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

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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.

Ten common child welfare misconceptions: essential reading for child welfare commentators and policymakers

In the current rush to make child welfare more “family-friendly,” many proposals are being made for major changes, and even for the total abolition of the current system. But many of these proposals are based on misunderstandings of what we currently know about child abuse, child neglect and child welfare programs. Acting based on these misconceptions may produce policies and practices that actually harm children. A group of eminent child welfare scholars, headed by Richard Barth of the University of Maryland School of Social Work, (and also including leading child welfare scholars Jill Duerr Berrick, Antonio Garcia, Brett Drake and Melissa Jonson-Reid and Johanna Greeson) have addressed ten of the most common misconceptions in one essential article, a must-read for anyone promoting change in our child welfare system.

The article, entitled “Research to Consider While Effectively Re-Designing Child Welfare Services,” was published in the journal Research in Social Work Practice on October 18, 2021. It highlights 10 common misconceptions which the authors assert (rightly in my view) are “inconsistent with the best available contemporary evidence.” Their treatment is structured around ten questions to which a wrong answer is commonly cited and used to justify policy changes. Unfortunately, a paywall blocks access to the article for readers who do not have access to the journal from their institution, though this link provides a one-paragraph summary and the reference list. This post provides a more detailed summary of the article. Readers can contact author Richard Barth at RBarth@ssw.umaryland.edu with questions.

Are Low-Income Children Inappropriately Referred to Child Protective Services (CPS) Due to Implicit Bias?

As the authors describe, there is no doubt that low-income children are referred to CPS at a higher rate than their higher-income peers. One theory is that mandated reporters, who are often middle-class professionals, are biased against low-income parents and their parenting styles. Barth and colleagues cite studies that look at this question in several ways, all suggesting that bias is not the major reason for higher reporting of poor children. First, low-income children experience bad outcomes (in the worst case, death) at differentials consistent with or higher than the differentials in reporting rates. Second, lower-income people are much more likely to self-report maltreatment than their higher-income counterparts. And finally, low-income children who are reported to CPS are more likely to have a range of negative outcomes than their low-income peers who are not reported to CPS.

Are Families who Receive Public Social Services and Have Contact With Mandated Reporters Disproportionately Likely to be Referred to Child Protective Services?

It is often asserted that families that receive more public services (such as clinics rather than private doctors to whom they are known) and encounter more mandated reporters are more likely to be reported to CPS. But the authors show that available evidence does not support this assertion. Two studies estimated “surveillance bias” to increase CPS reporting by less than two percent. Another study found that among children in families receiving income support, those who were reported to CPS also had higher rates of delinquency, mental health problems, and hospital visits for injury. Finally, national and state data show that “as individual or community poverty increases, the proportion of mandated reporters among all reports decreases, making low-income people less likely to be reported by mandated reporters.”

Is the Racial Disproportionality of Black Children in CPS Substantially Driven by Bias?

It is a fact universally acknowledged that Black children are more likely to be involved with child welfare than their share of the population would predict. The latest federal data shows that Black children are more than twice as likely to be reported to CPS than White children. But as I’ve often written, the evidence suggests that bias is not the main reason for this disparity. Among the reasons cited by Barth and colleagues, Black children are more than three times more likely to be poor than white children. Studies suggest that when compared to children with an equal income, Black children are at the same risk or at a slightly lower risk of being reported to CPS. The authors also cite a recent study suggesting that Black substance-abused infants are actually less likely to be reported to CPS than White or Hispanic substance-abused infants. Furthermore, they cite evidence that Black-White disparities in other objective indicators of well-being, such as child mortality, are actually greater than Black-White disparities in CPS reporting. The writers therefore contend that, in order to address racial disproportionality in CPS reporting, we need to address poverty itself, as well as the factors that place Black children at higher risk of growing up in poverty.

I do differ from Barth et al in believing that factors other than poverty affect racial disparities in child abuse and neglect, and the resulting disparities in reports, substantiations, and foster care placements. The importance of factors other than poverty is illustrated by the fact that Hispanic children are less likely to end up in foster care than White children even though their poverty rates are higher, while Native American children, with similar poverty rates, are much more likely to be placed in foster care than Black children. Hundreds of years history of slavery, racial violence, and segregation have left a legacy of intergenerational trauma that has affected mental health, substance abuse, and childrearing styles. Therefore equalizing Black-White poverty rates would probably not immediately equalize their rates of placement into foster care.

