A shattering new report from a Minnesota child advocacy group demonstrates that many of the more than 160 deaths of children from abuse and neglect over an eight-year period ending last May were preventable. These deaths, the report concludes, can be attributed to “a child welfare philosophy which gave such a high priority to the interests of parents and other adults in households, as well as to the goals of family preservation and reunification, that child safety and well-being were regularly compromised.” This report is essential reading for child advocates everywhere, because this philosophy reigns around the country, and the troubling factors identified exist in states where most of the child population resides.
Produced by the child advocacy group Safe Passage for Children of Minnesota, and authored by Safe Passage Executive Director Richard Gehrman and Maya Karrow, a fellow from a local law school, the project collected information about 88 children who were killed between 2014 and 2022. The Minnesota Department of Human Services (DHS) told project staff that it was aware of 161 child maltreatment deaths during a period that mostly coincides with the period studied.1 But DHS refused to provide information on any of these deaths (in violation of state and federal law), so the staff had to rely on news reports, online court records, and information provided by counties for the 88 cases it had identified.
Like child maltreatment fatality victims nationwide, the dead children were young, with 42 percent under a year old and 36 percent between one and three years old. Children under four were 78.4 percent of the Minnesota deaths very similar to the 76.3 percent for child maltreatment fatality victims nationwide. Black children accounted for 26.1 percent of all the fatalities reviewed. In contrast, Black children were 17.8 percent of children involved with child welfare and 10.6 percent of the state’s child population in 2021.2 Based on the statistics and case file reviews, the report’s authors expressed concern that chld welfare agencies in Minnesota “may have tended to leave Black children in more high-risk situations for longer periods of time than children of other races and ethnicities.” The report’s authors are not the first to have asked whether fears of being accused of racism may be leading agencies to leave Black children in harm’s way even more than children of other races.
The most common causes of death among the cases reviewed were blunt force trauma to the head (33 percent) and body (19.3 percent). The other major causes of death were asphyxiation (17.0 percent) and gunshot wounds (8.0 percent). Other causes included drowing, sepsis, poisoning from drugs, stabbing, hypothermia/hyperthermia, fire, and undetermined causes.
The most common perpetrators of child fatalities were mothers (27.3 percent), mothers’ significant others (23.9 percent), and fathers (22.7 percent). In 65.9 percent of the cases, one or more of the perpetrators had a history of substance abuse. Shockingly, there were seven deaths in foster care, of which six were in kinship foster care. In another appalling finding, there were seven cases in which a child was killed along with the mother or while attempting to intervene in an assault on the mother.
A concerning pattern was the evidence of child torture in a surprisingly large number of cases. The project’s reviewers identified 14 cases (or 15.9 percent) that displayed signs of torture, according to criteria outlined by experts. The authors used the case of Autumn Hallow, who was killed at the age of eight, as an illustration. Investigators found that Autumn’s father and stepmother frequently bound her in a sleeping bag as punishment, sometimes with her hands tied behind her back or overnight, and starved her for six months so that she weighed only 45 pounds when she died. A particularly appalling feature of her case was the “chilling indifference by all the authorities involved to the screams of a child [reported repeatedly by neighbors] and the pleas of an increasingly distraught mother.” Autumn’s cause of death was declared to be asphyxia and blunt force trauma. Her father and stepmother were convicted of second-degree unintentional murder in her death.
The project uncovered numerous systemic flaws that contributed to the 88 deaths reviewed. These included inappropriate assignment of reports to a “family assessment” rather than a factfinding investigation; the failure to respond adequately to repeated reports suggesting chronic maltreatment; seemingly endless chances given to parents to address chronic problems; the return of children from foster care to homes where safety had not improved;the placement of children with kin without appropriate vetting; leaving children with mothers who repeatedly failed to protect them from violent partners; and the lack of integration between child welfare and child custody cases.
The repeated inappropriate assignment of cases to the “Family Assessment” (FA) track, which is intended for low-risk cases, was a major recurring theme in the case reviews. Minnesota is one of 34 states that initially adopted a two-track model, often known as differential response, for responding to reports of suspected maltreatment. (Some states have since terminated the practice). The idea was that a less-adversarial response than an investigation would be a better way to engage families with lower-risk cases. But with its practices like informing parents of visits beforehand, interviewing children in front of their parents, and making no finding as to whether maltreatment occurred, the report explains that FA is not appropriate when the risk to children is high. Yet, by 2020, 62 percent of CPS reports in Minnesota were assigned to Family Assessment. The researchers found that 31 of the 59 families with Minnesota child protection history had at least one and as many as six Family Assessment cases prior to the fatality. As the authors point out, “it is self evident that the repeated use of FA in chronically referred families is inconsistent with the policy that FA be used only in low-risk cases.”
Among the examples cited by the authors for the inappropriate use of FA was one that occurred following a report that a mother and her boyfriend were hitting their children with objects and dragging them by their hair. This family was the subject of six previous reports that included allegations of “physical abuse, sexual abuse, and unhygienic and unsafe conditions, including rotten food, garbage, drugs, alcohol, and sharp objects accessible to children throughout the home.” Twenty days after that last FA, two-year-old Lyla Koob was dead. Her mother’s boyfriend admitted to shaking her in frustration after she vomited. Her autopsy revealed bleeding on the brain and injuries behind both eyes.
Based on analysis of court records, the researchers found that 71.6 percent of the dead children’s families had previous involvement with child protection. The 61 families included 59 with prior history in Minnesota and two with prior history in another state. In view of these percentages, it is not surprising that the project staff found that Minnesota child welfare had a pattern of failure to respond adequately to chronic maltreatment.
In some cases, the researchers noted a pattern of inaction by child welfare agencies in the face of chronic multitype maltreatment, or maltreatment that includes neglect as well as abuse. The case of Tayvion Davis, who died in 2018 at the age of eight, was used to illustrate this type of negligence. Before he was born, Tayvion’s mother was convicted of malicious punishment of a child after she and two adult relatives held down and beat one of her children. From that time until Tayvion’s death, the family was the subject of at least ten reports of physical abuse, sexual abuse, or neglect. According to court records, the children were hit with a hammer and a metal rod, whipped with a belt, burned with boiling water or chemicals, deprived of food and sleep as punishment, and threatened with death if they talked about the abuse. There were multiple reports of sexual abuse of Tayvion or a sibling by the oldest sibling, juvenile and adult relatives, and an unrelated adult.
