by abuse and starvation by the extraordinary bravery of one child. Within the past year, we’ve learned about Brook Stagles in New York, Evan Brewer in Kansas, and many other children who were allowed to suffer ongoing torture and abuse because of failures of the community and the systems designed to protect them. And those are only the cases that made the headlines. We will never know how many other children have suffered and perhaps died of chronic and severe abuse without ever being discovered.

In the article and briefing, Ms. Covington cited a number of actions by federal, state, or local governments that fulfill one or more of the 100 recommendations of Commission to Eliminate Child Abuse and Neglect Fatalities (CECANF). First and foremost according to Covington was the passage of the Family First and Prevention Services Act (FFPSA), which she hailed as a “seismic change,” because it makes resources available for the first time for services to prevent children who have already been abused or neglected from entering foster care. It’s hard to see how the passage of FFPSA could help victims of chronic and severe child abuse. The view that virtually no abused child should enter foster care may be one reason why many abused children are eventually killed by their parents. Moreover, it is hard to see how FFPSA will make the kind of difference expected by its advocates, since states are already funding the same services through funding streams like Medicaid and TANF.

Covington also mentioned the addition of $60 million in CAPTA funds in the current fiscal year for safe plans of care for drug-exposed infants as “another major federal improvement.” This is a good step that might aid in early identification of some children at risk of abuse, but it is a drop in the bucket compared to the need.

Several state and local initiatives mentioned by Covington are steps in the right direction to identifying victims of chronic and severe child abuse. These include the introduction of predictive analytics, improved data sharing between agencies, and more interagency planning and action.

However, conspicuously missing from Covington’s narrative are a set of major reforms that need to occur if we are to avoid more tragedies due to severe and chronic abuse. Some of these reforms are listed below:

  1. Improve vetting of potential adoptive parents. Jennifer and Sarah Hart arranged the adoption of their children through a Texas agency that reportedly put together adoptions against the wishes of the child welfare agency. Moreover, the second set of children was adopted even though the parents had already been investigated for abusing one of the first set. Agencies must not let their desperate search for homes for children considered to be hard to adopt lead them to disregard the future outcomes for these children.
  2. Monitor children whose parents receive adoption subsidies. Given the disproportionate number of serious cases of child maltreatment among adopted children and a valid state interest in the well-being of children supported by the state, parents receiving adoption subsidies should be required to document annually the child’s well-being through a social worker or doctor visit.
  3. Monitor homeschoolers and ban homeschooling by known child abusers. It is all too frequent for parents who have been substantiated for child abuse to withdraw their children from school as soon as their case is closed and they are no longer under the supervision of the child welfare agency. Parents with a record of abuse should not be allowed to homeschool their children. In addition, since homeschooled children appear to figure disproportionately in serious cases of abuse, all homeschooled children should have at least annual contact with a mandatory child abuse reporter such as a teacher, doctor or social worker.
  4. Adopt and promote universal mandatory reporting. Only 18 states and Puerto Rico require all adults to report suspected child abuse or neglect; most states require only certain professionals to do so. And even in the universal reporting states states (including Texas, where neighbors did not report the numerous red flags surrounding the Turpin family), it is unlikely that people know or observe the law. It should be mandatory for all adults to report any reasonable suspicion that a child is being maltreated and this duty should be promoted through a massive public information campaign.
  5. Demand greater accountability from mandatory reporters, as CECANF recommended. Incredibly, an Oregon pediatrician who saw the Hart children at the request of DHS reported that she had “no concern” that five out of six were so small and thin that their weights and heights did not even appear on the growth charts for children their age. CECANF recommended that mandatory reporting training and competency should be a requirement for licensure when applicable. Licensees and their agencies should be responsible for maintaining and refreshing their competency. And doctors who fail to fulfill their responsibilities should lose their licenses.
  6. Revamp investigations. Agencies need to separate the determination of whether abuse has occurred (which can be difficult when frightened children are coached to lie) from the decision to protect vulnerable children. Furthermore the definition of “safety” needs to be changed in many states. Often, a child deemed to be at high risk can be simultaneously labeled as “safe.” Thorough investigations also require manageable caseloads, which in turn require sufficient funding, which is not available in many states.
  7. Interstate registry: In child maltreatment death cases like that of Adrian Jones, parents have been able to escape detection by moving to another state. States should be required to participate in an interstate registry of child maltreatment reports and findings. This was recommended by foster care alumna and 2017 Congressional intern Tonisha Hora, who along with her sister suffered ten years of severe abuse before she was rescued by CPS.
  8. Reform in-home child welfare services so that meaningful services are provided and feedback is obtained from providers about parents’ progress. No case should be closed unless a state obtains credible testimony from service providers, the children and other professionals who know the family that parental behaviors have changed. Again, this require manageable caseloads and adequate funding.

