Neglect as poverty: the myth that won’t go away

Image: consumerhealthday.com

It’s one of those myths that won’t go away and instead is gathering steam–the idea that parents who are found to be neglectful by child welfare agencies are really just poor people being judged for their inability to provide sufficient material support to their children. It doesn’t matter how much evidence is cited against it. The myth continues because it is an essential part of the narrative that is currently dominant in the child welfare arena. Nevertheless it’s been over a year since my last attempt to shed some light on this issue, and some new research has become available, thus it seems a good time to revisit the topic.

It’s Time to Stop Confusing Poverty With Neglect, exhorted Jerry Milner, Children’s Bureau Commissioner and his special assistant David Kelly back in January, 2020, in a typical statement of this myth. “Most of the reasons for child welfare involvement fall into what we call “neglect” rather than physical abuse or exploitation. Our most recent child maltreatment data tell us that 60 percent of victims have a finding of neglect only…More times than not, poverty and struggles to meet the basic, concrete needs of a family are a part of the equation in all types of neglect.” Miller and Kelly now sell their expertise at Family Integrity & Justice Works, an arm of the Public Knowledge consulting firm which has the goal of “replacing child welfare.”

Media outlets have taken this story and run with it. Here is the Philadelphia Inquirer: “A common misunderstanding is that the leading reason kids are taken into the foster care system is because of physical or sexual abuse. But that accounts for only one of six cases. Children far more often are removed from their homes for ‘neglect,’ which often amounts to symptoms of poverty, like food insecurity or unstable housing.”

The Biden Administration has endorsed the idea that most neglect findings reflect nothing but poverty. The Administration on Children and Families (ACF) has solicited applications for a grant of between one and two million dollars “to support the development and national dissemination of best practices to strengthen the capacity of child abuse hotline staff to distinguish between poverty and willful neglect.”

There is no federal definition of child neglect, and state definitions vary. In contrast to abuse, it is usually defined as an act of omission rather than comission. According to the Child Welfare Information Gateway, neglect is “commonly defined in state law as the failure of a parent or other person with responsibility for the child to provide needed food, clothing, shelter, medical care, or supervision to the degree that the child’s health, safety and well-being are threatened with harm.” The most commonly recognized categories of neglect include physical neglect or failure to provide for basic physical needs, failure to provide adequate supervision , educational neglect or failure to educate the child as required by law, and medical neglect.

There is no dispute that more children are found to be neglected than abused. Based on data collected by the federal government and published in Child Maltreatment 2020, three-quarters (76.1 percent) of the children found to be victims of maltreatment in 2020 were found to be neglected. A total of 16.5 percent were found to be physically abused, 9.4 percent were found to be sexually abused, and six percent were found to be victims of some other type of maltreatment.* Of the children who were removed and placed in foster care, according to the 2020 AFCARS Report, 63 percent had neglect listed as a circumstance associated with the child’s removal, compared to 12 percent with physical abuse and four percent with sexual abuse.

But the idea that neglect findings represent nothing but poverty is questionable. First, the neglect deniers would probably agree that most poor parents do not neglect their children but instead find a way to meet their needs, relying on charity, extra work, or subordinating their own wants to the needs of their children. When poor children are deprived of food, clothing or adequate housing, other factors such as substance abuse, mental illness and domestic violence are often involved. Second, more than half of the states exempt from the definition of neglect any deprivation that is due to the lack of financial means of the parents. Third, the definition of neglect is not confined to the failure to provide adequate food, clothing or shelter but instead includes other acts of omission, such as failure to protect a child from dangerous caregivers, or failure to ensure that children go to school and get needed medical care. Lack of supervision, a common form of neglect, can reflect poverty when parents feel they must rely on inadequate arrangements in order to go to work; we just don’t know the degree to which neglect findings reflect such decisions by parents.

But until now we did not have quantitative data concerning the types of neglect being investigated or the importance of risk factors like substance abuse and mental illness. A recent study from California, the nation’s most populous state, begins to fill this data gap. Palmer and colleagues used a representative sample of 295 neglect investigations that took place in California in 2017. They found that only 14 percent of the investigations involved physical neglect–the deprivation of food, clothing, and housing that is most closely connected with poverty. The most common types of neglect that were investigated were inadequate supervision, investigated in 44 percent of the cases, and failure to protect (leaving the child in the care of a known abuser or failure to intervene with known abuse), in 29 percent of cases. Moreover almost all (99 percent) of the investigations of physical neglect included concerns related to substance use, domestic violence, or mental illness; or they involved another type of maltreatment such as physical or sexual abuse or an additional neglect allegation. Thus, the authors conclude that almost no parent was investigated for material deprivation alone, although it is true that they did not separate out any lack of supervision cases that involved the inability to obtain adequate childcare for work or other necessary activities.

The evidence from California is very suggestive, but as the authors caution, it is possible that other states receive more reports that focus on unmet material needs, are less likely to screen out such reports, or emphasize them more during the investigation. This is possible because California, according to a recent study of state neglect definitions, is one of five states that have adopted an “expanded” definition of child neglect, including more neglect types and allowing for the threat of harm, rather than actual harm, in neglect findings. Studies similar to the Palmer study from other states with more limited neglect definitions would be useful.

While the California study is not sufficient to negate the presumption that findings of neglect represent nothing more than poverty, it is important to note that there are no studies supporting this viewpoint. So why does the myth that child welfare treats poverty as neglect persist despite the lack of evidence supporting it, and the many reasons for skepticism? It persists because it supports the narrative and associated policy prescriptions of the child welfare establishment today–child welfare leaders, administrators, legislatures, and influential funders like Casey Family Programs. The dominant narrative describes a racist family policing system that persecutes people only because they are Black, Indigenous or poor. The policy prescriptions involve radically shrinking or even abolishing child welfare systems.

According to the prevailing view, if omissions that are labeled neglect are strictly due to poverty, there is no need to intervene with social services or child removal. Instead, governments should provide economic benefits to neglectful parents. There is a body of research suggesting that economic support for families does help reduce maltreatment, perhaps not only by helping parents meet their children’s financial needs, but also enabling them to provide better childcare and improving parents’ mental health through stress reduction. Independent of their impact on maltreatment, I strongly support increases in the safety net for families and children. But available information suggests that it will take more than financial assistance to cure neglect in most cases. Improved economic supports will not be a replacement for services to help parents address challenges with substance abuse, domestic violence, mental health, and parenting, and for child removal when there is no other option.

What can be done to alleviate the confusion and misinformation around child neglect and poverty? Collecting better data from the states would be helpful. In its annual Child Maltreatment reports, the Children’s Bureau uses data from the National Child Abuse and Neglect Data System (NCANDS). When reporting on the type of maltreatment alleged and then found, states must pick up to four out of eight categories, including physical abuse, “neglect or deprivation of necessities,” medical neglect, sexual abuse, psychological or emotional maltreatment, sex trafficking, no alleged maltreatment, other or “unknown or missing.” It is not clear whether the “neglect” category is supposed to indicate all types of neglect or just those involving “deprivation of necessities,” but there is no way for states to clarify what they mean or to distinguish between the most common types of neglect. The same problem exists with the AFCARS data used to compile federal reports on foster care and adoption.

Clearly, a reform of the data elements that states are required to submit is needed so that resesarchers can see the types of neglect that are being alleged and found for each child. However, such an improvement would not substitute for careful research like the California study cited above because it will never be possible to rely on the thoroughness of database entries by overworked social workers. We cannot be sure they will enter all of the applicable categories, for many reasons, including that not all the applicable categories may be substantiated for a particular case. Moreover, while states are required to report on some caregiver risk factors contributing to abuse and neglect, such as alcohol and drug abuse, emotional disturbance and domestic violence, these seem to be vastly understated by the social workers who enter these factors in state databases. For example, only 26.4 percent of caregivers of maltreated children were found to have the risk factor of drug abuse and only 36 percent of removals involved parental drug abuse, according to federal data. Yet anecdotal reports from states and localities tend to indicate a much higher percentage of cases that involve substance abuse.

Thus, a reform of data collection might help, but would not solve the problem, especially considering that that many child welfare leaders and funders seem inclined to maintain the hypothesis that CPS confuses poverty with neglect. Ideally, the federal government and other funders would support more studies like that of Palmer et al, and more academics would consider performing such studies.

The myth that CPS confuses neglect with poverty is pernicious because, like other myths currently prevalent in child welfare, it runs the risk of hurting abused and neglected children. It is being used to justify dismantling child protective services, eliminating mandatory reporting, or more modest proposals to hamper these critical protections for children. The federal government should improve data collection on child neglect and associated risk factors as well as supporting additional research to provide more accurate estimates of their prevalance.

*According to the report’s authors, “other” could be anything that does not fit into the categories offered by the Child Abuse and Neglect Reporting System and includes threatened abuse and neglect, drug addiction, and lack of supervision according to state comments submitted with the data.

Book Review: A Place Called Home: a needed antidote to the dominant narrative

It’s Christmas in Manhattan, and five-year-old David Ambroz (then called Hugh), six-year-old Alex and seven-year-old Jessica trudge through the freezing nighttime streets. “I’m only five,” writes Ambroz, “and all I know about Christmas is the stories I’ve heard at the churches where we go for free meals.” “Mom, we’re close to the Port Authority, can we go inside?” asks Hugh. “Walk straight. They’re after us” is the reply he receives. “There’s a calculation I make whenever I talk to Mom: Will she hit me, and is it worth it?” Ambroz explains.

So begins David Ambroz’s harrowing account of life with a mother, Mary Ambroz, whose mental state varies from manic to apathetic to floridly paranoid. A former nurse who was once married to a doctor,* Mary has been in the grips of her untreated mental illness for as long as Hugh can remember. The family bounces back and forth between New York City and Albany, eventually relocating to Western Massachusetts. The children are condemned to a life of sleeping at all-night Dunkin Donuts shops, dining on tiny cups of creamer mixed with sugar packets, and eating out of dumpsters, interspersed with short periods of relative normalcy when the family finds a temporary home. Those periods last until Mary decides the CIA or other pursuer is back on their trail. Some years the children don’t go to school at all, other years they change schools one or more times due to their frequent moves. The children don’t receive medical or dental checkups or vaccinations and visit the occasional clinic only for emergencies. When Hugh breaks his arm at the age of four, he is taken to the emergency room to have it set but never brought back to have the cast removed; when it starts to smell, Mary removes it with a kitchen knife.

Over the years the family has been investigated many times without getting any help, reports Ambroz. Mary Ambroz usually manages to convince authorities that she is a good mother, although she has lost custody more than once–one time when she threw a shoe at a judge in eviction court and was carted off to a psychiatric ward. The children went to a friend’s mother, but were returned to their mother as soon as she was released.

When she finds work as a live-in nurse for an older woman who allows the family to live with them, Mary instructs the children to call their benefactor “Aunt Flora.” Hugh is thrilled to live in an apartment where he can take a bath and to be enrolled in third grade only a month into the school year even though he missed most of second grade. In an apparent effort to ingratiate the family with “Aunt Flora,” Mary tells eight-year-old Hugh he is Jewish, renames him David, and immediately takes him to a doctor to be circumcised. But she does not bring him back for follow-up care and the wound becomes infected. Mary refuses to seek medical care despite “Aunt Flora”‘s pleas, rippimg off the protective mesh that had become stuck to the wound. Dismayed at Mary’s refusal to seek medical care for her son, “Aunt Flora” expels the family and they are living in Grand Central station again.

Even during relatively stable periods, when they are able to rent an apartment in Albany with the help of public assistance, life is far from normal for the children. Mary Ambroz doesn’t cook and when the food stamps start to run low the children have strategies for getting fed, like sneaking into Ponderosa Steakhouse by pretending to be part of a family that has already paid. A kitten they were allowed to adopt during a good period starves to death despite David’s attempt to steal enough food to keep him alive. “He ate his own shit and died,” his mother tells him. “Enough whining, David. You should have taken care of him,” she said, putting the body in a trash bag along with the cat toys and the litter box.

