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.

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

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.

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

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

Race and Ethnicity20162017201820192020
African-American4.654.865.485.065.90
American Indian/Alaska Native3.273.093.122.083.85
Asian0.580.610.440.700.33
Hispanic1.581.591.631.891.65
Pacific Islander3.374.472.223.342.05
White2.081.841.942.181.90
Two or more races2.972.453.503.073.27
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.

Report of Maltreatment: a major risk factor for child mortality

When I joined the District of Columbia’s Child Fatality Review Committee, I was expecting to review many deaths of children due to child abuse and neglect. Thankfully, that was not the case–or at least there were few cases that were clearly due to maltreatment. But over time I learned that the relationship between child maltreatment and child fatalities was more complicated. I was shocked to discover how many children who died of of natural causes, accident, homicide, or suicide came from families that had previously reported to Child Protective Services (CPS). There has been a spate of new research demonstrating that children who have been the subject of a child abuse or neglect report are more likely to die from many major causes than other children, even when confounding factors are controlled. This increasing body of evidence has major policy implications, including the need to intervene with high-risk infants at or before birth.

Many of the new studies come from California, where researchers linked prior CPS reports with birth and death records. The size of California, with its more than 10 million children, allowed the researchers to obtain statistically significant results despite the relative rarity of child fatalities. Moreover, the researchers could adjust for sociodemographic factors including birth payment method (public vs. private insurance), maternal age, maternal education, race and paternity establishment, birth order, child gender, and child health risk indicators (low birth weight and birth abnormalities). The researchers chose to focus on children with any maltreatment allegation, rather than only substantiated ones, because of the literature suggesting the difficulty of making an accurate finding of past maltreatment, as well as the absence of differences in subsequent outcomes between children with substantiated and unsubstantiated allegations.

In the first study using this approach, Emily Putnam-Hornstein of the University of California Berkeley sought to establish whether children reported for maltreatment were at higher risk of death by intentional and unintentional injury during their first five years of life. She linked CPS, birth and death records for over 4.3 million children born in California between 1999 and 2006. And what she found was striking: after adjusting for socioeconomic and other risk factors at birth, children with a prior report to CPS died of intentional injuries at a rate that was 5.9 times greater than children who were not reported. More surprisingly perhaps, these children died of unintentional injuries at a rate that was twice as high as that for unreported children. In total, children with a prior allegation of child abuse or neglect were fatally injured at a rate 2.5 times higher than children without a prior allegation. Putnam-Hornstein found that a prior report to CPS was the strongest independent risk factor for injury mortality in the first five years of life out of all the risk factors studied. The existence of more unintentional injuries among children with prior CPS reports may reflect the lack of age-appropriate supervision by parents, as Putnam-Hornstein suggests, given that these parents have already been the subject of CPS reports. But she also notes the probability that some of the injuries classified as unintentional may have actually been intentional injuries that were misclassified on death certificates.*

Putnam-Hornstein and colleagues, using the same dataset, also studied how the risk of fatal injury varies by the type of maltreatment allegation, adjusting for baseline risk factors. They found that children with a previous allegation of physical abuse died from injuries at a rate 1.7 times higher than children referred from neglect. Moreover, these children died from intentional injuries at a rate five times higher than children with an allegation of neglect. Yet, these children had a significantly lower risk of unintentional injuries than children with an allegation of neglect. They point out that these findings are consistent with the general conceptual understanding that abuse is an act of commission, while neglect is an act of omission.

In the next California birth cohort study to be published, Putnam-Hornstein and her colleagues sought to establish whether infants previously reported for maltreatment face a heightened risk of Sudden Unexpected Infant Death (SUID), a term that refers to children who die in the first 12 months of life with no immediately identifiable cause or explanation.** They started with the same dataset of all children born in California between 1999 and 2006 with corresponding CPS and death records through each child’s first birthday. Adjusting for risk factors at birth (including low birth weight and late or absent prenatal care), they found the rate of SUID was more than three times greater among infants who had been previously reported for past maltreatment than among infants who had not been reported. The authors suggest several possible explanations for this finding. The existence of a previous CPS report may indicate the presence of risk factors the researchers were not able to measure, such as maternal substance abuse, which has been found to be associated with SUID. In addition, families reported to CPS may be less likely to adhere to safe sleeping guidelines due to the stressors they face and the fact that they have not yet been reached or convinced by public health messaging around safe sleep practices.

To complement the first two studies, which focused on injury deaths and unexplained non-injury deaths, Schneiderman, Prindle and Putnam-Hornstein looked at non-injury, medically-caused deaths of infants in the first year of life. In this study, the researchers used records for the more than 3.4 million children born in California between 2010 and 2016. They found that after adjusting for baseline risk factors (including low birth-weight and preterm birth), infants with one CPS report were almost twice as likely to die of medical causes than infants with no CPS reports; infants with more than one CPS report were more than three times more likely to die of medical causes than those without a CPS report. The researchers also found that among infants reported for maltreatment, periods of foster care placement reduced the risk of death from medical causes by roughly half. The authors speculate that the higher risk of death from medical causes among infants in families with CPS reports is related to these families’ challenges around mental health, substance abuse, and extreme poverty, as well as their lack of social support. Medical neglect may also be more likely in these families given their CPS history. And unfortunately, as described by child welfare analyst Dee Wilson, there is a strong correlation between medical fragility and parental incapacity to care for a child, as parents with little or no prenatal care and those who abuse drugs are most likely to have babies with low birth weight and birth abnormalities. The protective effect of foster care suggests that many foster parents are better equipped to meet the medical needs of fragile infants than the families from which they have been removed.

But it is not just infants and young children previously reported to CPS who are more likely to die of non-maltreatment causes than their non-reported peers. In a newly published article, Palmer, Prindle and Putnam-Hornstein report on their study of CPS history and risk of suicide. Using linked birth, death and CPS records, they followed all children born in California in 1999 and 2000 and all death records through 2017. Using a “case-control design,” they matched each suicide case to four living controls based on demographic characteristics including sex, year of birth, maternal race and ethnicity, maternal age at birth, maternal education, and insurance type at birth. They found that over half (56.5 percent) of children who died by suicide had a history of past allegations of abuse or neglect, as compared to 30.4 percent of the control youth. Children with any CPS history were three times as likely to end their own lives than children without such a history. In a second study, they compared suicide victims with CPS involvement to a matched group of living adolescents with CPS involvement to determine if the nature of the allegation or the child welfare response affected suicide risk. In that study, they found that teens with one or more substantiated allegations were no more likely to die of suicide than teens with allegations that were not substantiated. Moreover, they found no difference in suicide risk between teens who were placed in foster care and those who were never removed from home. They did find increased odds of suicide among teens with more recent CPS reports, allegations of physical abuse, and allegations of sexual abuse.

As I stated in the top of this column, I have observed that many victims of homicide cases reviewed by the District of Columbia’s Child Fatality Review Committee had a history of CPS reports. Their families had long histories of calls to CPS alleging both abuse and neglect, with school absenteeism being one of the most frequent allegations. Eventually, these young people became involved in violent and illegal activities, ultimately leading to their deaths. There is some relevant evidence from an older study of Washington State children born between 1973 and 1986 who were reported to the state child abuse registry. Matching each reported child to three other children of the same sex, county of birth, and year of birth, the researchers found that children reported to the registry were almost 20 times more likely than the comparison population to die from homicide. These researchers were not able to to control for other variables that might affect homicide risk, including poverty and maternal education, so the differences may be exaggerated but are likely real.

