The Minnesota Child Maltreatment Fatalities Report: Essential reading for child advocates everywhere

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 between 2007 and 2015 which identified systemic flaws and made recommendations to correct them. 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.

Did child maltreatment fall under COVID-19?

As the Covid-19 pandemic took hold, stay-at-home orders were declared, and school buildings closed, many child advocates voiced fears that child abuse and neglect would increase but would remain unreported as children were locked in with their maltreaters. But some newly available data has led to a spate of commentaries announcing triumphantly that rather than increase, child maltreatment has actually decreased during the pandemic, suggesting to some that we may not need a child welfare system after all. In fact, while the data provides no definitive evidence of either an increase or decline in child maltreatment, there are some concerning indicators from emergency room visits, teen self-reports, and domestic violence data that there may have been an increase in child abuse and neglect after Covid-19 closed in.

There are many reasons to think that the Covid-19 pandemic and our nation’s response to it would have led to a spike in child abuse and neglect. Research indicates that income loss, increased stress, and increased drug abuse and mental illness among parents (all associated with the pandemic) are all risk factors for child abuse and neglect.* On the other hand, the expansion of mutual aid networks and the influx of new government assistance programs with few strings attached may have protected children against abuse and neglect. Data on hotline calls, emergency room visits, child fatalities, teen self-reports of abuse, and domestic violence are being cited as indicators of what happened to maltreatment during the pandemic. I examine the evidence below.

Child maltreatment referrals

As soon as stay-at-home orders were imposed, child advocates warned of the likely drop in reports to child abuse hotlines as children vanished into their homes. And indeed, this is exactly what happened. Individual jurisdictions began reporting large drops in reports starting in April 2020 But national data did not become available until the publication of Child Maltreatment 2020, the compendium and analysis of data the US Children’s Bureau received from states for the fiscal year ending September 30, 2020. According to the report, there were 484,152 screened-in referrals (reports to hotlines) between April and June 2020, following the declaration of emergencies at the national and local levels and the closure of most schools buildings and subsequent transition to virtual operation. This compares to the 627,338 referrals in the same period of 2019–a decrease of 22.8 percent.** For July through September, referrals decreased from 553,199 in 2019 to 446,900, or 19.2 percent. So even in the summer when schools are mostly out anyway, referrals decreased.***

Despite the concerns among child advocates about the drop in hotline calls as a natural consequence of lockdowns and school closures, some parent advocates, such as Robert Sege and Allison Stephens writing in JAMA Pediatrics, have argued that these decreases in hotline calls show that “child physical abuse did not increase during the pandemic.”**** Similarly, In her article entitled An Unintended Abolition: Family Regulation During the COVID-19 Crisis, Anna Arons argues that the decline in hotline reports during the first three months of pandemic shutdowns in New York City relative to the same period the previous year reflects an actual decline in maltreatment rather than the predictable effects of lockdowns and school closures.

Interpreting the decline in hotline reports to suggest a decline in child maltreatment during the pandemic is either naive or disingenuous. The drop in reports was predicted by experts as soon as schools shut down because school personnel make the largest share of reports in a normal year–about 21 percent in FY 2019. The number of reports from school personnel dropped by 58.4 percent in the spring quarter and by 73.5 percent from July through September.** Exhibit 7-B from Child Maltreatment 2020 shows the drastic decline in reports from school personnel, as well as smaller decreases in reports from medical and social services professionals. To claim that this drop in reports reflects reduced abuse and neglect is to disregard the most obvious explanation-that children were seeing less of teachers and other adults who might report signs of abuse or neglect.

Source: Child Maltreatment 2020, https://www.acf.hhs.gov/sites/default/files/documents/cb/cm2020.pdf

In her article about New York City, Anna Arons cites the absence of an oft-predicted surge of child maltreatment reports when schools reopened in September 2020. Far from such a surge, she states, reports did increase, but only “at a rate in line with the typical increase in a non-pandemic fall, rather than a more dramatic leap.” But the grounds for predicting a surge in reports are far from clear. First, only 25 percent of New York City children returned to school buildings in September, as Arons reports. Moreover, is not obvious that the concept of a backlog makes sense in reference to abuse and neglect reports, as it does with tax returns, for example. Bruises may heal, a hungry child may be fed when there is money in the house; living situations may change. Many of the most troubled families are the subject of multiple reports of maltreatment over the course of a year; a child who would have been reported in the spring and again in the fall will not necessarily receive an “extra” report in the fall.*****

Emergency room visits for suspected maltreatment

As the pandemic closed in, child advocates feared that hospital emergency rooms would see an influx of maltreatment-related injuries among children. To address this question, Elizabeth Swedo and colleagues at the Center for Disease Control and Prevention used a platform that provides information on approximately 73 percent of all Emergency Department (ED) visits in the United States. The authors did not find the increase that these advocates feared, reporting that the total number of ED visits related to child abuse and neglect decreased sharply during the early part of the pandemic as compared to the analogous period in 2019, though ED visits for all causes increased even more during that period. Despite the decreases in the number of ED visits for maltreatment, the number of such visits ending in hospitalization stayed the same, which suggests there was no decrease in maltreatment severe enough to result in hospitalization.

Using an administrative database from 52 U.S. children’s hospitals, Kaiser et al. found a sharp decline in all ED visits and hospital admissions, and in visits and admissions for child physical abuse (not including admissions related to sexual abuse or neglect) during the first six months of the pandemic period compared to previous years. Moreover, they found no increase in the severity of the child physical abuse cases resulting in ED visits or hospitalizations. They concluded that coronavirus aid programs and eviction protections might have resulted in reductions in child physical abuse.