Are Decisions to Substantiate or Place in Foster Care Largely Driven by Racial Bias?

Not only are Black children disproportionately more often reported to CPS; they are disproportionately more often the subject of substantiated allegations and placed in foster care.  This is clearly a concern of the authors although their analysis indicates that what is commonly asserted– that this discrepancy is largely due to a racist decision making in the child welfare system—is not supported by the evidence. The authors report that the large majority of recent studies find that “as they move through the system, socioeconomically disadvantaged Black children are generally less likely to be substantiated or removed into foster care compared to White children.” Black children do stay in foster care about 25 percent longer than White children, perhaps because they are less likely to be reunified with their parents or adopted. However, the frequently-cited idea that they are more often substantiated once economic status is taken into account has been roundly disproved, according to the paper’s authors. As I have pointed out relative to this question and the previous one, attempting to reduce disparities that are due to different levels of need might require establishing lower standards for the care of Black children by their parents, allowing them to remain in situations that would cause White children to be removed.

Is Child Neglect Synonymous With Family Poverty?

The trope that child neglect is synonymous with poverty is one of the most common myths used by advocates of child welfare reform, and I devoted part of a recent post to dismantling it. It is true, as Barth and colleagues state, that 70 percent of maltreatment reports and fatalities include neglect as a factor. And they acknowledge that there “is clear evidence establishing the relationship between poverty and child neglect.” However, this association does not mean that poverty and neglect are one and the same. Barth et al point out that studies examining the impact of both poverty and neglect have found distinct negative impacts on children for each one. They also found that studies using both officially reported and self-reported neglect found “unique constellations of risks and/or parenting behaviors” for neglect as opposed to poverty. As the authors point out, much of of the confusion between poverty and neglect is due to the fact that some states allow parents to be found neglectful when a child’s material needs are unmet, even when this deprivation was involuntary on the part of the parent. In those cases, neglect could be seen as reflecting poverty alone. But the authors point to a study showing that only a small proportion of neglect referrals (maybe one in four) is due to material needs, and that these referrals are only about a quarter as likely to be substantiated as other neglect referrals. This is not surprising, since many jurisdictions would respond in such cases by helping the family address the material need rather than substantiating an allegation of neglect by the parent.

Barth et al make an important point that “[N]arratives that conflate poverty and child neglect unfairly characterize low-income families, the majority of whom provide appropriate care for their children.” Most poor parents do not neglect their children, and eliminating poverty alone would not eliminate neglect caused by mental illness, substance abuse, or other non-material factors. Moreover, characterizing neglect as nothing more than poverty risks obscuring the harms caused by neglect, which the authors discuss in their response to the next question.

Is Child Neglect Harmful to Children?

The seriousness of child neglect is often minimized by those who say it is just a reflection of poverty. Yet, Barth and colleagues remind us that severe neglect means “the lack of the basic nurturing, care, and supervision needs of a child.” When such severe neglect is chronic or occurs at critical periods in child development, it can lead to death, hospitalization, and impaired development. The authors cite multiple studies showing the many poor outcomes that have been associated with neglect, including poor cognitive outcomes, mental illness, trauma symptoms, and substance abuse, and point out that such poor outcomes have been found even when controlling for poverty.

Are Research-Supported Practices Effective for Families of Color?

With the passage of the Family First Prevention Services Act allowing Title IV-E funding to be used to pay for “evidence-based practices” to keep families together, some advocates are asserting that programs deemed evidence-based are not actually shown to be effective for people of color. Barth and colleagues cite a study showing that four of popular programs in the California Evidence-Based Clearinghouse for Child Welfare – Parent Child Interaction Therapy, Trauma-Focused Cognitive Behavioral Therapy, Level Four Triple P and Multi-Systemic Therapy – have been found to be well-supported in studies with samples that include at least 40 percent children and families of color. Moreover, Cognitive Behavioral Therapy, the basis of many interventions, has been shown to be broadly effective across populations. Nevertheless, it is clear that the overwhelming majority of the interventions in the clearinghouse have not included many people of color. I am more persuaded by the authors’ suggestion that just because an intervention study did not include people of color does not mean it would not be effective for them with modifications to make them more relevant to families of color. However, I do feel compelled to report on my skepticism about many of these programs that have been found to be “evidence-based,” regardless of the nature of the families served. In the enthusiasm to replace foster care with family preservation, at least one popular program (Homebuilders) has been approved for Family First funding even though the evidence does not strongly support its effectiveness for any families, as I have discussed previously.

