Tag: child neglect

A fundamental conflict: addressing implicit bias in mandatory reporter training

by Marie Cohen

Recognizing implicit bias in mandated reporting training is a national focus for addressing racial inequity in child welfare. States from New York to Washington have updated their training for mandatory reporters to include implicit bias or highlight the distinction between neglect and poverty in an effort to reduce racial disparities in child welfare involvement. My recent experience taking the updated training in Washington DC made clear that there is a fundamental conflict between preparing mandated reporters for their responsibility to report and advising them to assess their biases before reporting. The basic conflict is this: the core training instructs mandatory reporters to report any suspicion of abuse or neglect, while the implicit bias unit urges mandatory reporters to doubt their instincts and reconsider their duty to report.

In FY 2023, the District of Columbia’s Child and Family Services Agency (CFSA) updated its online mandated reporter training to include a module focused on understanding and addressing implicit bias for mandated reporters. This training is required for all mandated reporters, who include both professionals (doctors, nurses, teachers, social workers, etc.) and volunteers who work with children. I had taken the training several times in the past–first for my work as a social worker with CFSA and later as a mentor to a foster youth. I had my first experience with the updated training last month as part of my preparation to serve as a Court Appointed Special Advocate (CASA) for a child in foster care.

The Implicit Bias Module

The implicit bias module appears to have been shoehorned into the existing DC mandatory reporter training right after a brief introduction to mandatory reporters and their role. The video introducing the section explains that implicit bias harms “families of color” in the child welfare system, without providing any evidence of such harm. It goes on to assert that “the point of this portion of the training is to make sure that reporting is based on observations and not assumptions. Ultimately we want mandated reporters to consider this before responding to a child’s disclosure of suspected abuse or neglect: Do I have any implicit bias in my decision to call or not to call the hotline.” It may sound reasonable, but as the training unfolds, a conflict with the goals of the overall training and mandatory reporting itself becomes clear.

The implicit bias module continues by explaining that nationally and in DC, mandated reporters call the CFSA hotline about Black families disproportionately more than White families; this leads to more “Black and Brown” children having in-home cases or entering foster care because they are assessed more closely. A graph has been provided, with text saying “In this graph, disproportionality is where you see that Black and Brown children make up approximately 64% of hotline calls. However, only 57% of people in the District are a race/ethnicity other than white.” Unfortunately, one does not see this in the graph, which does not include hotline calls at all! It does include children who are the subject of an investigation after a call to the CFSA hotline, and it shows that Black children made up 57 percent of the investigated children, while comprising 53 percent of the population. That is a very small disparity, and in any case could reflect unequal rates of abuse and neglect between Black and White children. The data does show a larger Black-White disparity in confirmed maltreatment (71 percent of the children confirmed as maltreated are Black) and “foster care” (whether this is children in care or entries into care is unclear) at 92 percent. But these increasing disparities come in at the investigation stage (where the substantiation and foster care decisions are made), not at the reporting stage, calling into question the need for training mandatory reporters about implicit bias. To make matters worse, the data on investigations contain a whopping 40 percent without race or ethnicity data; 26 percent of the confirmed maltreatment data, and 23 percent of the in-home case data also lack race and ethnicity information. (Note that the bars of the graph have been shifted by one column to the left of the corresponding columns from the numerical table, as in the original.) So it is impossible to draw meaningful conclusions from these data.

Source: DC Mandated Reporter Training, Lesson 3, page 6, available from

Other than the mention of the hotline call data, which is missing from the graph, the only analysis of the data in the text reads as follows. “Disparity occurs when these children and families have cases open to either in home or foster care support. As you can see that [sic] 85% of in-home cases, and more than 92% of foster care cases in 2020 were opened with Black and brown families, while again the District’s make-up is only 57% Black and brown.” The inclusion of “brown families” is somewhat disingenuous. The graph shows that Hispanics and Asians, the only “brown” children with non-zero populations on the graph, are underrepresented in investigations, confirmed maltreatment, foster care, etc.1 Switching categories, the lecturer goes on to state that “At every stage, Black and Indigenous families face racial discrimination and unequal treatment.” DC is not known to have a large indigenous population; there is no row on the table for Native Americans, and Native Hawaiians and Pacific Islanders are zero percent of every category except that they are listed as making up two percent of children aging out of foster care in 2019.

A central motif of the training is that the confusion of poverty with neglect contributes to the racial and ethnic disparities in child welfare. The video states that “under current law, most children in the US are separated for neglect, a code word that typically represents conditions of poverty, resulting in disproportionate separation and harm to Black families….” But there is a problem with this. We know that neglect is often associated with serious drug abuse and/or mental illness. After all, most poor people don’t neglect their children. Moreover DC Code Section 16.2301 forbids a court to find maltreatment when the deprivation of food, clothing, shelter or medical care is due to the parent’s lack of financial means. The law does not allow removing children because of poverty in DC, and the small number of removals compared to investigations in DC (224 children placed in foster care compared to 3,767 investigations in FY 2024) suggests that CFSA does not remove children for poverty alone.

The training includes practice scenarios to help trainees distinguish between poverty (or “need” according to the training) and neglect. The participant must read the scenarios and decide whether they represent need (and presumably do not call for a hotline report) or neglect. After providing their own answer, trainees learn the “right answer” according to CFSA. One of the three “need” scenarios is particularly troubling and is reproduced here:

The 4-year-old child came into the center smelling of a strong smell and her nails are long and dirty. There is sticky stuff on her chest that is black underneath her shirt on her skin. The child often comes to the center unbathed. She was wearing shoes that were too small, but the dad was made aware, and he got her new shoes. The child comes in with an old pamper not changed, soaked or soiled. Sometimes she comes to school with the same clothes on from the day before or sometimes wears the same clothes for three days.

The child does not talk or engage with staff or peers. The mother has been observed yelling at the child and all she does is cry. The child covers her eyes but does not ask for anything.

The caller is aware that the family was recently evicted after the mother lost her full-time job and they are being supported on the income made from the father’s part-time employment. The family moves from the homes of family and friends because they refuse to go to a shelter. Caller suspects sometimes the family may sleep in the car.

The characterization of this scenario as “need” rather than neglect is troubling. The combination of factors that are cited suggest something more than poverty. The fact that the child “does not talk or engage with staff and peers,” and that the mother “has been observed yelling at the child and all she does is cry” suggest problems this beyond the realm of need. The refusal to go to a shelter under current conditions, when the District of Columbia guarantees shelter to families with children and has replaced its dilapidated shelter with modern new facilities, increases the likelihood that this is a case of neglect.

In the content that follows, a video tells mandatory reporters that although they are required by law to report suspected abuse or neglect, they should not make reports “solely based on assumptions, schemas, or biases.” It seems rather disrespectful to think that a doctor, nurse, teacher, social worker or volunteer would do this. Trainees are presented with the following questions to ask before making a report.

This is confusing indeed. Is the agency saying that mandatory reporters should not make a report “solely out of legal obligation,” even though they are legally required to report and could receive consequences for not doing so? Providing resources to assist the family is fine, but if there is abuse or neglect, does that exempt the reporter from the duty to report? It seems unlikely and unwise.

“Granted,” the presenter continues, “there are many times when you recognize your legal obligation, have the resources to support a family, and have checked your biases, and a report still needs to be made.” But the speaker goes on to state that “Each of us holds a responsibility to address disproportionality and disparity in the lives of Black and Brown families in the District.” She then invites us to “walk through how we can do this together,” by listening to two videos that are a total of five minutes in length. The first video, on “Mitigating Bias” counsels reporters to follow a three-step process consisting of of “deliberate,” “reflect,” and “educate,” with each step containing mutiple steps or suggestions. Mandatory reporters then learn about “cultural humility” and its three attributes: “lifelong learning and critical self-reflection,” “recognition and challenging of power imbalances,” and “institutional accountability.” And then training participants are told that “[u]ltimately, our goal is to ensure that children who are experiencing neglect in the District receive the support they need to thrive within their families. To do this effectively, we each have to ensure our implicit biases, whether personal or institutional, are not the foundation for calls to the CFSA hotline.” Apparently, no children in the District need to be removed from their families in order to thrive; even though the agency providing the training removed 244 children in the last Fiscal Year, as mentioned above.

To sum up, the implicit bias section of the training teaches child-serving professionals and volunteers that mandatory reporting harms Black children and that to avoid that harm, mandatory reporters must engage in a lengthy deliberative process before making a report. Mandatory reporters learn nothing of the costs of not making a report, which include the possible death of a child. They also learn nothing about the different risks facing Black children, who are three times more likely than White children to die of maltreatment.2 Instead, they are told that “we are delinquent in addressing the institutionalized racism and bias that pervades our family and wellbeing systems. This has been perpetuated by the misconception that we are nobly rescuing children from dangerous situations.” The clear implication is that making a report is much more risky than not making one.