To disentangle the effects of reduced healthcare usage during the pandemic changing levels of child maltreatment, Maassel et al. looked at hospitalizations for abusive head trauma (AHT), arguing that it is more difficult for caregivers to forego medical care for such life-threatening injuries. They found a significant decrease in admissions for AHT among 49 children’s hospitals during the COVID pandemic compared to the three previous years.****** They hypothesize that the marked increase in job losses for women, along with more adults working from home, may have led to more children being cared for by two or more caregivers, and specifically fewer being cared for by sole male caregivers, who are the most common perpetrators of AHT.

Swedo et al’s finding that the number of ED visits for abuse or neglect that ended in hospitalization stayed the same contrasts with Kaiser et al and Maassel et al’s findings that hospitalizations for child abuse (and specifically) AHT declined during the early period of the pandemic. One explanation may be that abuse decreased but neglect did not; it may also be relevant that Swedo et al used a different database than did the other two teams. More research is needed to explain these differences.

Child Fatalities

One might argue that child maltreatment fatalities are best indicator of maltreatment rates during the pandemic because fatalities are less likely to avoid being reported than non-fatal maltreatment. Child Maltreatment 2020 contains estimates of child fatalities due to abuse and neglect from all states but Massachusetts, plus the District of Columbia and Puerto Rico. These jurisdictions reported a total of 1,750 fatalities, for a population rate of 2.38 per 100,000 children, compared to 1,825 or 2.50 per 100,000 children in FFY 2019. But to say that the maltreatment fatality rate went down in 2020 as compared to 2019 would be incorrect, because the fatalities counted in one year did not necessarily occur in that year. Rather, the authors indicate that “the child fatality count in this report reflects the federal fiscal year … in which the deaths are determined as due to maltreatment,” which may be different from the year the child actually died.” Such determinations may come a year or more after the fatality occurred. So it is not possible to make inferences from this small decrease in the child maltreatment fatality rate in FY 2020. Moreover, it is not not implausible that the pandemic affected reporting, so that year-to-year comparisons between pandemic years and non-pandemic years are particularly problematic.

Teen Self-Reports of Abuse

Results from a nationwide survey of 7,705 high school students conducted in the first half of 2021 and reported by the New York Times revealed disturbing indications that abuse, at least of teens, increased during the pandemic. Over half (55.1 percent) of adolescents reported being emotionally abused by a parent, and more than one in 10 (11.3 percent) reported being physically abused by a parent. Black students reported the highest rate of physical abuse by a parent–15 percent, compared to 9.8 percent for White students. Students who identified as lesbian, gay or bisexual, and those who identified as “other or questioning” experienced the highest rate of emotional abuse (74.4 percent and 75.9 percent respectively). Female students were more likely to experience emotional abuse by a parent than male students (62.8 percent vs. 46.8 percent). While using a different sampling frame, methodology and wording, a survey of a nationally representative sample of children aged 14 to 17 conducted in 2011 (as quoted by the authors of the new survey) found much lower estimates of abuse–13.9 percent for emotional abuse by a caregiver in the past year and 5.5 percent for physical abuse. The change in these percentages, even if accurate, is not necessarily due to the pandemic, but it is a troubling indicator nonetheless.

Trends in Domestic Violence

Domestic violence is highly correlated with child abuse and neglect, and the same risk factors, heightened by the pandemic, contribute to both of these problems. A systematic review of 12 US studies, most including multiple cities, concluded that domestic violence incidents in the US increased by slightly over eight percent after jurisdictions imposed stay-at-home orders. The authors speculated that the increase in domestic violence was driven by factors such as increased unemployment and financial insecurity and stress associated with childcare and homeschooling–the same factors that might contribute to increased child maltreatment.

I have written often about the propensity for wishful thinking in child welfare, whether it relates to home visiting programs, “race-blind removals,” or other programs and issues. Unfortunately, this propensity is on full display in the commentaries that try to portray reduced calls to child abuse hotlines as showing that child maltreatment did not rise during the pandemic. But it is certainly true that emergency room and hospitalization data do not provide evidence of a surge in child abuse and neglect, and there are even some suggestions that abuse may have declined perhaps due to fewer children being left alone with male caregivers. Overall, the data we have so far do not conclusively demonstrate that maltreatment rose or fell. Some children who lived through this period will eventually share their memories of life at home during the period. But these memories of course will be impossible to generalize. We may never know what really happened to maltreatment during the covid-19 pandemic.

This commentary was revised on May 18, and May 19, 2022 to incorporate new findings on ER visits and hospitalizations by Kaiser et al and Maassel et al.

*How neglect would be affected by a pandemic is somewhat less straightforward than with abuse. Many neglect cases involve lack of supervision, which may have increased with parents leaving children alone to work, with schools and childcares closed. Increased drug and alcohol abuse by parents might have also increased the occurrence of neglect. On the other hand, with more parents unemployed or working at home, lack of supervision may have become less prevalent during the pandemic.

**Unfortunately, the Bureau did not provide the total number of referrals including those screened in and screened out, by quarter. For the whole year the report shows that 54.2% of referrals were screened in, compared to 54.5% in FY 2019.

***The continued suppression of hotline calls could be due to fewer children in summer camps, summer schools, and childcare, as well as fewer attending health appointments and family gatherings in the first summer of the pandemic.

****It is not clear why Sege and Stephens refer to physical abuse only, as they data they discuss concern all types of child maltreatment,

*****However, it is interesting that even in September 2022, when almost all NYC children returned to school, reports did not return to their 2022 level. There are several reasons this could be the case, including a decline in child maltreatment and a decrease in reporting due to changes in messaging coming from ACS and advocates.

******Maassel and colleagues compared AHT admissions between March 11 and September 30 in 2020 to admissions during the same period over the previous three years.