Why were none of these proposals mentioned in the article and briefing? The most direct cause is that only one of these proposals (holding mandatory reporters accountable) was recommended (in part) by CECANF. But that just begs the question of why they were not among the CECANF recommendations.  There are three reasons I can identify:

  1. More children die of neglect than abuse. Of the children who were reported to the federal government who died of maltreatment in 2016, 75% suffered neglect and 44% suffered abuse either exclusively or in combination with another maltreatment type. At the briefing, a speaker from the Virginia Department of Social Services stated that unsafe sleep was the primary driver of child fatalities in Virginia, so the department was concentrating its fatality prevention work on safe sleep. Of course we should promote safe sleep, but we can’t ignore those children who die of severe and chronic child abuse because they are fewer in number.
  2. Many of these measures would draw intense political opposition for ideological reasons or because they would require increased spending. Homeschooling parents and adoptive parents have been adamantly opposed to any monitoring of their children. Doctors would virulently oppose greater penalties for malfeasance. Beefing up child welfare systems would cost money and systems around the country are struggling to obtain enough funds to meet increasing needs.
  3. The narrative currently embraced by the child welfare establishment is that all parents want the best for their children and that all children do best with their parents, no matter how abusive or neglectful. Perhaps that is why there has been so little response to the Hart tragedy and similar tragedies from the agencies responsible for protecting children.

The child welfare establishment needs to recognize that there are some parents to whom the prevalent rosy attitude simply does not apply. Ms. Covington opened her article by stating that deaths of children from abuse and neglect increased by more than 7 percent from 2015 to 2016. We don’t know how many of these deaths stemmed from severe and chronic child abuse. If there is such a thing as “a fate worse than death,” then years of torture by the people who are supposed to protect you qualifies. As you are reading this, how many children are being deprived of food, chained to their beds, or being beaten? One is too many, and political barriers should not be allowed to prevent action.

Secrecy in child welfare: cover up or get better?

 

Kansas-Kids-
Evan Brewer, Caleb Blansett, Adrian Jones: From http://www.crimeonline.com

Clint Blansett’s 10-year-old son had been dead just a few days when a social worker from the state knocked on the family’s door in south-central Kansas . She wasn’t there to offer condolences after Caleb’s death or ask about his sister, Blansett said. She wanted him to sign a form saying he wouldn’t talk about his son’s death or the Kansas Department for Children and Families. No details about contact the agency had with the family before Caleb’s mom smashed his head with a rock while he slept and then stabbed him seven times.

So begins a story by the Kansas City Star entitled Secrecy inside child welfare system can kill: ‘God help the children of KansasIn it. reporter Laura Bauer describes an agency that chooses to protect itself at the expense of fulfilling its mandate to protect kids. Among the examples included in the story are

  • A DCF deputy director resigned after she was asked to shred notes of meetings about critical cases. Furthermore,  her attempt to implement a systemwide review process for such cases was refused because administrators did not want mistakes documented in writing lest they would be used in court against the agency.
  • For a year and a half, DCF refused to release information about its repeated interactions with the family of Adrian Jones, who was killed by his father and stepmother and fed to their pigs. It was only after the murderers were sentenced to life in prison that DCF reduced 2,000 pages of records that were haphazardly thrown together in what looked like a purposeful attempt to baffle readers. The records, once put in order, revealed multiple investigative errors, particularly three that probably cost Adrian his life.
  • A Wichita television station reported that DCF received several reports of mistreatment of Caleb Blansett, beginning in 2012 and continuing in the months before his death. On August 3, 2017, the Star requested information about these calls and any ensuing investigations. Three months later, DCF responded that it did not have the staff to respond to the request.
  • Just this past September, the body of three-year-old Evan Brewer was found in a cement structure outside the house where his mother and boyfriend were living. He had been missing at least since the previous March. His father claims to have made multiple reports to DPS alleging abuse of Evan.  DCF denied a request from a local TV station for the records relating to these reports.