Mary Ambroz uses a gift of $500 to take a taxi to Boston, and the family ends up in a domestic violence shelter in Pittsfield, Massachusetts. Shelter staff try to help her get back on her feet and David tries to assist, accompanying her in selling vacuum cleaners door to door. The children are enrolled in school But that situation falls apart when Mary accuses a 65-year-old staffer groundlessly of sexually abusing David, after beating David up for allowing it to happen. “Nobody wants to tangle with my mother….And so, at this shelter for abused women, the response to our mother’s unhinged behavior is to move us to an apartment where they won’t have to witness the abuse.” And that is the same story, reports Ambroz, that repeats over and over again in their lives. Adults intervene with temporary kindnesses but don’t take steps to rescue the children from what is clearly a dangerous situation.

The children are thrilled with their new apartment, but Mary grows worse, alternating between almost catatonic apathy and violence. Twelve-year-old David realizes that foster care could be his salvation. He and his siblings been have been hiding their bruises for years at their mother’s demand but he finally understands that he must reveal his injuries in order to be saved. He shows his bruises to a DARE officer visiting his school. Two weeks later, two social workers knock on their door. “David, does your mother hurt you?” asks one of them, in front of his mother. As often happens when children are asked this question in the presence of the abusive caregiver, David retracts the allegation and the case is closed.

Mary Ambroz’s violence continues to escalate. She beats Alex severely with a curtain rod when he refuses to make a list of all the men with whom he has had sex. The children hatch a plan: 14-year-old Alex will ride a stolen bike 40 miles over the hills of Western Massachusetts at night to get help from a friend’s mother in Albany. The children gather $40 worth of food stamps, candy, and snacks and Alex is off. The family hears nothing for three weeks, and then the police call. Alex had made his way to Albany and disclosed the abuse to police and social services and is now in foster care. Once again, David is interviewed in front of his mother. Once again, denies the abuse. Once again, the social workers leave him and Jessica at home.

Just a few days later, Mary throws David down the stairs of their apartment building and then kicks his head, and everything goes dark. Covered with blood, David drags himself into the nearby courthouse and collapses into the arms of a bailiff. Finally David has had enough. From his hospital bed, he tells the investigating social worker what happened. His mother insists that he fell down the stairs, but the doctor opines that “it is not impossible, but these are pretty extensive injuries for a fall.” The CPS worker, unbelievably, tells David that while the investigation proceeds, “we think it’s best that you go home with your mom.” But a week later, the police knock on the door. A social worker tells David to pack his things. As he drives away from the apartment, David thinks, “This is it. I’m free.”

And now starts David’s life in foster care, which is only slightly less harrowing than his life with his mother. Jessica is placed in the foster home where Alex is living, but the home is not open to David and he knows why; the social workers can tell that he is gay. David spends his first night in foster care sleeping in the Department of Social Services (DSS) office, an experience of many children in foster care today. Then David is brought to a facility for juvenile delinquents, after being told by a social worker that it was not the right place for him but “we don’t have a place that can accept your kind.” At the facility he is called “fag” and “Ms. Ambroz” by a staffer, loses privileges for talking back, and is beaten up by other residents at the apparent instigation of the homophobic staffer. David’s illusion of safety is gone. “I am destroyed. It took everything I had to escape my mother. I thought nothing could be worse, but now, at twelve years old, I feel like this is it.”

David quickly cycles through several foster and group homes. He is finally placed with his siblings in the home of Buck and Mae, a couple who should never have been accepted as foster parents. After the children go to bed in their basement, they are not allowed upstairs for any reason, not even to go to the bathroom. They can’t use the shower without an escort, they can’t go into the kitchen except for mealtimes, and no snacking is allowed. Abetted by a succession of therapists, Buck and Mae try to suppress David’s homosexuality, forbidding him to close the door to the bathroom all the way and designing “manly” chores like clearing a swamp and digging out a backyard swimming pool. He is sent out to hang up wet laundry in the winter without gloves. They say he is too fat and put him on a starvation diet, and now he is hungry again and scrounging for food.

Thanks to a high school friend of David’s siblings, he is hired to work at a summer camp, and that summer changes David’s life. He bonds with the camp director, Holly, and her small daughter, a camper. Holly senses that something is wrong in David’s home. Knowing he needs support, she visits him weekly after camp ends but the visits eventually stop. Later David learns that Holly stopped visiting him after Mae became furious when she bought him new clothes. Holly called David’s social worker and asked to become his foster parent. She and her husband were working on receiving their foster care license until the social worker told them that Mae and Buck insisted it was better for him to be kept with his siblings.

Finally, Jessica and Alex run away. They disclose abuse at the foster home and refuse to go back. But there is no room in the new foster home for David, and DSS keeps David with Buck and Mae even while recognizing their abuse, requiring them to do additional training and not allowing them to take on new children. (Holly is never told that David is no longer with his siblings or invited to apply for her foster care license). Mae restricts David’s food even more while citing his obesity, even though he is dangerously underweight. Nobody at school appears to notice or care. Even when David faints in school, he does not explain that he is starving and no red flags are raised. Buck and Mae begin taking him out of school to work for an acquaintance, pocketing his pay and that too raises no concerns at school.

The torture escalates until one spring morning in 1995, Mae tells David he is staying home from school and David decides he is not going to take it anymore. He leaves the house and tracks down Holly, learning of her attempt to have him placed with her. Finally, David is placed with Holly, her husband Steve, and their two small children. He cannot believe that he is allowed to freely roam upstairs, or that he is allowed to eat whatever he wants, whenever he wants. Steve teaches David how to drive and laughs when he destroys their mailbox, saying he never liked it anyway. Holly ensures that he, Alex and Jessica get the braces that Mae refused to let them get since her kids could not have them.

David always loved school, but the dislocations imposed by his mother, and the hunger and absences posed by his foster parents, often affected his grades. One he is stable and fed, he gets straight A’s. As a high school junior, he joins the Foster Youth Advisory Council and begins attending annual meetings in Washington. But even with loving foster parents, David is tired of the system. He emancipates himself with the help of a fictitious custody arrangement with his siblings’ father and goes off to Spain for a miraculous year of healing and fun with a loving host mother. He applies and is accepted to his dream school, Vassar, with a generous financial aid package.

Even with his financial aid, David struggles to buy books and to survive during school breaks. (It is not clear why he does not ask Holly and Steve for these things or return to them for the holidays; it seems to be a matter of pride or reluctance to burden them.) He eventually gives up on fulfilling his mother’s dream that he become a doctor and switches his major to political science and his plan to law school, remembering his experience as a White House intern the summer before. At a meeting of the Foster Youth Advisory Council, he agrees to be a liaison to a collaboration working to help gay foster youth. That’s when he comes out as a gay man. The story ends with his graduation from Vassar in May 2002. He is on his way to UCLA to study law and public policy. Now, Ambroz works for Amazon as head of Community Engagement (West) and is the founder of Fostermore.org, an organization that encourages those in the entertainment industry, businesses, and nonprofits to raise money and heighten awareness about the needs of foster children.

A Place Called Home provides some important corrections to the prevailing narrative in child welfare. That narrative features struggling parents who are doing the best they can, and who are being persecuted by an evil “family policing system” that is dead set on removing their children. Clearly, that is not the story of David Ambroz and his siblings. At every stage of the child welfare process–reporting, investigation and reunification–the deck was stacked against the children’s interest in safety and stability and in favor of their mother’s keeping them. While it has been some years since David Ambroz was an abused child (he does not give his date of birth but we know that he graduated from Vassar in 2002 and we can assume he was born close to 1980) the problems he identified are very familiar to those with knowledge of the system and indeed some of them may even have worsened due to the current ideological climate in child welfare.

Failure to Report: The number of people who knew that David and his siblings were suffering but took no action to help them is truly staggering. As Ambroz puts it, “Priests, rabbis, teachers, shelter directors, church members, welfare employees and Aunt Flora have all been witnesses to our bruises and lice, our hunger, a ceaseless tide of neglect and abuse.” David acknowledges that reports were made and the children were even removed once or twice, but the vast majority of people who witnessed their abuse apparently did not report it. We often hear similar stories in the wake of a child’s maltreatment death. For example, eight-year-old Dametrious Wilson was killed by his aunt in June 2022. Though he missed 60 days of school in the year before he died, his Denver Colorado school never reported his absences as required by law, even when his aunt said she was keeping him home “for few weeks” as punishment for his behavior!

And yet, today there is a groundswell of opposition to mandatory reporting and serious proposals to eliminate it, mostly on the grounds that children of color are disproportionately reported. It is true that a staggering proportion of Black children are investigated by CPS; it has been estimated that over half of Black children experience a CPS investigation by the time they turn 18, compared to 28 percent for white children and 37 percent of all children. It is possible that reporting is overused in some communities and underused in others. But it seems more logical to address these problems directly (and also educate ordinary citizens about the need to report suspected maltreatment) rather than eliminating mandatory reporting itself.

Flawed investigations: Even when reports were made, the investigations were often flawed. Ambroz states that “Over the years we’ve been investigated many times without getting help. Mom always fights to keep us, and it’s a battle she’s mostly won.” So what went wrong? Ambroz gives us part of the answer when he explains that social workers and police interviewed him at least twice in front of his mother. Both times he recanted and denied the abuse he had alleged earlier, knowing that he risked severe punishment for telling the truth. It seems obvious that children should be interviewed away from their parents since either love or fear or both will lead them to lie. Yet, this clueless and dangerous practice of interviewing children in front of the alleged perpetrator contnues in many jurisdictions. In Minnesota, a young woman named Maya, who was forced to report her fathers’s sexual abuse while he was listening, worked with an advocacy group to draft Maya’s Law, which required that Minnesota children be interviewed privately regarding allegations of abuse. But like the previous attempts, Maya’s Law failed. Instead, the language was revised to read “When it is possible, and the report alleges substantial child endangerment or sexual abuse, the interview may take place outside the presence of the alleged offender…” Sadly, many “advocates” for Black and indigenous children argued against the requirement for private interviews, fearing that it would increase disproportional involvement of these groups in child welfare.

Unwarranted reunifications: Even when David and his siblings were removed from their mother briefly, they were returned at least twice with no indication they would be safe. When Mary returned from the psychiatric ward after throwing a shoe at a judge, “nobody cared that we are being put in the custody of a homeless woman who’d recently thrown a shoe at a judge in a court of law.” We know that many children are reunified with their parents despite a lack of evidence of any change in their behavior or capabilities. In Lethal Reunifications, I wrote about two such cases that ended in a child’s death, but clearly that is just the tip of the iceberg. We never know about the children left to suffer in silence, unless they decide to write about their experiences.

Necessity of foster care in some cases: The current narrative holds that foster care is almost never necessary. But David Ambroz’s story reveals the stark truth that some children must be removed in order to be saved. Of course every effort should be made to help parents conquer their problems while monitoring children for safety in the home. But in cases of chronic maltreatment, ingrained patterns may be impossible to change. As Dee Wilson put it in his briliiant commentary on chronic multitype maltreatment, “Chronic neglect is marked by the erosion or collapse of social norms around parenting resulting from chronically relapsing conditions.” There is no better example of such collapsed social norms than Mary Ambroz, who had completely lost any sense of responsibility to keep her children clothed, fed, and housed, not to mention to avoid abusing them. In such cases, it is wrong to sacrifice the well-being of the child or children for the general value of family preservation.

Ambroz’s story also provides a needed antidote to the current trope that what child welfare describes as neglect is actually just poverty. The confusion of poverty with neglect is a pernicious misconception being perpetrated today by those who wish to eviscerate the child welfare system. David’s story clearly shows the difference. He says of the mother of friends they make in Albany: “Aurora and her sons are poor like us, and yet she still manages to take care of them. She feeds and clothes them. She cares about where they are when they roam around at night. She gives them a home that is stable in all the ways I’ve never dreamed.” And there, in a nutshell ,is the distinction between poverty and neglect.

The dominant narrative portrays foster care as harmful for children and even abusive at times. That part of the narrative is accurate for the first part of David’s time in care, when the system proved incapable of keeping David and his siblings safe, let alone meeting their needs. Among the major reasons for this failure, Ambroz draws attention to the lack of qualified foster parents and overwhelmed social workers.