Child Maltreatment 2020: what did and didn’t happen in the first pandemic year

On January 21, 2022, the Children’s Bureau finally released its long awaited report, Child Maltreatment 2020, which contains data submitted by the states, the District of Columbia and Puerto Rico. Coming over a year after the end of the period covers, the report holds few surprises. As we already know from individual state reports, the pandemic resulted in plunging calls to child abuse hotlines and an attendant drop in the numbers of children who were investigated, found to be abused or neglected, receiving family preservation services or placed in foster care. Vast differences between states in these numbers continued to be present, reflecting differing policies, practices, and conditions. These differences remind us that the use of the terms “victimization” and “victim” in the report is deceptive; they describe the state’s finding that maltreatment has occurred – not the actual existence of maltreatment.

Large disparities between racial and ethnic groups in the rate at which children are found to be victims of maltreatment also continued to exist, with Native American and Alaskan Native children having the highest rates, followed by African American children. For child maltreatment fatalities, African-American children having by far the highest rate of all racial and ethnic groups, three times greater than that for White children. This staggering disparity in fatalities (a much clearer concept than “victimization”) suggests that those who blame racial disparities in child welfare system involvement on racism in the system may be missing the main point–the greater need for protection among Black and Native children.

Effects of Covid-19

Almost as soon as governors began issuing stay at home orders and schools closed in the wake of the pandemic, experts and advocates feared that the isolation of children from adults other than their caregivers would result in reductions in calls to child abuse hotlines and in turn investigations and protective interventions like family preservation services and foster care. Data coming directly from states has already confirmed these fears. And on November 19, the Children’s Bureau released the AFCARS Report for 2020, which showed that both entries to and exits from foster care decreased during the first year of the pandemic, but since entries fell more than exits, the total number of children in foster care fell by over four percent, the largest decrease in the past decade. (This report was discussed in my last commentary.)

The annual Child Maltreatment reports from the Children’s Bureau of the federal Administration on Children and Families summarize data from the National Child Abuse and Neglect Data System (NCANDS), which is a federal effort to collect data on child abuse and neglect that is mandated by the CAPTA amendments of 1988. Child Maltreatment 2020 provides the backdrop to the foster care declines documented by AFCARS by showing that the number of hotline calls, children receiving an investigation or alternative response, and children determined to be victims of abuse or neglect all dropped substantially in Federal Fiscal Year (FFY) 2020 relative to FFY 2019. Breaking down the data by quarter showed that these drops relative to the previous year occurred mainly during the second two quarters of the Fiscal Year (April through September 2020), after the pandemic shutdowns began. Exhibit S-1 from the report shows the declines in the rates of total referrals, screened-in referrals, children subject to an investigation or alternative response, and children determined to be victims of abuse or neglect between FFY 2016 and FFY 2020.

Referrals

The word “referrals” in child welfare denotes calls to child maltreatment hotlines, as distinct from “reports,” which are referrals that are “screened-in” for investigation. There were a total of 3.925 million referrals involving 7.1 children in FY 2020, for a rate of 53.5 referrals per thousand children. This was a drop of 10.4 percent in the referral rate compared to FFY 2019, which is particularly significant given that the annual number of referrals had been increasing annually since FFY 2016. As in previous years, there were big differences across states: the number of referrals per 1,000 children ranged from a low of 19.1 in Hawaii to highs of 126.9 in Alaska and 137.7 in Vermont. These differences may reflect differing laws and attitudes toward maltreatment reporting in the respective states more than they reflect actual maltreatment rates.

Due to the pandemic, teachers lost their usual place as the source of the largest number of referrals: in 2020 legal and law enforcement personnel made 20.9 percent of referrals, with education personnel coming next (17.2 percent), followed by medical personnel (11.6 percent), social services personnel (10.5 percent), parents and other relatives (6.3 percent each) and smaller amounts from mental health personnel, friends and neighbors, anonymous sources, and others.

Nationally, 54 percent of referrals were “screened in” for investigation or assessment, and the remaining 46 percent were screened out as not meeting the state’s definition of abuse or neglect. There was no change in the screened-in percentage from FY 2019 but the number of screened-in referrals dropped by 10.5 percent from FY 2019 to FY 2020. Of the 47 states reporting screened-in and screened-out referrals, the percentage that were screened in ranged from 17.3 in South Dakota and 17.5 in Vermont (a low that may be related to that state’s very high referral rate) to 98.7 in Alabama.

Investigations and substantiations

The number of children receiving an investigation or alternative response in FFY 2020 was 3.145 million, which was about 46.7 per thousand children. The rate was a decrease of 9.5 percent from FFY 2019, mostly due to decreased activity in April through September. Out of these children, an estimated 618,000, or 8.4 per thousand children, were the subject of reports that were “substantiated” or “indicated,” which means that the agency determined the allegation of abuse or neglect to be true. ACF calls this the “victimization rate,” which is a deceptive term. An investigator’s decision about the truth of an allegation is based on limited information and with limited time, and evidence indicates that many referrals are unsubstantiated when maltreatment actually exists. Moreover, substantiation rates are dependent on state policies and practices, as described below. Because of the confusion caused by the term “victimization,” I will use the term “substantiation” instead.

The national child substantiation rate fell by 5.8 percent in 2020 due to reductions in maltreatment findings in the second half of the fiscal year, suggesting that the drop was mainly the result of the fall in referrals due to the pandemic. This decrease was only about half the magnitude of the 10.5 percent decrease in screened-in referrals, suggesting that a higher percentage of reports was substantiated in FY 2020 than in FFY 2019.* Part of the explanation for this lesser decrease in substantiations may be the reduced proportion of referrals from teachers, whose reports are more likely than others to be unsubstantiated. Many commentators argue this is because teachers often make calls to comply with the mandatory reporting requirement, rather due to genuine concern for a child’s safety. Whether or not this is true, the loss of reports from teachers doubtless meant the loss of serious referrals that would have been been substantiated, as the reduced substantiation rate suggest.