The studies reviewed here show that children who are reported as possible victims of abuse and neglect are at risk for more than “just” further abuse and neglect, but for other bad outcomes, including a sudden infant death and for deaths due to injuries (intentional or unintentional), medical causes, suicide, and homicide. While different factors may come into play for different causes and manners of death, maltreatment allegations generally suggest parents who, even if not actually abusive or neglectful, are not well equipped to protect and nurture their children. As Putnam-Hornstein puts it in her article about injury deaths, these data confirm that “children reported for maltreatment have a truly distinctive risk profile defined by much more than just birth into poverty.”

The research described above suggests that youths who previously reported for abuse or neglect are more likely to die due to their own self-harming behaviors, not just directly through acts of commission or omission by their parents. This is not surprising, as a large body of research links child maltreatment and wide variety of adverse outcomes, including, diminished cognitive and executive function, poor mental and emotional health, attachment and social difficulties, post-traumatic stress, juvenile delinquency, and substance abuse. In a recent commentary, Dee Wilson describes specific pathways by which childhood abuse and neglect lead to early-onset mental health conditions, which in turn result in higher rates of suicide, substance abuse and lethal violence in adolescence and young adulthood.

The growing body of research linking child abuse reports with mortality from causes other than child maltreatment itself has important implications for policy. More intensive supports should be put in place for all children remaining at home after a CPS report, especially infants and young children, who are most vulnerable and whose development is most affected by maltreatment. Such intensive approaches could include supportive housing, residential drug treatment programs where children can stay with their mothers, and high-quality early care and education programs. Older children who are the subject of a report should receive a mental health assessment and access to activities and services that provide them with nurturing relationships and opportunities to develop talents and skills, as Dee Wilson describes in his commentary.

But while one can argue for more intensive services for children with substantiated allegations, the idea of mandating services when allegations are not substantiated is a non-starter at a time when the conversation is about restricting the role of CPS, not expanding it. But the research described above also lends support to the growing chorus of voices that is calling for putting more resources into programs that prevent the occurrence of child abuse and neglect, rather than responding to its occurrence. There is a growing interest in “targeted universal prevention programs,” like Hello Baby in Allegheny County Pennsylvania and Family Connects in North Carolina and Oregon, which reach out to all families but provide a more intensive intervention to the families of children who are most at risk of being abused or neglected. Family Connects has already shown some promising results, reducing CPS referrals and emergency room visits among infants receiving the intervention.

It is important to note that mortality is not the only outcome that matters. Because the definition of death is unambiguous, and death data are collected everywhere, death rates are a good way to calculate risk differentials between groups. But for every child who dies as a direct or indirect consequence of abuse or neglect, there are many more who are seriously disabled or injured or suffering from the kinds of adverse outcomes mentioned above, including poor mental and emotional health, juvenile delinquency, and substance abuse. We need a stronger response to reports of child maltreatment, whether or not they are substantiated or the child is placed in foster care. And we must intervene as early as possible to protect high-risk children, rather than waiting for them to be the subject of a child maltreatment report.

*It should be noted that evidence cited by Putnam-Hornstein shows that death certificates “severely” undercount the number of deaths due to child maltreatment and inflicted injuries, and it is likely that over half of fatalities due to maltreatment may be incorrectly classified as due to accidents, natural causes, or undetermined.

**Ultimately about half of these deaths are classified as caused by sudden infant death syndrome (SIDS), a term which connotes a death that remains unexplained following an in-depth investigation.

***Emily Putnam-Hornstein and colleagues found that in California, 82 percent of infants remained at home following their first CPS report. Of these infants remaining at home, only one in ten of their parents received services through an open case, and 60.7 percent were re-reported within five years. Those who did not receive services through an in-home case may have received community-based services but that information is not available.

Targeted Universalism in child maltreatment prevention: the promise and the challenge

Image: Family Connects Durham

A growing chorus of voices is calling for a shift of resources away from responding to child abuse and neglect toward preventing its occurrence. Interest is coalescing around a newer idea that would combine universal reach with a response that is targeted based on a family’s risk, sometimes called targeted universalism. Several jurisdictions are already implementing initiatives based on this approach. Governments interested in adopting such a system need to resolve a number of questions concerning the system’s entry point, goals, lead agency, program content, and how to attract and retain the families that are most at risk. But the idea of targeted universalism is worth pursuing as it combines the advantages of both approaches.

The new focus on prevention should not be confused with the changes made by the Family First “Prevention” Services Act of 2018, which allows funds under Title IV-E of the Social Security Act to be be diverted from foster care to services to help keep children with their families. Despite its name, Family First funds can be used only for services to families in which abuse or neglect has already occurred. Such services are generally considered treatment, not prevention, although public health specialists refer to them as “tertiary prevention,” which mean preventing the recurrence of a problem. But this is not the meaning of prevention to the layperson, and the placement of “prevention” in the title of the act continues to cause confusion.

Preventing a problem, if possible, is certainly preferable to addressing it after it appears. As child maltreatment prevention expert Deborah Daro states in an issue of The Future of Children devoted to universal approaches to promoting healthy development, doctors don’t send away patients with precancerous cells and tell them to come back when they have Stage 4 cancer. Yet, that is exactly what we do in child welfare. As Daro points out, “our public response lacks an adequate early assessment when people become parents, and we often offer the appropriate level of assistance only after a parent fails to meet expectations or a child is harmed.” For this reason, many child welfare thought leaders like Daro are calling for a new emphasis on preventing maltreatment before it occurs.

The consensus on prevention still leaves the question of how much to invest in universal approaches (known as primary prevention) as opposed to “secondary prevention” approaches that target families who are deemed to be at risk. Secondary prevention has a lot going for it. Targeting a program to those who need it most can be justified on grounds of efficiency. Why spend money reaching people who do not need help? But investing only in secondary prevention has drawbacks, as described by Kenneth Dodge and Benjamin Goodman in the Future of Children issue referenced above. Even the lowest-risk groups have some risk of child maltreatment. And because they are much larger than the high-risk groups, they may account for most cases of maltreatment. Moreover, interventions with targeted groups rarely reach a high proportion of that population, and thus cannot have a detectable impact on the problem overall. Finally, targeted programs are often stigmatized and not politically popular, leading to lower funding–and less participation by targeted groups.

Dodge and Goodman point out that a debate over universal vs. targeted approaches played out when public schooling was first discussed in the United States. Some advocates argued that middle and upper class families could pay for their children to be educated, and that confining public education to the poor would save taxpayers money. Of course the proponents of universalism won out. Even though affluent families continue to be able to buy a more expensive education through higher property taxes and access to private school, one can only imagine the sorry state of our public education system if at been confined to the poor.