A Case of Mixed Messages

After at least an hour of training on implicit bias, mandatory reporters finally arrive at the original training, which seems mainly unchanged. They learn about how to respond to a child’s disclosure of abuse or neglect. They learn they must report when they have reasonable cause to believe a child has been, or is in immediate danger of, being abused or neglected. They learn what and how to report. They learn that the identity of reporters is confidential and that failure to make a report can be punished by a fine of up to $1,000 or imprisonment for up to 180 days. They learn about different types of abuse and neglect, which children have higher risks of being maltreated, situations in which CFSA does not intervene, what happens when a report is made, and how child welfare services work in the District of Columbia. They are told to “[r]eport any suspicion of child abuse and neglect,” and that “every call matters!” A key instruction is buried in the section on how to distinguish discipline from child abuse. It says: “The good news is, as a mandated reporter, you do not need to know the details or all the facts before making a report. You just need to be suspicious of abuse/neglect and CFSA’s response, if it does respond, will do the rest.” (This should be moved to the top and emphasized, as it may have been in an earlier version of the training). In closing, trainees are told that:

Abuse and neglect place children at great risk of physical and emotional injuries and even death. As a mandated reporter, the District is expecting you to do the following:

  • Recognize the signs of child abuse and neglect.
  • When children have the courage to disclose abuse or neglect to you, take them seriously.
  • When you suspect or know of incidents of child abuse or neglect, call CFSA at (202) 671-SAFE.
  • Be responsible for calling the CFSA Hotline yourself, even if you have informed your supervisor.
  • If necessary, be helpful and available during the investigation.

The fundamental conflict between the training’s two messages is clear. According to the original training, abuse and neglect are dangerous to children and it is our responsibility to report. According to the implicit bias section, it is reporting that is dangerous and needs to be inhibited. Neglect is a serious type of maltreatment according to the original training but a “code word”d according to the implicit bias section. It is not really surprising that the implicit bias element of the training seems to be in opposition to the preexisting content. Perhaps those who inserted this content would prefer to eliminate mandatory reporting training entirely and are just trying to minimize it within the requirements of current law. But the half-measure of trying to train the implicit bias out of mandatory reporters creates a training that simply does not make sense.

In addition to this fundamental disconnect, the training exhibits many factual errors and is padded with extraneous content. The factual errors are discussed in an addendum to this post. The extraneous content includes discussions of the racial wealth gap and instructions for “self-reflection, in which trainees are instructed to define their values by a three-step process that is painstakingly described in a three-minute video. Perhaps the most striking extraneous content is a section that describes in detail six types of “mental models related to diversity, equity and inclusion.” One of the six types is “active opposers,” who are typically deeply rooted in their choice to be a strong opponent of DEI. These are the people whose minds cannot be changed and who are committed to disrupting the work of DEI.” One cannot help wondering how the current federal leadership would respond if they knew of this content, and being offended at the disrespect for the time of busy professionals or volunteers.

In summary, there is a fundamental conflict between the original message of CFSA’s mandatory reporter training and the message of the implicit bias unit that has been added to it. Unlike the original message stressing the duty and importance of reporting suspected abuse and neglect, the new message states that reporting damages children and families of color and should be avoided whenever possible. This fundamental conflict is not unique to the District and by necessity affects all mandatory reporter trainings that attempts to temper the duty to report by inserting considerations related to race and ethnicity.

Notes

  1. Nationally, Hispanic children are reported to CPS at about the same rate as White children. Raw data shows them slightly more likely to be substantiated and placed in foster care once reported. See Brett Drake et al., Racial/Ethnic Differences in Child Protective Services Reporting, Substantiation and Placement, With Comparison to Non-CPS Risks and Outcomes: 2005–2019. ↩︎
  2. From U.S. Children’s Bureau, Child Maltreatment 2023, page 59. States reported that 6,04 per 100,000 Black children were found to be victims of a child maltreatment fatality compared to 1.94 per 100,000 White children. These are deaths that have been confirmed as due to maltreatment by child protective services, medical examiners, or police, a process that may be affected by bias. ↩︎

Addendum: Factual Errors in CFSA’s Mandatory Reporter Training Implicit Bias Module

The implicit bias module in CFSA’s mandatory reporter training curtains numerous factual errors and omissions. Here are a few. 

  1. “National studies by the US Department of Health and Human Services reported that minority children and in particular black children are more likely to be in foster care than receive in-home services even when they have the same problems and characteristics as White children.” I asked the CFSA’s Communications Director for a citation and I found the exact language in one of the three references that were provided–a 2019 ABA brief entitled Race and Poverty Bias in the Child Welfare System: Strategies for Child Welfare Practitioners. A footnote referred readers to an essay by Dorothy Roberts for PBS’ Frontline program. That essay in turn attributes the same quote to “a national study of child protective services by the U.S. Department of Health and Human Services” with no citation. When consulted, ChatGPT references the outdated 1996 National Incidence Survey of Child Abuse and Neglect, which has been superseded and contradicted by the more sophisticated study published in 2010.
  2. “Rates of child abuse are not higher for children of color than white children. People of color do not treat their children worse than White families do. Racial disproportionality in CW is due to systemic racism, cultural misunderstandings, stereotypes, and biases that influence the decision to report alleged child report or neglect to CPS.” This is simply not true. First, we don’t have definitive evidence of child abuse rates as it occurs in secret, may not be reported, and investigations may not come up with the right results. But all the evidence we have indicates that Black families do abuse and neglect their children more than White families. This is likely due to the history of slavery and racism, which led to higher poverty and concentration in impoverished neighborhoods characterized by crime, substance abuse, unemployment, and limited community services, as well as a legacy of intergenerational trauma associated with these factors as well.
  3. “Although African American families tend to be assessed with lower risk than White families, they are more likely to have substantiated cases, have their children separated, or be provided family based safety services.” I could not find any resource on the internet that indicates that Black families tend to be assessed with lower risk than White families It is true that Black children tend to have more substantiated cases, have their children removed, or receive in-home services. But that is before controlling for family characteristics that affect risk. The only research article cited by CFSA actually reported that when they controlled for family risk factors, agency and geographic contexts, and caseworker characteristics, Black children were not at significantly higher risk of substantiation or removal.

Child Maltreatment 2023: A reduction in child maltreatment victims or a retrenchment of child protection?

“New Federal Report Demonstrates Reduction in Child Maltreatment Victims and Underscores Need for Continued Action,” the Administration on Children and Families (ACF) of the US Department of Health and Human Services proclaimed in releasing the latest annual report on the government response to child abuse and neglect. As in the past several years, ACF’s language suggested that child abuse and neglect are decreasing. But with states around the country changing law, policy and practice to reduce child welfare agencies’ footprint, the number of “child maltreatment victims” cited by ACF is likely more a reflection of policy and practice than an indicator of actual maltreatment.

The annual Child Maltreatment reports, produced by the Children’s Bureau of ACF, are based on data that states submit to the National Child Abuse and Neglect (NCANDS) data system. The new report, Child Maltreatment 2023 (CM2023), provides data for Federal Fiscal Year (FFY) 2023, which ended on September 30, 2024. The report documents the funnel-like operations child welfare protective services (CPS), which at each stage select only a fraction of the cases or children to proceed to the next stage. Exhibit S-2 summarizes the findings of the newest report. Child welfare agencies received 4.399 million “referrals” alleging maltreatment in Federal Fiscal Year (FFY) 2023 and “screened in” 2.1 million of them as “reports” for “disposition” through an investigation or alternative response. The investigation or assessment of those reports resulted in a total of 546,159 children determined to be victims of child abuse and neglect. (The final stage of the funnel involves services and is not covered in this post.) State and local policies and practice affect every stage of this process, as explained in detail below.

Referrals

NCANDS uses the term “referrals” to mean reports to child welfare agencies alleging maltreatment. Agencies received an estimated total of 4,399,000 referrals through their child abuse hotlines or central registries in FFY 2023, according to CM 2023. This is a very slight increase over the previous year and represents about 7.8 million children, or 60 per 1,000 children. As shown in Exhibit S-1, the total number of referrals has been increasing since 2020, when the COVID-19 pandemic resulted in a large drop in referrals. In FFY 2023, the number of referrals surpassed the pre-Covid 2019 total for the first time as the lingering effects of the pandemic, which acted to suppress reports, finally dissipated.

As in past years, the state-by-state tables document large differences in referral rates, from 19.9 per 1,000 children in Hawaii to 171.2 per 1,000 in Vermont–also the top and bottom states in 2022. These differences reflect not just different numbers of calls to child abuse hotlines but also state policy and practice. Vermont reports that it counts all calls to the hotline as referrals, while other states do not do so. For example, Connecticut reported in CM2022 that none of the calls that are assigned to alternative response are included in NCANDS, resulting in a far lower number of calls than the number they actually receive. Referral rates may also affected by a state’s policy on who is required to report and what must be reported. Such policies are disseminated to mandatory reporters through training and agency communications. New York reported implementing in FFY 2023 a new training for mandated reporters that helps them identify when concerns do not rise to a level legally requiring a report be made.” The training also focuses on implicit bias in order to “reduce the number of SCR reports influenced by bias about race or poverty.” The number of referrals in New York dropped by a very small fraction in FFY 2023. Missouri reported in CM2022 that it stopped accepting educational neglect referrals in 2021 as the COVID emergency ended, resulting in a decreased number of referrals received the following year.