State substantiation rates ranged from a low of 1.9 per thousand children in New Jersey to a high of 19 per thousand in Maine. As the report explains, these rates are affected by state policies and practices, such as their definitions of abuse and neglect, their use of investigation versus alternative response, and the level of evidence they require to substantiate an allegation. Other factors not mentioned by the authors include differences in the messages coming from an agency’s leadership about the relative importance of child safety versus family preservation. Also not mentioned are 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 as the child is now considered safe with a family member. (In a previous commentary, I speculated that New Jersey’s extremely low “victimization” rate might be at least partially due to the practice of kinship diversion.)

Most states had a decrease in the their substantiation rates during FFY 2020, but a few showed little change and some, including Alaska, Arkansas, Illinois, and Maine, even had an increase despite the pandemic. In its commentary, Alaska cited a successful effort to eliminate backlogged investigations and Maine described an increase in reports, which may have been the consequence of several highly-publicized child deaths. North Carolina had a large increase from a very low substantiation rate in 2019 of 2.4 per thousand children to 9.7 in FY 2020 but was “not able” to submit commentary in time to appear in the report. Illinois reported an increase in substantiations due to large increases in the two pre-pandemic quarters but did not provide an explanation. It is worth noting that Arkansas and Illinois were two of only three states to report an increase in foster care entries during FFY 2020 – an increase which is probably related to the increased substantiation rates in those states.

Nationally, children younger than one had the highest substantiation rate at 25.1 per 1,000 children, and the rate decreased with age. Comparison to 2019 shows that the number of children aged eight to 12 who were found to be victims of maltreatment had the largest percentage decrease of 8.2 percent when compared to children aged under one, 1-5 and 13-17, presumably because reporting on this group is most likely to be affected by school closures. Next came children aged 1-5, with a 5.0 percent decrease in the number of substantiated victims, while children under one had a decrease of 3.9 percent. The number of substantiated victims aged 13-17 decreased about the same amount as the youngest group at 3.7 percent.** This is also not surprising because these older children are not dependent on teachers and care providers to report abuse or neglect concerns.

American Indian/Alaskan Native children had the highest substantiation rate of all racial/ethnic groups at 15.5 per thousand children in the population; African-American children had the second highest at 13.2 per thousand, followed by multiple race children at 10.3 per thousand, Pacific Islander children at 10.0 per thousand, Hispanic children at 7.8 per thousand, White non-Hispanic children at 7.0 per thousand, and 1.6 per thousand for Asian children. There is considerable controversy about the higher referral, substantiation, and foster care placement rates for African-American and Native American children. Many scholars and advocates attribute these disparities to racism among those who report alleged maltreatment and those who investigate the reports. Nevertheless, there is evidence from other sources that these disparities may reflect greater underlying maltreatment rates among these populations. The latter view is supported by the even greater racial difference in child maltreatment fatality rates, as described below.

While substantiation rates went down for almost all racial categories during the second half of FFY 2020, these rates actually increased for Native American and Alaskan Native children. Quarterly data reveals that, unlike all other groups, this group experienced an increase in substantiation in the April-June quarter of 2020 relative to that quarter of 2019. But there was a large decrease of 20.3 percent in the July-September quarter relative to FFY 2019. It is almost as if the effects of the pandemic appeared later for this population. Further inquiry is needed to understand what might have caused this anomalous result.

Nationally in FY 2020, three-quarters (76.1 percent) of children found to be maltreatment victims were found to be neglected, 16.5 percent physically abused, 9.4 percent sexually abused, 6.4 percent psychologically maltreated, 6.0 percent victims of an “other” type of maltreatment, and 0.2 percent victims of sex trafficking. A child can be found to be maltreated in more than one way, so the percentages add up to more than 100. The percentages were fairly similar in 2019.

Starting in FFY 2018, states were required to report on the number of infants born with prenatal exposure to drugs or alcohol. In 2020, 49 states reported that 42,821 infants were referred to CPS agencies for prenatal substance exposure. That was an increase over the 38,625 reported by 47 states in FFY 2019; this increase may reflect the addition of two states and an improvement in reporting by states as they phased it in. Many states are clearly not yet reporting all substance-exposed infants, with a large state like Florida reporting only nine substance-exposed infants in FFY 2020.

NCANDS collects data on caregiver risk factors, although these data may be incomplete as many risk factors may go undetected and not every state collects data on every risk factor. From the data available, domestic violence was the most common risk factor, with 37 states reporting 28.7% of the victims had a caregiver with this risk factor. Substance abuse was almost equally prevalent, with caregivers of 26.4 percent of the victims having this risk factor in 41 reporting states; alcohol abuse was reported as a factor for 15.8 percent of caregivers in 34 states; unfortunately mental illness was not included in the reported data. The prevalence of domestic violence as a risk factor confirms reports from around the country about the importance of this factor in families involved with child welfare. This data suggests that domestic violence services should be included in services for which reimbursement should be provided under the Family First Act.

Child Maltreatment 2020 contains estimates of child fatalities due to abuse and neglect from all states but Massachusetts, plus the District of Columbia and Puerto Rico. These jurisdictions reported a total of 1,750 fatalities, for a population rate of 2.38 per 100,000 children, compared to 1,825 or 2.50 per 100,000 children in FFY 2019. But to say that the maltreatment fatality rate went down in 2020 as compared to 2019 would be deceptive, because the fatalities counted in one year did not necessarily occur in that year. Rather, the authors indicate that “the child fatality count in this report reflects the federal fiscal year … in which the deaths are determined as due to maltreatment,” which may be different from the year the child actually died.” Such determinations may come a year or more after the fatality occurred. There is no evidence of a declining or increasing trend in the child maltreatment fatality rate based on data from 2016 through 2020 presented in the report; rather there are small annual fluctuations.