Do Children Grow up in Foster Care?

It is very common to read about children “growing up” in foster care, but as Barth et al point out, that is a rare occurrence today. While long-term foster care was common in the past, today’s emphasis on permanency has made stays much shorter. Barth et al cite “overwhelming” evidence that fewer than one percent of infants and ten percent of children 13 and under who enter foster care grow up in care. Infants entering care spend only about 10% of their time between 0 and 18 in care; children who are older when they enter care spend less time in care. Children who “age out” of care are mostly those who entered as teenagers, and many of them were admitted to foster care because of behavioral problems. As the authors point out, talking about children who “grow up” in foster care overemphasize the importance of the foster care experience as part of the life trajectory for most children and understate the importance of foster care as a temporary, last-resort option.

Does Foster Care Cause Poor Outcomes for Children and Youth?

There is no doubt that studies of young adults who have spent time in foster care show that they have worse outcomes than those who have not. Sadly, some commentators use this research to argue that being in foster care leads to worse outcomes than remaining at home. But as Barth and his colleagues had already explained in a previous section of their paper, child maltreatment has been shown to have many negative outcomes, which should not be confounded with the effects of foster care. Another review by Barth and others of “dozens of methodologically rigorous studies” examining outcomes in multiple domains suggests that it is unlikely that foster care worsens outcomes, and it improves them in some areas like child safety–as one would hope. Barth et al attribute the widespread misstatements about the role of foster care in adult outcomes to the strong impact of anecdotes from some foster care alumni about their bad experiences. This is despite the fact that studies reviewed by the authors show that most young people reported satisfaction with their foster care experiences.Majorities of young people in multiple studies reported that they had positive relationships with their caregivers, received quality care, felt safer in their foster homes than in their original homes, and felt that their removal was justified by the circumstances. Another reason for inaccurate conclusions about foster care, according to the authors, may be an over-reliance on studies of youth who aged out of care. This is a group that tends to have more issues even before entering care than other youth. In summary, as the authors state, “an evidence-informed understanding of the role of foster care in the lives of maltreated children indicates that the average experience of care is more favorable than conditions in the birth home at the time of removal.”

Is Adoption Breakdown Common for Former Foster Children?

The final misconception addressed by Barth and his colleagues is that a large fraction of adoptions end in breakdown. They mention commentators who have expressed concerns that the push to permanency may result in some adoptions being finalized too quickly, resulting in later dissolution. Instead, Barth et al show that research suggests adoption dissolution rates typically fall below five percent across a range of studies. Instead of the embracing the misconception that adoptions are likely to dissolve, Barth and his colleagues suggests that advocates for children in foster care should think of adoption as “a stable permanency alternative for children who otherwise cannot be reunified.” As they rightly state, “reform efforts that seek to curtail the opportunity for adoption among children who cannot be reunified would deny… children the lifetime of permanency that our laws seek to promote.”

Policy based on wrong assumptions is likely to be bad policy. Yet, the daily child welfare news is full of reports of child welfare leaders spouting these misconceptions–and worse, making policy and passing legislation based on them. In just one recent example, the New York City Council recently passed legislation requiring the Administration on Children’s Services “to report on various demographic information including race, ethnicity, gender, community district, and primary language of parents and children at every step of the child welfare system and to create a plan to address any disparities identified as a result of such reporting.” Perhaps those voting for this legislation had no idea that anything besides bias could contribute to these disparities, nor that “creating a plan to address them” could mean imposing a lower standard of parental care for children who come from over-represented groups–leaving aside the waste of time and money that could be better spent in helping children.

The misconceptions highlighted by Barth and his colleagues are already affecting child welfare policy and practice around the county in ways that are likely to put abused and neglected children at risk of further harm. This magisterial review, with its more than 140 references, is essential reading for anyone who prescribes or develops child welfare policy or practice. Let us hope it receives the attention it deserves.

No Way to Treat a Child: a needed corrective to the dominant narrative

No Way to Treat a Child: How the Foster Care System, Family Courts, and Racial Activists Are Wrecking Young Lives

These days, It is a bit difficult to be a left-leaning liberal while also being an advocate for abused and neglected children. I would never have expected that a Senior Fellow at the American Enterprise Institute (AEI), Naomi Schaefer Riley, would be one of my closest allies in child advocacy. Or that my proudest achievement since starting this blog would be my service on a child welfare innovation working group that she organized out of AEI, or that, with a few quibbles over details, I would agree with the main points of her new book. But that is the case in these strange times, in which many of my fellow liberals appear effectively indifferent to the fate of children whose parents they view as victims of a racist “family policing system.”