As Dodge and Goodman point out, not all universal programs must provide the same services for everyone, and they cite pediatric care as analogy. All children are seen for well-child visits, during which pediatricians screen them for conditions that might warrant services from specialists, and refer them accordingly. Therefore, they argue that “the best strategy may be to embed targeted interventions in a universal strategy that reaches the entire population while offering intensive interventions for targeted subgroups.” This approach, which they call “targeted universalism,” involves screening all families at a single point in time, such as the birth of a child, identifying the family’s risks and needs, and connecting them with community resources for addressing those risks and needs.

This is the approach that they embedded in the Family Connects Program, starting with a home visit fro a nurse. Nurse home visiting is a popular platform for a universal program, and there is a lot of precedent for a universal nurse home visiting program. Universal nurse home visiting is used by many European countries, where it is part of a comprehensive maternal and child health system, and is also used in other parts of the world. Perhaps the best developed application of this approach in the United States is Family Connects, which Dodge and his team at Duke University initiated in Durham, North Carolina in 2008 as Durham Connects. The model is now being implemented in over two dozen communities around the country, and Oregon is rolling it out statewide. Family Connects aims to reach every family giving birth in a community, assess the parents to determine their risks and needs, and refer them to appropriate services. The program rests on three “pillars:” home visiting, community alignment and data and monitoring, as described by Dodge and Goodman.

The first pillar is home visiting by a trained public health nurse who visits the family in the hospital to welcome the baby and offer a free home visit when the baby is about three weeks old. During the home visit, the nurse uses a structured clinical interview to assess risk in 12 key domains that predict adverse outcomes among children. At the end of the interview, the nurse works with the family to develop a plan of action which may include follow-up visits, phone calls, or contact with external agencies. With parental consent, this plan is shared with the baby’s pediatrician and the mother’s primary care provider. Four weeks later, a program staff member calls the family to check on their progress and determine if the referrals were successful. If the family has not succeeded in making the connection, the program either helps the family try again or makes another referral.

The second pillar, called community alignment, is a compilation of community resources available to families at birth, including targeted home visiting programs, early care and education, and mental health. This directory is available in electronic for for nurses to use on their visits. The third pillar is an electronic data system that documents each family’s assessment, referrals, and connections with community agencies. These records, scrubbed of identifying information, are aggregated to provide information about each agency and on a community level to identify gaps between needs and services. To contain costs, Family Connects is limited to seven contacts (phone calls and visits) over the course of 12 weeks. Dodge and Goodman report that the cost of Family Connects ranges from $500 to $700 per family.

Family Connects has been evaluated with two randomized controlled trials (RCT’s) in Durham, NC and one field study in four rural counties in the state. Eighty percent of the intervention families in the first trial scheduled a visit and 86 percent completed it, for a total “completion rate” of 69 percent. In the second trial, the percentages were 77 percent scheduled and 84 percent completed for a total of 64 percent. The first and second RCT’s found 49 and 52 percent of families respectively to have moderate needs, 46 and 42 percent to have serious needs requiring referral to a community resource, and one percent with a crisis needing immediate intervention. Of the families referred to a community agency, 79 percent and 83 percent reported they had followed through and made the connection. In the first RCT, researchers found that intervention infants had 39 percent fewer referrals to Child Protective Services (CPS) than did the control infants by the age of 60 months, controlling for demographic risk factors, as well as a 33 percent decrease in emergency room use.

Nurse home visiting is not the only possible platform on which to base a targeted universal program, Other options for locating a universal service include pediatric practices. There are two different models based in pediatrician’s offices that have shown promise for preventing child maltreatment–SEEK and Healthy Steps. SEEK trains pediatric primary care providers (PCP’s) to use a questionnaire to assess for a specific set of risk factors. The PCP initially addresses identified risk factors and refers the parent to community resources, ideally with the help of a behavioral health professional. Healthy Steps, as described by Valado and coauthors in The Future of Children, functions as a targeted universal model with three tiers. All families receive screenings and access to a child development support line. Second-tier families receive short-term consultations, along with referrals, additional guidance and resources. Families classified in the highest-risk tier receive “a series of team-based well child visits incorporating a Healthy Steps specialist.”

Models based in pediatric practices have had some promising results. A study testing SEEK with a high-risk sample of patients from a pediatric primary clinic in Baltimore found a “striking” 31 percent reduction in CPS reports. The other SEEK study focused on a low-risk population and there were not enough cases of maltreatment to find impacts on abuse and neglect; however, the study found a lower rate of physical punishment and psychological maltreatment reported by participating mothers. A multisite evaluation of Healthy Steps, as described by Velado et al, showed similar effects, such as a 33 percent reduction in the use of severe physical discipline in the intervention group vs the comparison group when the child was 30-33 months of age. The philanthropic partnership Blue Meridian Partners has chosen Healthy Steps as one of five models to receive large grants to help bring them to a national scale as a potential solution to poverty and lack of economic mobility.

Neither of these primary care-based models has been used universally throughout a jurisdiction. Moreover, pediatric care based models have less reach than models based on the birth hospital. Almost all babies are born in hospitals, but fewer infants attend their regularly scheduled well-baby visits. But according to the National Survey of Children’s Health for 2019, only an estimated 89 percent of children aged 0 to five had experienced one or more preventive care visit in the past year. While hopefully the percentage is greater for infants, it is probably less than the nearly 100% who are born in hospitals.

Many questions must be answered in developing a “targeted universal” child maltreatment prevention system.

What should the entry point be, and should there be more than one? Having all families enter the program through the same portal (be it the GYN practice, birth hospital, or pediatrician’s office) would avoid overlap and inefficiency. Choosing the system that meets parents earliest–the OB-GYN office–would allow programs to make a difference at a crucial time but would also miss the children who get little or no prenatal care. The founders of Family Connects chose to use the birthing hospital because it covers the most families, even though they are missing the chance to address problems that begin prenatally. Combining two or more portals may increase a program’s reach and the opportunity to coordinate and extend services. In Guildford County, NC, Healthy Steps is being integrated with Family Connects. Michael Wald, in a forthcoming article in the Handbook of Child Maltreatment, proposes a prevention system that starts with OB-GYN’s and WIC programs in the prenatal stage and continues with universal services at birth through pediatricians, home visitors and family resource centers. All of these entry points in turn would refer families to targeted services. Using more than one portal requires linkages and procedures for hand-off or collaboration, adding complexity to the system, but increases potential coverage.

What should the goals of the system be? A basic question is whether the system would be framed as a child maltreatment prevention system or something broader. It is hard to separate the goal of preventing maltreatment from that of promoting healthy child development, and indeed most of the programs discussed above have broader goals. The mission of Family Connects is “to increase child well-being by bridging the gap between parent needs and community resources.” Healthy Steps has the goal of “promoting the health, well-being and school readiness of babies and toddlers.” Clearly it is hard to separate the goals of child maltreatment prevention and the promotion of child well-being and healthy development.