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. States are now required to consult certain sources (such as Vital Statistics agencies, medical examiners, and Child Fatality Review Teams), or to explain in their state plans why they are not using these sources. But for 2020, only 28 states reported on such additional fatalities, adding 233 fatalities to the total. And we cannot assume that even those states identified all of the child maltreatment fatalities that were known to other sources. Moreover some fatalities resulting from abuse or neglect are mistakenly labeled as due to accident, sudden infant death syndrome, or undetermined causes for lack of a comprehensive investigation.

As in the case of abuse and neglect in general, younger children are much more likely to die from child maltreatment according to NCANDS data: 68 percent of the fatalities were younger than three years old. As in the past, there were sharp demographic differences in the proportion of the population that was found to be the victim of a child maltreatment fatality. Black children died at a rate that was 3.1 times greater than the rate of White child fatalities and six times greater than the rate of Hispanic child fatalities. These differences cast doubt on the arguments that racial disparities in referrals, substantiations and foster care placements reflect racism in the child welfare system, since unlike substantiation, death is an unambiguous outcome. (It is true that racism could affect decisions about whether a death is attributable to maltreatment, but this unlikely to be a large effect). Looking back at Child Maltreatment reports since 2016 shows that Black child fatalities as a percent of the population increased in four out of the five years, and went up from 4.65 to 5.9 over the entire period, as shown in the second table below, so there is reason to fear that this year’s increase reflects a real trend. American-Indian and Alaskan Native children had the second-highest rate of maltreatment fatalities, followed by children of two or more races.

Fatalities per 100,000 children by Race and Ethnicity and Federal Fiscal Year

Race and Ethnicity	2016	2017	2018	2019	2020
African-American	4.65	4.86	5.48	5.06	5.90
American Indian/Alaska Native	3.27	3.09	3.12	2.08	3.85
Asian	0.58	0.61	0.44	0.70	0.33
Hispanic	1.58	1.59	1.63	1.89	1.65
Pacific Islander	3.37	4.47	2.22	3.34	2.05
White	2.08	1.84	1.94	2.18	1.90
Two or more races	2.97	2.45	3.50	3.07	3.27

Sources: Child Maltreatment 2016-2020, https://www.acf.hhs.gov/cb/data-research/child-maltreatment

NCANDS does not collect data on the cause or manner of a child’s death, but 73.7 percent of the children who died were found to have suffered neglect and 42.6 percent were found to be abused, either exclusively or in combination with other types of maltreatment. More than 80 percent of the perpetrators were parents. Anecdotal information and some research indicates that mothers’ boyfriends are disproportionately found to have perpetrated child abuse homicides, but NCANDS does not collect this information. Nor is NCANDS able to provide an estimate of how many child victims of maltreatment fatalities had prior CPS contact; some states are able to report on how many of them had prior family preservation or reunification services, but as the authors indicate, “the national percentage is sensitive to which states report data.”

Services

Based on state data, the authors of Child Maltreatment estimated that about 1.1 million children received “postresponse” services, which include a wide variety of family preservation services and foster care. This was a decrease of 9.4 percent from the number receiving such services in 2019, with states attributing the decrease to the decline in referrals due to Covid-19. Nationally, based on the reporting states, 59.7 percent of children determined to be maltreatment victims and 27.1 percent of those not determined to be victims received postresponse services. Children who were not determined to be victims may receive post-response services after being assessed as at risk despite the inability to substantiate an allegation, or because their parents voluntarily accepted services. The percentage of such children who received post-response services varied greatly between states, from 2.2 percent in Colorado to 100 percent in Iowa. Such high percentages may reflect the inclusion of very short-term and “light-touch” services, such as the provision of referrals, gift cards for food or clothing, or bassinets for safe sleep.

Based on data provided by 49 states, the report indicates that 124,360 children determined to be victims of maltreatment (or 21.8 percent) were removed from their homes, along with 48,710 (or 1.8 percent) of children not determined to be victims, for a total of 173,079 children.*** The latter may have been removed because they were deemed to be in imminent danger despite the lack of substantiation; some may have been siblings of children for whom abuse or neglect was found that was serious enough to warrant removal of all children from the home.

The data available from some states show that many children found to be maltreatment victims had prior child welfare involvement: data from 30 states indicates that 13.9 percent of these children had received family preservation services in past five years and data from 39 states indicates that 4.9 percent were reunited with their families in the past five years. Of course these percentages do not include children that were the subject of reports, referrals or investigations, but not services, in the previous five years, which would undoubtedly be much larger.

In closing, it is worth reiterating that many of the results of the annual Child Maltreatment reports are open to misinterpretation–even by the very agency that publishes the reports. The press release announcing the report is titled, “Child Fatalities Due to Abuse and Neglect Decreased in FY 2020, Report Finds” even though the report explains that many of the child fatalities counted for a given year actually occurred in previous years. While the report is very clear in attributing the drop in victimization findings to the pandemic, ACF Acting Assistant Secretary JooYeun Chang is quoted in the press release as saying, “While the data in today’s report shows a decrease in child maltreatment, there is still work to do.” These misstatements suggest that agency leaders either did not read the report or knowingly distorted the data to support an optimistic message. It is not surprising that federal leaders are trying to present the data to their advantage. In my commentary on the AFCARS report, I reported that states that were taking credit for the falling foster care rolls due to the pandemic. The urge to take credit seems to be irresistible; that is why it is so important for the media and commentators to analyze these reports independently rather than paste the press release statements into their articles, as some outlets are all too willing to do.