Naomi Schaefer Riley is a journalist, a former editor for the Wall Street Journal, and the author of five previous books. In her new book, No Way to Treat a Child: How the Foster Care System, Family Courts, and Racial Activists Are Wrecking Young Lives, uses examples, data and quotes from experts to show in heartbreaking detail how policymakers from the left and the right have converged in creating a child welfare system that puts adults first. Much of this occurs because in deciding how to treat abused or neglected children, the people who create and carry out child welfare law and policy “consider factors that are completely unrelated to and often at odds with a child’s best interests,” as Riley puts it.

Take family preservation and reunification, for example. Instead of placing the safety of the child as the highest priority, Riley illustrates that child welfare agencies leave many children in dangerous homes long past the time they should have been removed, with sometimes fatal results. They give parents more and more chances to get their children back, long after the law says that parental rights should be terminated. The book is full of stories of children ripped away from loving foster parents (often the only parents they have ever known) only to be returned to biological parents without evidence of meaningful changes in the behaviors that led to the children being removed.

Not only do today’s advocates of “family first” wrest children away from loving families to return home, but Riley describes how they send other hapless children to join distant relatives that they never knew, on the grounds that family is always best even if the relative does not appear until as much as two years after an infant has been placed in foster care. The fact that a relative may display the same dysfunction that the parent showed may be ignored. I would add, based on personal experience, that in my foster care work I often met grandmothers who seemed to have gained wisdom (and finally, for example, gave up drugs) with age, as well as aunts and uncles who avoided the family dysfunction and went on to lead productive lives, making their homes available to the children of their less well-adjusted siblings. But Riley is right to say we should consider not just blood, but also fitness and bonding before removing a child from a good pre-adoptive home to live with a relative.

As Riley describes, one of the primary factors that is now taking precedence over a child’s best interest is that of race or ethnicity. Riley explains how data on the overrepresentation of Black and Native American children in foster care in relation to their size is being attributed to racism in child protective services, as I have explained elsewhere, ignoring the evidence that the underlying disparities in abuse and neglect are largely responsible for these differences in foster care placement. And they don’t seem to have a problem with holding Black parents to a lower standard of parenting than White children to equalize the ratios. Moreover, many of these “racial activists” are recommending eliminating child welfare systems entirely along with abolishing the police. As Riley states, Native children are the canaries in the coal mine, “for what happens when you hold some parents to a lower standard, as we have done with the Indian Child Welfare Act with devastating effects for Native children.

Another way we subordinate the interests of children is by minimizing their parents’ responsibility for their treatment by saying it is simply due to poverty. Riley addresses the common trope that “neglect,” the reason that 63 percent of children children were removed from their families in 2019, is “just a code word for poverty,” a myth that I have addressed as well. I’d venture that anyone who has worked with families in child welfare knows there is often much more going on in these families than poverty alone, including substance abuse, mental illness, and domestic violence. Riley puts her finger on an important issue when she suggests that part of the problem may be that we use a general category called “neglect” as the reason behind many removals. However, I don’t agree with her recommendation to discard neglect as a reason for removal. As I explain in a recent post, we need to distinguish between the over-arching categories of “abuse” and “neglect” and the specific subcategories of neglect such as lack of supervision, educational neglect, and medical neglect. Contrary to Riley’s suggestion that they are types of neglect, substance abuse and mental illness are factors that contribute to it. This important information should be included in the record but should not be confounded with types of neglect.

Another way that policymakers disregard the best interests of the child is by deciding that foster homes are better than institutions for almost all children instead of recognizing that some children need a more intensive level of care for a limited time, or that others can thrive in group homes that simulate a family setting but provide more intensive attention than a typical foster home can provide. The Family First Prevention Services Act (FFPSA), which went into effect for all states on October 1, does allow for children to be placed temporarily in therapeutic institutions, although it sets some unreasonable limits on these institutions and on placement of children in them. But it does not provide any funding for placement in highly-regarded family-like group settings such as the Florida Sheriff’s Youth Ranches. (I’m not sure why Riley says in later in the book that FFPSA “is looking like another piece of federal legislation that will be largely ignored by states, many of which have already been granted waivers from it.” Those waivers were temporary and there is no way states can ignore the restrictions on congregate care).