What should the lead agency be? A key question about universal prevention is which system should take the lead. Child welfare leaders like Jerry Milner, head of the Children’s Bureau under the Trump Administration, have expressed the desire to expand the role of child welfare to include primary prevention. But if the goal is the broader enhancement of child development, and if the main providers of universal services are health professionals rather than social workers, another agency like public health may be a more appropriate home. Moreover, the child welfare system is already overburdened and underfunded. The work of investigating existing abuse and neglect (which will never be totally eliminated), helping parents and children heal, and making sure children have a safe environment to thrive either temporarily or permanently, is work enough for this beleaguered system. It is interesting that many modern child welfare leaders are so discontented with their primary mission that they are crying out to take on prevention. Perhaps the answer lies in the current political climate, which disparages child protective services and foster care, rather than recognizing the crucial role these services play in protecting children from harm,

What should the targeted services be? Michael Wald raises the question of whether a limited set of evidence-based models should be supported as part of a prevention system or whether jurisdictions should be given free rein in program selection. There are arguments for both, but it may be more practical to allow local jurisdictions to choose their own programs, especially since most “evidence-based” programs have only modest effects. But there are many reasons to advocate that every family found to be high-risk receive early care and education (ECE) interventions such as Early Head Start and Educare, which reduce child maltreatment risks in so many different ways, as I argued in an earlier post. The proposed Child Care for Working Families Act should help make such quality programs more available around the country.

How can we engage the highest-risk families? This is perhaps the thorniest question of all. All of the existing and proposed programs discussed above are voluntary, and voluntary programs never succeed in involving all eligible families. Moreover, it is often hardest to enroll and retain the highest-risk families in parenting support programs. We have already seen that Durham Connects provided a home visit to only 69% and 64% of eligible families in its two RCT’s. And considering that only 79 percent and 83 percent accessed the recommended services, the actual completion rate goes down further. In a study of Durham Connects, the researchers found that parents with a higher risk based on demographic factors like age and income were more likely to agree to a home visit but less likely to follow through. They also found that infant health risk, as measured by low birth rate, birth complications, and medical diagnoses, was associated with lower levels of both initial engagement and follow-through. An HHS issue brief suggests many ways to improve a program’s performance in enrolling and engaging families in home visiting programs. Not listed is the idea of including a peer mentor in the program model, which is embedded in some newer initiatives like Hello Baby and the Detroit Prevention Project. But the fact remains that a voluntary program will leave some children unprotected until they are actually harmed by abuse or neglect. Yet, it is clear that a mandatory child abuse prevention program will not be accepted in the U.S–just look at the debate over the COVID vaccine. We can hope that If a universal, voluntary prevention program is adopted, it will gradually gain in acceptance by high-risk and low-risk parents alike as a valuable benefit. In case that does not occur, we must record identifying information about the parents who do not accept the initial offer to participate and and follow up on future outcomes for their children in order to assess the efficacy of the program at preventing maltreatment among the highest-risk groups. Moreover, CPS must have access to this information when they receive a new report on a family.

Can the system be funded by cutting child welfare budgets? Congress has an unfortunate history of cutting funds to unpopular programs prematurely with the hope of achieving savings by a new approach, rather than waiting for a new approach to yield savings. One could mention mental health deinstitutionalization but a closer analogy might be the Family First Act’s moving money away from congregate care toward family preservation services, before states have the foster homes to replace these facilities, thereby simply shifting the cost of such facilities to states. We hope that establishing a robust system of prevention may well eventually result in a reduction of calls to Child Protective Services and in the need for foster care and in-home services. But we cannot reduce funding for traditional child welfare unless and until this effect has occurred, as Brett Drake argued in in a webinar recently conducted by the American Academy of Political and Social Science (AAPSS) in conjunction with their 2020 volume on child maltreatment. Even then it may make sense to retain current funding as the system is currently stretched thin.

What about anti-poverty programs? Adopting a system of targeted universalism to prevent child maltreatment does not directly address poverty, a prime risk factor for abuse and neglect, as discussed in my last post. Targeted universal programs will not change the level of welfare benefits or housing availability. However, it is important to remember that most poor families do not neglect their children, as University of Maryland’s Brenda Jones-Harden mentioned in the AAPSS webinar. Those families that are functioning well will find a way to get the resources they need to care for their children, and the supportive services provided through targeted universalism may help the others do the same. But at the same time, prevention advocates should fight to improve economic supports so that no child is deprived of what he or she needs to grow up into a healthy and functioning adult. Some of the new programs already passed or under discussion under the Biden Administration and the new Congress, such as the expanded child tax credit and the Child Care for Working Families Act, will help make targeted interventions more effective by addressing some of the poverty-related risk factors that cannot be addressed by targeted programs.

There is a growing consensus in the child welfare world that we must focus on prevention of abuse and neglect, and there is an increasing interest in using the approach of targeted universalism. The current historic expansions of the safety net will provide the perfect backdrop for such an initiative by addressing the economic risk factors for child abuse and neglect. With the motivation to build a better society in the wake of the pandemic, the time may be right to develop a universal, targeted system to prevent child maltreatment and allow every child the conditions for optimal development.

New Jersey to foster parents: thanks but no thanks!

Foster Parents Needed As COVID-19 Pandemic Strains Families is a typical headline these days, as illustrated in an article from Illinois. The pandemic has imposed new impediments to recruiting and retaining foster parents, including fears of exposure to COVID-19, loss of employment and income, and concerns about supervising virtual schooling. But these issues do not seem to be affecting New Jersey, where prospective foster parents are told that they are not needed, thank you very much! While the state credits its efforts at child abuse prevention and family preservation for its lack of need for foster parents, the explanation seems to lie elsewhere. Over the course of five years, the state has cut in half its rate of confirming allegations of abuse and neglect–resulting in a similar fall in the number of children entering foster care. This is a big change, and one that demands explanation in order to ensure that the agency is continuing to fulfill its mission of ensuring children’s safety in New Jersey.

Would-be New Jersey foster parents who click on “Be A Foster Parent” on the website of the Department of Children and Families (DCF) are greeted with the following message: “Thank you for your interest in becoming a resource parent to children and youth in state care.  Due to the COVID19 Pandemic and its impact on operations, DCF has suspended all new inquiry submissions at this time. Please continue to check our website for any updates.” This is an odd message indeed, as it seems to imply that the pandemic has made recruitment and licensing impossible. But agencies around the country have adapted quickly to move vetting and training online in order to enable new foster parents to enter the pipeline. Not so New Jersey.

When we asked DCF why foster parents are being turned away, we received the following reply from DCF Communications Director Jason Butkowski. “[W]e did experience a 19.17% reduction in out-of-home placements from 2019 to 2020.  This is attributable both to New Jersey’s statewide prevention network and our ongoing work to preserve families and keep children and parents together in their homes while receiving services.”

Interestingly, a message sent earlier to prospective foster parents gave a different answer. In May, 2020, would-be foster parents received a message saying, “In New Jersey, the number of youth in foster care continues to be reduced each year because we are focusing first on kinship placements,” as quoted in an article by Naomi Schaefer Riley. We asked Mr. Butkowski which explanation was more accurate–prevention and family preservation or kinship placements–but received no answer.

So what is going on in New Jersey? Certainly, foster care numbers have been decreasing. According to the data portal maintained by Rutgers University, annual entries to foster care fell from 5,504 in 2013 to 2,525 in 2019, as shown in the chart below. The rate of decrease in foster care entries became even steeper between 2018 and 2019, with a decrease of 23.7 percent in the number of entries in that one year alone. The total number of children in foster care dropped from a high of 7,775 in May 2014 to 4,463 in February 2020–before the pandemic closures occurred. So what could be causing this drastic decline in foster care placements and caseloads?