Reports

Once a state agency receives a referral, it will be screened in or out by agency staff. In general, referrals are screened out if they are deemed not to contain an allegation of child abuse or neglect, contain too little information to act on, are more appropriately assigned to another agency, or for some other reason do not fall under the mandate of the child welfare agency. In the language used by NCANDS, a referral becomes a “report” once it is screened in. “Reports” are assigned for an investigation or “alternative response.” State data indicates that child welfare agencies screened in 2.1 million referrals, about 47.5 percent of referrals for an investigation or alternative response, and “screened out” the other 52.5 percent as not warranting a response. The number of screened-in referrals was 11.6 percent less than in FFY 2019 and slightly less than in FFY 2022.

A total of 42 states reported a decrease in the number of screened-in referrals in FFY 2023. In their commentaries, several of these states described policy and practice changes that led to their screening out more referrals. Ohio reported that two of its major metropolitan counties, which had significantly higher screen-in rates than the rest of the state, adjusted their screening procedures to be consistent with the rest of the state, resulting in a lower screen-in rate in those counties and statewide. Mississippi reported an increasing the amount of screening it conducted, especially when a report was received regarding a case that was already open; perhaps this is why its screen-in rate dropped from 41.3 to 36.5 per 1,000 children. Nebraska reported dropping a policy to require accepting all referrals from a medical professional involving children under six. Some states explicitly reported that their screening changes were adopted in order to decrease the number of screened in referrals. Kentucky reported adopting a new SDM® screening tool designed to decrease the number of referrals that are “incorrectly accepted for investigation.” Nevada reported a decrease in screened-in referrals because it established new intake processes to ensure that referrals are screened out when they do not meet criteria for acceptance.

“Victims”

The next phase in the funnel of CPS is the determination of whether abuse or neglect has occurred. At this stage, the level of analysis shifts from the case to the child, and the number of “victims” is the result. In NCANDS, a “victim” is defined as “a child for whom the state determined at least one maltreatment was substantiated or indicated1; and a disposition of substantiated or indicated was assigned for a child in a report.” “Victims” include children who died of abuse or neglect if the maltreatment was verified. Some children receive an “alternative response”2 instead of an investigation; these children are not counted as victims. According to CM2023, states reported a total of 546,159 victims of child abuse and neglect in FY 2023, producing a “victimization rate” of 7.4 per 1,000 children.

The number of “victims” reported by states according to the NCANDS definition does not represent the true number of children who experienced abuse or neglect, which is unknown. Many cases of child maltreatment go unreported. Children assigned to alternative response are not found to be victims unless their case is reassigned to the investigation track. And finally, substantiation may not be an accurate reflection of whether maltreatment occurred. Making a determination of whether maltreatment occurred is difficult. Adults and children do not always tell the truth, the youngest children are nonverbal or not sufficiently articulate to answer the relevant questions. So it is not surprising that research suggests that substantiation decisions are inaccurate3 and a report to the hotline predicts future maltreatment reports and developmental outcomes almost as well as a substantiated report.4 

State “victimization rates” range from a low of 1.5 per 1,000 children in New Jersey to a high of 16.2 in Massachusetts. It is unlikely that Massachusetts has more than ten times more child abuse and neglect victims than New Jersey–a not dissimilar Northeastern state. Policy and practice must be at play, including different definitions of abuse or neglect, levels of evidence required to confirm maltreatment, and policies regarding the use of alternative response or “Plans of Safe Care”5 to divert children from investigation, among other factors. Maine reported the second highest “victimization rate.” The Maine Monitor asked experts why this might be so. Among the reasons suggested were the definition of maltreatment; Maine allows abuse or neglect to be substantiated when there is a “threat” of maltreatment, even if there is no finding that it already occurred. In view of the deceptiveness of these terms, I have put the terms “victims” and “victimization rates,” when not preceded by the word “reported,” in quotation marks in this post.

The national “victimization rate” of 7.4 per 1,000 children, is a small decrease from 7.7 in FFY 2022 and the total number of reported “victims” was 19.3 percent less than the total reported in FFY 2019. This “victimization rate” has declined every year since FFY 2018. Of course, this decline is in part a result of the decline in the number of screened-in referrals that was discussed above. Any referral that is screened out is one less reported “victim,” even though some percentage of the screened-out referrals almost certainly reflected actual incidents of maltreatment.6 It is also clear that changes in policy and practice have contributed to the decline in the number of “victims” reported by states, as described below.

Policy and practice changes affecting “victimization” numbers

The change in the number of “victims” between FFY 2019 and FFY 2023 ranged from a 52 percent decrease in North Dakota to a 32 percent increase in Nevada, suggesting that these changes may reflect policy and practice more than actual trends in abuse and neglect. And indeed, two of the largest states made it more difficult to substantiate maltreatment in FFY 2022, and both found a decline in the number of maltreatment victims. In Texas, the legislature narrowed the definition of neglect, requiring the existence of both “blatant disregard” for the consequences of a parent’s action or inaction and either a “resulting harm or immediate danger.” Perhaps this helps account for the drop in the number of reported victims from 65,253 in FFY 2021 to 54,207 in FFY 2022. But the number of victims actually rose very slightly in FFY 2023. Perhaps the new definition had been assimilated into practice and was no longer resulting in a decrease in substantiations. In New York, the level of evidence required to substantiate an allegation of abuse or neglect was changed from “some credible evidence” to “a fair preponderance of the evidence” in FFY 2022. The number of victims found in New York dropped from 56,760 in FFY 2021 in to 50,056 in FFY 2022, which the Office of Child and Family Services attributed in its CM 2022 commentary to that change in evidentiary standards. The number of reported victims fell further to 46,431 in FY2023; perhaps the changed evidentiary standards were continuing to take hold or other state policies affecting other parts of the funnel–such as the attempt to rein in mandatory reporting–were contributing factors. The agency did not address this issue in its 2023 commentary.

A few states did mention in their CM 2023 commentary changes in policy or practice that might have contributed to changes in the number of “victims” in FFY 2023. North Dakota attributes a decrease partly to a change in state statute and policy which allows protective services to be provided when impending danger is identified, even without a substantiation. The agency appears to believe that workers are not substantiating as many reports now that they do not need a substantiation to provide services. Arkansas attributed a decrease in victims to the adoption of a new assessment tool that may have contributed to the routing of more reports to the differential response pathway. Kentucky reported that the adoption of new “Standards of Practice” may have contributed to the increase in the number of “victims” reported in FFY 2023.

Fatalities

Based on reports from 49 states (all but Massachusetts), the District of Columbia, and Puerto Rico, CM2023 estimated a national maltreatment fatality rate of 2.73 per 100,000 children. That rate was then applied to the child population of all 52 jurisdictions and rounded to the nearest 10 to provide a national estimate of 2,000. But experts agree that the annual estimates of child fatalities from NCANDS significantly undercount the true number of deaths that are due to child maltreatment. I discussed this in detail in A Jumble of Standards: How State and Federal Authorities Have Underestimated Child Maltreatment Fatalities.

The annual fatality estimates presented in the report increased by 12.3 percent between FFY 2019 and FFY 2022 and then fell slightly from 2,050 to 2,000 in FFY 2023, a fact that ACF mentioned in its press release. Such a small reduction of less than three percent over the previous year cannot be statistically distinguished from random fluctuation, especially because it is based on much-smaller numbers from the individual states. State commentaries illustrate the randomness of these year-to-year changes. In CM 2022, two individual states explained year-to-year jumps in fatalities by explaining that many children in one family died and that a large group of fatalities that occurred the previous year were reported in the current year. But even aside from statistical fluctuations, there are many reasons one cannot rely on year-to-year changes. These include the timing of reports and changes in policy and practice.

Timing

According to CM 2023 (and previous reports), “The child fatality count in this report reflects the federal fiscal year (FFY) in which the deaths are determined as due to maltreatment. The year in which a determination is made may be different from the year in which the child died.” The authors go on to explain that it may take more than a year to find out about a fatality, gather the evidence (such as autopsy results and police investigations) to determine whether it was due to maltreatment, and then make the determination. Alabama, for example, explained in its commentary that the deaths reported in a given year may have occurred up to five years before.