Tayvion Davis froze to death in 2018 after his mother locked him in the garage overnight in subzero temperatures. The autopsy found numerous scars that suggested years of abuse that may have escalated into torture. Unbelievably, Tavion’s siblings were returned to their mother after being removed in the wake of Tavion’s death. They remained with her for another five months, during which she was the subject of several additional reports. It was not until they were removed again that they told their foster parents that Tavion was deliberately locked in the garage, resulting in murder charges against the mother.
The researchers also found that counties gave parents multiple chances to address chronic problems, while failing to execute effective safety plans for children remaining at home. One example of this tendency was the case of Aaliya Goodwin, who died at the age of five months. There had been eight reports for two older siblings regarding the parents’ substance abuse. Between 2015 and 2021, four safety plans were mentioned in court records, the oldest sibling was placed in foster care and returned home twice, the mother was charged with nine drug-related offenses and convicted of five, and the father was charged seven times with two convictions. The county opened a new FA in January 2022 due to a report of domestic violence and the mother agreed to a substance abuse assessment. Three days later she was found passed out on the couch after using drugs and alcohol. Aaliyah, squashed between her mother and the couch, was dead of positional asphyxia.
Another pattern cited in the report was counties’ tendency to return children from foster care to a home that was still unsafe. The project revealed that 26 percent of the children who died had been previously removed from their parents and then returned. The case of Khamari Golston was provided as an illustration of this pattern. Multiple abuse injuries to four-month-old Khamari resulted in his and his twin sister’s removal and placement in foster care. Their mother was charged with felony malicious punishment and assault. But only two months after adjudicating these children to be in need of protection, the judge sent them home for a “trial visit.” The mother was said to be cooperating with her case plan but there was no documentation of this in the court record. Eight weeks later, Khamari was dead of suffocation or smothering. He also had multiple injuries consistent with physical abuse. Khamari’s ten-year-old sister reported that their mother frequently choked him and covered him up when he cried.
Some children were returned from foster care to parents with serious mental illness. The report cites six-year-old Eli Hart, whose mother killed him with multiple shotgun blasts to the head and torso nine days after he was returned home. Eli was returned home without evidence that his mother’s mental illness was under control. Instead, her mental health remained a concern throughout the year that he was in foster care and during a trial home visit. She received eight traffic-related convictions (including for speeding and reckless driving) and was also charged with theft of pharmaceutical drugs during the time he was in foster care.
The occurrence of seven deaths of children in foster care, of which six were in kinship care, was a startling revelation of this study. There have been concerns raised around the country that the growing focus on kinship placements may be leading to the placement of children with family members who have not been adequately screened and are not appropriate caregivers. And indeed, the project staff found a “lack of due diligence in deciding whether a kinship placement would ensure the safety and well-being of the child.” To illustrate this pattern, the report offers the history of Leila Jackson, a 17-month-old who was killed by her foster father in 2018. Her autopsy showed “extensive subdural hemorrhages and severe brain injury, as well as extensive bruising on her buttocks.” Layla and her brother were placed in the kinship home after their mother’s parental rights were terminated. The foster parents denied having criminal records or substance abuse histories, but a background check (which was never conducted) would have revealed convictions for DWI, theft, possession of drug paraphernalia, and disorderly conduct.
The pressure to keep children with mothers who were victims of domestic violence, even when these mothers showed they were unable to protect their children, was another systemic problem noted by the project team. The authors found that 28.4 percent of the cases involved domestic violence–not surprising in view of the co-occurrence of child maltreatment with domestic violence. But that seven children were killed along with their mothers, or in an attempt to protect them, was shocking indeed. This is a difficult issue, and removals of children from domestic violence victims by CWS have been harshly criticized. But as the report put it, “at a certain point a line is crossed and it becomes imperative to move children to a safe place.”
In Minnesota, public child welfare cases are heard in juvenile court and custody cases in family court, which means that the same family can have two different court cases with different judges. The findings of the report suggest that the failure to consolidate these cases can place children at risk. In the case of Eli Hart, who was killed by his mentally ill mother, the custody case filed by his father was put on hold pending a resolution of the juvenile court case surrounding his mother. This is despite the fact that the mother’s mental health remained a concern and that all reports indicated that the father was a good and safe parent for Eli.
In sum, the report concludes that “the professional norms currently guiding child protection and foster care are out of alignment with those of the broader community.” As a first step, the report recommends that DHS release more information about child maltreatment fatalities, including making public the fatality and near-fatality reports that counties are required to submit to the state; such reports include information about previous reports and investigations on these families. This recommendation is particularly important because if the public knew about the types of egregious failures described in this report, there might be more public support for changes.
The report contains many specific recommendations to correct the systemic flaws found in the case studies. This year, Safe Passages will be distributing the report to legislators and briefing them on its findings and recommendations. Rick Gehrman, Executive Director Rick Gehrman reports that he will be working with legislators to translate some of these recommendations into legislation to be introduced in the next session, addressing at a minimum some of the Family Assessment practices that endanger children. The ultimate goal, Gehrman says, is to “raise public and legislative awareness of the child welfare practices that endanger children and to bring about a change in the overall philosophy of child welfare services in Minnesota.”
In effect, Safe Passages for Children has unofficially implemented the first recommendation of the Committee to Eliminate Child Abuse and Neglect Fatalities in its 2016 final report, Within Our Reach. That report recommended that each state, with federal funding and assistance, identify and analyze all of their child abuse and neglect fatalities from the previous five years in order to identify factors associated with maltreatment fatalities and agency policies and practices that need improvement to prevent fatalities. Based on this report, every state would develop a fatality prevention plan. Unfortunately, legislation supporting this proposal stalled in Congress and no state has elected to do this on their own. Maryland’s Council on Child Abuse and Neglect and its Child Fatality Review Board, inspired by this recommendation, formed a joint subcommittee that produced an excellent review of child maltreatment fatalities in Baltimore between 2012 and 2015 which identified systemic flaws and made recommendations to correct them.3 Other than that report, I am not aware of any other similar project by a state or local government agency. Let us hope that this report encourages other child advocacy groups and community boards to act where governments have not.