Source: NJ Child Welfare Data Hub, available from https://njchilddata.rutgers.edu/portal/entering-placement-reports#

One possibility might be a decline in child abuse and neglect, which Butkowski is implicitly assuming by attributing part of the fall in foster care cases to DCF’s “statewide prevention network.” In that case, one might expect reports to child abuse hotlines to decline significantly. But according to monthly state reports, calls to child abuse hotlines hardly changed between 2014 and 2019, decreasing very slightly from 165,458 to 164,417. Of course we cannot be sure that reports are an accurate measure of child maltreatment; but one might expect a significant reduction in hotline calls if a large reduction in maltreatment were occurring.

DCF’s Butkowski also credited the agency’s work to “keep children and parents together in their homes while receiving services” as a reason for declining foster care entries. It is true that most substantiations of abuse or neglect do not result in foster care. Instead, DCF works with many families in their homes to help them avoid future maltreatment. But DCF has been emphasizing in-home services for years. Of all the children who were under DCF supervision in foster care or in-home services, the percentage receiving in-home services rather than foster care was 84.7 percent in May 2014 and 90 percent in February 2020. So children were somewhat more likely to receive in-home services in 2020 than in 2014, but the difference was small and not likely to explain the big fall in the foster care rolls.

So with hotline calls basically unchanged, and only a slight increase in the emphasis on in-home services, how did New Jersey manage to reduce its foster care entries by almost half in six years? One can think of the child welfare process as a funnel, starting with referrals, the child welfare term for hotline calls. As we discussed, those have fallen only slightly. Only some referrals are screened-in and accepted for investigation; many are rerouted or receive no action because hotline workers determine that they do not concern abuse or neglect. But a reduction in screened-in referrals is not part of the explanation for New Jersey’s drop in foster care placements. New Jersey reported that 60,934 referrals were screened in in FFY 2019, compared with 59,151 in FFY 2013–a slight increase.

The next step in the child welfare funnel is investigation, and here the count shifts from the number of referrals to the number of children. According to data submitted to New Jersey to the Administration for Children and Families (ACF) and published in Child Maltreatment 2019, the number of children receiving an investigation in New Jersey increased slightly from Federal Fiscal Year (FFY 2015) to FFY 2019–from 74,546 to 78,741. However there was a stunning drop in the proportion of these children who were found to be abused or neglected (known as “substantiation” in the child welfare world). In FFY 2015, 13.0 percent of the children who received investigations (or 9,689 children) were found to be abused or neglected. In FFY 2019, only 6.5 percent of the children receiving investigations (5,132 children) were found to be victims of maltreatment. In other words, among the children who were involved in investigations, the proportion who were found to be maltreated dropped by half. Similarly, the number of children found to be maltreatment victims dropped by 47 percent. (This is very similar to the 44.6 percent decrease in foster care entries between those years shown in the Rutgers data portal cited above).

Note: The substantiation rate is the number of children found to be maltreatment victims divided by the number of children who were the subject of CPS investigations. Data are from Child Maltreatment 2019, available at https://www.acf.hhs.gov/sites/default/files/documents/cb/cm2019.pdf

It turns out that aside from Pennsylvania, which is not comparable to other states because it does not report on most neglect allegations, New Jersey had the lowest rate of substantiation per 1,000 children of all the states in FFY 2019. Only 2.6 children per 1,000 were found to be maltreated, compared to a national rate of 8.8 children per 1,000. In FFY 2015, this rate was 4.9 per 1,000 children in New Jersey–almost twice as high.

How did the number and percent of children found to be victims of child maltreatment drop so much in New Jersey over a four-year period, despite little decline in hotline calls? We asked DCF this question but received no reply. In the notes it submitted to ACF with its 2019 data, DCF acknowledged a decrease in the number of substantiated victims of maltreatment and stated that this is consistent with a continued trend–but provides no explanation. Perhaps policy or practice has changed to make it more difficult to substantiate abuse or neglect, through a change in definitions or in the standard of proof, or perhaps in training or agency culture. But such a change was not mentioned either by Butkowski or in DCF’s submission to ACF.

Let us revisit DCF’s previous message to foster parents saying that “In New Jersey, the number of youth in foster care continues to be reduced each year because we are focusing first on kinship placements.” This is an interesting statement because it implies that these kinship placements are not through the foster care system. It is important to understand that children can be placed with relatives in two ways. A child can be found to be a victim of maltreatment and placed with a relative, who becomes licensed as a foster parent. In New Jersey, 1,619 foster children (or 41 percent of the 3,951 children in foster care) were living with licensed kinship foster parents in November 2020. But these children are included in the state’s count of children in foster care, so they cannot account for the caseload drop. DCF must have been referring to something else.

Perhaps DCF’s earlier message to foster parents referred to the agency’s increasing use of a practice called “kinship diversion.” As described in an issue brief from ChildTrends, kinship diversion is a practice that occurs during an investigation or an in-home case when social workers determine that a child cannot remain safely with the parents or guardians. Instead of taking custody of a child, the agency facilitates placing the child with a relative. If this occurs in the context of an investigation, kinship diversion may result in a finding of “unsubstantiated” even when abuse or neglect has occurred, on the grounds that the child is now safe with the relative. We have no idea how widespread this practice is in New Jersey or nationwide since neither New Jersey nor other states report the number of these cases. However, the system of informal kinship care created by diversion has been called America’s hidden foster care system and nationwide it appears to dwarf the provision of kinship care within the foster care system.

There are many concerns about kinship diversion, as described in an earlier post: caregivers may not be vetted or held to the same standards as foster parents; they and the children they are caring for do not receive case management and services; they do not receive a foster care stipend and may have to depend on much-lower public assistance payments; there is nothing preventing caregivers giving children back to the parents without any assurance of safety; and parents are not guaranteed the due process rights and help with reunification that come with having their children in foster care. Because of the various concerns around kinship diversion, litigation has been filed in several states challenging this practice.

There is one other possible explanation that comes to mind for DCF’s foster parent surplus–dropping foster care rolls due to the COVID-19 pandemic. We removed data from the time of the pandemic from the above discussion to avoid confounding its effects with those of policy and practice changes but we need to ascertain whether the pandemic’s impact on calls to the hotline has affected entries into foster care. As in most states, hotline calls in New Jersey fell sharply in the aftermath of school closures and other pandemic measures. The number of child maltreatment referrals between March (the onset of school closures and quarantines) and November 2020 (the last month for which data are available on the DCF website) was 98,306, compared to 131,344 in the same period of 2019–a drop of 25 percent, based on monthly reports from DCF. It is likely that fewer calls from teachers now teaching virtually were a major factor behind this drop in hotline calls.

Entries into foster care also fell sharply in the wake of the pandemic. Foster care entries dropped from 1,949 in March through November 2019 to only 1,211 in the same months of 2020–a drop of 37.9 percent–which may have reflected in part the reduction in hotline calls and in part the continuing decrease in foster care entries that we have described. But the number of children in care did not drop nearly as much as entries into care. Between February and November 2020, the total number of youth in care decreased only 11 percent from 4,463 to 3,951. This drop is surprisingly low–in fact it is less than the decrease in the foster care caseload during the same months of 2019 (16.1 percent). The small size of this caseload decline reflects the fact that foster care exits dropped even more than foster care entries. Exits from foster care dropped from 2,754 in March through November 2019 to 1,661 in the same months of 2020. That is a drop of over 1,093, when the drop in foster care entries was “only” 738.[1] As a result, it appears that the number of children in foster care was higher, rather than lower, due to the pandemic. Therefore, it does not appear that the pandemic contributed to the decline in demand for foster parents.