Lack of Qualified Foster Parents: David fell victim to one of the scourges of our system, insufficient numbers of good foster parents. For this reason, he was initially placed in a facility for juvenile delinquents where he was abused for being gay, and then in a totally unsuitable home. In Buck and Mae, David provides a classic example of a couple who become foster parents to make ends meet. The foster care payments they received helped Buck and Mae keep their house and clothe their children. It is not surprising that such foster parents exist: some foster care agencies leave recruiting brochures in food stamp offices and laundromats; one that I worked for advertised in in a publication called the PennySaver. And yet, even when David’s siblings ran away and their abuse allegations that were taken seriously enough that the agency decided to send no more children to this couple, they were allowed to keep David. One reason, as Ambroz points out, is that there are not enough foster parents, especially for large sibling groups, so the focus is on finding any “bed” for a child. As a foster care social worker in the District of Columbia, I knew many foster parents who were motivated mainly by money. My recommendations to fire such foster parents were never accepted because the agency needed the beds.

To address the shortage of good foster parents, Ambroz recommends recruiting more middle and upper-income foster parents with higher education degrees. In order to do this, he suggests providing benefits that might attract such parents, such as government pensions, participation in the federal employee health plan, and access to free or subsidized tuition and state colleges and universities. I’m not confident that any of these benefits will attract more educated foster parents, and financial incentives also pose the risk of attracting more educated versions of Buck and Mae. Perhaps the lesson of David’s story lies the willingness of Holly and Steve to be his foster parents and the unresponsiveness of the system to this request. There is now a big push to locate kin who can care for children who are removed–and this may be happening much more frequently than when David and his siblings entered care. Perhaps agencies can do more to find unrelated adults who may have bonded with children as their teachers, parents of their friends, mentors or employers, who might serve as foster caregivers. This is certainly done; I myself agreed when asked by CPS to provide a temporary home to a friend of my son’s. If most children who are removed could be placed with adults known to them, it would be easier to fire the Bucks and the Maes and reserve the great foster parents for the children for whom no known adults are available.

Overwhelmed social workers: One reason David’s social worker did not jump at the chance to move him to Holly’s home may be that she was overwhelmed. “I have a rotating cast of social workers, who don’t have the bandwidth to pay attention to anything but immediate and obvious problems,” Ambroz reports. Based on my experience as a social worker in foster care, I could not agree more. Foster care, especially for older and more troubled children, is plagued with constant crises. With caseloads in most jurisdictions far too high, social workers have no time to deal with anything besides the latest crisis. Contributing to the problem are frivolous paperwork and metrics that have nothing to do with child wellbeing. Between the foster parents who did not perform the most basic parental responsibilities, and the caseloads that were too high for me to pick up the slack, I could not spend the time I needed to ensure that each child received the care they needed to thrive, and I eventually left the job.

David Ambroz recommends attracting more and better social workers by decreasing their caseloads and increasing their pay and benefits by either a salary increase or alternative compensation such as student loan forgiveness and home loan assistance. These are excellent ideas. There are other ideas worth considering, such expanding and publicizing the current Title IV-E social work education program that provides tuition assistance for social worker students who want to go into child welfare. Also worth considering are recruiting among populations that do not traditionally seek these jobs, such as military retirees, and perhaps changing education requirements for social workers in child welfare to allow other backgrounds besides social work.

Flaws in the Analysis

While David Ambroz’s story is powerful and carries many important lessons, his acceptance of the current child welfare zeitgeist may have prevented his drawing the conclusions that logically flow from his story. First, he buys into the currently popular misconception that parents are being found neglectful when they are simply poor. Second, he misses the opportunity to advocate for strengthening child protection services, not weakening them.

Poverty vs. neglect: While I’ve already described how Ambroz’ story contradicts the currently popular assertion that “neglect” is synonymous with poverty, he unfortunately repeats that same trope. Describing the domestic violence shelter staff’s decision to place the family in an apartment after observing Mary Ambroz’s abuse of her children, Ambroz states that “[T]his is a pattern that is repeated across the country–children in poverty are given kernels of assistance but are rarely rescued from their circumstances.” But David and his siblings were abused children, not just children in poverty. As mentioned above, he acknowledges that other poor families were not like theirs. By confusing poverty with maltreatment, Ambroz loses a key opportunity to clarify the difference between these problems and to explain that eliminating maltreatment requires more than just economic assistance .

Child protection failures: In his list of policy prescriptions, included in an appendix to the book, Ambroz does not address any of the problems with CPS that were revealed in his memoir. He focuses mainly on foster care, as if his earlier experience as an abused child did not have policy implications. Ambroz could have thrown his weight behind mandatory reporting in light of the movement to end it and could have argued for education of all citizens on the need to report suspected abuse. He could have supported reforms requiring that children be interviewed away from her parents. But these such policies are opposed to the current climate in child welfare which favors hobbling or eliminating CPS and minimizing interference with families. Ambroz appears to be determined to stay within the mainstream, saying “the best way to reform foster care is to decriminalize poverty and help families remain intact whenever possible with wraparound support–be it jobs, mental health care, or whatever is needed.” If abused and neglected children can remain safe with wraparound support that is clearly the best option, but to receive this support, these children must be identified through reporting and investigation. It is unfortunate that Ambroz did not recognize the discrepancies between some of the lessons of his story and the dominant narrative in child welfare and missed the opportunity to spell them out.

Despite its flaws, Ambroz’s story takes its place with other haunting memoirs of abused children, like Stacey Patton’s That Mean Old Yesterday, Regina Calcaterra’s Etched In Sand, and most famously Educated by Tara Westover, which put the lie to the current narrative of good parents vs. the evil state. If only Ambroz had recognized the conflict between his narrative and the dominant one, his book would be even more useful. But the story speaks for itself; the commentary is secondary. David Ambroz’s story is a must-read for anybody who cares about the abused and neglected children among us, including those who are in foster care.

*The doctor was the father of Alex and Jessica, but Mary Ambroz never told David who his father was.

Chronic maltreatment: A blind spot for child welfare

A CPS supervisor in St. Louis City once told the author about something he called “the 500 families.” When asked what this meant, he said that this referred to the small group of families that we see in the city again and again over many years, and sometimes over generations. They consume most of the time of workers and eat up most of the money available to the agency. These are the FE [frequently encountered] families.

L Anthony Loman, PhD., Families Frequently Encountered by Child Protection Services

It is a fact universally acknowledged that some families are reported to child protective services (CPS) again and again over a period of years. Many or most of these referrals involve some type of neglect, but there are often allegations of physical and sexual abuse as well. But in many cases, CPS fails to recognize families that are experiencing chronic maltreatment and when it does provide services, they may conclude with little or no change in the parents’ behavior or the children’s situation. As a result, children suffer lifetime damage, sometimes extending the cycle of maltreatment to the next generation, and sometimes the maltreatment even results in a child’s death. Sadly, today’s climate of anti-interventionism, combined with the reluctance to spend money and the lack of public concern about maltreated children, makes it unlikely that any relief for these at-risk children is forthcoming in the near future.

What is chronic maltreatment?

Every child welfare social worker seems to know families who have been reported to CPS repeatedly over a period of years. Dee Wilson, a former child welfare worker, supervisor and administrator who writes an essential child welfare blog called Sounding Board, asks participants in his training classes to tell him the highest number of CPS reports they have ever seen on one family. For almost 20 years, he has heard no answer less than 30 in any group of caseworkers, and he has received answers as high as 90 or 100 on several occasions.1 

There are different ways of describing those families who are frequently reported to CPS. The most commonly used term is “chronic neglect,” but this term can be misleading, as Anthony Loman explains. While these families usually have multiple reports of neglect, they often have reports of physical and sexual abuse as well. Loman uses the term “frequently encountered families,” meaning families who are reported again and again to CPS, and Jonson-Reid et al write about “chronically reported families” to refer to the same group. Dee Wilson prefers to focus on chronic multitype maltreatment, which he defines as maltreatment that is both chronic and includes more than one maltreatment type, such as neglect, physical abuse, and sexual abuse. But all of these writers are talking about the essentially the same families, as discussed below.

The case histories of frequently reported families consist of a sequence of reports followed by diverse outcomes. Some reports are screened out by hotline staff. Others receive an investigation or alternative response. Some investigated reports are substantiated, others are ruled as “unfounded” or “inconclusive.”2 The substantiated reports may result in the opening of an in-home case or the removal of.a child or children, or no action may be taken if the children are deemed safe or not at risk. New reports often come in and are investigated even while a case is open. An in-home case may turn into a foster care case based on a new incident or a new investigation. Removed children are returned home and the cycle continues, with new reports, investigations, case openings, and removals. Loman calls this the “replay cycle.”

There is a surprising lack of research about frequently encountered families, and most of it is over two decades old. Loman, in his magisterial study, used a sample of 33,495 Missouri families who were reported to CPS for the first time between July 1997 and June 1998 and followed for five years after that first report. He defined “frequently encountered families” as those that received five or more reports in five years. He also used a smaller sample of 797 families from one Minnesota county who were selected in 2001 or 2002 and tracked for 27 months; for this sample he defined frequently encountered families as those with three or more reports. Jonson-Reid et al used a longitudinal study of children reported for maltreatment in a midwestern metropolitan area in 1993 or 1994. They limited their sample of 6,412 children under the age of ten at the time that they were first reported to CPS to allow a follow-up period of at least seven years. While there are a number of studies that examine maltreatment recurrence, I found no others that focus on families classified according to the number of reports received.3

The limited research available suggests that frequently reported families are a significant part of the population of families known to child welfare. Loman reports that of his sample of 33,395 Missouri families with screened-in CPS reports, one-fifth had five or more reports in five years. Of this group, nearly half had five or six reports during the five-year follow up period, a quarter had seven or eight reports, and the remaining quarter had nine or more reports. It is important to remember that these families were followed for only five years, and that they could have received many more reports after the follow-up period was over, perhaps as high as the 90 or 100 reports some social workers described to Dee Wilson. In their study, Jonson-Reid et al found that 27 percent of their sample had four or more reports by the end of the seven-year followup period.

Using their entire sample of over 33,000 Missouri families, and defining twelve different types of abuse and neglect. Loman found that the type of maltreatment alleged in the first report on a family is not a reliable predictor of the allegations in subsequent reports. In terms of the broad categories of “abuse” and “neglect,” many family histories showed reports of abuse interspersed between neglect reports, and much diversity in the type of abuse and neglect alleged in different reports. It is often observed that neglect by a single mother opens the door to abuse by her boyfriend, especially when he is caring for her children. And indeed, Turner and her co-authors, using 2011 and 2014 responses from 7,852 children or their parents to the National Surveys of Children’s Exposure to Violence, found that both physical and supervisor neglect were “strongly associated with risk of other maltreatment and most other forms of victimization.” These findings suggest that “chronic neglect,” “frequently encountered families,” and “chronic multitype neglect” refer to mostly the same families.

Using mostly his smaller but richer Minnesota dataset in which “frequently encountered” meant three or more reports in 27 months, Loman was able to compare frequently encountered families to those families that were reported less frequently. He found that frequently enountered families were more likely than others to be in extreme poverty and to have no employed adults. Younger parents, younger children, larger numbers of children, domestic violence, substance abuse, children with mental illness and disabilities, and caregivers with low self-esteem were more prevalent among frequently encountered families. Not surprisingly, these are the same factors that are associated with having any re-report or recurrence of maltreatment after the first report, and they are also associated with child maltreatment in general.

As might be expected, frequently encountered families account for a disproportionate share of child welfare spending. Loman found that the one-fifth of families in his Missouri sample that were defined as frequently encountered accounted for half the spending on families over a five-year period. The majority of these expenditures was for foster and group care and residential treatment. Case management and administrative costs for these families, which were probably disproportionate as well, were not included in this estimate.

Source: I Anthony Loman, Families Frquently Encountered by Child Protection Services, Institute of Applied Research, 2006, https://www.iarstl.org/papers/FEfamiliesChronicCAN.pdf

What are the consequences of chronic maltreatment?