The final words of the report deserve to be repeated. “The erosion in professional norms that has gradually caused human services entities to tolerate the current level of neglect and physical abuse of children has developed over the course of decades. A concerted effort by a community of professionals will be required to restore standards that were once taken for granted, and to place appropriate limits on the ability of adults in a child’s life to harm them.”
Notes
The actual number was likely two to three times as high because the manners of so many maltreatment deaths are misclassified.
See Child Maltreatment 2021. Table C-2, Child Population 2017 to 2021 shows the state’s child population rose from 1,300,061 in 2017 to 1,317,567 in 2021. Table C-3, Child Population Demographics, shows that there were 140,129 Black children in Minnesota in 2021. That figure, divided by 1,317,567 gives the Black percentage of all children in Minnesota as 10.6 percent in 2021.
City of Baltimore Health Department, Eliminating Child Abuse and Neglect Fatalities in Baltimore City. January 2017. This report appears to be no longer available online. Please email marie@childwelfaremonitor.org for a copy.
The federal government’s annual maltreatment report for 2021 was released on February 9, 2023, and the child welfare establishment is celebrating. New Child Maltreatment Report Finds Child Abuse and Neglect Decreased to a Five-Year Low, crowed the Administration on Children and Families (ACF). “Number of Abuse and Neglect Victims Declines Again,” trumpeted The Imprint, a journal that typically reflects the prevailing voices in child welfare today. Left for the body of the ACF press release (and totally omitted by The Imprint) was the fact that in 2021 the nation was still in a pandemic that kept many schools closed for much of the year, and that child maltreatment “victimization” reflects jurisdictions’ policy and practice much more than it reflects actual maltreatment. Thus, there is no reason to celebrate a decrease in child maltreatment based on this report.
Child Maltreatment 2021 , the latest edition in the annual series from the ACF, combines data from the 50 states, the District of Columbia and Puerto Rico about the number of reports or children involved in each stage of the child welfare system in Federal Fiscal Year (FFY) 2021, which ran from October 1, 2020 to September 30, 2021. The data are obtained from the National Child Abuse and Neglect Data System (NCANDS), a national data collection program run by the Children’s Bureau under ACF. Arizona did not submit data in time to have its data included in this report, so only 49 states are included in this year’s report, along with the District of Columbia and Puerto Rico. Commentaries from most of the states regarding policies and conditions that may affect their data are attached in an appendix. The report’s findings are summarized in Exhibit S-2. All of the figures in this post are taken from the report.
A family’s journey through the child welfare system starts with an initial report, known as a “referral.” Figure 2-D below shows that the total number of referrals (the purple line) rose between 2017 and 2019, dropped sharply in the wake of the Covid pandemic in 2020, as schools closed and many families isolated at home, and increased only slightly in FFY 2021. It is important to remember that in FFY 2021, which began in October 2020, many schools were still closed. Most schools opened over the course of FFY 2021, but some remained closed the entire year. Thus, reporting from school personnel was suppressed for the federal fiscal year.
The rate of referrals as a portion of the child population varied greatly by state. Table 2-1 of the report shows that the total referral rate per 1,000 children in 2021 ranged from a low of 17.8 in Hawaii to a high of 137.0 in Vermont in 2021. Such differences exist every year and reflect factors such as public opinion and knowledge of child maltreatment reporting, as well as state practices. Some states do not even report most referrals to NCANDS, as described in the state commentaries. Pennsylvania has a unique system in which most reports that are not for abuse are classified as “General Protective Services” and not reported to NCANDS. Similarly, Connecticut does not report referrals receiving an alternative (non investigation) to NCANDS. In 2021, state-to-state differences may also reflect how soon in-person schooling resumed in the state after the pandemic. Vermont reported in its commentary that it has been receiving more referrals for concerns that do not reflect maltreatment. Vermont also included several reasons for its high referral rate, including the fact that reports on multiple children in the same family are counted separately. Kansas reported a decrease in reports due to “engaging communities to focus on prevention.”
Once a referral is received, it can be screened in or out by agency hotline or intake units. In general, agencies screen out referrals that do not meet agency criteria, which vary by jurisdiction. Reasons for screening out a referral may include that it does not meet the definition of child abuse or neglect, that not enough information is provided, that another agency should more appropriately respond, or that the children being referred are over 18. Despite receiving slightly more referrals than the previous year, child welfare agencies screened out a larger proportion of them in FY 2021, resulting in a slight decrease in screened in referrals (known as “reports“), from 2020 to 2021 – the blue line in Exhibit 2-D. In the 46 states that provided both data points, 51.5 percent of referrals were screened in and 48.5 percent were screened out.
There is great diversity in the proportion of referrals accepted by states. The percentage of referrals that was screened-in ranged from 15.3 in South Dakota to 98.5 percent in Alabama.1 There are many reasons for these variations, mostly associated with differing policies and practices between jurisdictions. For example, Georgia mentioned in its commentary that after hotline calls increased in 2021, it adjusted screening criteria to screen out more of them. Indiana tried to reduce its screen-in rate by changing criteria related to sexual behavior among teens and preteens, marijuana use by children, and educational neglect. Kansas reported a decrease in reports due to a change in the screening process for educational neglect. Missouri, on the other hand, changed screening criteria to screen in more referrals out of concern for children isolated because of the pandemic.
In FFY 2019, teachers were the most common source of referrals, submitting 21 percent of all referrals. They lost that position in FFY 2020 with the pandemic school closures, while legal and law enforcement personnel increased their share of reports. Perhaps it is not surprising that teachers did not recoup their leading role in 2021, since many students were still attending school virtually for some part of the year. Teachers actually submitted a smaller proportion of referrals in 2021 (15.4 percent) than in 2020 (17.2 percent). It is possible that teachers were making more calls but that more of these calls were being screened out than in the year before. But since ACF does not show the distribution of all referrals by reporting source, one cannot use this data to test that hypothesis.
Investigations
In Chapter 3 of Child Maltreatment 2021 the focus shifts from the referral or report to the child. ACF estimates that 3.016 million children or 40.7 children per 1,000 in the population received an investigation or alternative response2 in 2021. This was a slight decrease over 2020, when 42.0 per 1,000 children received an investigation or alternative response. These rates varied greatly by state, from a low of 12.8 per 1,000 in Pennsylvania to a high of 129.8 in West Virginia. The low in Pennsylvania is not surprising due to its unique system in which most neglect referrals are not reported to NCANDS. But Maryland and Hawaii also investigated small proportions of children– 15.7 and 15.9 per 1,000. These investigation rates reflect the number of referrals and how many were screened in, as well as the number of children per referral.