One might expect to hear expressions of concern, or at least interest, in the recent precipitous drop in the number and rate of substantiations and in the foster care caseload from the court-ordered monitor charged with ensuring that New Jersey’s child welfare system is fulfilling its mission of protecting children. Since 2006 New Jersey has been operating under a settlement agreement in a lawsuit filed in 1999. The Court Monitor is Judith Meltzer, Executive Director of the Center for the Study of Social Policy (CSSP). In its most recent report, CSSP praised DCF for maintaining its progress toward meeting all the benchmarks required to exit the lawsuit, despite the challenges posed by COVID-19. Ironically, the report mentions DCF’s progress in “Prioritizing Safety.” The report does not mention the precipitous drop in foster care entries or substantiations before the pandemic or the fact that the state is turning away prospective foster parents.

New Jersey may be the first state to have stopped accepting applications for foster parents, and the reasons cited by DCF do not seem to explain this unusual event. Careful study of DCF data shows that the rate at which allegations of abuse or neglect are substantiated has been cut in half, and that there has been a similar reduction in entries into foster care. This cut in the substantiation rate could be due to policy or practice changes making it harder to confirm child maltreatment or it could be due to an increased tendency to place children with relatives without establishing officially that maltreatment has occurred. Without an adequate explanation from the state, the extent to which either of these factors is driving these trends is unknown. It is imperative to know the explanation of this trend to ensure that DCF’s new policies and practices are not compromising its mission of keeping children safe.

[1]: Reasons for this drop in foster care exits may include court shutdowns and delays and suspension of services parents need to complete their reunification plans.

Declining child abuse? The misuse of data in child welfare

Lowest number of maltreatment victims in five years, crowed the Administration on Children and Families (ACF), summarizing its annual report, Child Maltreatment 2019. Child welfare newsletter The Imprint eagerly repeated the claim, claiming that the Number of Child Abuse and Neglect Victims Reached Record Low in 2019. The venerable Child Welfare League of America followed suit in its Children’s Monitor saying “Data Shows Decline in Child Abuse in FY2019.” It is only by reading the report that one learns that the decline was not actually in the number of victims of abuse or neglect. Instead, it was a decline in the number of children who were found by Child Protective Services (CPS) to be abused or neglected, which is not the same thing at all.

Child Maltreatment, the Children’s Bureau’s annual report on child abuse and neglect, is based on data from the states, the District of Columbia, and Puerto Rico collected through the National Child Abuse and Neglect Data System (NCANDS). Child Maltreatment 2019 is based on data from Federal Fiscal Year (FFY) 2019, which ended September 30, 2019. (Note that these data reflect the year before the inception of the coronavirus pandemic.) Displayed below is a summary of four key national rates reported by ACF between 2015 and 2019. The first indicator shown is the referral rate, which describes the number of calls and other communications describing instance of child maltreatment per 1,000 children. Next is the screened-in referrals rate, which includes referrals that are passed on for investigation or alternative response. Once screened in, only some reports are referred for investigation, and the third set of bars represents children who received an investigation per 1,000 children. The fourth group shows the rate of children found to be abused or neglected–or those who received a substantiation. Let us go over these numbers in more detail.

*Note that Investigation and Substantiation Rates are based on number of children, not referrals
Source: Child Welfare Monitor tabulation of data from Child Maltreatment 2019, available from
https://www.acf.hhs.gov/sites/default/files/documents/cb/cm2019.pdf

Total referrals: A referral is a call to the hotline or another communication alleging abuse or neglect. In 2019, agencies received an estimated total of 4.4 million referrals, including about 7.9 million children. The “referral rate” was 59.5 referrals per 1,000 children in FFY 2019. This rate has increased every year since 2015, when it was 52.3 per 1,000 children. It is worth noting that the referral rate differs greatly by state, ranging from 17.1 referrals per 1,000 children in Hawaii to 171.6 per 1,000 children in Vermont, as shown in the report’s state-by-state tables. These differences in referral rates may stem from cultural differences regarding the duty to intervene in other families, differences in publicity for child abuse hotlines and ease of reporting, or temporal factors like a recent highly-publicized recent child abuse death.

Screened-in referrals (reports): A referral can be either “screened in” or screened out because it does not meet agency criteria. In FFY 2019, agencies screened in 2.4 million referrals, or 32.2 referrals per 100,000 children. This was a decrease in the rate of screened-in referrals per 1,000 children after three straight years of increases. This percentage of referrals that were screened in varied greatly by state, ranging from 16 percent in South Dakota to 98.4 percent in Alabama. States reporting a decrease in screened-in referrals gave several reasons, such as a change in how they combine multiple reports and a decision to stop automatically screening in any referral for a child younger than three years old.

Children who received an investigation (child investigation rate): Once a report is screened in, it can receive a traditional investigation or it can be assigned to an alternative track, which is often called “alternative response” or “family assessment response.” (Two-track systems are often labeled as “differential response.”) This rate represents the number of children who received an investigation as opposed to an alternative response. Only an investigation can result in a finding of abuse or neglect; an alternative response generally results in an offer of services. Like the referral rate, the investigation rate increased from 2015 to 2018 and then decreased in 2019. This rate also varies widely between states and over time. Some states eliminated or expanded their differential response programs in 2019, resulting in more or fewer investigations, as described in the report.

Substantiation: A “victim” is defined in NCANDS 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.” The report’s authors refer to the number of such children per 1,000 as the “victimization rate.” But clearly substantiation does not equal actual victimization. The difficulty of making a correct decision on whether maltreatment has occurred is well-documented. Stories of families with repeated reports that are never substantiated or not confirmed until there is a serious injury or even death are legion. So are reports of parents wrongly found to be abusive or neglectful. Therefore, we have chosen to use the term “substantiation rate” instead of ‘victimization rate.” This rate varies greatly by state, from 2.4 per 1,000 children in North Carolina to 20.1 in nearby Kentucky.[1] The national substantiation rate in FFY 2019 was 8.9 per 1,000 children, down from 9.2 per 1,000 in FFY 2019 and FFY 2015. States reported a total of 656,000 (rounded) victims of substantiated child abuse or neglect in FFY 2019–a decline of four percent since 2015.

So does this decline in the number and rate of substantiations really connote a decline in child abuse and neglect? The range in substantiation rates among states argues against this idea. Unless states differ by almost a factor of 10 in the prevalence of child abuse and neglect, these numbers must reflect factors other than the actual prevalence of maltreatment. And indeed the report’s authors acknowledge that “[s]tates have different policies about what is considered child maltreatment, the type of CPS responses (alternative and investigation), and different levels of evidence required to substantiate an abuse allegation, all or some of which may account for variations in victimization rates.” Changes in these policies and practices can account for changes in these rates over time. Moreover, changes in all the earlier stages of reporting, screening, and assignment to investigation or alternative response contribute to changes in the substantiation rate. In 2019, screened-in referrals and investigations per thousand-children both decreased, which clearly contributed to the decrease in the substantiation rate.