Many studies show that exposure to maltreatment is linked to multiple adverse outcomes, and several have found that children exposed to chronic maltreatment tend to experience worse outcomes than those exposed to a single incident.4 In The Science of Neglect, the Harvard Center on the Developing Child explains how chronic severe neglect–defined as “the absence of sufficient attention, responsiveness and protection that are appropriate to the age and needs of a child” –can produce “serious physiological disruptions that lead to lifelong problems in learning, behavior, and health.”

It is also important to note the relationship between reports of child maltreatment and mortality from all causes, which I wrote about in an earlier commentary. There has been a spate of new research demonstrating that children who have been the subject of at least one child abuse or neglect report are more likely than other children to die from many causes, including childhood injury, sudden unexplained infant death, medical causes, suicide and homicide, even when confounding factors are controlled. As a member of the District of Columbia’s Child Fatality Review Committee, I have observed that children who die of all these causes often have long family histories with CPS. For example, the families of many young victims of homicide had a history of CPS reports often starting in the infancy of their first child. Many of these case histories reveal numerous calls to CPS alleging both neglect and abuse, with school absenteeism and lack of supervision being among the most frequent allegations. Eventually, many of these young people became involved in violent and illegal activities, ultimately leading to their violent deaths. There is no evidence of whether chronic maltreatment has worse effects on mortality than a single episode, but common sense suggests that is the case.

In discussing the consequences of chronic maltreatment, it is important to bear in mind the relationship between chronic maltreatment and the placement crisis that is currently plaguing child welfare agencies around the country. Many of the young people currently sleeping in offices and hotels, housed in psychiatric wards after being ready for discharge, and sent out of state, are undoubtedly victims of chronic maltreatment. Because they were allowed to stay in their toxic environments for so long without intervention, they developed cognitive, emotional or physical problems making them difficult to care for in a foster family; some are too hard to handle for most group homes and residential treatment centers and end up being rejected or expelled from those facilities as well.

How does CPS respond to chronic maltreatment?

CPS often fails to respond to chronic maltreatment in a family early enough to help parents make changes in their behavior and prevent serious harm to children. As Dee Wilson describes, many families referred to CPS several times for less serious neglect often receive no services until maltreatment is so ingrained that opportunity for effective early intervention has been lost. Wilson blames CPS’ tendency to focus on the incident alleged in the last report rather than the pattern revealed by a family’s history of reports over time.

And even when CPS responds, the response is often inadequate. The “replay cycle” described by Loman – with repeated reports, case openings, case closures, foster care removals and reunifications – continues because parents’ mental health, substance abuse, domestic violence or parenting style remain problematic. And indeed, research suggests that even when a family receives services as a result of a substantiated report, these services are generally too brief and do not result in behavior change. Chaffin et al, studying parents in home-based child welfare services, found that chronically maltreating parents tend to enter services with high levels of problems and do not improve much as the result of participation in services. They concluded that the “episodic and reactive service model characterizing traditional child welfare services” may be a “mismatch” for chronically matreating families.

Another reason for the “replay cycle” in some jurisdictions may be that at least one of the allegations being investigated must be substantiated in order for the agency to open a case. As a member of the Child Fatality Review Team in the District of Columbia, I have observed that many children who later died were assessed to be at high risk by the CPS investigator but were left at home with no support or monitoring when the allegations were not substantiated. When asked why this happened, agency representatives invariably explain that social workers are not allowed to open a case if an investigation did not result in substantiation of at least one allegation.

Similarly, accounts of child abuse or neglect deaths in states like California and Kansas have revealed that these children were assessed to be at high risk by CPS investigators one or more times but were left at home with no support or monitoring. Again, one reason was the requirement that an allegation be substantiated before a case can be opened.5 In the wake of the horrific child abuse death of Yonatan Aguilar in Los Angeles County, who was kept in closets for three years before he died, after four unsubstantiated allegations, the Office of Child Protection analyzed 1,225 referrals investigated by DCFS between 2012 and 2016 involving a child was later seriously injured or killed. They found that as in the case of Yonatan, more than half of the fatalities and near-fatalities occurred when the allegation was not substantiated. Yet we know from research that whether a report has been substantiated is a poor indicator of future behavior among parents who have been reported to CPS.6 Requiring substantiation to open a case ensures that some at-risk children will remain unprotected.

How can agencies respond better to chronic maltreatment?

There may be some social problems that we know how to solve but cannot do so due to financial or political constraints. But chronic maltreatment is not one of those problems. There are no easy answers to chronic maltreatment. But one thing is clear. The system itself must stop neglecting chronically maltreated children by leaving them at home without monitoring or support. Different commentators have supported different policies and some of these are discussed below.

Early Identification and support: Loman suggests that many families that will go on to become frequently encountered can be identified after the first or second report. These are the families that have many risk factors for child maltreatment and few protective factors against it and therefore score high on risk assessments. Ideally, child welfare agencies would identify these families after the first or second report and intervene to prevent their becoming chronically maltreating families. But, realistically, this is not going to happen in the current ideological climate, which favors restricting rather than expanding the role of child welfare services. However, it should be possible to offer all of these families a referral to high-quality childcare that includes family support services and staff trained to spot signs of abuse or neglect. For example, Educare, a nationwide network of birth-to-five schools, provides high-quality early childhood education, family support services, and links to needed services in disadvantaged neighborhoods around the country. At least in the Washington DC location, children are checked daily for signs of abuse.

Standards for removal based on age: Dee Wilson contends that the requirement of “imminent danger” for child removal is inappropriate in light of what we now know about the damage that long-term maltreatment causes to children’s developing brains and its contribution to mortality from all causes. He suggests considering developmental harm to children, rather than the narrow criterion of imminent danger, in the decision of whether to place the youngest children (those five and under) in foster care. Conversely, he suggests that children aged six to 17, unless they are in extreme physical danger if they remain at home, should be placed out-of-home only when a child welfare agency has a known therapeutic resource for that child, or when there is an extended family member, family friend or professional with whom the youth has a good relationship and who is committed to the youth. But removing more children at any age is unlikely to gain support in today’s ideological climate, which perceives child removal as punitive “family policing.” Removing fewer older children as Wilson proposes may leave many in harm’s way, especially those who might be in danger of self-harm from emotional abuse. Nevertheless, these ideas are worth further attention and exploration.

Reducing the role of substantiation/mandating services: Jurisdictions where substantiation of an allegation is required in order to open a case can consider changing that requirement. Los Angeles’s Office of Child Protection, in the report referenced above, spoke to experts who supported placing more emphasis on risk (instead of on allegation dispositions) when making case decisions, and on offering services and supports to families that may help to reduce this risk. However, agencies may need to do more than “offer” such services. Children who are assessed to be at high or intensive risk and in families that have multiple reports of maltreatment should not be left in their homes without monitoring. When there are three or more reports, and a child or children are found to be at high or intensive risk, a case should be opened for services and a court petition should be filed if the family refuses to participate. Court petitions should also be used more often during in-home cases to oversee parents’ compliance and incentivize their cooperation with services in in-home cases.

Services for Parents

Unfortunately, there is a dearth of interventions that have been found to be effective for parents with histories of chronic child neglect, especially when accompanied by substance abuse and mental health disorders, as well as parents displaying multiple types of maltreatment. Such families need a variety of services to address all of their risk factors, and the services must be sequenced so as not to overwhelm the parent or to provide certain services before a parent is ready for them. Drug treatment and mental health services are major needs for these parents. They also need services to address their financial need and employability, as research has shown that poverty and financial stress make child maltreatment more likely. Adequate housing will have to be provided for some families. Also needed, as Loman describes, are services to bolster protective factors like social supports, for example by trying to reconnect a family with an estranged relative.

Case management itself should be considered one of the most important services that cna be provided to frequently encountered families. Given the serious issues of these families, case managers need to have lower caseloads or work in teams. Dee Wilson recommends the creation of case management teams consisting of a CPS caseworker, substance abuse assessment specialist, mental health therapist, a public health nurse and a parent advocate to work with these families. Another approach is to assign one case manager with a smaller caseload to such families. The District of Columbia’s Child and Family Services Agency implemented chronic neglect units but they were dropped after barely a year. Case managers or teams should be allowed to work with families for at least a year, or even longer when a parent is mentally ill or cognitively impaired. Deep-seated problems that are often multigenerational cannot be solved in a matter of months.

Serving Parents and Children Simultaneously

Therapeutic childcare: An intervention that has not received enough support is therapeutic childcare, such as that offered by the relief nurseries in Oregon. Relief nurseries seek to prevent the cycle of child abuse and neglect through comprehensive and integrated early childhood therapeutic and family support services. Seattle’s Childhaven used to operate a similar model, combining therapeutic childcare with coaching parents in how to interact with their children. Such therapeutic childcare addresses many of the issues with chronic maltreatment. Quality care with family support can replace some of the missing interaction that is so essential to healthy child development, while at the same time training parents to interact this way themselves. Reducing the hours that a child spends alone with the parent, and enabling observation by staff trained to spot signs of abuse or neglect, increase child safety. Stress on parents is reduced by family support and availability of childcare. It is hard to think of an approach that addresses child maltreatment through so many pathways. As mentioned above, high quality childcare should be offered to families reported for the first time and at every subsequent report. But therapeutic childcare designed for children who are the victims of maltreatment should be mandated for those who have an open in-home case.

Residential Services: Keeping parents and children together while parents get treatment can keep children safe while not disrupting the parent-child bond. Drug treatment programs where children can stay with their parent are one approach that deserves more funding. Dee Wilson, in another helpful commentary about in-home services, also suggests trying out the concept of Shared Family Care, widely used in some Northern European countries, in which whole families with a substance abusing or mentally ill parent are placed with resource families.

Services for Children

Mentoring: Every school-aged child with an in-home case or in foster care should be matched with an adult mentor7 providing both another set of eyes on the child and some of the nurturing that the parents may not be providing. Mentors can be volunteers or employees of a professional mentoring program like Friends of the Children, which aims to break the cycle of intergenerational poverty and has a special concentration on children in foster care or involved with child welfare. Credible Messengers is a quickly-spreading model that uses people with similar life experiences to mentor youths involved with juvenile justice, and the District of Columbia’s child welfare agency has begun using it in foster care as well.

Creativity and Mastery: As Dee Wilson suggests,7 agencies managing the cases of abused and neglected school-age children should invest as much in their talent development as in their mental health treatment. Developing a child’s talent in arts, sports or another arena provides multiple benefits, including the psychological benefits of mastery of a skill, and in the case of the arts, the opportunity to process and understand trauma, as described in an Imprint article about an arts programs for incarcerated youth.

Specialized Education: Some public education models are designed to support children with child welfare involvement. Haven Academy in the Bronx is a public charter school that is open to all students but prioritizes admitting children whose families are involved with the child welfare system. Their model integrates family support services with the academic program. Some school-aged children who are candidates for foster care may do well in a boarding school that takes them away from their homes for much of the time while their parents receive needed services. Monument Academy Public Charter School in the District of Columbia is a weekday boarding school designed to serve students who have experienced significant adversity, including involvement or risk of involvement in the child welfare system. The school works to provide its students with the “academic, social, emotional, and life skills to be successful in college, career, and community.”

Coordination with other agencies

Shared Data: The families that come back again and again to every child welfare agency are probably the same families known to other agencies that work primarily with the poor–such as income support, mental health, juvenile justice and probation. The schools probably know these families as well because of their children’s issues with absenteeism, behavior, and disabilities. With a database shared between these agencies, families with issues could be identified early and helped in a more coordinated manner, perhaps allowing earlier intervention (and not always by CPS) with chronically maltreating families. But privacy and other concerns are often used to block any attempt at information-sharing between agencies. In a future commentary, I will discuss how such concerns ended San Francisco’s Shared Youth Database, a successful and award-winning data sharing project.

Shared Case Management: Another way to coordinate services between agencies would be to actually merge case management for child welfare and income support programs, returning to something more like the model that existed when cash welfare was administered by social workers who monitored parents to ensure that they were meeting the needs of their children. This model was phased out between 1968 and 1972 after criticism that it was coercive and also to save money, and it is unlikely to get a good reception in today’s ideological climate. But returning to a shared case management arrangement for cash welfare and child protective services would have many advantages. It would make the receipt of benefits contingent on taking proper care of one’s children and provide an incentive for families to cooperate with their case plans.