ACF found that of the children who received an investigation or alternative response, 16.7 percent were found to be victims of child abuse or neglect, as shown in Exhibit 3-B.3 The remaining children were not determined to be victims or received an alternative response. Estimating for missing data from Arizona, ACF calculated a national “victimization rate” of 8.1 per 1,000 children. As Exhibit 3-C shows, this rate has been decreasing since 2018 but the greatest decrease was in 2020 with the arrival of the pandemic.
ACF’s use of the term “victimization” can be misleading. An investigator’s decision about the truth of an allegation is based on limited information and is constrained by available time and staff, and evidence indicates that many referrals are unsubstantiated when maltreatment actually exists. Moreover, these rates are dependent on state policies and practices. Because of the misleading nature of the term “victimization,” the term “substantiation” is used for the rest of this commentary. State substantiation rates per 1,000 children ranged from 1.6 in New Jersey (even lower than Pennsylvania’s 1.8) to 17.0 in West Virginia, suggesting that these rates reflect much more than the prevalence of child abuse and neglect.
Among the many factors that can influence state substantiation rates are:
Differences in referral rates and screening practices, as decribed above;
Different policies about what is considered child maltreatment and different levels of evidence required to substantiate an abuse allegation;
Whether and how much a state uses an alternative (non-investigation response);
Natural and social disasters that may vary in their impact between states. Some states went back to in-person schooling for the entirety of 2021, others opened midyear, and others were virtual almost all year. West Virginia, with the highest substantiation rate, has been particularly hard-hit by the opioid epidemic. The state has the highest overdose mortality rate in the nation;
Differences in the messages coming from an agency’s leadership about the relative importance of child safety versus family preservation;
Variations in the use of kinship diversion, the practice of placing children with a relative without court involvement or case opening. If this happens before the investigation is completed, it may result in an “unsubstantiated finding.
All of these factors can change over time, affecting substantiation rate trends from year to year. It is clear that nationwide, the COVID-19 pandemic continued to suppress reports to CPS hotlines, and therefore investigations and maltreatment findings, in 2021. But the effect of the pandemic differed greatly between states: it appears that some states had more in-person days of school in 2021 than in 2020, and others had less. Additionally, several states described changes in their screening practices in 2021, usually to screen in fewer referrals. Delaware and Washington mentioned an increase in reports diverted to differential response as a reason for declining substantiation numbers in FFY 2021. The emphasis on prevention as an alternative to intervention has been increasing in most states, perhaps affecting the likelihood of substantiation. It is possible also that increases in kinship diversion may have reduced substantiation rates: there is no data to prove or disprove this, but concern over this practice is certainly growing.
To state that maltreatment decreased between 2020 and 2021 is to ignore that “maltreatment victimization” is not a measure of actual abuse and neglect. It is the result of a winnowing process that starts even before a referral arrives. At each stage, the numbers remaining may depend on a wide variety of factors, including policy, practice, natural and man-made disasters and more. The vast differences between state data on referrals, reports, investigations and substantiations shows how unlikely it is that the total number of children found to be victims of maltreatment reflects the actual number of maltreated children, and how irresponsible it is to suggest this might be the case.
A note onChild Fatalities
Last year, ACF used a decline in fatalities due to child maltreatment to headline its press release, Child Fatalities Due to Abuse and Neglect Decreased in FY 2020, Report Finds. This year, the number of child abuse and neglect fatalities reported by states increased slightly, a rise that was not the subject of a headline by ACF. Whether there is a small increase like this year or a decrease like last year means very little, for several reasons. As ACF explains, these child fatality counts reflect the federal fiscal years in which the children were determined to have died of maltreatment, which may be different from the year the child actually died. Such determinations may come much later due to the time it takes to complete a death investigation. For example Alabama reported that for the fatalities reported in FFY 2021, the actual dates of death were between FFY’s 2016 and 2021. Michigan even reported that its child fatality data included the child abuse death of twins in 2003 which was revealed by a cold case investigation.
A second problem with the fatality estimates is that they are widely believed to be too low. One reason is that many states report only on fatalities that came to the attention of child protective services agencies. As the report’s authors point out, many child maltreatment fatalities do not become known to agencies when there are no siblings or the family was not involved with the child welfare agency. Moreover, some fatalities resulting from abuse or neglect are labeled as due to accident, “sudden infant death syndrome,” or undetermined or unknown causes because insufficient evidence was found. Irecently reviewed the child fatality review report produced by the District of Columbia’s Child and Family Services agency (CFSA). CFSA relied on the decisions of the medical examiner, which chose not to classify as maltreatment deaths an infant who died after a mother who was high on PCP rolled on top of him when sleeping with him in the same bed (counted as “unknown); a baby left on his stomach with a bottle in his mouth when his mother left the apartment (counted as “undertermined); a child who was shot to death by gunmen trying to kill her father, involved in the violent drug trade, outside a liquor store at 11:00 PM (“non-abuse homicide”), and a child who died of an untreated bacterial infection and had beating injuries diagnosed by doctors as due to abuse (“undetermined”). The total number of maltreatment fatalities was estimated at only three for the District in CY 2021, not including those four deaths. Some researchers suggest that the actual number of abuse and neglect fatalities may be as much as twice or three times that given in the Child Maltreatment reports,4 and the District of Columbia data suggest this may well be the case.
Notes
This leaves out three states that are listed as screening in 100 percent of referrals: Illinois, New Jersey and North Dakota. Both Illinois and New Jersey explained in their state commentaries that reports must meet certain criteria to be accepted for investigation, so it is not clear why they responded that they screen in 100 percent of referrals. North Dakota actually screens in all referrals, but that is more semantic than real. Reports that do not meet agency criteria for a report of suspected chlid abuse or neglect are categorized as receiving an “administrative assessment,” and are not investigated. North Dakota does not report the number of referrals receiving an “adminnistrative assessment;” hence the reports that 100 percent of cases are screened in. It is unclear why New Jersey and Ilinois provided this figure of 100 percent but the reason may be similar.
Alternative response is, as defined in NCANDS, the “provision of a response other than an investigation that determines if a child or family needs services. A determination of maltreatment is not made and a perpetrator is not determined.”