To add to the uncertainty around timing, the writers of CM 2023 are not exactly correct when they state that all states report on the fatalities determined in the reporting year. In their annual submissions to NCANDS, several states add fatalities for the previous year, implying that their practice is to report on fatalities that occurred in a specific time period, not those determined in the applicable year. Four states revised their number of 2022 fatalities in their submissions to CM2023. This suggests that their 2023 reports are in turn incomplete and will be revised in succeeding years. California, for example, explained that:

Calendar Year (CY) 2022 is the most recent validated annual data and is therefore reported for FFY 2023. It is recognized that counties will continue to determine causes of fatalities to be the result of abuse and/or neglect that occurred in prior years. Therefore, the number reflected in this report is a point in time number for CY 2022 as of December 2023 and may change if additional fatalities that occurred in CY 2022 are later determined to be the result of abuse and/or neglect.

So California is reporting (for CM 2023) a truncated count of child maltreatment deaths for Calendar Year 2022. But it did add 12 fatalities to the count of fatalities that it reported for FFY 2022, raising its total from 164 to 176. California reported 150 fatalities for FY2023; one can assume that additional deaths will be reported in the next report. The four states together added 56 deaths for FFY 2023. Arizona’s total increased from 14 to 39, Maine from three to 10 and Virginia from 39 to 51. .

Policy and Practice: Fatality Definition and Measurement

In addition to timing issues, year-to-year changes in fatality counts can reflect changes in how states screen or define child maltreatment fatalities. In previous issues of CM, states have reported on improvements in their collection of fatality information. Over time, some states have eliminated obsolete practices in screening and information collection. West Virginia reported in its 2016 commentary that it had begun investigating child fatalities in cases where there were no other children in the home. North Carolina ended its restrictive policy of reporting only fatalities determined by a chief medical examiner to be homicide, and it also began efforts to incorporate vital statistics and criminal justice data. 

During FY 2023, some states reported changes that may have resulted in a reduced number of child fatalities reported. 

  • Texas did not submit commentary for FFY 2023. But as reported above, it changed its screening policy so that reports involving a child fatality but include no explicit concern for abuse and neglect are not investigated if the reporter and other pertinent sources had no concern for abuse or neglect. DFPS reports that the number of child fatalities it investigated decreased from 997 in FY2022 to 690 in FY2023 (a 31 percent decrease) due to this new screening policy. And the number of child maltreatment fatalities fell from 182 to 164. But with a drastic drop in foster care placements in Texas, there is reason to fear that maltreatment fatalities increased rather than decreased. If that is the case, this change screening policy may have resulted in the failure to investigate and confirm actual maltreatment deaths.. 
  • The Illinois Division of Child Protection reported that it added a new administrative review process for sleep-related deaths. A senior administrator reviews the investigation to ensure that death included evidence of “blatant disregard.” DCF links this new policy with a decrease of 24.6% in reported child fatalities in FFY 2023.

Other states reported changes that might result in an increased number of child fatalities reported. Maryland attributed an increase in reported fatalities to a policy change requiring local agencies to screen in sleep-related fatalities as part of its prevention effort. Alaska reported a change that may affect fatality counts in future years: in December 2023 the agency dropped its practice of screening out cases where no surviving children remained in the home; from now on the agency will be making maltreatment findings even when there are no surviving children. 

It is regrettable that most state commentaries do not include explanations for the changes in their reported number of referrals, reports, and victims. Worse, several states do not even submit commentaries in time to be included in each year’s report. In CM023, commentaries are missing for Arizona, Hawaii, Kansas, New Hampshire, North Carolina, Oregon, Texas, and West Virginia. Given the importance of the state commentaries for understanding the data they submit, the preparers of the CM reports should reach out to agency personnel in states that have not submitted commentaries by a certain date or have not answered the important questions and ask the questions directly directly. This information is too important to be left out.

It is unfortunate that ACF continues to misuse term “victimization” and “victimization rate” to suggest that child maltreatment (including fatalities) is declining, particularly in its press release and executive summary, which do not provide any explanation of the true meaning of the terms. The deceptive language is not a surprise given the previous Administration’s desire to take credit for ostensible and support the prevailing narrative regarding the need for a reduction in interventions with abusive and neglectful families. One does not have to be a statistician or data scientist to realize that we will never get an accurate measure of child maltreatment because so much of it occurs behind closed doors. Finding fewer victims is one way to reduce CPS intervention in the lives of vulnerable children–and to deny that the reductions are harmful. Sadly, this report will be used as evidence to support policies that continue to roll back protections for our most vulnerable children.

Notes

  1. Substantated is defined as “supported or founded by state law or policy.” “Indicated” is a less commonly used term meaning a “disposition that concludes maltreatment could not be substantiated understate law or policy, but there is a reason to suspect that at least one child may have been maltreated or is at risk of maltreatment.” ↩︎
  2. An “alternative response” includes an assessment and referral to appropriate services if the parent agrees to participate. There is no determination on whether abuse or neglect occurred and no child removal unless the case is transferred to the investigative track. ↩︎
  3. Theodore Cross and Cecilia Casanueva, “Caseworker Judgments and Substantiation,” Child Maltreatment, 14, 1 (2009): 38-52; Desmond K. Runyan et al, “Describing Maltreatment: Do child protective services reports and research definitions agree?” Child Abuse and Neglect 29 (2005): 461-477; Brett Drake, “Unraveling ‘Unsubstantiated,’” Child Maltreatment, August 1996; and Amy M. Smith Slep and Richard E. Heyman, “Creating and Field-Testing Child Maltreatment Definitions: Improving the Reliability of Substantiation Determinations,” Child Maltreatment, 11, 3 (August 2006): 217-236. ↩︎
  4. Brett Drake, Melissa Jonson-Reid, Ineke Wy and Silke Chung, “Substantiation and Recidivism,” Child Maltreatment 8,4 (2003): 248-260; Jon M. Hussey et al., “Defining maltreatment according to substantiation: Distinction without a difference?” Child Abuse and Neglect 29 (2005): 479-492; Patricia L. Kohl, Melissa Jonson-Reid, and Brett Drake, “Time to Leave Substantiation Behind: Findings from a National Probability Study,” Child Maltreatment, 14 (2009), 17-26; Jeffrey Leiter, Kristen A. Myers, and Matthew T. Zingraff, “Substantiated and unsubstantiated cases of child maltreatment: do their consequences differ?” Social Work Research 18 (1994): 67-82; and Diana J. English et al, “Causes and Consequences of the Substantiation Decision in Washington State Child Protective Services,” Children and Youth Services Review, 24, 11 (2002): 817-851. ↩︎
  5. Plans of Safe Care are voluntary plans offered to the families of substance-exposed infants under the Comprehensive Addiction and Recovery Act (CARA). ↩︎
  6. We. know this from child fatality reviews that many children who die have been the subject of previous referrals, which were not substantiated but later found in fatality investigations to have been correct. See discussions of the deaths of Thomas Valva and Gavin Peterson, for example. ↩︎

A Fatal Collision: The Opioid Epidemic and the Dismantling of Child Protection Services in Washington State

by Marie Cohen

“B.B.” was born in 2022 and died of fentanyl poisoning in March 2023. During the ten years before B.B.’s death, DCYF had received 30 reports on B.B.’s family (many before B.B. was born) for issues including use of heroin, marijuana and alcohol in the home; lack of supervision of the children; domestic violence; an unsafe caregiver living with the family; an unsafe and unclean living environment unsecured guns in the home “out-of-control” behaviors by B.B.’s older siblings at school, with the mother described as “out-of-it” and unresponsive to school concerns; concerns about the children’s hygiene; and the mother driving under the influence of marijuana. An in-home services case that had been open since January 2023 was closed days before B.B.’s death. 

On August 24, 2024, the Washington Department of Children, Youth and Families (DCYF) proudly announced in a press statement that it had reduced the number of children in out-of-home care by nearly half since 2018. Specifically, the number of children in foster care had fallen from 9,171 in 2018 to 4,971 as of August 14, 2024. “Outcomes like this demonstrate our agency’s commitment to keeping families together and children and youth safe,” DCYF Secretary Ross Hunter said. “Although the number of reports we are receiving remain [sic] consistent, we are seeing fewer children and youth in out-of-home care as families are being referred to support services rather than having children removed from their homes. Indeed, “safely reduce the number of children and youth in out of home care by half” (without a baseline date from which this can be measured) is one of DCYF’s six strategic priorities. But treating the decline in foster care (the direct result of government actions) as a desirable outcome in itself can contribute to a disregard of actual child welfare outcomes like safety and permanency.

How did DCYF reduce foster care by nearly 50 percent?

How did DCYF manage to slash its foster care rolls so radically in such a short time? Without providing specifics, the press release cites DCYF’s implementation of the Family First Prevention Services Act (FFPSA) and its emphasis on “supporting and collaborating with families by providing access to services and programs.” A DCYF spokesperson told the Seattle Times that the department was using services to avoid removing children or to reunite families sooner, citing efforts to connect parents to substance use or mental health treatment programs, bring a social worker into the home to “problem solve,” or “offer practical items, like diapers, car seats and beds.”

