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

Anthony Avalos
Image: Los Angeles Times

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

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

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

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

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

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

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

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

This state secrecy is not unique to Los Angeles. Only a few states provide for the release of information about agency interactions with children who died of abuse or neglect. Texas’ Office of Child Safety posts reviews of fatalities but only when a child died of abuse or neglect during an open case. Florida requires an immediate investigation of a child’s death if the family was involved with CPS in the past year and posts the review if the child was found to have died of abuse or neglect.  In Washington, the Children’s Administration (CA) conducts a review (by experts with no prior involvement in the case) when the death or near-fatality of a child was suspected to be caused by child abuse or neglect, and the child had any history with the CA at the time of death or in the year prior. These reviews must be completed within 180 days and posted on the agency’s website.

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

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

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

This post was updated on July 27, 2018.

“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.

Why Kansas let Adrian and Evan die

 

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

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

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

Looking at Root Problems

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

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

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

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

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

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

 

 

Why The Child Welfare Establishment May Not Want to Know About Child Torture

Turpins toilet
Image: CNN

The Child Welfare League of America (CWLA), one of America’s most venerable child welfare organizations, issued its weekly update on January 21 with something conspicuously missing.  “Last Week in Child Welfare, January 14 -21” contained updates on Mississippi’s lack of representation for families involved with child welfare, a recent report from New Jersey’s court monitor, and an opinion piece in the Indiana star about Indiana’s struggles with opioid abuse and its impact on the foster care system.

You would never know that on January 14, a starving seventeen-year-old escaped from a house of horrors where she and her twelve siblings were being starved, beaten, chained to beds, and kept prisoner. The teenager told police that her parents would kill her if her escape plan failed. During the week after the children’s rescue, public and press around the country and indeed the world were fixated on this story, trying to understand why it could happen and what could be done to prevent similar occurrences in the future. But this event apparently did not figure in CWLA’s “week in child welfare.”

One might think that an organization with a self-described mission “to advance policies, best practices and collaborative strategies that result in better outcomes for children, youth and families that are vulnerable” would be concerned that 13 children were allowed to suffer for so many years. You’d think that they would be putting out information  about the warning signs of child abuse and neglect and an admonition to make the call that might save a life. But you’d be wrong.

CWLA is part of what I think of as the child welfare establishment–the group that dominates the national conversation around child welfare. These organizations’ resources have enabled them to dominate the national conversation around child welfare by funding materials, conferences, and technical assistance to state and local child welfare agencies.  Since the 1970s, this group has been preoccupied with keeping families together and children out of foster care–with scant concern about the costs to kids in families that are so dysfunctional and dangerous that foster care is clearly a better alternative

Like the other members of the child welfare establishment, CWLA believes that “children fare better in their own homes compared to children in foster care who have been similarly maltreated, suggesting that social services should promote therapy, education, and treatments to increase family stability instead of relying on removals. ”

Of course child removals should should be minimized unless absolutely necessary, but it is difficult to imagine that parents like the Turpins could be helped through “therapy, education, and treatment” to love and nurture their children. The child welfare establishment appears not to want to believe in the existence of such parents who are so bad as to be beyond rehabilitation.

The child welfare establishment also fears that publicizing cases like that of the Turpins will result in a flood of calls to child abuse hotlines, resulting in the type of “foster care panic” that sometime occurs after a tragic case. Perhaps they would rather not encourage members of the public to report suspicions of child abuse that might save children in the future, because they believe such reports must increase the foster care rolls.

Of course we don’t want the public making frivolous, malicious, or fallacious reports. Nor do we want investigators responding to tragic events by sweeping kids up into foster care who don’t need to be there. In some cases, we can help children by monitoring their situation and providing services to their parents without removing the children. But in other cases, the children can only be protected by removing them from their toxic families.

The desire to avoid publicizing extreme cases of abuse and neglect might also explain why the child welfare establishment was not part of the coalition that supported the establishment of the Commission the Eliminate Child Abuse and Neglect Fatalities. And it might explain why, as I wrote in an earlier post, child deaths and other tragedies that are missed by CPS are often followed by the comment from system administrators that “systems should not be judged by one case.”

During the week the Turpins were uncovered, CWLA thought it was more important to cite an op-ed piece that criticized Indiana’s highly respected former child welfare commissioner, who resigned with warnings that children would die if more funding was not provided. CWLA assured readers that “Even infants who have been exposed to narcotics fare better when they are kept with their mothers, assuming the mother has access to government resources and drug treatments.”

Unfortunately, the child welfare establishment’s obsession with keeping kids out of foster care may be condemning more children to suffering, physical and emotional injury, and death at the hands of their own parents.

This post was updated on January 29, 2017.

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Yes, A System Should be Judged by One Case

Katia Tirado
Image: Hartford Courant

“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) Katz’ words were reported by the Hartford Courant.