Recognizing when to give up on birth families: Finally, child welfare agencies must recognize when it is time to remove a child from a toxic family environment or when the prospect of reunification should be given up for good. It is not appropriate to close an in-home services case or to reunify a family if there is no indication that the parents have changed their behavior, and yet this happens all the time. Many of the most egregious child abuse and neglect deaths have been associated with startling failures to remove a child after long histories of abuse, or incomprehensible reunifications with parents who are clearly dangerous. Social workers and judges should be more rigorous about demanding evidence of change before putting a child in harm’s way by closing a case or sending a child home. When starting work with frequently encountered families, social workers should immediately seek out relatives or family friends who could serve as sources of support as the parents try to improve and as alternative caregivers if the children must be permanently removed.

Dee Wilson provides several reasons why there little motivation to find effective responses to the problem of chronic maltreatment. There is certainly no great public concern with the emotional and developmental damage to children from growing up with chronic abuse and neglect. Child welfare commentators in the spotlight today are clamoring for a narrower standard for child welfare intervention, not a broader one. And finally, understaffed and underfunded child welfare agencies are not looking to expand their services to maltreating families, although paradoxically many of them apparently want to expand their mission to encompass prevention of maltreatment among the group of families not yet known to them. The combination of public indifference, resistance to government spending (traditionally the province of the right wing) and resistence to any sort of “family policing or regulation” regardless of the danger to children (now the province of the left wing), is particularly toxic. Nevertheless, those who care for children must keep raising our voices, hoping one day that those in power will understand the need to protect the most vulnerable children and thereby interrupt the transmission of chronic maltreatment from generation to generation.

Notes

  1. Dee Wilson, email to this author, November 29, 2022.
  2. Substantiated means that there is credible evidence that abuse or neglect has occurred. Unsubstantiated or unfounded generally means there is not credible evidence concluding that abuse or neglect has occurred. Some states have an intermediate finding of “inconclusive” or “indicated” meaning that there is some evidence that maltreatment has occurred but not enough to substantiate the case. See Children’s Bureau, Child Protective Services: A Guide for Caseworkers 2018, p. 8-0.
  3. Jonson-Reid, M., et al. (2010). Understanding chronically reported families. Child Maltreatment, 15 (4):271-281. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3628675/. Jonson-Reid et al were able to find only one study (the Loman study) that focuses on these chronic cases. To determine if there were any such studies later, I went through the list of articles citing the Reid et al paper and found no more estimates of the proportion of families that are chronically reported by any definition.
  4. English, D. J., Upadhyaya, M. P., Litrownik, A. J., Marshall, J M., Runyan, D. K., Graham, J. C., & Dubowitz, H. (2005). Maltreatment’s wake: The relationship of maltreatment dimensions to child outcomes. Child Abuse and Neglect, 29,597-619; Ethier, L.S., Lemelin, J.P., and Lacharite, C. (2004). A longitudinal study of the effects of chronic maltratment on children’s behavioral and emotional problems. Child Abuse & Neglect, 28, 1265-1278; Jaffee, S., and Malkovich-Fong, A.K (2011). Effects of chronic maltreatment and maltreatment timing on children’s behavior and cognitivec abilities. Journal of Child Psychology and Psychiatry, 52(20, 184-194; Lemmon, J. H. (2006). The effects of maltreatment recurrence and Child Welfare services on dimensions of delinquency. Criminal Justice Review, 31, 5-32.
  5. See my commentary, Risk not substantiation should drive services to families. But not all jurisdictions require substantiation in order to open a case for in-home services or foster care. In Washington State, an allegation does not need to be substantiated for an agency to file a neglect petition in court; the purpose of filing a petition is to “prevent harm” and there is no need to prove that harm already occurred. Nevertheless, we know from Dee Wilson that despite this possibility, families continue maltreating long enough to accrue 30 or more reports, so clearly it is not the only answer. In Michigan and Minnesota, a case can be opened or a child removed because of “threatened harm,” which can be substantiated as a type of maltreatment.
  6. See Drake, Jonson-Reid, Way, & Chung, Substantation and Recidivism; Kohl, Jonson-Reid, and Drake, Time to leave substantiation behind: Findings from a National Probability Study; Putnam-Hornstein et al., Risk of re-reporting among infants who remain at home following alleged maltreatment.
  7. Dee Wilson, Email to the author, December 21, 2022.

Using child welfare data to learn from the past: why is it so unpopular?

Photo by Rene Asmussen on Pexels.com

Miracle Jackson, a seven-month-old in Detroit, died with a sock stuffed down her throat and her face covered in duct tape at the hands of her father in 2000. During the same week in the same city, a five-month-old named Jamar was severely beaten. It turned out that Miracle’s mother and Jamar’s parents had abused or neglected their previous children seriously enough that their rights to parent those children were terminated. Yet, when Miracle and Jamar were born, nobody checked on them to make sure they were safe. But that was about to change in Michigan, which became the first state to match birth and child welfare data to identify new children born to parents who had severely abused or neglected previous children – a practice that has become known as “birth match.”

The logic behind birth match is simple. Research suggests that in parenting as in other areas, past behavior is often the best predictor of future actions. Current technology makes it possible to match existing databases maintained by the child welfare and health agencies in order to identify infants born to parents who have had their parental rights terminated, been convicted of a crime against a child or have other history identifying them as a safety risk to a newborn. So it is not surprising that the Committee to Eliminate Child Abuse and Neglect Fatalities (CECANF) in its 2016 report recommended birth match as one strategy to identify children at high risk of maltreatment so that action can be taken to keep them safe. Yet, only four other states have adopted birth match, and only one (Missouri) has adopted it since the CECANF recommendation.

In a report called Learning from the Past: Using Child Welfare Data to Protect Infants Through Birth Match Policies, published by the American Enterprise Institute, I discussed what we know about birth match in the five states that use it. As the report illustrates, birth match policies and procedures varied widely from state to state.

All of the states that use birth match identify infants born to parents who had their rights terminated because of abuse or neglect, with some specific differences. It is not surprising that they all identify parents with a termination of parental rights (TPR), because a TPR usually means that there has been severe abuse or neglect and and the parent has been given multiple chances to ameliorate the behaviors or conditions that caused the child’s removal.

Each state has chosen to include certain other parents in addition to those who had a TPR. Maryland has the most limited policy, including (in addition to those who had their rights terminated) only parents who have been convicted of the murder, attempted murder, or manslaughter of a child. Minnesota includes the broadest group of parents–all those who were determined to have committed “serious maltreatment,” the highest of four categories of severity that are assigned to all substantiated instances of maltreatment. States also differ in how far back they look in time for evidence of dangerous parental behavior: Texas looks back only two years, Maryland and Missouri look back ten years, and Michigan and Minnesota match all available records, regardless of when the maltreatment or termination occurred.

States also differ in whether they treat birth match referrals as allegations of abuse and neglect, requiring a regular CPS investigation. The first two states to adopt birth match, Michigan and Minnesota, already had a category of child maltreatment called “threatened harm” or “threatened injury.” Birth matches in those cases receive a CPS investigation of an allegation of threatened harm or injury. In Texas, matched infants and their families also receive a regular investigation, but the type of allegation depends on the content of the report.1 In general, investigations result in a finding on the truth of the allegation; if it is “substantiated,” or found to be true, it may result in the removal of a child or children into foster care, the provision of in-home services and monitoring to ensure their safety, or a possibly a placement with a relative or family friend with the consent of the parent.

In contrast to the other three states, Maryland and Missouri treat birth match referrals differently from allegations of child abuse and neglect. In Missouri, birth match referrals are treated as “Non-Child Abuse/Neglect Referrals” and receive a “Newborn Crisis Assessment,” a special type of investigation that was designed to respond to calls from hospital personnel who are hesitant to release newborns from the hospital because of safety concerns. If no safety concerns are identified, parents can decline any services that are offered; if safety concerns are identified, social workers have the same choices as in a regular investigation: they may go to court to request immediate custody, allow the child to stay at home under a safety plan supervised by the department, or negotiate a voluntary placement with a relative.

In Maryland matched families receive an “assessment,” which is less comprehensive than a regular investigation. Families can refuse to participate, unless there is “reason to believe a child has been abused or neglected or is at substantial risk of abuse or neglect,” in which case the local department of social services is directed to make a report to CPS. Similarly, the department is directed to call CPS if there is such a concern at any time during the birth match assessment process.

The lack of data makes it difficult to assess the impact of existing birth match processes. Other than Missouri, where birth match has been in use for less than a year, none of the states publishes data on the results of these programs as part of their regular reporting, and it appears that administrators do not review this data internally. In response to the request for data for the report, child welfare officials had to generate new tables from their databases. But the data raised many questions and without knowing exactly how it is obtained, one cannot judge its accuracy. There were some anomalies that state administrators were unable to explain, like the fact that the total number of matches in Michigan dropped from 1186 in FY 2019 to to 873 in FY2020 and then down to 515 in FY2021–a drop of 50 percent in two years! It appeared that state administrators were unaware this anomaly before being asked about it, and they were unable or unwilling to provide an explanation. 

If the data provided by the states is approximately accurate, birth match is identifying significant numbers of children. The number of matched infants identified in FY2019 (before the pandemic) was 1,188 in Michigan, 1,138 in Texas, 420 in Minnesota, and 243 in Maryland. Between half and two-thirds of these children already had an open investigation or case. It is encouraging that so many of these infants were known to CPS without birth matching, but it also shows that a sizable number and proportion of infants at risk due to their parents’ earlier behavior would be unidentified in the absence of this tool.

But the effectiveness of birth match depends on the quality of the investigations or assessments that are conducted and whether they result in actions to ensure child safety. The limited evidence is not encouraging. The number and percentage of matched children and families reported to be actually receiving services was surprisingly low. In Texas, of the 302 families investigated due to birth match in FY2019, only 70 received in-home services and 28 had a child or children removed. In Michigan, of the 484 investigations due to birth match, only 49 cases opened for services and 24 had a removal of a child. In Maryland, only four of the 89 families investigated due to birth match were documented to have received services. Minnesota provided no data beyond the number of matches. Without better data and case reviews, it is impossible to know why so few families received services.

The fact that the data requested had to be specially generated suggests that child welfare administrators in birth match states have little interest in the implementation and effects of of birth match. That was not always the case, at least in Michigan. One former CPS director in Michigan, who had served as a CPS worker and supervisor earlier in his career, had a strong belief in the potential of the process to protect children if correctly implemented. He conducted an internal review of birth match cases and found that 75 percent of the investigations resulted in no finding of threatened harm to the child, and only 6.5 percent of the cases eventually went to court for removal or court-ordered services. He concluded that investigative workers were not following agency policy and that supervisors were nevertheless approving the findings of the flawed investigations. He was working on ways to improve implementation through oversight of supervisory decisions. But with a change of personnel, those efforts never came to fruition. Now, birth match is under review in Michigan as part of a “front end redesign” of the child protection system.

Many former birth match advocates appear to have lost interest as well. In Texas, birth match was adopted in response to a recommendation by the State Child Fatality Review Team (SCFRT). But after requesting updates on implementation in FY2013 (which were never provided) and recommending expanding the program to look back five years in FY2018 (a recommendation which DFPS rejected), the SCFRT stopped making recommendations about the program. In Maryland, advocates pushed to strengthen the program by increasing the “lookback” period from five to ten years. But after such legislation was passed in 2018, it does not appear that advocates asked about its implementation nor about the effects of the expansion. Moreover, in passing the 2018 legislation, the legislature included a provision that appears to be aimed at finding less controversial alternatives to birth match.

The changing ideological climate might be the reason for the loss of interest in birth match among officials and advocates in the first four states to adopt it. In today’s atmosphere, identifying parents based on their past involvement in child welfare or criminal justice is likely to be criticized because these systems involve Black people at a rate that is disproportionate given their share of the population, though proportionate to their rate of abuse and neglect compared to other populations. There is no escaping the conclusion that birth match is simply at odds with the current zeitgeist in child welfare. Missouri was the only state to institute birth match since it was recommended by CECANF in 2016.