Apparently not satisfied with the changes implemented by DCYF, the Washington legislature in 2021 passed the Keeping Families Together Act (KFTA, also known as HB 1227), which took effect on July 1, 2023. Among other provisions, KFTA increased the standard for the court to order removal of a child from the home, which previously required the agency to demonstrate that “reasonable grounds that the child’s “health safety or welfare will be seriously endangered if not taken into custody and that at least one of the grounds set forth demonstrates a risk of imminent harm to the child.” As amended by KFTA, the law now requires the agency to demonstrate “that removal is necessary to prevent imminent physical harm to the child due to child abuse or neglect.” The petition for removal is required to contain “a clear and specific statement as to the harm that will occur if the child remains in the care of the parent, guardian or custodian, and the facts that support the conclusion.” Moreover, the court must consider whether participation by the parents or guardians in “any prevention services” would eliminate the need for removal. If so, they must ask the parent whether they are willing to participate in such services and shall place the child with the parent if the parent agrees.

On a page dedicated to KFTA implementation, DCYF explains that it has implemented the law by adopting new policies and procedures to determine whether to remove a child and by training and supporting staff to implement the new procedures and determine whether there is an imminent risk of serious harm to the child. DCYF reports that internal reviews show that staff are “taking additional steps to prevent removal of a child and to support a safety plan for the family.” 

Shortly before KFTA took effect, DCYF, along with the Department of Health, the Health Care Authority, and the Washington State Hospital Association issued new guidelines to birthing hospitals and mandatory reporters. These guidelines stated that infants born substance exposed, but for whom there are no other safety concerns, can receive “voluntary wrap-around services from a community organization” without being reported to CPS. These voluntary services are being provided through federally-mandated “Plans of Safe Care (POSC).” Healthcare providers identifying a substance-exposed infant are instructed to access an online portal where they are directed  to call DCYF if safety concerns are identified and to complete a POSC referral if not.

DCYF has been issuing quarterly data updates to assess the impacts of the KFTA. According to the most recent (October 2024) update, the law is having the intended impact of further reducing removals to foster care. DCYF reports a 16 percent decrease in the number of children removed in the July through September quarter of 2024 compared to the same quarter of 2022, before passage of KFTA. However, comparing foster entries for all ages in July through September 2024 to those in the same quarter of the previous year, the data indicate that foster care entries actually increased! Will this be the beginning of the end of the foster care reductions? That remains to be seen.

A longer-term view raises questions about the difference KFTA made, compared to the previous and ongoing efforts by DCYF to reduce foster care placements.  Entries into foster care in Washington have decreased annually from 2017 to 2024, as shown in the chart below. The rate of decrease remained about the same between 2019 and 2024, while KFTA was not implemented until July 2023. Perhaps more children would have entered care if not for KFTA, but there is no way to assess the impact of KFTA as compared with DCYF’s ongoing effort to reduce removals. 

Source: DCYF, Child Welfare Agency Performance Dashboard, Children Entering Care in SFY, https://dcyf.wa.gov/practice/oiaa/agency-performance/reduce-out-of-home-care/cw-dashboard

The reduction in foster care placements was supposed to be accompanied (and made possible) by an increase in in-home services (which DCYF calls Family Voluntary Services or FVS), and DCYF reports that the number of cases receiving FVS increased by nine percent from 1,809 in SFY2023 to 1,994 in SFY2024. This increase in FVS cases cannot be compared to the 17-percent decrease in children placed in foster care over the same period, as the unit of analysis is different (families rather than children). But the key question is the nature and intensity of these services and whether they really kept the children safe. 

The cost of foster care reductions

The purpose of foster care is to keep children safe when they cannot be protected at home. So the essential question is whether the reduction in foster care placements has occurred without any cost to children. Trends in child fatalities and “near fatalities”1 due to child abuse or neglect can provide a clue. These deaths and serious injuries are the tip of the iceberg of abuse and neglect. For each child who dies or is seriously injured, there are many more that are living in fear, pain, or hunger, and incurring lifelong cognitive, emotional, and physical damage. There are troubling signs of an increase in child fatalities and near fatalities over the past several years. In its most recent quarterly update, DCYF reports on the number of “critical events” or child fatalities and near fatalities that met its criteria for receiving an “executive review.” These include the deaths of any minor that had been in DCYF custody or received services within a year of the death that were suspected to be caused by child abuse or neglect.2 They also include near fatality cases in which the child has been in the care of or received services from DCYF within three months preceding the near fatality or was the subject of an investigation for possible abuse or neglect. DCYF reports that the number critical events it reviewed increased from 23 in 2019 to 51 in 2023 and projects that it will increase to 61 in 2024.3

Source: DCYF, Keeping Families Together Act Quarterly Date Update, October 2024, https://dcyf.wa.gov/sites/default/files/pdf/DataUpdate_HB1227_October2024.pdf


The increase in critical events reflects, in part, the growing opioid crisis in Washington, as well as decisions Washington has made regarding how it intervenes to protect children.  Opioid related emergencies have “dramatically increased for the entire population (adults and children) in Washington,” and children have not been immune. Fentanyl is particularly dangerous to young children because it takes only a tiny amount to kill a baby or toddler, who can mistake the pills for candy or put straws or foil meant for smoking the drug in their mouths. The number of fatalities and near fatalities reviewed by DCYF that involved fentanyl climbed from four in 2019 to a projected 35 in 2024. Since 2018, Washington’s Office of the Family and Children’s Ombuds (has observed an annual increase in child fatalities and near fatalities involving accidental ingestions and overdoses. Fifty-seven (or 85 percent) of the 67 incidents examined in 2023 involved fentanyl. Over half of these incidents involved children under three years old and a shocking 14 out of the 85 infants were 12 months old or less.  As Dee Wilson and Toni Sebastian point out, the limited mobility and motor skills of infants suggests that some of these infants may have been given a small amount of fentanyl as a means of sedation.

The Washington Legislature was concerned enough about the possibility that KFTA is contributing to an increase in child fatalities and near fatalities in the context of the fentanyl epidemic that it passed a new law (SB 6109) in 2024. The law provides that a court must give “great weight” to the “lethality of high-potency synthetic opioids.….in determining whether removal is necessary to prevent imminent physical harm to the child due to child abuse or neglect.” However, it appears that there is confusion about exactly what that means.

Has DCYF given up on protecting children?

“We know that supporting and collaborating with families by providing access to services and programs increases their number of protective factors, leading to better outcomes,” said DCYF Assistant Secretary Natalie Green. “Giving families the tools they need to thrive and safely parent means more children and youth remain safely at home.”

DCYF, Washington Reduces the Number of Children in Out-Of-Home Care by Nearly Half, August 14, 2024.

But the work of DCYF’s own analysts, in their quarterly KFTA updates, raises doubts about whether DCYF is adequately performing its child protection function. These updates  acknowledge that the agency is not removing as many children with a high risk of future encounters with child welfare (in other words, those who have a high risk of being harmed). And they also report that the department has seen “an increasing percentage of moderately high to high risk cases being re-referred to CPS within 90 days of the risk assessment. DCYF also reports that the overlap between KFTA and Plan of Safe Care (POSC)  is resulting in fewer screened-in intakes involving substance-exposed newborns because these infants are now being referred to voluntary services under POSC.

There has been a chorus of voices alleging that DCYF is abdicating its child protection responsibilities. One foster parent told the Seattle Times that “she and other foster parents are finding children who now come into their care are in worse shape than they used to be, with more serious mental health conditions or greater exposure to lethal drugs like fentanyl.” She contends they’ve been left too long in unsafe conditions because of the heightened legal standard for removal. In The Erosion of Child Protection in Washington State, Toni Sebastian and Dee Wilson have cited the weakness of the management of Family Voluntary Services, which is often employed as an alternative to foster care. 