NCANDS defines a “victim” as “a child for whom the state determined at least one maltreatment was substantiated or indicated, and a disposition of substantiated or indicated was assigned for a child in a report.” “Indicated” is defined as a disposition that concludes that maltreatment could not be substantiated under state law or policy, but there is a reason to suspect that at least one child may have been maltreated or is at risk of maltreatment.”
Herman-Giddens, M. E., et al. (1999). Underascertainment of child abuse mortality in the United States. JAMA , 282(5), 463-467. Available from http://jama.jamanetwork.com/article.aspx?articleid=190980. Also, Cotton, E. E. (2006). Administrative case review project, Clark County, Nevada: Report of data analysis, findings and recommendations. Crume, T. L., DiGuiseppi, C., Byers, T., Sirotnak, A. P., & Garrett, C. J. (2002). Underascertainment of child maltreatment fatalities by death certificates, 1990-1998. Pediatrics, 110(2). Abstract available from https://pubmed.ncbi.nlm.nih.gov/12165617/. Herman-Giddens et al. estimate actual child abuse and neglect deaths to be as high as three times the national reported amount; Cotton et al. and Crume et al. found the actual number of deaths to be twice that reported.
These days, It is a bit difficult to be a left-leaning liberal while also being an advocate for abused and neglected children. I would never have expected that a Senior Fellow at the American Enterprise Institute (AEI), Naomi Schaefer Riley, would be one of my closest allies in child advocacy. Or that my proudest achievement since starting this blog would be my service on a child welfare innovation working group that she organized out of AEI, or that, with a few quibbles over details, I would agree with the main points of her new book. But that is the case in these strange times, in which many of my fellow liberals appear effectively indifferent to the fate of children whose parents they view as victims of a racist “family policing system.”
Naomi Schaefer Riley is a journalist, a former editor for the Wall Street Journal, and the author of five previous books. In her new book, No Way to Treat a Child: How the Foster Care System, Family Courts, and Racial Activists Are Wrecking Young Lives, uses examples, data and quotes from experts to show in heartbreaking detail how policymakers from the left and the right have converged in creating a child welfare system that puts adults first. Much of this occurs because in deciding how to treat abused or neglected children, the people who create and carry out child welfare law and policy “consider factors that are completely unrelated to and often at odds with a child’s best interests,” as Riley puts it.
Take family preservation and reunification, for example. Instead of placing the safety of the child as the highest priority, Riley illustrates that child welfare agencies leave many children in dangerous homes long past the time they should have been removed, with sometimes fatal results. They give parents more and more chances to get their children back, long after the law says that parental rights should be terminated. The book is full of stories of children ripped away from loving foster parents (often the only parents they have ever known) only to be returned to biological parents without evidence of meaningful changes in the behaviors that led to the children being removed.
Not only do today’s advocates of “family first” wrest children away from loving families to return home, but Riley describes how they send other hapless children to join distant relatives that they never knew, on the grounds that family is always best even if the relative does not appear until as much as two years after an infant has been placed in foster care. The fact that a relative may display the same dysfunction that the parent showed may be ignored. I would add, based on personal experience, that in my foster care work I often met grandmothers who seemed to have gained wisdom (and finally, for example, gave up drugs) with age, as well as aunts and uncles who avoided the family dysfunction and went on to lead productive lives, making their homes available to the children of their less well-adjusted siblings. But Riley is right to say we should consider not just blood, but also fitness and bonding before removing a child from a good pre-adoptive home to live with a relative.
As Riley describes, one of the primary factors that is now taking precedence over a child’s best interest is that of race or ethnicity. Riley explains how data on the overrepresentation of Black and Native American children in foster care in relation to their size is being attributed to racism in child protective services, as I have explained elsewhere, ignoring the evidence that the underlying disparities in abuse and neglect are largely responsible for these differences in foster care placement. And they don’t seem to have a problem with holding Black parents to a lower standard of parenting than White children to equalize the ratios. Moreover, many of these “racial activists” are recommending eliminating child welfare systems entirely along with abolishing the police. As Riley states, Native children are the canaries in the coal mine, “for what happens when you hold some parents to a lower standard, as we have done with the Indian Child Welfare Act with devastating effects for Native children.
Another way we subordinate the interests of children is by minimizing their parents’ responsibility for their treatment by saying it is simply due to poverty. Riley addresses the common trope that “neglect,” the reason that 63 percent of children children were removed from their families in 2019, is “just a code word for poverty,” a myth that I have addressed as well. I’d venture that anyone who has worked with families in child welfare knows there is often much more going on in these families than poverty alone, including substance abuse, mental illness, and domestic violence. Riley puts her finger on an important issue when she suggests that part of the problem may be that we use a general category called “neglect” as the reason behind many removals. However, I don’t agree with her recommendation to discard neglect as a reason for removal. As I explain in a recent post, we need to distinguish between the over-arching categories of “abuse” and “neglect” and the specific subcategories of neglect such as lack of supervision, educational neglect, and medical neglect. Contrary to Riley’s suggestion that they are types of neglect, substance abuse and mental illness are factors that contribute to it. This important information should be included in the record but should not be confounded with types of neglect.
Another way that policymakers disregard the best interests of the child is by deciding that foster homes are better than institutions for almost all children instead of recognizing that some children need a more intensive level of care for a limited time, or that others can thrive in group homes that simulate a family setting but provide more intensive attention than a typical foster home can provide. The Family First Prevention Services Act (FFPSA), which went into effect for all states on October 1, does allow for children to be placed temporarily in therapeutic institutions, although it sets some unreasonable limits on these institutions and on placement of children in them. But it does not provide any funding for placement in highly-regarded family-like group settings such as the Florida Sheriff’s Youth Ranches. (I’m not sure why Riley says in later in the book that FFPSA “is looking like another piece of federal legislation that will be largely ignored by states, many of which have already been granted waivers from it.” Those waivers were temporary and there is no way states can ignore the restrictions on congregate care).
In her chapter entitled “Searching for Justice in Family Court, Riley describes the catastrophic state of our family courts, which she attributes to a shortage of judges, their lack of training in child development and child welfare, and their leniency with attorneys and parents who do not show up in court. As a model for reform, Riley cites a family drug court in Ohio that meets weekly, hears from service providers working with parents, and imposes real consequences (like jail time) on parents who don’t follow orders. But this type of intensive court experience is much more expensive. These programs are small, and expanding this service to everyone would require a vast infusion of resources.