The report makes three recommendations. Due to its support in research and common sense, birth match should be added to every state’s set of tools to prevent child abuse and neglect and Congress should consider mandating birth match as a requirement to receive funds under the Child Abuse Prevention and Treatment Act (CAPTA). Birth match provisions should include all parents who committed severe abuse or neglect whether or not they had a TPR or criminal conviction. And finally, states with birth match programs should track and publish data on the children matched and should conduct case reviews to assess the implementation of their programs. But it is not likely that any of these recommendations will be widely adopted until the pendulum swings toward the needs of children living in unsafe homes.

When a new baby is born to parents who had their rights terminated to a previous child due to severe abuse or neglect, or who killed or severely harmed another child, the child welfare agency should be notified, and a professional should make contact with the family to ensure the child is safe and offer the parents any assistance needed. It is such a commonsense idea that it’s hard to imagine anyone would oppose it. Nevertheless, only five states have adopted such a program, and and the four states with programs that have been in effect for more than one year have displayed what appears to be little interest in assessing or improving their implementation; on the contrary, there seems to be some interest in eliminating the programs among administrators and legislators in some states. The current ideological climate in child welfare may be be responsible for our failure to use a simple tool to protect children.

Notes

  1. How the allegation type is determined and by whom, and how maltreatment can be found before it has occurred are unclear. Birth match is not mentioned in the department’s policy manual and DFPS’ Media Relations Director was not able or willing to answer these questions.

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.

“Five Myths about the Child Welfare System” misleads more than it corrects

Source: UAlberta.ca

by Marie Cohen and Marla Spindel

The following was submitted as an Op-Ed to the Washington Post in an effort to ensure the. public has the benefit of various viewpoints on this topic but, unfortunately, the Post chose not to publish it.

We were troubled to read Dorothy Roberts’ “Five myths about the child welfare system” in the April 17th Outlook section of the Washington Post. Roberts’ version of reality does not agree with what we see every day as child advocates in the District of Columbia, nor with the research on child welfare.

“Myth” No. 1: Child welfare workers mainly rescue children from abuse. Roberts is correct that at most 17 percent of the children placed in foster care in FY 2020 were found to be victims of physical or sexual abuse. But she is wrong when she implies that most neglect findings reflect parents who are too poor to provide adequate housing, clothing and food to their children. Many of the neglectful parents we have seen have serious, chronic mental illness or substance use disorders that impact their parenting, and they are unwilling or unable to comply with a treatment plan. Meanwhile, the children in their care are often left to fend for themselves because their parents cannot feed and dress them, change their diapers, or get them to school. Many children neglected in this way develop cognitive and social deficits, attachment disorders, and emotional regulation problems. Most poor parents do not neglect their children. Even with scarce resources, they find a way to provide safe and consistent care.

“Myth” No. 2: Homes are investigated only if children are at risk of harm. The purpose of an investigation is to determine whether children are at risk of harm. Professionals who work with children are trained to report concerns about possible maltreatment, not to investigate on their own. The system is not perfect. Some reports are too minor to meet the definition of maltreatment, or even maliciously motivated. A surprisingly large number of children are reported every year and only a minority of these reports are substantiated—but that does not mean they are not true. But to propose that investigations should take place only if it is first determined that children are at risk puts the cart before the horse and disregards the safety of children.

“Myth” No. 3: Foster children are usually placed with loving families. Roberts’ statement that large numbers of children are placed in some form of congregate care — group homes, residential treatment centers and psychiatric hospitals—is misleading. Only eight percent of children in foster care were in a group home or institution at the end of September, 2020, though the percentage is higher for older youth. The problem is the lack of quality therapeutic placements for children who have been so damaged by long histories of abuse and neglect that they cannot function in a family home. It is true that many children bounce from one foster home to another, but these are often youths with acute behavior problems that make it difficult for them to function in a home. Roberts also fails to mention that 34 percent of foster children were residing in the homes of relatives as of September 2020, and that they have more placement stability than children placed in non-kinship homes.

“Myth” No. 3: Foster children are usually placed with loving families. Roberts’ statement that large numbers of children are placed in some form of congregate care — group homes, residential treatment centers and psychiatric hospitals—is misleading. Only eight percent of children in foster care were in a group home or institution at the end of September, 2020, though the percentage is higher for older youth. The problem is the lack of quality therapeutic placements for children who have been so damaged by long histories of abuse and neglect that they cannot function in a family home. It is true that many children bounce from one foster home to another, but these are often youths with acute behavior problems that make it difficult for them to function in a home. Roberts also fails to mention that 34 percent of foster children were residing in the homes of relatives as of September 2020, and that they have more placement stability than children placed in non-kinship homes.

Myth No. 4: Placing children in foster care improves their well-being.” Arguing that foster care is harmful is like arguing that treatment in a cancer ward increases the risk of dying of cancer. Foster youths are likely to have poor outcomes given their history of maltreatment, which foster care cannot erase. It is difficult to assess how foster care placement affects children, since we cannot do a controlled experiment in which some children are placed and a similar set of children are not. Roberts quotes only one study, from 2007, that shows harm from foster care—and that study included borderline cases only, leaving out children suffering severe and obvious maltreatment. She does not quote the same author’s brand-new paper, which finds both positive and negative effects for different contexts, subgroups, and study designs.

“Myth” No. 5: This system was founded after the case of Mary Ellen Wilson. This is an esoteric myth, as few people have heard of Wilson. Roberts is right that many histories trace the roots of today’s child welfare system to the case of that little girl. We appreciate Roberts’ clarifications but are not convinced of their significance. We believe other myths are much more relevant, such as that neglect is synonymous with poverty, or that all children are betteroff with their parents no matter how badly abused or neglected they are.

It is disappointing that the Post allowed Roberts to use this series to propagate new myths, rather than dispel old ones.

Marie Cohen is a former foster care social worker, current member of the District of Columbia Child Fatality Review Committee, and author of the blog, Child Welfare Monitor. You can findher review of Dorothy Roberts’ new book here. Marla Spindel is the Executive Director of DCKincare Alliance and a recipient of the 2020 Child Welfare League of America’s Champion for Children Award.

Torn apart: A skewed portrait of child welfare in America

In her 2009 book, Shattered Bonds: The Color of Child Welfare, Dorothy Roberts drew attention to the disproportional representation of Black children in foster care and child welfare in general and helped make “racial disproportionality” a buzzword in the child welfare world. In her new book, Torn Apart: How the Child Welfare System Destroys Black Families–And How Abolition Can Build a Safer World, Roberts revisits the issues addressed in Shattered Bonds and creates a new buzzword, renaming child welfare as the “family policing system.” Those who liked Shattered Bonds will likely love Torn Apart. But those who value accuracy in history or in data will find it to be sadly misguided, although it does make some valid points about flaws in the U.S. child welfare system.

Roberts starts with a horrific anecdote about a mother, Vanessa Peoples, who was doing everything right–she was married, going to nursing school, about to rent a townhouse and was even a cancer patient. But Peoples attracted the attention of both the police and child welfare and ended up hogtied and carted off to jail by police, placed on the child abuse registry, and subjected to months of monitoring by CPS after she lost sight of her toddler at a family picnic when a cousin was supposed to be watching him. But citing these extreme anecdotes as typical is very misleading. This particular story has been covered in numerous media outlets since it occurred in 2017 and continues to be cited regularly. One can counter every one of these horrific anecdotes with a story of a Black child who would have been saved if social workers had not believed and deferred to the parents. (See my commentary on the abuse homicides of Rashid Bryant and Julissia Batties, for example).

Roberts’ book restates many of the old myths that have been plaguing child welfare discussions as of late and that seem to have a life of their own, impervious to the facts. Perhaps the most common and pernicious is the myth that poverty is synonymous with neglect. Roberts embraces this misconception, suggesting that most neglect findings reflect parents who are too poor to provide adequate housing, clothing and food to their children. But parents who are found to have neglected their children typically have serious, chronic mental illness or substance use disorders that severely affect their parenting, and have refused or are unable to comply with a treatment plan. Many are chronically neglectful, resulting in children with cognitive and social deficits, attachment disorders, and emotional regulation problems. Commentator Dee Wilson argues based on his decades of experience in child welfare that “a large percentage of neglect cases which receive post-investigation services, or which result in foster placement, involve a combination of economic deprivation and psychological affliction…., which often lead to substance abuse as a method of self-medication.” Perhaps the strongest argument against the myth that poverty and neglect are one and the same is that most poor parents do not neglect their children.  They find a way to provide safe and consistent care, even without the resources they desperately need and deserve.

Roberts endorses another common myth–that children are worse off in foster care than they would be if they remained in their original homes. She argues that foster care is a “toxic state intervention that inflicts immediate and long-lasting damage on children, producing adverse outcomes for their health, education, income, housing, and relationships.” It is certainly true that foster youth tend to have bad outcomes in multiple domains, including education, health, mental health, education, housing and incarceration. But we also know that child abuse and neglect are associated with similar poor outcomes. Unfortunately, the research is not very helpful for resolving the question of whether these outcomes are caused by the original child maltreatment or by placement in foster care. We cannot, of course, ethically perform a controlled study in which we remove some children and leave a similar set of children at home. We must rely on studies that use various methodologies to disentangle these influences, but all of them have flaws. Roberts cites the study published in 2007 by Joseph Doyle, which compared children who were placed in foster care with children in similar situations who were not. Doyle found that children placed in foster care fared worse on every outcome than children who remained at home. But Doyle focused on marginal cases* and left out the children suffering the most severe and obvious maltreatment. In a brand-new paper, Doyle, along with Anthony Bald and other co-authors, states that both positive and negative effects have been found for different contexts, subgroups, and study designs.

There is one myth that Roberts does not endorse: the myth that disproportional representation of Black children in child welfare is due to racial bias in the child welfare system, rather than different levels of maltreatment in the two populations. After an extensive review of the debate on this issue, Roberts concludes that it focused on the wrong question. In her current opinion, it doesn’t matter if Black children are more likely to be taken into foster care because they are more often maltreated. “It isn’t enough,” she states, “to argue that Black children are in greater need of help. We should be asking why the government addresses their needs in such a violent way, (referring to the child removal). Roberts was clever to abandon the side that believes in bias rather than different need as the source of disparities. The evidence has become quite clear that Black-White disparities in maltreatment are sufficient to explain the disparity of their involvement in child welfare; for example Black children are three times as likely to die from abuse or neglect as White children. As Roberts suggests and as commentators widely agree, these disparities in abuse and neglect can be explained by the disparities in the rates of poverty and other maltreatment risk factors stemming from our country’s history of slavery and racism. Unfortunately, Roberts’ continued focus on these disparities in child welfare involvement will continue to be used by the many professionals who are working inside and outside child welfare systems all over the country to implement various bias reduction strategies, from implicit bias training to “blind removals.”

In Part III, entitled “Design,” Roberts attempts to trace the current child welfare system to the sale of enslaved children and a system of forced “apprenticeship” of formerly enslaved Black children under Jim Crow, whereby white planters seized custody of Black children from their parents as a source of forced labor.** As she puts it, “[t]hroughout its history US family policy has revolved around the racist belief that Black parents are unfit to raise their children. Beginning with chattel slavery and continuing through the Jim Crow, civil rights, and neoliberal eras, the white power structure has wielded this lie as a rationale to control Black communities, exploit Black labor, and quell Black rebellion by assaulting Black families.” In other passages she adds other groups to the list of victims, adding “Indigenous, immigrant and poor people to the list of communities that are being controlled by the “family policing system.” But most of her statements refer to Black victims only.

Roberts’ attempt to connect slavery and Jim Crow practices with child welfare systems highlights a major flaw of the book. She herself explains that due to racism the child welfare system served only White children when it emerged in the nineteenth century with the creation of child protection charities and the passage of state laws allowing maltreated children to be removed from their homes and placed in orphanages. Foster care was established in the middle of the century and also excluded Black children. The system did not begin serving Black children until after World War II, so it is difficult to understand how it could stem from slavery and Jim Crow practices. It seems much more plausible that the child welfare system arose from basically benevolent concerns about children being maltreated, and that with the rise of the civil rights movement, these concerns were eventually extended to Black children as well.