A survey of executive reviews of 2023 and 2024 child maltreatment child fatalities with DCYF involvement within a year provided examples of problems with screening, investigations, and case management, including the following:

  • Hotline issues. Reviews documented multiple intakes screened out on the same family even when the family had been the subject of multiple calls. The reviews also suggest that too many cases may be assigned to the Family Assessment Response (FAR) pathway, an alternative to a traditional investigation designed for lower-risk cases. In FAR cases, a social worker assesses the family and refers it to voluntary services. There is no finding about whether maltreatment has occurred and no child removal unless the case is transferred to the investigative track.
  • Premature closure of FAR cases. Reviewers noted instances in which FAR cases were closed after parents failed to cooperate, without caseworkers considering a transfer to the investigative track or before determining that the parent had followed through with services.
  • Assessment failures: Reviewers noted multiple failures to adequately assess parents for domestic violence, mental health, and substance abuse; failures to contact collaterals (relatives and friends) and instead relying on parental self-reports; lack of recognition of chronic maltreatment; ignoring evidence of past problems if not included in the current allegation; and failing to anticipate future behavior based on historical patterns.4
  • Inadequate understanding of substance abuse: Reviewers noted the failure to conduct a full assessment of substance abuse including history, behavioral observations, and collateral contacts; disregarding the unique danger to children posed by fentanyl; downplaying the significance of marijuana use, particularly as an indicator of relapse from harder drugs; and disregarding alcohol abuse because it is legal.
  • Failure to obtain information from treatment and service providers. The failure to communicate with service providers about clients’ participation in services like drug treatment and relying on clients’ self-reports was noted by more than one review team. Sometimes the providers refused to cooperate.  Staff told the team reviewing one case about a substance abuse treatment provider that routinely refuses to cooperate, even when parents sign release forms, and routinely tells clients not to cooperate with DCYF.
  • Lack of subject matter expertise. Reviewers pointed to the lack of deep knowledge about domestic violence, substance use disorder, and mental health among staff doing investigations, assessments, and case management and the need to provide access to subject matter experts when needed.
  • Failure to remove a child despite safety threats. The team reviewing the case of a four-year-old who died after ingesting fentanyl reported that there were at least two different times where an active safety threat was present that would have justified filing a petition in court to place the child in foster care. However, the staff believed, based on past experience, that the court would have denied the petition and therefore did not file. 
  • Delayed Reunifications: “P.L,.” a toddler allegedly beaten to death by his mother, was in foster care for over three years but his mother’s rights were never terminated. He was on a trial return to his mother for just over five months when he was found dead with bruises and burns all over his body. 

Staff shortages and high turnover were mentioned as contributing to the observed deficiencies in case practice in almost every fatality review. In B.B.’s case, the reviewers noted that the office had been functioning with a 50 percent vacancy rate for the last several years, stating that such a vacancy rate leads to high turnover, high caseloads, caseworkers with little experience, and supervisors forced to carry cases rather than support their caseworkers. Even caseloads that comply with state standards may be too high. The standard of 20 families per caseworker in FVS was noted to be unmanageable by one review panel, which noted that FVS cases are often discussed as high risk cases and require multiple contacts per month with family members, services providers, and safety plan participants. As Dee Wilson and Toni Sebastian put it,  “[b]etting young endangered children’s lives on in-home safety plans developed and implemented by inexperienced and overwhelmed caseworkers is reckless, ill-advised public policy.”

Conclusions and Recommendations

Treating the decline in foster care as a desirable outcome in itself, as Washington and other states have done, is both disingenuous and dangerous. Any government can slash the foster care rolls reducing or ending child removals, as many “child welfare abolitionists” recommend. The central purpose of child welfare services, including foster care, is to protect children from child abuse and neglect. A reduction in foster care placements that results in the failure to protect children is no kind of success. 

DCYF told King5 that “the increase in child fatalities and near fatalities in Washington is not being driven by the change in removal standards under House Bill 1227 or the reduction in the number of children in foster care. It is being driven by the increased availability of a highly addictive and hazardous drug and a lack of substance use disorder treatment in our communities.” But whether the agency’s policy or the drug epidemic is more at fault is not the right question. It is DCYF’s job to protect children given the circumstances that exist, including the drug epidemic and the lack of sufficient treatment, keeping in mind that treatment often does not work the first, second, third or subsequent times. 

What can be done? DCYF needs to address the workforce crisis, which will probably require increasing pay and improving working conditions, or even possibly relaxing requirements for employment as a caseworker in investigations, assessment, and FVS. DCYF should consider policy and practice changes such as reducing the FVS caseload cap from 20 cases per worker; Instituting a chronic neglect unit, with expert caseworkers and even lower caseloads, for chronic cases; finding a way to limit the use of FAR to cases that are truly low-risk; and promoting the use of dependency petitions for court supervision when children remain in the home, as suggested by two fatality review committees.5 DCYF should request and the legislature should fund a variety of ancillary services for families, starting with therapeutic childcare for all preschool aged children with FVS cases as well as those who have been reunited with their parents. Such childcare would give parents a break and parenting support, keep children safe for a large part of the day, and ensure another set of eyes on the child, among other benefits. Also needed are more residential drug treatment centers where parents can live with their children. 

Finally, more transparency is needed so that legislators, advocates and the public have access to the findings of DCYF’s executive review teams.  Washington deserves credit for sharing its executive child fatality reviews. But there is no reason that the DCYF should not share its near-fatality reviews as well. We know something about how DCYF failed B.B. and the other children who died. But the public needs access to the reviews of those children who narrowly escaped death as well as those who did not. It is only through such transparency that the public can see the actual impact of all the self-congratulatory proclamations about “safely reducing the number of children in out-of-home care.”

Notes

  1. A “near fatality” is defined by state law as “an act that, as certified by a physician, places the child in serious or critical condition.”
    ↩︎
  2. DCYF relies on the Office of the Family and Children’s Ombuds (OFCO) to determine whether the fatality appears to have been caused by abuse or neglect, therefore requiring DCYF to conduct a review.
    ↩︎
  3. Data collected by OFCO are more confusing. OFCO reviews all fatalities and near fatalities in which the child’s family was involved in Washington’s child welfare system within 12 months of the fatality. There number of near-fatalities reviewed by OCFO increased annually from 21 in 2018 to 70 in 2023, according to its most recent annual report on Child Fatalities and Near Fatalities in Washington State. But fatalities reviewed by OFCO did not show the same pattern. They reached a peak of 87 in 2018 and fell sharply in 2019, then rose yearly until they reached 85 in 2022 and then dropped to 79 in 2023. Nevertheless, adding fatalities and near fatalities together shows an alarming increase in critical incidents from 108 in 2018 to 149 in 2023.
    ↩︎
  4. For example, in the case of “R.W.,” a child who died at age four after ingesting fentanyl, an investigation was closed because the children were staying with relatives, despite the mother’s history of repeatedly removing the children from relatives with whom she had left them. A month later the child was found dead at a motel in the custody of the parents. 
    ↩︎
  5. See https://dcyf.wa.gov/sites/default/files/pdf/reports/mk-cfr-final-redacted.pdf and https://dcyf.wa.gov/sites/default/files/pdf/reports/ecfr-os-24.pdf ↩︎

Seven children and all she needed was a van: large families and the blindness of the child welfare establishment

By Marie Cohen

Working in the field of child protection, it is sometimes hard to avoid the feeling of living in some type of alternate reality, where bizarre statements are accepted and obvious questions go unasked. A case in point was a hearing on the Family First Prevention Services Act (FFPSA) that took place on May 22, 2024 under the leadership of Senator Ron Wyden of Oregon, one of the original sponsors of the FFPSA. This hearing and the fundamental misunderstanding about FFPSA that it uncovered has already been discussed in a previous post on this blog. But today’s post focuses on one particularly jarring vignette–the story of a mother, her seven children, and a van–and what it means about how child welfare policy is made and discussed today.

David Reed, the Deputy Director of Child Welfare Services in Indiana, introduced the story of this family in his testimony. Reed was trying to illustrate how the provision of economic and concrete supports can make children safer–an application of the theory that much of what is called child neglect is actually only poverty, which has been questioned previously in this blog. Reed explained the Indiana Family Preservation Services (IFPS) model requires that “concrete support be provided to families when not doing so would result in children having to come into foster care.” He gave an example of how this worked in a specific case:

DCS was called about a neglect allegation involving a single mother who had seven children, all of whom were school-aged or younger. This mother worked but struggled financially. DCS was called because she was unable to take all seven of her children in rural Indiana to school and/or daycare at the same time so that she could go to work. She took them in “shifts” leaving some children home alone. This resulted in the neglect allegation and the opening of a DCS case. The provider delivering INFPS to this family recognized what this mom really needed to ensure that her children could all be transported together—a bigger vehicle—and used the concrete supports built into INFPS to purchase her a used minivan. That $3,000 van “solved’ the reason for DCS’ involvement and very likely prevented seven children from coming into foster care, which is exactly what most likely would have happened prior to INFPS.

There is something strange about this example. Is it really possible that this mother needed nothing but a van in order to parent her children adequately? The rarity of seven-child families and the association of such large families with family dysfunction, including abuse and neglect, raise doubts about this mother’s appropriateness as a poster child for the provision of material supports as a solution to child maltreatment.

The rarity of a seven-child family

Seven children is such unusual number that it raises questions about why this mother had so many children and how she managed to care for them. The National Center for Health Statistics has estimated that 28 percent of women aged 40-49 (near the end of their childbearing years) who had given birth to children had only one child, 40 percent had two children, 27 percent had three children, and only 13 percent had four or more children.1 It is likely that the proportion with seven or more children is a tiny fraction of that 13 percent–and that is a percentage of women aged 40-48. We don’t know this woman’s age, but the younger she is, the more of an outlier she is, and the more questions this story should raise about her needs.