I appreciated Riley’s chapter on why CPS investigators are underqualified and undertrained.” Having graduated from a Master in Social Work (MSW) program as a midcareer student in 2009, I could not agree with her more when she states that the “capture of schools of social work and child welfare generally by a social-justice ideology has produced the kind of thinking that guides social welfare policy.” I’d add that some students are ill-prepared for their studies and may not get what they need while in school to exercise the best judgment, critical thinking, effective data analysis, and other important hard and soft skills. Riley suggests that the function of a CPS worker is really more akin to the police function than to the type of traditional social work function performed by other social workers in child welfare–those who manage in-home and foster care cases. As a matter of fact, Riley quotes my post suggesting that CPS Investigation should be either a separate specialty in MSW programs or could be folded into the growing field of Forensic Social Work.
Riley’s chapter on the promise of using predictive analytics in child welfare shows how concerns that using algorithms in child welfare would exacerbate current discrimination are not borne out by history or real-world results. Use of an algorithm to inform hotline screening decisions in Allegheny County Pennsylvania actually reduced the disparities in the opening of cases between Black and White children. As Riley states, this should not surprise anyone because data has often served to reduce the impact of bias by those who are making decisions. As she puts it, “if you are concerned about the presence of bias among child-welfare workers and the system at large, you should be more interested in using data, not less.”
Perhaps not surprisingly, it is Riley’s two chapters on the role of faith-based organizations in child welfare that made me uncomfortable. Riley describes the growing role of these groups, especially large evangelical organizations, in recruiting, training, and supporting foster and adoptive parents.” Like it or not,” she states, “most foster families in this country take in needy children at least in part because their religious beliefs demand such an action.” But the Christian Alliance for Orphans, an organization often quoted by Riley, was one of the groups behind the “orphan fever” that took hold among mainstream evangelical churches in the first decade of this century. Many families were not prepared for the behaviors of their new children and some turned to a book by a fundamentalist homeschooling guru named Michael Pearl that advocated physical discipline starting when children are less than a year old. Many of the adoptions were failures, some children were illegally sent back to their own countries, some children were abused, and at least two died of the abuse. But Riley’s narrative suggests that many evangelical churches working with foster youth are using a trauma-focused parenting model (Trust-Based Relational Intervention) that is diametrically opposed to the Pearl approach. Nevertheless, the association of evangelical Christianity with a “spare the rod” parenting philosophy as well as the possibility that saving souls is part of the motivation for fostering or adoption, make me a bit queasy about over-reliance on evangelical families as foster parents, and I would have liked to see Riley address this issue.
In her esteem for religious communities and their role in child welfare, Riley is worried that some jurisdictions will bar all organizations with whom they work from discriminating on the basis of sexual orientation or gender identity, driving religions institutions out of business. Since the book was written, however, the Supreme Court has ruled that the City of Philadelphia violated the First Amendment when it stopped referring children to Catholic Social Services for foster care and adoption because the agency would not certify same-sex foster parents. So this threat may be dwindling for the time being. In general, unlike many liberals, I agree with Riley that, as long as there is an agency to work with any potential foster parent, we should “let a thousand flowers bloom” rather than insisting that every agency accept every potential parent.
Riley ends the book with a list of recommendations for making the system more responsive to the needs of children rather than adults. She agrees with liberals that we need an influx of financial resources as well as “better stewardship of the money we already spend.” We need both a massive reform of our child welfare agencies and a family court overhaul, she argues. She wants recruitment of more qualified candidates for child welfare agencies and better training for them. She urges the child welfare system to move away from “bloodlines and skin color” and allow a child to form new family bonds when the family of origin cannot love and protect that child. I certainly hope that policymakers on both sides of the aisle read and learn from this important book.
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.
A new report from Eyewitness News has cast doubt on my pieced-together account of the process by which Justyna Zubko-Valva lost custody of Thomas and her other sons. My initial account, relying on reports from other media outlets, suggested that a judge revoked the mother’s custody and gave it to the father in an arbitrary manner without seeking to evaluate either parent’s capability of raising the children. Based on the documents described by Eyewitness News, ot appears that this was not the case. I have updated my post to account for the new information, as described below.
My post initially relied on available media accounts in stating that Judge Hope Schwartz Zimmerman became fed up with Justyna Zubko-Valva for failing to follow two orders, including one to get her children evaluated. In fact, the court documents obtained by Eyewitness News state that the Zubko-Valva was refusing to follow an order that she herself be evaluated, unless the interview could be videotaped. The evaluator refused due to the “sensitive nature of the testing materials.”
Without a psychological evaluation of the mother, Judge Zimmerman stated that she was unable to bring the case to trial. She announced that she was awarding “temporary, temporary” custody to the father. The rationale for that decision is not explained in the quotes from Eyewitness News. Perhaps Judge Zimmerman thought that moving the children would induce Zubko-Valva to obtain the evaluation. Using the children as tools to induce parental compliance would be inappropriate in any case. In this case, the transfer of custody not only failed to achieve the judge’s goal but resulted in the death of one child, horrific abuse of another child, and potential lifelong damage to the two living children. The “temporary, temporary custody” ended up lasting for two years after Valva filed an abuse report against Zubko-Valva and Zubko-Valva later refused supervised visitation, as described below. Nevertheless, my statement the judge cavalierly transferred custody of the boys without evaluating the parents appears to have been wrong. Instead, she apparently transferred custody in order to obtain the evaluation she required
Of course Zubko-Valva could not know that her intransigence about the evaluation would lead to suffering, death and lifelong damage to her children. But there are other disturbing aspects of her behavior cited in the Eyewitness News account. It appears that she did not see her children for two years, from January 2018 until Thomas’ death in January 2020. Eyewitness News stated that visits were cut off in January 2018 due to the abuse accusations against Ms. Zubko-Valva but that another judge, Joseph Lorintz, offered her visits starting in April 2018, when the charges were dismissed. Zubko-Valva reportedly refused to visit the children unless they were moved from Valva’s home–a request which the judge denied. In July 2019 the judge again offered her visits, but said the visits must be supervised because “I’m not going to allow you to see your children after a year and a half without some form of supervision in place.” Eyewitness News reports that Zubko-Valva refused to visit her children in a supervised setting. She reportedly refused the same offer in September, 2019, only four months before Thomas’ death. According to the transcripts cited by Eyewitness News, Judge Lorintz almost pleaded with Zubko-Valva, saying “You haven’t seen your children since January 14, 2018. It may only be a few times, but I need for them to be reintroduced to you.” The transcripts show the judge offering three more times to order visits, without receiving an answer from Zubko-Valva. She would never never again see her son Thomas alive. By refusing the opportunity to see her children, did she miss the chance to save Thomas? We will never know.