While Black children’s representation as a share of foster care and child welfare caseloads rose rapidly starting in the 1960’s, and Black children are much more likely to be touched by the system than White children, the system still involves more White than Black children. According to the latest figures, there were 175,870 White non-Hispanic children in foster care (or 44 percent of children in foster care) and 92,237 Black (non-Hispanic) children in foster care, or 23 percent of children in foster care. Moreover, the disparity between Black and White participation in child welfare and foster care as a percentage of the population seems to be decreasing.*** So the idea that this whole system exists to oppress the Black community and maintain white supremacy seems farfetched.

Roberts’ attempt to make Black children the focus of the book results in some awkward juxtapositions, like when she admits that though the Senate investigation of abuses by a for-profit foster care agency called MENTOR “highlighted cases involving white children, we should remember that Black children are more likely to experience these horrors in foster care—not only because Black children are thrown in foster care at higher rates, but also because government officials have historically cared less about their well-being.” A page later she states that the “child welfare system’s treatment of children in its custody is appalling but should come as no surprise. It is the predictable consequence of a system aimed at oppressing Black communities, not protecting Black children.” It is hard to understand how White children being maltreated in bad placements supports this narrative.

Fundamental to Roberts’ critique is her system is “not broken.” “Those in power have no interest in fundamentally changing a system that is benefiting them financially and politically, one that continues to serve their interests in disempowering Black communities, reinforcing a white supremacist power structure, and stifling calls for radical social change.” Even if one believes there is a white supremacist power structure, it is hard to see the direct connection between the abuses Roberts is highlighting and the disempowerment of Black communities; it seems more likely that the more abusive the system, the more protests it would generate. And at a time when the federal government and some of the wealthiest foundations and nongovernmental organizations are echoing much of Robert’s rhetoric, her reasoning seems particularly off-target.

Roberts makes some valid criticisms of the child welfare system. Her outrage at the terrible inadequacies of our foster care system is well-deserved. She is right that “The government should be able to show that foster care puts Black children [I’d say “all children”] on a different trajectory away from poverty, homelessness, juvenile detention, and prison and toward a brighter future.” Any society that removes children from their parents needs to be responsible for providing a nurturing environment that is much, much better than what they are removed from. And we are not doing that. As Roberts states, “The state forces children suffering from painful separations from their families into the hands of substitute caretakers…..who often have unstable connections, lack oversight and may be motivated strictly by the monetary rewards reaped from the arrangement.” As a foster care social worker in the District of Columbia, I was driven to despair at my inability to get my superiors to revoke the licenses of such foster parents; the need for “beds” was too great to exclude anyone was not actually guilty of abuse or severe neglect. Roberts is also right to be concerned the outsourcing of foster care to private for-profit organizations that may be more concerned with making money than protecting children, sometimes resulting in scandals like the one involving MENTOR Inc., which was found to hire unqualified foster parents and fail to remove them even after egregious violations like sexual assault.

Roberts also raises valid concerns about children being sent to residential facilities, often out of state, that resemble prisons rather than therapeutic facilities. But she ignores the need for more high-quality congregate care options for those children who have been so damaged by years of maltreatment that they cannot function in a foster home, no matter how nurturing. Instead, she repeats the usual litany of scandals involving deaths, injuries, fights and restraints, without noting the undersupply of truly therapeutic residential settings, resulting in children sleeping in office, cars, and hotels or remaining in hospital wards after they are ready for discharge. Ironically, she supports defunding the system, even if that would mean even worse situations for these children.

Roberts decries the fact that parents sometimes relinquish custody of their children in order to get needed residential care, arguing that “rather than providing mental health care directly to families, child welfare authorities require families to relinquish custody of children so they can be locked in residential treatment centers run by state and business partnerships.” That statement is completely backwards. The child welfare system does not provide mental health services but, like parents, it often struggles to secure them for its clients. Some parents are forced to turn to the child welfare system because their insurance will not pay for residential care for their children. That is not the fault of child welfare systems, which clearly do not want to take custody of these children. The underlying problem is the lack of adequate mental health care (including both outpatient and residential programs), which has destructive consequences for the foster care system. This is exacerbated by the lack of parity for mental health in health insurance programs. It’s hard to believe Robert is unaware of these well-known facts.

Roberts is correct that parents as well as children are shortchanged by inadequacies in our child welfare program, such as the “cookie cutter” service plans which often contain conflicting obligations that are difficult for struggling parents to meet. But she is wrong when she says that parents need only material support, not therapeutic services. But this error flows logically from her concept of neglect as simply a reflection of poverty. In fact, many of these parents need high-quality behavioral health services and drug treatment, which are often not available because of our nation’s mental health crisis, as well as the unwillingness of taxpayers and governments at all levels to adequately fund these services.

In her final chapter, Roberts concludes that, like the prison system, the child welfare system cannot be repaired because it exists to oppress Black people. “The only way to end the destruction caused by the child welfare system is to dismantle it while at the same time building a safer and more caring society that has no need to tear families apart.” In place of family policing, Roberts favors policies that improve children’s well-being, such as “a living wage and income support for parents, high-quality housing, nutrition, education, child care, health care; freedom from state and private violence; and a clean environment.” I agree with Roberts that aid to children must be expanded. The US is benighted when compared to many other Western countries that invest much more heavily in their children through income support, early childhood and K-12 education, healthcare, and housing. But family dysfunction occurs even if a family’s material needs are met. That is why every other developed nation has a child welfare system with the authority to investigate maltreatment allegations and assume custody of children when there are no other options. Moreover, some of the countries with the strongest safety nets for children also have higher percentages of children living in foster care than the United States.****

Torn Apart is a skewed portrait of the child welfare system. In it Roberts restates the common but easily discredited myths that poverty is synonymous with neglect and that foster care makes children worse off than they would have been if left at home. The underlying flaw in her account is the idea that this system exists to repress the Black community, even though it was established solely for the protection of White children. Roberts makes some valid criticisms of child welfare systems and how they shortchange the children and families they are supposed to help. But when she talks of dismantling child protection, she is proposing the abandonment of abused and neglected Black children in homes that are toxic to them, an abandonment that will perpetuate an intergenerational cycle of abuse and neglect. These children are our future; abandoning their well-being to prioritize that of their parents is a bad bargain with history.

*Doyle’s study included only those cases that would have resulted in foster placement by some investigators and not by others, leaving out the cases in which children were in such danger that all investigative social workers would agree that they should be placed.

**In various places, she also attributes it to different combinations of slavery and apprenticeship of Black children with the transfer of Native American children to boarding schools, the exclusion of Black children from charitable aid and the servitude of impoverished White children.

***A recent paper reports that disparities between Black and White children began to decrease in the twenty-first century in nearly every state, closing entirely in several Southern states.

****Unicef’s report, Children in Alternative Care, shows that Denmark has 982 children in “alternative care” per 100,000 and Sweden has 872 per 100,000, compared to 500 per 100,000 for the United States.

Child Abuse Prevention Month becomes “Family Strengthening Month” in two states: will more follow?

I’m not a big fan of these months, days, and weeks dedicated to specific causes, whether they be Social Work Month, Child Abuse Prevention Month or Foster Care Month. These days, weeks, and months often allow us to feel good by paying lip service to a group or a the cause on social media without taking any concrete steps to help the group or address the problem. But when states begin renaming Child Abuse Prevention Month, there is reason to ask whether this change is a significant reflection of a changed child welfare zeitgeist.

Ronald Reagan declared April to be National Child Abuse Prevention Month in 1983, and the designation soon took hold around the country, with public and private agencies displaying blue pinwheels, sharing information about child maltreatment, and urging the public to get involved in preventing child abuse and neglect. But no longer is that the case in Utah, where April has been renamed Family Strengthening Month, or Montana, where it has been declared Strengthening Families Month.

In Utah, a document called, a bit confusingly: Family Strengthening Month: A Toolkit for 2022 Child Abuse and Neglect Prevention Month, begins with an attempt to answer the question, “Why Family Strengthening Month?” Diane Moore, the director of Utah’s Division of Child and Family Services (DCFS) starts by asserting that “focusing on…. an individual family’s failure ignores any societal or economic influence, and the potential for communities to take action to strengthen families to safely care for their own children.” This statement is confusing. Almost every commentator in the field recognizes that socioeconomic factors influence child abuse and neglect. And asking communities to support families has been a focus of child abuse prevention month on the federal level for some time.

Moore goes on to state that 55% of confirmed allegations are related to some type of neglect in Utah. The preponderance of neglect is often used by left-of-center leaders and commentators as support for the argument that child protection agencies are finding parents guilty of neglect when the real problem is poverty. But Utah is a Republican state, and Moore is not about to blame child maltreatment on poverty. Instead, she states that “High stress, substance abuse, social isolation, and lack of support for parents are among the most common risk factors associated with child abuse and neglect.” Not a word about poverty, unless “lack of support for parents” is an euphemism for it. So it’s not clear what purpose is served by the mention of neglect, or what the “economic influences” mentioned in the first sentence might be.

Moore goes on to say that “When we truly care about the safety and well being of children, then we must equally care about the safety and well being of the adults in those children’s lives.” This statement is questionable as well. Children are more vulnerable than adults, especially the youngest children, and the power imbalance is huge. Moreover, children are our future, and will parent the next set of children. Most parents put the needs of their children before their own needs, so why wouldn’t society do the same? That being said, I agree that parents must be safe and well if they are to keep their children safe and well. But if I have to choose between the well-being of a child and that of an abusive or neglectful parent, I’ll go with the wellbeing of the child any day.

Finally, Moore concludes that “We want to do more in Utah than just prevent abuse and neglect. We want to back away from that line of crisis by leaning in as communities and neighbors in order to ensure that every family has the resources and support they need to be truly successful.” More than “just” prevent abuse and neglect? If that were easy, I’d certainly be happy to aim for more, but I think we are a long way from doing that.

So Utah’s justification of the name-change depends on a set of vague and questionable statements. Then what is the real reason to take the focus off child maltreatment and replace it with “strengthening families”? This change is certainly in tune with the current climate n child welfare. We are supposed to lead with family strengths rather than weaknesses, prioritize keeping families together and minimize government intrusion in family life. If those are the priorities, child abuse and neglect prevention may have to take a back seat. We might even be willing to tolerate more abuse and neglect in order to keep families together – a bit of collateral damage, so to speak. The social worker and supervisor working with Noah Cuatro‘s family wanted to concentrate on its strengths, not its weaknesses. So they ignored the signs of abuse, and Noah was killed by his parents. Collateral damage.

It is interesting that two red states were the first to drop the “Child Abuse Prevention Month” designation. As a child advocate, I have been more critical of Democratic leaders and commentators, because they have tended to be more extreme, with statements equating neglect with poverty proposals like abolishing the “family policing system.” But I’ve been equally hard on the Trump and the Biden appointees to the Administration on Children and Families, because their views are essentially the same. And that is because child welfare is an issue where both sides of the aisle often agree on what I think are terrible policies. The focus on parents’ rights rather than children’s needs jibes with the Left’s focus on racism as the cause of almost everything and its reluctance to punish parents who may be victims of poverty. For the right, parents’ rights have always been important: keep your government out of my family, except when it comes to abortion and birth control. That’s how Left and Right could agree on the Family First Act, a terrible bill which transferred the costs of necessary group care to states while paying lip service to family preservation by offering funding for services that were already funded from other sources.

In Texas, Democrats and Republicans agreed in the 2021 legislative session on a slate of reforms designed to restrict CPS intervention into the lives of families. These laws were pushed by a coalition of strange bedfellows indeed: “abolitionists” who want to abolish child welfare along with police and prisons, with conservative groups intent on reducing government intrusion into families.

So it turns out that two “red” states were the first to rename Child Abuse Prevention month to focus on strengthening families. But next to follow suit may be one or more blue states that are eager to demonstrate their progressive bona fides. Who will be the next? Stay tuned.