It is interesting to note that while referrals increased every year between FFY 2015 and FFY 2019, both screened-in referrals and investigations decreased in FFY 2019. This suggests a general tendency among states to be less aggressive in responding to allegations of maltreatment, perhaps in accord with the prevalent mindset among child welfare leaders nationally and around the country, as discussed below.

Understanding the difference between “victimization” and “substantiation” and the many possible causes of a decrease in this rate reveals the deceptiveness of ACF’s statement that “[n]ew federal child abuse and neglect data shows 2019 had the lowest number of victims who suffered maltreatment in five years.” Lynn Johnson, the HHS assistant secretary for children and families, is quoted in ACF’s press release as saying that “[t]hese new numbers show we are making significant strides in reducing victimization due to maltreatment.” Unless Johnson and the ACF leadership intended to mislead, it appears they are woefully ignorant of the meaning of these numbers.

Most regular leaders of this blog already know why ACF wants to support the narrative of declining child maltreatment. The current trend in child welfare policy, regardless of political party, is to oppose intervention in families. Republicans who oppose government spending and interference in family life have made common cause with Democrats who think they are reducing racial disparities and supporting poor poor families by allowing parents more freedom in how they raise their children, even if it means leaving children unprotected. Members of both parties came together to pass the Family First Act, which encoded this family preservation mindset into federal law.

Child Welfare Monitor has pointed out many other instances where ACF or by other members of the child welfare establishment in the interests of supporting the family preservation mindset. For example, we wrote about the Homebuilders program, which was classified by a federally-funded clearinghouse as “well-supported” despite never having been proven effective for keeping families together. In fact, Homebuilders had to be classified as well-supported because it was one of the key programs touted by ACF and others in promoting the Family First Act and other policies promoting family preservation.

So if ACF’s “victimization” data do not in fact tell us what is happening to abuse and neglect rates, what else is available? We call on Congress to pass an overdue re-authorization of the Child Abuse Prevention and Treatment Act and include a fifth National Incidence Study of Child Abuse and Neglect. Data for the last study was collected in 2005 and 2006; it is high time for an update which should put an end (at least temporarily) to the misuse of NCANDS data as an indicator of trends in child maltreatment.

President Biden has called for ending a “culture in which facts themselves are manipulated and even manufactured.” We hope that ACF under its new leadership, as well as the rest of the child welfare establishment, will take these words to heart and commit themselves to truth and transparency from now on.

[1]: Pennsylvania has a substantiation rate of 1.8, even lower than that of North Carolina, but in Pennsylvania, many of the actions or inactions categorized as “neglect” are classified as “General Protective Services” and not included in the substantiation rate, making its data not comparable to that of the other states and territories.

[2]: Massachusetts did not provide data on FFY 2019 child maltreatment fatalities.

Illinois’ Intact Family Services: What happens when family preservation trumps child safety?

ChapinHallIllinois’ 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: 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:  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: 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.

 

Primary prevention of child maltreatment should include family planning

familyplanning
Image: mattapanchc.org

Primary prevention is the phrase of the day in child welfare. As Jerry Milner, Associate Commissioner of the Children’s Bureau of the Department of Health and Human Services put it in a letter attached to the program for the recent NCCAN conference, “Right now, our child welfare system typically responds only after families have lost much of their protective capacity and children have been harmed. We need to create environments where families get the support they need before harm occurs. This calls for an intensified focus on primary prevention and a reconceptualization of the mission and functioning of child welfare systems.”

Primary prevention refers to the prevention of abuse and neglect before it occurs through universal approaches. This is distinguished from secondary prevention, which focus on those at risk for a problem like child maltreatment, or tertiary prevention, which focuses no preventing on recurrence of a problem that has already occurred. (The much touted Family First Act allows funds to be used only for tertiary prevention, which is perhaps why it was not mentioned at the conference and why the Children’s Bureau has been dragging its feet on issuing guidance to states and counties.)

Yet, discussions of primary prevention (including those at NCCAN) often leave out the most primary of all–encouraging people to delay childbearing until they are ready to be parents, to wait at least 18 months between pregnancies, and to curb the overall number of children they have.

The connection between teen pregnancy and child maltreatment is well-known, but adolescence is lasting longer than ever, and even mothers aged 20 to 25 are more likely to abuse or neglect their children than older mothers. California researchers Emily Putnam-Hornstein and Barbara Needell found that babies born to mothers who were under 20 were twice as likely to be reported to child protective services (CPS) by the child’s fifth birthday as those born to mothers 30 or older. Among children referred to CPS by age five, almost 18 percent were born to a teenage mother and 50 percent were born to a mother younger than 25. Among children with no CPS contact, only 8 percent were teen births and 30 percent were born to a mother under 25.

Less well-known or discussed is the consistent evidence that larger family size and closer child spacing are correlated with child maltreatment. The Fourth National Incidence Study of Child Abuse and Neglect found that households with four or more children had a maltreatment rate of 21.2 per thousand, compared with 11.9 per thousand for families with two children. Putnam-Hornstein and Needell found that children who fell third or higher in the birth order were more than twice as likely to be the subject of a maltreatment report as first children.

Not surprisingly, research suggest that the interaction between birth order and maternal age creates the highest risk for a child maltreatment fatality. A study using linked birth and death certificates for all births in the U.S. between 1983 and 1991 found that the most important risk factors for infant homicide were a second or subsequent infant born to a mother less than 17 years old. These infants had 11 times the risk of being killed compared with a first infant born to a mother 25 years old or older. A second or subsequent infant born to 17 to 19-year-old mother had nine times the homicide risk of the first infant born to the older mother.

And setting the research aside for a moment, anyone who has worked for or with CPS, or in foster care, knows the prevalence of larger families with closely-spaced children in the system, often with a mother that started childbearing as a teen. This blogger has observed the same pattern as a member of the District of Columbia’s Child Fatality Review Committee, and it has been observed in other jurisdictions as well.1  

If it is not the lack of research, why do supporters of child maltreatment prevention fail to include family planning and contraception in their suggestions? Judging from the reactions this blogger has received when raising this issue,  it is our country’s shameful history of attempting to restrict childbearing by women of color through means including forced sterilization and the promotion of birth control methods like Norplant.

But advocates for children of color should not allow this racist history to prevent thinking clearly about what is best going forward. There are few if any policies that could be more helpful to the future of black children and the elimination of racial disproportionality in foster care placement than ensuring that black women have access to the most effective methods of contraception so that they can determine their own futures.

Family planning and contraception need to be included in the discussion about child maltreatment prevention. Research suggests that media messaging, better information, and use of more effective contraceptive methods contributed to the drastic decline in the teen birth rate from 61.8  per thousand in 1991 to 18.8 per thousand in 2017. However, it is still high among certain populations, including Black (27.5 per thousand) and Hispanic (28.9 per thousand) teens.

We now have safe, effective long-lasting reversible methods of contraception. Known as LARC’s, for “Long Lasting Reversible Contraceptives, these methods provide long-lasting contraception without requiring action by the user. They include IUD’s and contraceptive implants. But LARC’s are not universally available, and even when available, women desiring these methods may have to return for a second appointment. Moreover, health care professionals are often not trained to address myths and misconceptions concerning longer-lasting contraception. The Colorado Family Planning Initiative improved access to LARC’s by training public health providers, supporting family planning clinics, and removing financial barriers. As a result of this initiative, the state’s teen birth rate was cut in half in just five years.