Unless the Eyewitness News account of the court transcripts is terribly wrong, it appears that Zubko-Valva was not acting in the best interests of her children when she refused the evaluation and the visits. Her refusal to visit her children is very hard to understand and very concerning as it relates to her current fitness as a parent to her two very damaged young sons. The courts and CPS have already failed these children catastrophically; it is hoped that their continued involvement will serve to protect these children and ensure that they receive the treatment and monitoring they need.
The difficulty of piecing events together based on incomplete press accounts illustrates the need for an independent children’s ombudsman to review such cases of systemic failure and release their reviews (redacted as necessary) to the public. Only with such independent reviews can taxpayers understand how and why the system they paid for has failed. If I knew that such a review was forthcoming, I would not have even tried to come up with a credible narrative of this case without the court transcripts and CPS documents. The public should not have to rely on guesswork to find out how the system failed and what has to change.
Illinois’ child welfare services to families that are allowed to keep their children have major systemic flaws that put children at risk. Most importantly, there is extreme reluctance to remove children from their homes and place them in foster care. Those are the findings of a review from Chapin Hall at the University of Chicago that was commissioned by the Governor in the wake of several deaths of children whose families were being supervised by the state.
This report follows an earlier one, discussed in a previous post, by the Inspector General (OIG) for the Illinois Department of Children and Family Services (DCFS) stating that child safety and well-being are no longer priorities for the agency. One problem area identified in that report was Intact Family Services, which are the services provided to families in order to prevent further abuse or neglect without removing the child. OIG’s 2018 annual report included an eight-year retrospective on the deaths of children in Intact Family Services cases, which concluded that in many of these cases the children remained in danger during the life of the case due to violence in their homes, when DCFS should have either removed the children or at least sought court involvement to enforce participation in services,
Increasingly, child welfare systems around the country have been relying on services to intact families (often called in-home or intact family services) in order to avoid placing children into foster care. In 2017, according to federal data, only 15% of children who received services after an investigation or assessment were placed in foster care; the other 85% were provided with services in their homes. These services may become even more predominant with implementation of the Family First Prevention Services Act, which allows federal Title IV-E funds to reimburse jurisdictions for the cost of such services.
It is important for child welfare agencies to be able to work with families that remain intact. This allows the agency to monitor the children’s safety and avoid the trauma of placement in foster care while working to ameliorate the conditions that might lead to a foster care placement. But agencies must be cognizant that not every family can be helped this way, keep a close watch what is going on in the home, and be ready to remove children when necessary to ensure their safety. The deaths of children who have received Intact Family Services in Illinois have raised questions about whether the agency is accomplishing these tasks.
In Illinois, Intact Family Services (referred to below as “Intact”) are provided mostly by private agencies under contract with DCFS. The Chapin Hall report found systemic issues that create barriers to effectively serving intact families.
Avoiding foster care placement: Perhaps the most important issue observed by the researchers was the high priority that Illinois places on avoiding placement of children in foster care. As a result of many years of such efforts, Illinois now has the lowest rate of child removal in the country. Intact staff expressed the belief that “recommendations to remove children based on case complexity, severity, or chronicity will not be heard by the Division of Child Protection (DCP) or the Court.” As a result, Intact supervisors are reluctant to reject referrals of families even when they believe a family cannot be served safely in the home. They are also reluctant to elevate cases for supervisory review when they have not been able to engage a high risk family.
Supervisory Misalignment:Â In the past, negotiations between DCP and Intact over the appropriateness of a referral occurred on a supervisor-to-supervisor level, allowing Intact to push back against unsuitable referrals. An administrative realignment that placed investigators and Intact under different administrations eliminated this ability of Intact to contest inappropriate referrals. According to the researchers, this resulted in the opening of Intact cases for families with “extensive histories of physical abuse” that Intact staff believed they could not serve effectively.
High Risk Case Closures:Â Â Intact service agencies are expected to work with a family for six months and then close the case with no further involvement by DCFS. The researchers learned that there was no clear pathway for intact staff to express concerns when they been unable to engage a family. As a result, some providers told the researcher that they may simply close the case when a family will not engage.
Staffing Issues: Caseload, capacity and turnover. The researchers found that DCP investigators are overwhelmed with their high caseloads and are desperate to make referrals to Intact to get families off their caseload as soon as possible. The prescribed caseload limit of 15 cases per worker is very hard to manage, and some workers carry even more cases. Moreover, DCP workers tend to stop managing safety plans and assessments as soon as a referral is made to Intact, which leaves children in limbo until services begin. For their part, Intact workers’ caseloads are often over the prescribed limits and are not adjusted for travel time or case complexity. Moreover, the difficulty of their clientele makes the current caseload of 10:1 difficult to manage. High turnover among Intact workers, investigators and other staff can also contribute to the information gaps and knowledge deficits mentioned below.
Role Confusion:Â DCP workers and Intact workers seem to have different views of the role of the DCP worker, according to the researchers. DCP workers view their role as making and justifying the decisions about whether to substantiate the referral and remove the child. However, the Intact Family Services policy calls upon them to engage the family and transmit all necessary information to the Intact staff. Cultural differences between the two sets of workers compound the problems.
Information Gaps: Because of the role ambiguity mentioned above, investigators often fail to pass on crucial information to Intact workers. Yet, these workers often cannot access investigators notes or key features of the case history. Moreover Chapin Hall’s reviews of the two recent deaths of toddlers in intact cases found that much of the family’s history was inaccessible because cases were expunged or purged. DCFS expunges most unsubstantiated reports and shreds investigators files and appears to be more aggressive about such expungements than most other states, according to a previous DCFS Director, George Sheldon.
Service Gaps: The researchers also mentioned gaps in service availability, especially long waiting lists for substance abuse prevention, which make it very difficult to engage families as well as providers.