*We cannot assert this as fact because the unit of analysis for substantiation switches to children rather than reports. Theoretically, the difference in percentages could occur if each substantiation involved half as many children in FFY 2020 as in FFY 2019–which is very unlikely.

**Decrease for 13-17 age group was calculated by Child Welfare Monitor from data in Table 7-5.

***In contrast, the AFCARS report indicates 216,838 children were placed in foster care. The reason for the difference might be the missing data from some states in NCANDS as well as the fact that AFCARS includes all removals that took place in 2020, not just those that occurred after a referral made in the same year.

Lethal reunifications: two children dead in New York and Florida

Sources: trinityfuneralchapel.com, nydailynews.com

Their names were Rashid Bryant and Julissia Battles). She was seven years old and he had lived for only 22 months. He lived in Opa-Locka, Florida, and she lived in the Bronx. They were both taken into state care at birth. Julissia had a life of safety and love with her grandmother, occasionally punctuated by disturbing visits with her mother, until the age of six, when she was dropped off for a visit that ended in her death. Rashid knew 14 months of safety and care starting at birth, before the months of torture began. An inexplicable drive to reunify families, regardless of the lack of change in the parent’ ability to care for their children, is behind both of these tragic stories.

The 694 days of Rashid Bryant

By the time Rashid Bryant was born, on December 13, 2018, his parents were already known to the Florida Department of Children and Families, according to Carol Miller of the Miami Herald, whose articles from May 10 and July 8 are the basis of this account. Rashid’s parents, Jabora Deris and Christopher Bryant of Opa-Locka, had first come to the attention of the Florida Department of Children and Families (DCF) in 2013 and were reported at least 16 times to DCF. The allegations included parental drug abuse, physical injury, domestic violence, and inadequate supervision of their many children. The reports alleged that Deris smoked marijuana with her older children, that most of her children did not to school, that her home had no running water and that the children were hungry and losing weight. An allegation that Bryant had thrown one of his children into a car when escaping from police finally resulted in court-ordered in-home supervision of this family by DCF. When Deris and her newest child tested positive for marijuana, all of the children were removed but were soon returned to the family in August 2018.

By that time, Deris and Bryant had eight children including two younger than two and a hotline report said that the couple were leaving a 15-year-old in charge of several younger siblings, including a two-year-old who was seen outside naked. In October and November 2018, DCF received seven new reports, including drug abuse, inadequate supervision and “environmental hazards.” The couple’s children were taken into custody around Nov. 22, 2018 and were placed with relatives and foster parents. Less than a month later, their ninth child, Rashid, was born and was immediately taken into state care.

The 14 months from his birth in December 13, 2018 until his return “home” on February 2 may have been the only time that Rashid received the love and care he deserved. But the system had reunification on its mind. By August 2019 the parents were given unsupervised visitation, which was revoked after they suddenly moved without notifying the court, but was restarted again in January 2020. That same month, a supervisor with a private case management agency handling the case for the state of Florida stated that conditions for the children’s return had been met. But records reviewed by the Herald show that DCF did not agree, stating that “This determination was not supported, given that the reason for removal had not been remedied.”

On February 28, 2020 14-month-old Rashid and three brothers were returned to their mother by the court, despite the fact that DCF had asked the judge to return the children gradually, starting with one older child. According to agency records reviewed by the Herald, the children were sent home without supportive services to assist the mother with her four young children. As if that were not enough, the judge also saw fit to give “liberal, unsupervised visitation” to Deris with her other five children.

About a month later, Deris’ tenth child was born, to the “complete surprise” of caseworkers, who reported that she had denied in court that she was pregnant. Three weeks after the birth of her tenth child, the judge saw fit to return her remaining four children, leaving the new mother with the custody of ten children including five that were younger than five years old. Oversight of Rashid and the three brothers sent home with him ended in August of 2020, and all monitoring of the family end by October of that year at the judge’s order.

We don’t know when Rashid’s suffering began. We do know that he injured his leg around June 2020, but his mother waited two days to seek medical help, leaving the hospital with Rashid after refusing to allow an X-Rray. It appears Rashid spent the last five months of his life mostly in bed. At a June 22 pool party at the house of an aunt, Rashid and his father never left the car, according to the aunt. When she tried to pick him up from his car seat, she reported that Rashid began to cry. She never saw him again. Rashid’s maternal grandfather, who frequently visited the home, reported not seeing Rashid for about two months. (Why these family members did nothing in view of these red flags is another question.) Rashid’s brother, then 16, told police that he noticed something wrong with Rashid’s leg two months before he died because the little boy cringed and cried when it was touched. The teen described another incident where Rashid vomited all over his bed and then lay still and shaking with his legs up in the air. The teen could not remember if his mother sought medical attention after either of these incidents. After that incident, reported the teen, Rashid could not move his right arm. Four days before he died, a sister saw Rashid vomit after eating. She reported that the right side of his body appeared limp and his eyes were moving in different directions.

On November 6, 2020, two weeks after DCF closed the case on the family by court order, Rashid was dead. He had lived 694 days. The arrest warrant said that Rashid had suffered two seizures in the month before his death but his mother had never bothered to take him to a pediatrician. On the morning of Rashid fatal seizure, Deris called her sister saying he was unresponsive and “foaming from his nose and mouth.” Her sister told her to take him to the hospital. Deris did call for an ambulance–83 minutes later.

The Medical Examiner reported that in the months before his death Rashid had suffered two cracks to his skull — one healing, the other fresh. He also had a healing rib fracture and a recently broken leg. The cause of Rashid’s death was “complications of acute and chronic blunt force injuries.” The contributory cause was “parental neglect.” Deris and Bryant were arrested within a week of Rashid’s death and are awaiting trial on manslaughter and aggravated child abuse.