In her chapter entitled “Searching for Justice in Family Court, Riley describes the catastrophic state of our family courts, which she attributes to a shortage of judges, their lack of training in child development and child welfare, and their leniency with attorneys and parents who do not show up in court. As a model for reform, Riley cites a family drug court in Ohio that meets weekly, hears from service providers working with parents, and imposes real consequences (like jail time) on parents who don’t follow orders. But this type of intensive court experience is much more expensive. These programs are small, and expanding this service to everyone would require a vast infusion of resources.

I appreciated Riley’s chapter on why CPS investigators are underqualified and undertrained.” Having graduated from a Master in Social Work (MSW) program as a midcareer student in 2009, I could not agree with her more when she states that the “capture of schools of social work and child welfare generally by a social-justice ideology has produced the kind of thinking that guides social welfare policy.” I’d add that some students are ill-prepared for their studies and may not get what they need while in school to exercise the best judgment, critical thinking, effective data analysis, and other important hard and soft skills. Riley suggests that the function of a CPS worker is really more akin to the police function than to the type of traditional social work function performed by other social workers in child welfare–those who manage in-home and foster care cases. As a matter of fact, Riley quotes my post suggesting that CPS Investigation should be either a separate specialty in MSW programs or could be folded into the growing field of Forensic Social Work.

Riley’s chapter on the promise of using predictive analytics in child welfare shows how concerns that using algorithms in child welfare would exacerbate current discrimination are not borne out by history or real-world results. Use of an algorithm to inform hotline screening decisions in Allegheny County Pennsylvania actually reduced the disparities in the opening of cases between Black and White children. As Riley states, this should not surprise anyone because data has often served to reduce the impact of bias by those who are making decisions. As she puts it, “if you are concerned about the presence of bias among child-welfare workers and the system at large, you should be more interested in using data, not less.”

Perhaps not surprisingly, it is Riley’s two chapters on the role of faith-based organizations in child welfare that made me uncomfortable. Riley describes the growing role of these groups, especially large evangelical organizations, in recruiting, training, and supporting foster and adoptive parents.” Like it or not,” she states, “most foster families in this country take in needy children at least in part because their religious beliefs demand such an action.” But the Christian Alliance for Orphans, an organization often quoted by Riley, was one of the groups behind the “orphan fever” that took hold among mainstream evangelical churches in the first decade of this century. Many families were not prepared for the behaviors of their new children and some turned to a book by a fundamentalist homeschooling guru named Michael Pearl that advocated physical discipline starting when children are less than a year old. Many of the adoptions were failures, some children were illegally sent back to their own countries, some children were abused, and at least two died of the abuse. But Riley’s narrative suggests that many evangelical churches working with foster youth are using a trauma-focused parenting model (Trust-Based Relational Intervention) that is diametrically opposed to the Pearl approach. Nevertheless, the association of evangelical Christianity with a “spare the rod” parenting philosophy as well as the possibility that saving souls is part of the motivation for fostering or adoption, make me a bit queasy about over-reliance on evangelical families as foster parents, and I would have liked to see Riley address this issue.

In her esteem for religious communities and their role in child welfare, Riley is worried that some jurisdictions will bar all organizations with whom they work from discriminating on the basis of sexual orientation or gender identity, driving religions institutions out of business. Since the book was written, however, the Supreme Court has ruled that the City of Philadelphia violated the First Amendment when it stopped referring children to Catholic Social Services for foster care and adoption because the agency would not certify same-sex foster parents. So this threat may be dwindling for the time being. In general, unlike many liberals, I agree with Riley that, as long as there is an agency to work with any potential foster parent, we should “let a thousand flowers bloom” rather than insisting that every agency accept every potential parent.

Riley ends the book with a list of recommendations for making the system more responsive to the needs of children rather than adults. She agrees with liberals that we need an influx of financial resources as well as “better stewardship of the money we already spend.” We need both a massive reform of our child welfare agencies and a family court overhaul, she argues. She wants recruitment of more qualified candidates for child welfare agencies and better training for them. She urges the child welfare system to move away from “bloodlines and skin color” and allow a child to form new family bonds when the family of origin cannot love and protect that child. I certainly hope that policymakers on both sides of the aisle read and learn from this important book.

Report of Maltreatment: a major risk factor for child mortality

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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