The authors made a number of recommendations for addressing these problems they identified. These include:
Work with courts and State’s attorneys to refine the criteria for child removal in complex and chronic family cases;
Develop and refine protocol for closing Intact cases;
Direct attention to cases at greatest risk for severe harm; revisit the use of predictive models which should be transparent, based on broad input and be supported by ethical safeguards’
Clarify goals and expectations across staff roles;
Utilize evidence-based approaches to preventive case work;
Improve the quality of supervision;
Adjust the preventive services offered through Intact to meet the needs of the population;
Restructure Intact Services to address the supervisory mismatch with DCP; and
Redesign the assessment and intake process to reduce redundant information, improve accuracy or assessments to support decision-making and improve communication across child serving systems.
We would have liked to see a recommendation to modify Illinois’ policy of expunging and purging all unsubstantiated investigations. At a hearing in May, 2017, the DCFS Director, George Sheldon, expressed his support for allowing DCFS to keep records of all investigations, even if they are unsubstantiated. Research suggests that it is very difficult to make accurate decisions about whether maltreatment has occurred; moreover, unsubstantiated reports are as good as substantiated ones in predicting future maltreatment. Examples of children killed after families have had multiple unsubstantiated reports have been observed all over the country.
This report should be a must-read for all child welfare agencies. Children in many states have died of abuse or neglect after intact cases have been opened for their families. (Think about Zymere Perkins in New York or Anthony Avalos and Gabriel Fernandez in Los Angeles.) Many of the issues identified by the Chapin-Hall report may have contributed to these deaths as well, particularly the extreme avoidance of child removals that has condemned so many innocent children to death ever since the widespread push to reduce the foster care rolls, supported by a coalition of wealthy and powerful foundations and advocacy groups.
On June 21, the suffering ended for ten-year-old Anthony Avalos when his tortured body finally succumbed to years of abuse. The ten year old had severe head injuries and cigarette burns all over his body when his mother found him unresponsive and called 911. Anthony died the next morning. Despite sixteen reports to the Los Angeles Department of Child and Family Services (DCFS) or the police, the agencies tasked with protecting Anthony never rescued him from the adults that had abused him for years. Without a new law requiring public disclosure of the details of such cases, the public will never know how Anthony’s peril was missed or what changes are needed to protect future children from his horrible fate.
School administrators, a teacher, a counselor, family members and others called police or the child abuse hotline at least 16 times since 2013 to report abuse of Anthony or one of his six siblings, as revealed in a devastating article by respected investigative reporter Garrett Therolf published by the Los Angeles Times. DCFS received twelve reports between 2013 and 2015, according to its director, Bobby Cagle.
According to these reports, “Anthony or his six siblings were denied food and water, sexually abused, beaten and bruised, dangled upside-down from a staircase, forced to crouch for hours, locked in small spaces with no access to the bathroom, forced to fight each other, and forced to eat from the trash.”
Most of the allegations concerned Anthony. Among the alleged abusers were his mother, Heather Barron, her boyfriend, Karim Leiva, and another family member who was left in charge of the children and was accused of sexual abuse.
According to the sources, only some of the investigations resulted in a finding of child abuse. And even when abuse was found, the children were only once placed with an uncle and aunt, from whom they were soon removed and brought back to their mother over protests from the relatives, according to the aunt. She reports that she started making calls to DCFS in 2015 when she noticed injuries the children said were inflicted by Leiva.
Anthony’s father, a Mexican citizen, reported that Anthony asked to live with him but his mother refused. Aware that Anthony was being treated badly, he repeatedly gave case workers his contact information in Mexico. But he never heard back.
Instead of placing Anthony with his father or aunt and uncle, DCFS workers opened at least two cases to help Anthony’s mother improve her parenting while the children remained in the home. But these cases where closed without any resolution of the safety threat to these vulnerable children.
These horror stories of deaths of children after multiple serious allegations to police and child welfare agencies never seem to end.  The first step in preventing more tragedies is to conduct a detailed case review to identify the critical decision points where an opportunity was missed. It is likely that DCFS has already begun such an internal review. But it will be shared only with the county Board of Supervisors, which will hold it close.
This state secrecy is not unique to Los Angeles. Only a few states provide for the release of information about agency interactions with children who died of abuse or neglect. Texas’ Office of Child Safety posts reviews of fatalities but only when a child died of abuse or neglect during an open case. Florida requires an immediate investigation of a child’s death if the family was involved with CPS in the past year and posts the review if the child was found to have died of abuse or neglect.  In Washington, the Children’s Administration (CA) conducts a review (by experts with no prior involvement in the case) when the death or near-fatality of a child was suspected to be caused by child abuse or neglect, and the child had any history with the CA at the time of death or in the year prior. These reviews must be completed within 180 days and posted on the agency’s website.
The Washington legislation is the broadest and most useful requirement. However, the universe of cases covered should be increased to include families that had contact with the child welfare agency within the past five years at a minimum. The last report on Anthony’s family was made in April 2016, more than two years before Anthony’s death, according to a statement by Bobby Cagle, the DCFS Director. After the sixth abuse report concerning Yonatan Aguilar (also in Los Angeles County), Yonatan was locked in a closed for over four years until he was found dead in 2016.
Reviews should also be required for cases of children who suffer severe injuries due to abuse or neglect as well as cases of chronic severe maltreatment that was allowed to continue despite reports to CPS. These would include another Los Angeles County case recently in the news when a jury awarded $45 billion to a girl who suffered two years of sexual abuse after child welfare workers left her in a home with an a accused molester. We need to know how these errors happen as well.
A requirement that all states conduct and post such reviews of children who died should also be added as an amendment to the Child Abuse Prevention and Treatment Act, which is expected to be reauthorized in 2018. When an agency egregiously abdicates its responsibility to protect children, the public must know how and why it happened. Only then can they hold their government accountable for making the changes necessary to prevent such tragedies in the future.
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:
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.
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.
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.
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.
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.
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.
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.
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:
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.
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.
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.
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. Â 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.Â
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.Â
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.Â
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. Â
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.
A new report from 
Illinois’ child welfare services to families that are allowed to keep their children have major systemic flaws that put children at risk. Most importantly, there is extreme reluctance to remove children from their homes and place them in foster care. Those are the findings of a 
Child Welfare Monitor 