But somehow, DCF has not decided whether Rashid died of abuse or neglect–so they refuse to release the case files that they are required to release by law when a child dies of abuse or neglect by a caregiver . That requirement is in a state law that was passed requiring such revelations in the wake of the Miami Herald’s publication in 2014 of, Innocents Lost, detailing the deaths of about 500 children after DCF involvement. The Herald has filed suit against DCF and has been joined in the suit by a dozen media companies and advocacy groups.

Julissia Batties: from home to hell

On August 10, police and medics were summoned to the 10th-floor Bronx apartment where Julissia Batties lived with her mother, Navasia Jones, her 17-year-old half-brother, and one-year-old brother, as reported by the New York Times and many other media. Her mother gave inconsistent accounts to the police but it appears that after finding Julissia “vomiting and urinating on herself” at 5am, she waited three hours, and went to the store and the bank, before she called for emergency services shortly after 8:00 AM. Julissia was pronounced dead shortly after 9am. Julissia’s 17-year-old half-brother later told police that he had punched Julissia in the face eight times that morning because he thought she had taken some snacks. But those were not the injuries that killed Julissia. The medical examiner found injuries all over her body. On Friday her death was ruled a homicide caused by blunt force trauma to the abdomen. There have been no arrests so far.

Records show that Julissia’s mother had a long history of involvement with ACS and police. In 2013, the year before Julissia was born, Jones lost custody of her four older children. When Julissia was born in April 2014, she was immediately removed from her mother’s custody and placed with her paternal grandmother, Yolanda Davis. A family court judge initially granted Jones’ motion for custody of the new baby, but ACS appealed, and the appeals court stayed enforcement of the custody transfer pending their decision on the appeal. In 2015, the appellate court agreed with ACS, stating that “the mother had failed to address or acknowledge the circumstances that led to the removal of the child.” The court stated that although the mother complied with the services required by her case plan, “she was still prone to unpredictable emotional outbursts, even during visits with the children, and she was easily provoked and agitated. Indeed, the case planner testified that she had not seen any improvement in the mother’s conduct even after the mother participated in the mandated services.” The court concluded that “until the mother is able to successfully address and acknowledge the circumstances that led to the removal of the other children, we cannot agree that the return of the subject child to the mother’s custody, even with the safeguards imposed by the Family Court, would not present an imminent risk to the subject child’s life or health.” Wise words indeed. Julissia remained with her grandmother, Yolanda Davis, until being returned to her mother on March 2020, when she was almost six years old.

It appears that the COVID-19 pandemic had some role in the transformation of a weekend visit into a custody change that resulted in a child’s death. Davis told a local TV station, PIX-11, that a caseworker told her the visit had been extended due to the pandemic, and the extension never ended. Sources told the New York Post that the mother was officially granted custody in June 2021, though the circumstances are unclear. The decision to return Julissia to her mother appears to have been made at the recommendation of SCO Family of Services, a foster care nonprofit that was managing the case for ACS. After the first month or so, Julissia was not even granted visits with her grandmother, which would have been a much-needed respite and could have saved her, had the grandmother seen or reported injuries or other concerns. The New York Daily News reported that in May 2020, Davis was denied visits with Julissia because she had allowed the child to see her own father, Davis’ son. The motivation behind denying a child visits with the only parent she had known for six years are truly hard to understand.

There were many indications that all was not well in Navasia Jones’ household in the months before Julissia’s death. A neighbor told the Times that “there was always a lot of commotion, always yelling, always screaming” in the apartment. As recently as August 6, his girlfriend had called authorities to report that Julissia had a black eye. The neighbor told the Times that he had spoken to police and ACS staff about the family several times. Police reported to the Times that officers had filed at least nine domestic abuse reports on the family and responded to five reports of a person needing medical attention.

The decision to send Julissia home with her mother after six years apart is particularly strange because the Adoption and Safe Families Act of 1997 (ASFA) requires that a state must file for termination of parental rights after a child has spent 15 of the last 22 months in foster care. The requirement was written into law because children were languishing for years in foster care without a plan for permanency. It was recognized that children need permanency and stability and it is hard to understand why ACS and its contractor would want to move a thriving child from the grandmother who had parented her from birth to age six.

Much needs to be clarified to understand how this child was returned to the family that would kill her. ACS and SCO have declined to comment on the case, citing confidentiality. ACS did issue a statement that “its top priority is protecting the safety and wellbeing of all children in New York City.” But it is clear that other priorities took a front seat in Julissia’s case.

Factors Contributing to lethal reunifications

What explains the adamant determination on the part of some agency personnel and judges to return children to biological parents who have shown no sign of changing the behaviors that caused the system to remove them in the first place? To some extent, it reflects an ideology–one that is becoming increasingly dominant in the nation– that is committed to family preservation and family reunification at almost any cost. Child welfare is known for pendulum shifts in the emphasis on child safety as opposed to family preservation and reunification, but the latter is clearly in the ascendant right now. Extreme deference to this ideology can blind agency employees and judges to what is right in front of their faces: the failure of a parent to change the behaviors and attitudes that resulted in the initial removal of a child.

The obsession with family reunification at all costs can be encoded into social worker evaluations. In Tennessee, a recent survey of social workers suggests that they are being judged by whether they close cases in a timely manner, regardless of child safety. As one worker put it, “Children are returned home or exiting custody to relatives quickly to lower the number of cases without regard to whether the children will be truly safe and the parents ready to parent again.”