The association of extremely large families with dysfunction

A family of seven is not just unusual; it is often a marker for family dysfunction and pathology. Despite the rarity of families with five or more children, anyone who has worked in child welfare or juvenile justice knows that children from extra-large families are overrepresented among their clients. These families frequently consist of mothers with children by multiple fathers, with both parents often suffering from mental illness and/or drug abuse, and domestic violence is commonly present. These mothers are often too disorganized or too influenced by drugs and alcohol to use contraception; moreover, they may consciously or unconsciously get pregnant to hold onto a new man. In its Study of the Root Causes of Juvenile Justice System Involvement,” the District of Columbia’s Criminal Justice Coordinating Council interviewed youth service providers with first-hand experience working with justice-involved and at-risk youth. Quotes from these interviews include:


A social service provider described one type of youth they see becoming justice involved, “You have those that the family may have multiple children and if mom has 13 kids and I’m the oldest and mom is high or dad is not involved, then they need to eat because they are looking at me. So, I need to be able to figure out how to get the next meal.

One interviewee who works with the juvenile justice system describedthe youth as coming from families with “Four, five, six, seven children” and growing up where there are “Three kids in a room, total bedlam all the time,” and as a result “They raise each other in the streets … because … a lot of times hanging out at home isn’t the pleasant environment.”

Research has consistently supported the association of larger families and closer birth spacing with higher rates of child abuse and neglect. In a groundbreaking 2024 article, Ahn et al report on their analysis of 20 years of data on almost 200,000 first-time mothers in California. They found a strong correlation between the number of children born to a mother and the likelihood that she would be reported to CPS in the next 20. The percentage of first-time mothers reported to CPS increased from 18.5 percent for mothers with one child to 25.4 percent for mothers with two children, 39.2 percent for mothers with three children, and 63.1 percent for mothers with four or more children.

Missing the Obvious?

Obviously not all large families are characterized by dysfunction and pathology. But common sense tells us that large family size can add to stress that in turn can lead to maltreatment. Moreover, having multiple children that one cannot afford may reflect other dysfunctions that may in turn be associated with child maltreatment. Yet somehow it never occurred to Senator Wyden or any of his colleagues at the hearing to ask whether this mother had any problems with mental health, drugs or domestic violence. Senator Wyden even mused aloud that federal law discriminates against large families, complaining that the child tax credit does not reimburse families based on the number of children they have! It appeared that he actually wanted to encourage unlimited childbearing regardless of the mother’s emotional or financial readiness.

And what about Mr. Reed, who actually provided this case as his only example of how material assistance can help resolve a child maltreatment report? According to the DCS website, Mr. Reed is a “licensed clinical social worker who has spent most of his career working with foster youth and children involved with the child welfare system.” One would think he had noticed that children from very large families were overrepresented among his clients. It is also worth noting, though slightly off-topic, that if this was the best example he could find, then his argument that many neglect cases can be solved with one-time material assistance appears to be in danger of collapsing for lack of support.

Perhaps one reason for Wyden’s and Reed’s blind spot is the current ideological tendency of what might be called the child welfare establishment, including the federal Administration on Children and Families, state leaders, and large and wealthy foundations and advocacy groups like Casey Family Programs. Many posts on this blog show how these groups’ focus on race and identity has restricted discussion about how to help prevent child abuse and neglect, among other problems. There seems to be a special taboo attached to any discussion about family size as it relates to child maltreatment, or any prescription for family planning as part of the solution. This taboo likely stems at least in part from our country’s shameful history of attempting to restrict childbearing by Black and poor women through means including forced sterilization and attempts to mandate that welfare recipients use an early injectable contraceptive called Norplant. But when efforts to be sensitive to past trauma to specific groups prevents the implementation of programs to improve the lives of at-risk children, it is time to set taboos aside.

What could be achieved by seeing extra-large families through clear eyes rather than a lens that is distorted by bias? Frontline workers faced with this type of client could look a little harder to see if the lack of a van was the real issue. Even if it was, requiring the mother to adopt one of today’s safe, long acting contraceptives in return for the gift of a van would hardly be unreasonable. In general, incorporating voluntary family planning, perhaps as a condition of receiving desired benefits, into family case plans might be a good start. Senator Wyden might not know this, but a new pregnancy for a mother who is trying to get her children back from foster care is one of the frequent setbacks observed by front-line workers.

The failure to regard unusually large numbers of children as a possible sign of pathology may reflect a genuine innocence about conditions in low-income urban and rural communities–conditions that are perfectly known to people in those communities and those who work there, but perhaps not to a US Senator like Wyden or his colleagues. A more cynical view is that self-imposed oblivion is needed to stay on the right side of advocacy groups and foundations that dominate the mainstream discourse on child welfare and provide funding to state and local agencies that are willing to toe the line. Whether it is ignorance or fear of losing the support of interest groups, national and local leaders’ disregard of the perils of repeated unplanned childbearing is hurting the very children these leaders claim they want to help.

  1. There is an error in the posted PDF of this report. The percentage of all women aged 40-49 who gave birth to three children was given as 2.4 percent instead of 22.4 percent. This was confirmed by an email to Marie Cohen from Brian Tsai, Public Affairs Specialist, Center for Disease Control and Prevention, November 21, 2024. ↩︎

The tragic life and death of Gavin Peterson: Utah’s statement leaves many questions unanswered

This post was prepared for and originally appeared on the website of Lives Cut Short, a project to document and analyze child maltreatment fatalities in the United States. See my interview with KUTV about this post here.

On October 10, the Utah Department of Children and Family Services (DCFS) finally released a statement summarizing its involvement with Gavin Peterson, who died on July 9, 2024 at the age of 12.  Gavin’s father, stepmother, and older brother are awaiting trial on reckless child abuse homicide, among other charges.  The much-awaited “CAPTA statement” from DCFS (named for the federal law requiring that states have a policy to disclose “information and findings” about child maltreatment fatalities and near fatalities)  provided some new information but raised new questions, especially when contrasted with media accounts. 

The DCFS statement begins with a disclaimer.  Gavin came from a “two-household family” and was residing with his biological father, Shane Peterson, and father’s long-term girlfriend, Nichole Scott, at the time of his death. The agency explains that although  it “worked with each household at several points in Gavin’s life as early as 2013,” the statement includes only “information relevant to Gavin in the household where his death occurred.” It is not clear from this disclaimer what information was withheld from the public, either because it was from the other household or because DCFS decided it was not “relevant to Gavin.”

Some of that information can be pieced together from media coverage. Gavin’s mother, Melanie Peterson, told a reporter at  KSL TV that she lost custody of all four of herchildren in 2014 or 2015. Court documents obtained by the reporter showed that two-year–old Gavin was found unsupervised outside of his home in 2014, and that in the same year Melanie pleaded guilty to allowing a child to be exposed to illegal drugs or drug paraphernalia. Melanie told the reporter that she never regained custody of her children from the courts, but that Shane Peterson unofficially returned her third child to her in 2018 and her second child in 2019. (Her first child was apparently Tyler, who is charged in Gavin’s death, and Gavin was the fourth child.) 

DCFS’ statement provides a chronology of abuse and neglect reports and agency responses, which are summarized below along with our commentary in italics.

May 28, 2019

The first report of abuse in Shane Peterson’s home is received. DCFS investigates and finds that Nichole Scott had physically abused another child in the home. The Peterson family accepts voluntary in-home services. After a month of services, DCFS concludes the safety concerns have been resolved and closes the case.

The “other child” was clearly Gavin’s sister Mayloni Peterson, now 19. She told KSL TV that she was abused even more severely than Gavin at the time, and was even punished for his actions.  She described being beaten, tied to her bed, fed only once or twice a day, forced to perform labor in the household and at her grandmother’s house. She reported that Scott once shaved off all her hair as punishment for combing her hair without permission and strangled her in the car following a failed attempt to run away. On Saturday, May 25, 2019, Mayloni told her father that she accidentally broke a sprinkler while mowing the lawn. Her father took her to her mother’s house without warning and left her there, possibly saving her life. Melanie Peterson reported that Mayloni was malnourished and “with all her hair buzzed off.” After hearing what her daughter had been through, Melanie made a report to DCFS after the Memorial Day holiday–clearly the May 28, 2019 report. (Mayloni mentioned a report that was made by her school in March; it is not clear whether that report was omitted by DCFS because it was “not relevant to Gavin.”)

February 27, 2020

DCFS receives a call reporting abuse of Gavin in “another household.” DCFS finds Gavin to be a victim of abuse and files a court petition. On May 27, the court orders both households to participate in DCFS in-home services. 

Melanie Peterson told KSL TV that she took a picture of an emaciated Gavin in February 2020. It would be the last time she saw him. She alleges that Nichole and Shane Peterson found out about the photo and made a false allegation about her, thereby ending her visitation rights pending a judgment by DCFS. That “false complaint” was likely the February 27, 2020 report, which resulted in an open case for both households. 