Katz was referring to the case of Matthew Tirado. Matthew, a 17-year-old diagnosed with Autism and Intellectual Disability, died on February 14, 2017 from prolonged abuse and neglect by his mother.  As revealed by a heartbreaking  report from Connecticut’s Office of the Child Advocate (OCA), Matthew had been known to DCF for 11 years, since he was five years old. Yet, DCF missed several opportunities to save Matthew, who was nonverbal and could not speak for himself. Matthew’s interactions with DCF included:

  • In December 2005, when Matthew was six years old, his school called DCF to report that Matthew had missed more than 30 days of school since the school year began, . DCF investigated and found neglect but later closed the case after Matthew’s attendance briefly improved.
  • In December 2006, the school again contacted DCF to report that Matthew had missed over 50 days of school. DCF closed the case six weeks later without finding neglect. Matthew’s mother told DCF that her mother was moving in to help her care for the children. This should have been a red flag because agency files documented Matthew’s grandmother’s  long history of involvement with DCF, alcohol abuse and mental illness. But repeated risk assessments erroneously noted that Matthew’s mother had no history of being abused or neglected as a child.
  • In 2009, school officials again called CPS stating that Matthew came to school with bruising on his face that was covered up with makeup. School officials also reported contacting Ms. Tirado on other occasions regarding bruises, which she responded were inflicted by Matthew’s two-year-old sister.  Matthew’s mother denied abusing him and the case was closed before requested medical records arrived.
  • In October, 2014, Hartford Public Schools (HPS) reported that Matthew’s sister, a first-grader, showed signs of physical abuse and reported that her mother hit her. She told school staff that Matthew was also hit, but he was not seen or assessed.
  • In November 2014, HPS reported to DCF that Matthew was not enrolled in school and may not have been in school for a long time. In fact, Matthew had hardly attended school since 2012.  DCF found Ms. TIrado to be neglectful and abusive and opened a case on the family for supervision by the agency.
  • Matthew attended less than 100 days of school between June 2012 and his death in February 2017. HPS made five reports to DCF between October 2014 and May 2016. about the children’s failure to attend school.  After March 2016, Ms. Tirado refused to allow DCF access to her children. In July, DCS iled a neglect petition with the Juvenile Court.
  • The Court held six hearings on the case between July and December 2016 but Ms. Tirado never appeared. In December 2016 DCS asked the court to terminate the case. No orders were sought to compel Ms. Tirado to produce the children, permit visitation of Matthew’s sister in school, or to remove the children, even though there was legal justification for any of these actions. Unbelievably, after a failed attempt to compel Ms. Tirado to come to court, the court accepted DCS’ request to close the case. DCS closed its own case on the family in January 2017.

After Matthew’s death, the Hartford Courant reported that Commissioner Katz shockingly told legislators that “As horrible as this may sound, there comes a point where you have to make a determination that you have done all that you can legally do. There are 15,000 cases and only so many social workers.”

The Commissioner also said that a system should not be judged based on one case. It’s an old refrain. But is it true? I don’t think so. There are many reasons why a system should be judged by one case.

First, we are not talking about one bad decision. A child suffered for as long as 11 years and agency social workers missed multiple opportunities to protect him. His sister fared a little better since she survived but will probably bear lifetime scars. This is more than a one-time event.

Secondly, for each “worst case, “we don’t know how many children suffer for years and don’t die while the system ignores repeated red flags.  At least Matthew is out of his misery. The others are still suffering. We may never know their names.

I’m tired of agency heads who tell us not to judge the system by the worst cases. Lets bury this trope once and for all. A system should be judged–above all–by the worst cases. For each of these cases represents many more children whose daily suffering will lead to lifetime emotional educational and physical damage.

 

 

 

 

 

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.

 

 

 

 

Domestic violence and child abuse: a lethal combination

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It did not take long for the press to discover that Devin Kelley, the the perpetrator of the  recent mass shooting in Texas, had repeatedly assaulted his first wife and fractured the skull of his infant stepson in 2012. He was court-martialed for those offenses, pled guilty, and was imprisoned for a year.

I could not help noting the parallel to the case that I wrote about in my last post–that of Antoine Flemons, who at two months old was beaten to death by his father, Antoine Petty. The post focused on one aspect of this case–the fact the father was known to have abused many other children.  I argued that baby Antoine might have been protected by a broader policy to identify at birth babies born to parents with such a record.

But the revelations about the Texas shooter reminded me of another important aspect of Antoine’s family that put the baby in grave danger.  In an interview with the Washington Post, Antoine’s grandmother stated that her daughter Geneice Petty loved her son but suffered from “battered women’s syndrome.” In other words, she was a victim of domestic violence.

The connection between domestic violence and child abuse is well-documented. Research suggests that “in an estimated 30 to 60 percent of the families where either domestic violence or child maltreatment is identified, it is likely that both forms of abuse exist.”

In the 40 states providing domestic violence data to the Administration Children and Families for its Child Maltreatment 2015 report, 25% of child maltreatment victims were found to have a caregiver who was either a victim, perpetrator or witness of domestic violence.

Co-occurring domestic violence and child abuse can take several forms. In many cases, one parent (usually the father) abuses both the other parent and the child or children. There are other configurations, such as families in which the abused parent in turn abuses the children.

In baby Antoine’s case,  no information has been released to the public. One can speculate in view of the father’s extreme violence that Geneice Petty was afraid to protect her children and that her husband bullied her into covering up his killing of their son.

The key question is what could have been done to prevent the death of Antoine. Historically, child welfare systems have had not responded effectively to domestic violence. Common and problematic patterns have included ignoring or minimizing the domestic violence and, conversely, giving women an ultimatum to leave the abuser or leave their children–a response which often leads women to fear and avoid child protection authorities rather than seek their help.

One study found that “[Domestic violence]appears to have only a minor role in influencing the decisions of child welfare workers; yet, children exposed to [domestic violence] often have multiple contacts with [child welfare services] due to the higher number of repeat allegations of maltreatment.”

The Children’s Bureau has has published a useful manual about how to handle child maltreatment cases in which domestic violence is present or suspected. The manual’s many recommendations provide alternatives to the problematic practices mentioned above.

Unfortunately, we don’t know if Maryland child welfare workers even identified domestic violence in earlier cases involving Antoine’s parents, let alone how they responded. That’s why, as I have said over and over again about all child maltreatment deaths and serious injuries, there needs to be a thorough investigation, a public report, and a proposal for changes in policy and practice to protect future baby Antoines.