The Colorado initiative could be adopted nationwide, combined with a mass media campaign to explain the benefits to both children and parents of planning and spacing of pregnancies and births. We know that such campaigns can change people’s health-related behavior, as in the case of smoking cessation and HIV prevention. 

The omission of pregnancy prevention from the primary prevention toolkit is particularly upsetting because very few programs have been shown to be effective in preventing abuse or neglect after a baby is born. Jerry Milner and other proponents of primary prevention in child welfare argue that we should help families before they maltreat their children. How much more efficient and humane it would be to postpone the birth of children who are likely to be maltreated and help troubled adults address their problems before they have a first or subsequent child rather than afterwards?

  1. Testimony of Dr. Angela Diaz, CECANF, August 6-7, 2015), https://slideblast.com/cecanf-nyc-meeting-transcriptfinal_59767e8e1723ddc0e0eedc5d.html 

 

 

 

Feds confuse substantiation with victimization

On January 28, the Administration of Children and Families (ACF) released its annual report on child maltreatment. In its press release, the agency heralded “a decline in the number of victims who suffered maltreatment for the second consecutive year.” There are three problems with this. First, the alleged decrease in victimization between Federal Fiscal Years (FFY) 2016 and 2017 is so small as to be insignificant. Second, what declined was not child maltreatment but rather the number of children who were “substantiated” as maltreated–a decline that may reflect changing state practice rather than declining child maltreatment. Finally, ACF’s presentation appears designed to support a narrative that favors family preservation over child safety rather than to report the data in an objective manner.

The newest edition of ACF’s Child Maltreatment report is based on state data for FFY 2017, which ran from October 2016 to September 2017. The report shows that states received 4.1 million referrals (calls to child abuse hotlines) alleging maltreatment involving 7.5 million children in 2017. The number of referrals as a percentage of the number of children has increased annually since 2013. ACF does not discuss the reasons for this ongoing increase, nor does it present referral numbers by state, but such increases could stem from increased awareness of child abuse and neglect (often due to highly-publicized child deaths), public information campaigns, or other factors.

Of the 4.1 million referrals received nationwide in 2017, 2.4 million  (or 58%), were “screened in” by state or county child welfare agencies, which means they met agency criteria for receiving a response. As a result, 3.5 million children received either a traditional child maltreatment investigation or were assigned to an alternative non-investigative track, as described below. And of these 3.5 million children, an estimated 674,000 or 19% were found to be victims of abuse or neglect. This flowchart, based on data from Child Maltreatment 2017, illustrates this funneling effect from referrals to substantiation.After rounding and a calculation to account for missing data from Puerto Rico in FFY 2016, HHS estimates that the number of children found to be maltreated decreased of 3,000 (or 0.4%) from the previous year. Such a small change is hardly meaningful; it would be more accurate to say that the number was basically unchanged. This difference from one year to the next is so small that the rate of children found to be victimized was the same in 2017 as in 2016–9.1 per 1000 children. In other words, almost one percent of all children were found to be the victims of maltreatment in 2016 and 2017.

But perhaps more important than the small size of the decrease is the fact that referring to a “decline in the number of victims” or the “victimization rate”  is deceptive, which is why I have used cumbersome terms like “found to be victims of child maltreatment.” Most states use the term “substantiation” to connote that they have concluded maltreatment have occurred; some have an additional finding called “indication” that is somewhat less conclusive than substantiation. But as we all know, a finding of maltreatment is not the same as actual maltreatment. Just look back at my columns on Jordan Belliveau in Florida, Anthony Avalos in California, the Hart children in Oregon, and Adrian Jones in Kansas to find cases where horrific abuse occurred but was not substantiated until a child died.

And that is not the only problem. As ACF itself explained, changes in state policy and practice can influence the number of reports that are substantiated. Different states have different evidence thresholds to substantiate an allegation. According to the report, 37 states require a “preponderance of” evidence, 8 states require “credible” evidence, 6 states require “reasonable” evidence and one requires “probable cause.” One state changed its evidence threshold between 2016 and 2017.

In addition to different criteria for substantiation, some states treat all screened-in referrals in the same way while others have a two-track system of responding to reports. In these two-track systems (often called “differential response” or “alternative response”), some allegations receive a standard investigation, but others (usually deemed to be at lower risk of harm) receive less rigorous response, often known as a “family assessment.” The children in these cases are not determined to be victims even if they have been abused or neglected. Instead their families are offered voluntary services. About half of states reported data on children in alternative response programs. As the above flow chart shows, 639,634 children received an alternative response, almost as many as the 674,000 who were determined to be maltreated.

So a given state’s substantiation rate will be influenced by whether it has differential response in all or part of the state. And if the use of differential response in a state was expanding or contracting over a given period, this will influence the change in the number of  children who are determined to be victims of maltreatment. Specifically, if states increased their use of differential response overall, that would have reduced the number of children found to be maltreated.

And indeed, ACF reports that “states’ commentaries suggest the increased usage and implementation of alternative response programs ….may have contributed to the changes noted in the 2017 metrics.” And upon review,  the commentaries, included in an Appendix to the report, do suggest that the number of reports subject to differential response increased between FFY 2016 and 2017. Six states, including New York, and Texas (two of the four states with the highest number of children)1 were ramping up their use of differential response during FFY 2017, while Massachusetts and Oregon stopped using the two-track system in FFY 2016 and 2017 respectively.

ACF also suggests that changes to state legislation and child welfare policies and practices might influence the number of substantiated allegations. The state commentaries reveal that some states experienced such changes, although it is not clear that they trended in one direction. Some states like Pennsylvania reported an increased emphasis on safety resulting in increased substantiations and others like New Jersey reporting reduced substantiations due to new policies.

As all this discussion shows, it is almost impossible to attribute a change in the number or rate of substantiation to an actual change in the amount of child abuse and neglect. Too many other things are influencing this number and rate.

Not only did ACF inaccurately herald a decrease in maltreatment but it went on to contrast this alleged decrease with the increasing number of referrals, stating “We are experiencing increases in the number of children referred to CPS at the same time that there is a decrease in the number of children determined to be victims of abuse and neglect.” Media outlets lost no time in picking up on this alleged contrast. For example,  the Chronicle of Social Change reported that Child Victimization Declines as Reports of it Continue to Rise.

The interpretation of child welfare numbers to paint a picture of decreasing maltreatment in the face of increasing reporting is not an accident. It feeds into the narrative that is currently dominating in most states and on the federal level without regard to party. According to this narrative, almost all children are better off staying with their parents, no matter how egregious the maltreatment. Removals should be prevented at all costs. If maltreatment is decreasing and reporting is increasing, perhaps something should be done to squelch those pesky hotline callers.

The data presented in Child Maltreatment is extremely important. It is too bad ACF did not stick to reporting it accurately so that readers can understand what it means–and what it does not.


  1. Colorado, Georgia, Nebraska and Washington were the other four states that expanded the use of differential response during FY 2017.