The power of wishful thinking revisited: the improbable growth of Healthy Families America

I have written before about the power of wishful thinking and how it causes people to disregard research and real-life results. In that earlier commentary, I discussed the successful promotion of a practice called race-blind removals based on data from an article by a scholar who now denies knowledge of their provenance, and which have been shown to be inaccurate. A program called Healthy Families America (HFA), which currently serves over 70,000 families per year according to its website, offers another example of the power of wishful thinking. This program has become the centerpiece of the nation’s oldest and largest charity dedicated to the prevention of child abuse, even though the program has failed to demonstrate its utility in preventing child maltreatment. This organization, now called Prevent Child Abuse America, launched HFA based on weak evidence that a program in Hawaii called Healthy Start Program (HSP) could prevent child maltreatment. The first experimental study of HSP found no impact on child maltreatment but did nothing to derail the launch of HFA. Studies of HFA programs around the country have found little evidence of reductions in child maltreatment, but the program has continued to grow and now serves more families than any other home visiting program. The story of HFA is a lesson in the power of wishful thinking and the failure of evidence (or lack thereof) to counteract it.

As told in a helpful history of home visiting, all modern programs can trace their origins to Henry Kempe, whose book, The Battered Child, brought about the recognition of child maltreatment as a national problem. To address child abuse, Kempe called for universal prevention through a network of home health visitors. Inspired by Kempe, modern home visiting began with Hawaii’s implementation of the Healthy Start Project (HSP) in 1975. As described in the 1999 evaluation by Duggan and colleagues, HSP was developed by the Hawaii Family Stress Center (HFSC) on the island of Oahu. It had two components: early identification (at the birthing hospital) of families with newborns at risk of child abuse and neglect and home visiting by trained paraprofessionals for those families classified as at-risk who agreed to participate. This initial program was never evaluated, but anecdotal information suggested it was successful in promoting effective parenting, and six similar programs were established on neighboring islands.

As described by Duggan et al., the Hawaii Legislature authorized a three-year pilot program focusing on one neighborhood in Oahu, which began in 1985. There was no control group in the pilot study, and the researchers used CPS reports and changes in family stress in participating families to measure program effectiveness. During the three-year pilot, there were few reports of physical abuse, neglect or imminent harm for program participants. Because evaluations of other home visiting programs had found much higher rates of reported maltreatment in comparison group families, these results were viewed as evidence that the program had a positive impact. According to Duggan and her co-authors, “The pilot study results might have been given too much weight, given the lack of a control group and the short period of follow-up for most families.” Nevertheless, the results of this unpublished study were enough evidence for the Legislature to expand HSP throughout Hawaii starting in 1989.

Home visiting in general was gathering steam in the 1980s and early 1990’s. In 1990, the U.S. General Accounting Office (GAO) issued a report promoting home visitation as a “promising early intervention strategy for at-risk families.” In its summary of research evidence, GAO focused mostly on health and developmental benefits for children, rather than maltreatment prevention. In 1991, the U.S. Advisory Board on Child Abuse and Neglect issued a report recommending a pilot of universal voluntary neonatal home visitation, stating that the efficacy of home visiting as a preventive measure was “already well-established.” The Board cited the results of a federally-funded demonstration begun 17 years earlier as well as the the nurse home visitation program started by David Olds in 1977. But HSP was not mentioned.

Despite the lack of a rigorous evaluation, the National Committee to Prevent Child Abuse (NCPCA, now called Prevent Child Abuse America) the nation’s “oldest and largest organization committed to preventing child abuse and neglect before it happens,” had become interested in using HSP as the nucleus of a national home visiting program. But first, NCPCA conducted a one-year randomized trial of HSP, as described by Duggan et al. The trial suffered from severe methodological limitations, including “less than ideal followup,” differential dropout rates in the program and control groups, the failure to blind interviewers to experimental or control status, and reliance on program staff rather than researchers to measure some outcomes. Nevertheless, the trial concluded that HSP reduced child maltreatment, and this apparently gave NCPCA the assurance it needed to invest in the model.

NCPCA launched Healthy Families America in 1992, with financial support from Ronald MacDonald House Charities, arranging visits to 22 states by Hawaii Family Stress Center Staff. The “theory of change,” or theoretical basis for the program, as quoted by Duggan et al, started with the targeting to all newborns and their parents, which allows for diversified service options determined by individual need. Also part of the theory was a commitment to change at the individual and community levels. Rather than impose a single service model, HFA contained a set of critical elements, which included the prenatal initiation of services and the assessment of all new parents. A network was launched to bring together researchers doing experimental and quasi-experimental studies of HFA programs.

Unlike NCPCA, The Hawaii Department of Health recognized the limitations of both the pilot study and the NCPCA study and initiated a more rigorous evaluation of HSP in 1994. This was a randomized controlled trial, with at-risk families identified at the hospital and randomly assigned to the experimental and control groups. In 1999 the results of the Evaluation of Hawaii’s Healthy Start Program were released as part of an issue of the Future of Children journal containing evaluations of six different home visiting models.  No overall positive program impact emerged after two years of service in terms of child maltreatment (according to maternal reports and child protective services reports). Early HFA evaluation results, published in the same issue, also failed to find effects on abuse and neglect in three randomized trials, which included the HSP evaluation discussed above and another Hawaii HSP study.

David Olds had had begun testing his Nurse Home Visiting Program in 1977 and already had long-term results on the program in Elmira, NY, as well as shorter-term results for a replication in Memphis, Tenn. That program, now known as Nurse Family Partnership, was very different from HFA. It was restricted to first-time teenage mothers and the home visitors were nurses rather than paraprofessionals. The nurses followed detailed protocols for each visit. The researchers found that among low-income unmarried women (but not other participants), the program reduced the rate of childhood injuries and ingestions of hazardous substances that could be associated with child abuse or neglect. Follow-up of the Elmira group when the children were 15 found that the nurse-visited mothers were significantly less likely to have at least one substantiated report of maltreatment. These results are particularly impressive because they overrode a tendency for nurse-visited families to be reported for maltreatment by their nurse visitors. The researchers concluded that the use of nurses, rather than paraprofessionals, was key to the success of the program. In their analysis of all six studies published in the volume, Deanna Gomby et al. concluded that while the HFA and HSP evaluations showed some change in maternal attitudes and self-reported behaviors related to abuse and neglect, only the Nurse Home Visiting Program showed impacts on abuse and neglect other than from self-reports.

Gomby and her co-authors also concluded that the results of the six home visiting evaluations were discouraging for those who had high hopes for home visiting for solving an array of problems. All the programs “struggled to enroll, engage and retain families.” Program benefits generally accrued to only a subset of enrolled families and were often quite modest. The authors explained the disappointing results by concluding that human behavior is hard to change, particularly when problems are community-wide. They recommended that “any new expansion of home visiting programs be reassessed in light of the findings presented in this journal issue” and stated that home visiting services are “best funded as part of a broad set of services for families and children.”

But the home visiting juggernaut was already in motion nationwide. And NCPCA had already made HFA its centerpiece program. Home visiting grew, and HFA grew with it. In 2010, Congress created the Maternal, Infant and Early Childhood Home Visiting Program (MIECHV), which was re-authorized in 2018 with funding of $400 million per year through FY 2022. According to the HFA website, HFA is the model most frequently implemented with MIECHV dollars. Home visiting programs can also receive funding through Medicaid, Title IVB and IVE of the Social Security Act, and many other funding sources.

The infusion of funding for HFA research by NCPCA initiative set in motion a multitude of research projects (both randomized trials and less rigorous studies) that continues to result in publications. Nevertheless, HFA research has yet to find solid evidence that these programs have an impact on child maltreatment: The California Evidence-Based Clearinghouse for Child Welfare (CEBC), the pre-eminent child welfare program clearinghouse, reviewed 19 research reports on HFA. It gave the program a rating of “4” on a scale of 1 to 5 for prevention of child abuse and neglect, meaning the evidence fails to demonstrate that the HFA has an effect on abuse and neglect. HFA did receive a rating of 1 for “child well-being,” based on its impacts on outcomes like physical health, child development, and school readiness. In contrast, Nurse Family Partnership was rated as “1,” “well-supported by the research evidence, for the prevention of child abuse and neglect, as well as for child well-being.

Despite the lack of evidence of its impact on maltreatment, HFA received a rating of “Well Supported” from the new clearinghouse established by the Family First Prevention Services Act (“Family First”) to determine whether a program can receive federal funding under Title IV-E of the Social Security Act. To get such a rating, the program must show improved outcomes based on at least two randomized trials or rigorous quasi-experimental studies. But these outcomes could be any sort of “important child and parent outcome,” (not just child abuse or neglect) and there is no standard for how to measure each outcome. Based on its review of all HFA studies that met their criteria for inclusion, the Clearinghouse found 23 favorable effects, 212 findings of no effect, and four unfavorable effects across 16 outcomes. This included five favorable effects on child safety based on parents’ self-reports of maltreatment, with no favorable effects on other measures of child safety. Self-report is generally frowned upon as a measure of child maltreatment, for obvious reasons. A positive impact of HFA might reflect that participants in HFA were more eager than control group members to provide the “right answer” to questions about maltreatment.

The “well-supported” rating from the Title IV-E clearinghouse opened up a new source of funding for HFA. Passage of Family First as Title VII of the Bipartisan Budget Act of 2018, allowed states to spend Title IV-E funds on programs on services to families with a child welfare in-home case. To take advantage of this new demand, HFA announced in September 2018 that families referred by the child welfare system were now able to enroll until 24 months of age. To serve these families, HFA introduced special child welfare protocols, with limited evidence that that the program was effective for parents who had already abused or neglected their children.* The program had already departed from its initial mission of screening all families with newborns in a geographic area. Even without the child welfare protocols, each program can choose its own admission criteria and there is no universal screening; potential participants are generally referred by health or child welfare agencies, who often can choose between several home visiting programs when referring a client.

Another part of HFA’s original theory of change was a “dual commitment to change at the individual and community levels.” As described by Daro and Harding in their 1999 evaluation of HSA, this meant that HFA “must move beyond direct efforts to help families and begin to serve as a catalyst for reshaping existing child welfare and health care efforts and improving coordination among other prevention and family support initiatives.” This vision has clearly gone by the wayside as HFA has become one choice in a menu of home visiting programs offered by local jurisdictions. Far from trying to enhance and coordinate available community offerings, HFA is busy trying to maximize its share of the pie through its public relations effort, exemplified by the self-promotional statements on its website.

It is disappointing that Prevent Child Abuse America (“Prevent Child Abuse,” formerly NCPCA), an organization that defines its mission as child abuse prevention, decided to fund HFA before it was proven to prevent child maltreatment and without apparently considering other approaches also being tested at the time. And it is concerning that the organization continued with this commitment even after the disappointing evaluations of 1999 might have led them to diversify their investment beyond HFA or even beyond home visiting or to focus more on advocacy rather than services. And finally, that Prevent Child Abuse continues to use charitable contributions made for the prevention of child abuse and neglect to fund a program that has not been proven after 40 years to accomplish this goal, raises serious ethical questions. Twenty-two of the 40 staff listed on the Prevent Child Abuse website have positions with Healthy Families America. Perhaps the charity has backed itself into a corner; it would be difficult to escape this commitment without serious repercussions.

Some federal administrators do not seem to be much more interested in evaluation results than Prevent Child Abuse. The legislation authorizing MCHIEV required a randomized controlled trial (RCT), which may provide useful information on the relative merits of these programs in addressing different outcomes. But strangely, HHS indicated in a response to a critique from the Straight Talk on Evidence Blog that it is not interested in a “horse race” between the models but rather is interested in assessing home visiting in general. This odd statement is an indicator of the kind of thinking that allowed Prevent Child Abuse to invest in HFA for 40 years despite the lack of evidence that it does “Prevent Child Abuse.”

The story of Healthy Families America is not an unusual one. My discussion of the Homebuilders program could also be called “the power of wishful thinking.” Such stories are all too frequent. They show us how wishful thinking can drive leaders to disregard research, especially after they have made a premature decision to commit to one program or course of action.

*One study of Healthy Families New York, published in 2018, looked at a subgroup of 104 mothers who already had a substantiated CPS report, and found a decrease in abuse and neglect among the mothers who were in the experimental group. However, the sample was small and was not planned in advance, so the authors recommend further testing home visiting programs as prevention of repeat maltreatment for child welfare-involved mothers.

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.