Kansas law requires that “in the event that child abuse or neglect results in a child fatality or near fatality, reports or records of a child alleged or adjudicated to be in need of care received by the secretary, a law enforcement agency, or any juvenile intake and assessment worker shall become a public record and subject to disclosure.” But unfortunately, the law does not define “reports and records.”

To receive federal money under the Child Abuse Prevention and Treatment Act (CAPTA), a state must allow “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.” Unfortunately, the vagueness of this language allows states to avoid releasing information necessary to identify how the agency failed. In a report entitled State Secrecy and Child Deaths in the U.S., two child advocacy groups found that all states have some sort of public disclosure policy regarding child abuse deaths. However, the report gave 20 states (including the three most populous states) a grade of C or below on these policies based on a variety of criteria, including whether they were encoded in statute, whether the disclosure is mandatory, and the scope and specificity of the information that must be disclosed.

Kansas was actually in the better half of states. It received a “B” from authors of the state secrecy report, mainly because it has a policy, the policy is encoded in statute, and is mandatory, despite the vagueness of the information that must be released. It is worth noting that only 14 states got higher than a B grade. Moreover, the report’s authors also found that states often fail to abide by their own disclosure policies–as when Kansas claimed to lack staff to respond to the request for information about the death of Caleb Blansett.

New Jersey’s child welfare agency, under the guise of protecting children’s privacy, in 2013 adopted a rule that the child welfare agency must release information only “to the extent it is pertinent to the child abuse or neglect that led to the fatality or near fatality.”  Even the under the new tightened rules the agency should have disclosed information about its past interactions with the family of  JoJo Lemons after he became the third sibling in his family to die while sharing a bed with other family members. His  parents were charged with reckless manslaughter and child endangerment, and each pleaded guilty to a count of child endangerment. Nevertheless, CPS concluded that JoJo’s death was not caused by abuse or neglect. Therefore, the agency was not required to release information about its interactions with the family.

In Cleveland, 5-year-old Tenasia McCloud was beaten to death by her mother and her girlfriend on March 17, 2017.  At the time of her death, the child welfare agency had an open case on the family, according to News 5 Cleveland. A social worker had visited the home eight times, including three days before Tenasia was brought to the hospital in cardiac arrest. The paper tried to find out how the agency did not see that the child was in danger. But Cuyahoga County Children and Family Services refused to provide records of agency contacts with the family, citing a rule prohibiting disclosures that might jeopardize a criminal investigation or proceeding. Only five other states have a similar rule, according to the State Secrecy study, suggesting that it is not a necessary requirement. Moreover, two states conversely allow disclosure only if a person is criminally charged or would have been criminally charged if they had not died.

Congress and the states must strengthen disclosure requirements in the event of child maltreatment fatalities or near-fatalities. Congress should amend CAPTA to define specifically what data states must release in the event of a child maltreatment fatality or near fatality. Until that happens, states should amend their own laws to strengthen the disclosure requirements. These disclosures should be required with no exceptions to any member of the public. The information required to be disclosed should include a summary of all past reports on the family or household, whether these reports were investigated, results of all past investigations and reasons for the determinations made; as well as a summary of all cases opened for the family or household, what services were provided, when the cases were closed and the reasons for closure.

Congress and states should also require that a commission of experts review every death or near-death of a child in a family known to the child welfare system. As I stated  in a previous post, the death or severe injury of a child in a family known to the child welfare system should be treated like a plane crash or the loss of the space shuttle Challenger. All such deaths or severe injuries should be reviewed immediately and exhaustively by experts of the highest caliber with access to all agency records regarding contact with the family or household. The report should include recommendations to avoid similar tragedies in the future and should be released to the public with names redacted when necessary to preserve the privacy of innocent children and adults.

The point of requiring release of information and analysis of case history is not mainly to allocate guilt or punishment, although practitioners guilty of egregious errors should be retrained or let go. Rather it is to identify policies or practices that can save children in the future. As the authors of the state secrecy report put it:

Abuse and neglect deaths represent child welfare agencies’ most tragic failures.        Unfortunately, it is often only through such cases that lawmakers and the public learn of systemic inadequacies in child welfare systems. If improvements and reforms are to be achieved, it is vital that the facts about these cases reach the public in a meaningful way.