The current emphasis on family preservation and reunification is often justified as a way to ratify racial imbalances in child welfare involvement. A growing movement urges drastically scaling down or eliminating current child welfare services on the grounds that the overrepresentation of Black children in care compared to White children is a consequence of racism. Supporters call for elimination of the “disproportionality” between removals of Black and White children from their parents, while disregarding higher rates of poverty and historical trauma that result in more child maltreatment among Black families. To say that Black children need to stay with, or return to, abusive parents in order to equalize the percentages of White and Black children in care is to devalue children and reduce them to nothing more than their race, a strange position for an anti-racist movement to take. As described in a document entitled How we endUP: A Future without Family Policing, parts of this movement are fighting for repeal of ASFA, which would eliminate timelines and encourage jurisdictions to reunify children with their birth parents years after they had established parental bonds with other caregivers, such as grandmothers or former foster parents.

Racial considerations are not the only factor driving systems to support reunification at all calls. Lethal reunifications occur in states like Maine, where 88 percent of the children in foster care are White. Maine’s Office of the Child Advocate recently reported that the state’s child welfare system continues to struggle to make good decisions around two critical points–the initial safety assessment of a child and the finding that it is safe to reunify the child with her parents. In its review of seven cases closed through reunification, the OCA found multiple incidents where children were sent home with insufficient evidence that they would be safe. In one case, the parents had not been visited for a year-and-a-half despite the fact that home conditions were a reason for the original removal. In another case, providers were not contacted or given the information they needed to treat the issues that had resulted in the removal. In another case, the parent “failed to understand or agree to the reasons the children entered custody, but this was not considered significant.” In yet another case, the trial home placement started too soon and the parent never completed required substance abuse treatment. The child was sent home two months after the parent had a positive toxicology screen.

In responding to the criticisms of Maine’s OCA, OCFS admitted that “staff have been challenged with the current workload based on the increase in the number of calls, assessments, and children in care.” It is clear that insufficient of resources lead to excessive caseloads around the country, endangering children. In Tennesseee, for example, while caseloads are not allowed to exceed an average of 20 (a very high number in the experience of this former social worker) data obtained by the Tennessee Lookout, indicated that 30% of caseworkers had caseloads of more than 20, and that many had 30, 40 or even 50 cases. Insufficient funding often means low pay and a difficulty in attracting people with the education and critical thinking skills required for the job. High caseloads and poor pay lead to high turnover, resulting in a loss of institutional memory about specific cases that may drag on for years, such as those discussed here. In turn, high turnover leads to high caseloads as social workers have to pick up cases from those who leave. Such factors may or may not have contributed to the deaths of Rashid and Julissia; they have certainly contributed to other child deaths around the country. Most taxpayers don’t want to think about these systems or fund them; it is easy to avoid reading about the consequences when they occur.

And cost considerations drive reunifications in another way as well. Reunifications save money for cash-strapped child welfare systems. Once a child is sent home and the case is closed, the jurisdiction incurs no more expenditures for foster care. If the child is instead placed in guardianship or adoption with a relative or foster parent, the jurisdiction may end up paying a monthly stipend to the caregiver until the child turns 21. Of course, many relatives who step up to the plate like Julissia’s grandmother are not paid, due to the same budget concerns. giving rise to the current outcry and debate around hidden foster care.

Family court problems contribute to lethal reunifications as well. Rashid’s death appears to be primarily due to a judge who insisted against agency protests on the return of nine children in the space of two months, during which the mother also gave birth to a tenth child. The information available suggests that Florida DCF staff proposed a much slower reunification process. We don’t know what influenced the judge’s decision, but we do know that family courts are overwhelmed and in crisis, resulting too often in the deaths of children in both custody and child protection cases. These courts are inundated with cases, judges often lack the training they need, delays are all too frequent and were worsened by the pandemic. Judges rarely see consequences for decisions that lead to an innocent child’s death, and I have never heard of a judge being removed for the death of a child that was placed in a lethal home against all the evidence. The judge who sent Rashid to his death probably continues to endanger other children daily. This judge must be named, punished, removed and never again allowed to send children to their deaths.

The degree to which the pandemic contributed to Julissia’s and Rashid’s deaths is impossible to estimate. Julissia’s irregular reunification was justified to her grandmother on the grounds of the pandemic. Both Rashid and Julissia should have been visited regularly at least monthly once they were placed with their original families, depending on state regulations. Visits to Rashid should have occurred until the judge terminated them in August, well after the leg injury that left him bedridden, and he should have also been seen in the visits to his siblings that terminated in October. Even if the case managers were visiting (virtually or in real life) only the four children whose cases had not been closed, they should have had the curiosity to ask about little Rashid. For Julissia, there should have been visits throughout her 16 months in hell. Were these visits conducted at all, virtually, or in person? What information was gathered at these visits? This information that must be revealed.

This is not my first post about a lethal reunification in Florida. In January 2019, I wrote about Jordan Belliveau, who was murdered by his mother eight months after being reunified with her, even while a agency in Pinellas County was still monitoring the family. A caseworker for the agency and later resigned told News Channel Eight that the system “puts far too much weight on reuniting kids with unfit parents and makes it nearly impossible for caseworkers to terminate parental rights.” It does not appear that the state learned from Jordan’s death.

I could have written about other lethal reunifications in New Mexico, Ohio, and elsewhere. But I often resist writing about the deaths of a specific child or children known to the system that was supposed to protect them. There are so many reports of such cases, and they are only the tip of the iceberg. Why choose one and not another? I cried for Rashid but I did not write about him until I read about Julissia. Then I knew that I had to write about both, because they represent so many others whose names we will never know. Some of these children’s names may never be known to the general public because there was no outraged grandmother to speak out, no determination of the cause of death, no charges by police, or no alert reporter to reads a crime report and ask questions. But others are unknown because they are suffering in silence and darkness. Because death is not the worst thing that can happen to a child whose life is one of unremitting pain.