August 24, 2020

While the two households are receiving in-home services, DCFS receives a call reporting concerns about Gavin’s treatment in his father’s home. The information does not “meet the criteria required by Utah state law to open an investigation,” but the intake worker shares the information with the in-home caseworker.

May 21, 2021

The “Peterson family” successfully completes” in-home services, and the judge closes the case. No information is provided about what these services were. 

September 2, 2022

DCFS receives a report from “someone concerned about Gavin’s well-being, after observing some of his behaviors.” The hotline worker decides the report does not meet the legal criteria for opening an investigation. A supervisor approves this decision. 

This report most likely came from Gavin’s school, and his “behaviors” included eating food from the trash. Cafeteria worker Rachel Reynolds told KSL TV  that she suspected Gavin was hungry even before the school’s COVID-19-era free meal program ended in August 2022 and Gavin began taking leftovers from the trash. Her colleague Jan Davis said that she and a coworker began paying for Gavin’s lunch. That ended when Nichole Scott demanded they stop buying his lunch. But the workers continued to “sneak food” to him, according to Reynolds.

March 28, 2023

DCFS receives a report regarding physical neglect of Gavin and opens an investigation. Two days later, DCFS receives another report, which is added to the open investigation. Gavin is interviewed at school without his parents and does not disclose abuse. On May 8, 2023, DCFS receives a third report alleging physical abuse of Gavin. The investigator visits the home for a second time, interviews the adults and interviews Gavin outside the presence of the alleged abusers. The case is closed on May 15 with no finding of abuse or neglect.

These three reports likely came from the school.The school district reported the school made “multiple calls” about Gavin, and Rachel Reynolds said that at least four calls were made by cafeteria workers and the principal. Reynolds personally observed the nurse and school principal call DCFS when she brought Gavin to the nurse with fingers that looked swollen and infected from picking. Jan Davis mentioned that Gavin came to school with a chipped tooth shortly after Nichole Scott learned that cafeteria staff were feeding Gavin. Perhaps that accounted for the abuse allegation. 

In August 2023,  Gavin was withdrawn from school for schooling at home. There are no more reports until July 29, 2024. Utah has no policy in place for monitoring children withdrawn from school following allegations of abuse or neglect,

July 9, 2024

DCF receives a report that Gavin is in the emergency room with injuries that appeared to be the result of abuse or neglect. He dies the same day. 

The police investigation into Gavin’s death has revealed that Gavin was abused for years, was kept locked in an uncarpeted room without bedding or blankets while adults monitored him with multiple cameras, and was often beaten or starved, sometimes given only bread and mustard to eat. Nichole Scott, Shane Peterson, and Tyler Peterson were arrested and charged with child abuse homicide, aggravated child abuse, and endangerment of a child, and are awaiting trial. Gavin’s treatment can be defined as torture, a type of child abuse that some have observed may be increasing in Utah and around the country. These cases often include confinement, starvation, beating, and isolation.

Unanswered Questions

Utah’s report on Gavin Peterson’s death, when compared with the media accounts from Gavin’s mother, sister, and school staff, raises more questions than it answers. 

  • The May 28, 2019 report: The allegations that Mayloni made to her mother, who presumably included them in her May 28, 2019 report, concerned multiple reports of physical abuse, confinement, and forced labor.  Both children should have had a physical exam and a forensic interview. How is it possible that allegations of this magnitude (that turned out to be true) resulted in a case that was closed in a month and that was also described as “voluntary”? 
  • The February 2020 report: This report about the  abuse of Gavin in another household is clearly the “false allegation” stemming from his mother’s photograph of an emaciated Gavin. How did that result in a substantiation against her for abuse? The case was open for more than a year during the height of the COVID-19 pandemic. Were the visits virtual? Does that explain why the caseworker observed nothing of concern? Why did Melanie never get her visitation rights back after the case was closed?
  • The August 24, 2020 report: What concerns were raised and why did they not meet the criteria to open an investigation? Was this report really shared with the in-home worker and did that worker try to determine whether they were true?
  • The September 2022 report: How was this report,  obviously from the school and conveying that Gavin was seeking food in the trash, not judged to meet the legal criteria for an investigation, even by a supervisor?
  • The reports in March and May of 2023: Why did the investigation conducted from March to May 2023 fail to find the abuse of Gavin, which was so obvious to school personnel? Wasn’t Gavin very thin? Shouldn’t he have received a physical examination? If he denied the abuse, was the investigator unaware that is what scared children do? Was there any discussion  of taking him to a Child Advocacy Center for a forensic interview?

Key Takeaways

The first major takeaway of this report is that Utah’s CAPTA report does not tell us whether DCFS did all that it could do to protect Gavin. The information shared in the report complies with state policy, which in turn complies with the very vague requirements of federal law. But much more detail is needed including documentation of the reasoning behind rejecting certain reports as worthy of investigation, the entire record of each investigation including interviews and documents, and a report of every interaction with the family during the in-home case. A few states post “critical incident reviews” for some death and near fatality cases. But such reviews are expensive, not all cases get reviewed, and internal reviewers may be biased on behalf of the agency. The only way to ensure accountability and inform needed changes is to release the full case file on the family, with certain names redacted,1 for at least the five years preceding the fatal or near fatal event.

The second major takeaway is that in spite of the lack of detail, the information provided strongly suggests that the problems in this home were longstanding and there were many opportunities for DCFS to discover them. It appears that systemic issues prevented the diagnosis of issues that should have been obvious. A former DCFS caseworker told KUTV that she left the agency “after struggling with overwhelming caseloads and a culture of simply ‘checking boxes.” She explained that while cases demanding immediate action are usually addressed, other cases showing red flags are dismissed too soon as “safe enough.” She placed primary blame on the legislature for not allocating adequate resources, saying that workers want to do their jobs, but they are being placed in impossible situations. “It’s unfair to put them in these situations where they don’t have the time to produce quality work, or if they do decide to put in the time, they’re sacrificing so much.”

The third major takeaway is that Gavin’s fate was sealed once he was withdrawn from school and the reports stopped coming in. In its Make Homeschool Safe Act, the Coalition for Responsible Home Education proposes that a child cannot be withdrawn from school for homeschooling within three years of being investigated for abuse or neglect, regardless of the outcome, unless there is a risk assessment by social services or child welfare that finds that the child will not be endangered by being schooled at home, and the home educator agrees to a monthly risk assessment for the next 12 months.

Gavin Peterson was failed by the agency that was meant to protect him, A few children suffering similar torture have been lucky enough to escape to safety, like the boy who escaped from the home of parenting youtuber Ruby Franke and saved himself and his sister from likely death. But most children in these situations have no recourse unless the people being paid to protect them have the time, training, support and resources to investigate fully and respond appropriately. To ensure that happens, the public must have access to the complete records of cases in which the system has failed. 

  1. For example, the names of children and people who reported maltreatment. ↩︎

GUEST POST: Torn Apart: How the Abolition Movement Destroys Foster Youth – And How Listening To Us Can Build A Safer World

by Patty Flores

I am grateful to be publishing this essay by a gifted and needed young voice in the child welfare space. Liliana “Patty” Flores, MSW is a clinician, researcher, advocate, educator, and motivational speaker. Her intersectionality and affiliation with marginalized identities such as being an undocumented Salvadoran female, LGBTQ+, foster youth, homeless, and cycling in and out of juvenile jails, have shaped the way she sees social issues. Patty was born in El Salvador and migrated to the U.S. at age 10. She spent half of her life in foster care, struggling with substance abuse. Patty turned 18 years old in jail. She eventually graduated high school and enrolled in college while still incarcerated. She now has an A.A. in Social and Behavioral Sciences, an A.S. in Administration of Justice from Pierce College, a B.A. in Sociology from UC Riverside, and a Master’s in Social Work from Smith College. Her goal is to empower those of similar backgrounds like herself. Read more about Patty and her work at www.defyinglabels.com. –Marie Cohen

Imagine going to school with bumps on your head and bruises on your back and legs from being repeatedly punched and kicked; this was my reality as a kid. Youth with lived experiences in foster care face countless challenges, even when the abuse finally stops – one way or another. For me, it stopped because at age 12 I reported it. I then found myself in foster care and having to navigate the complicated child welfare system, speaking little English and knowing nothing about how the child protection system (CPS) works in this country. Although my experience in care was hard for numerous reasons, including substance use, incarceration, homelessness, and being undocumented, I am alive only because this country has a system of protection in place for children and youth like me who have been victimized by their parents.

The movement to abolish the current child welfare system –spearheaded by the organization upEND and its co-founder, Alan Detlaff–has sparked useless controversy and divided the community of people who are concerned with child safety, permanency, and wellbeing. Former foster youth like me, who are pursuing college and graduate education,  are silenced in our classrooms. Also silenced are our allies, who are shamed for wanting to pursue a career in child welfare. The child welfare abolition movement originated from academics like Detlaff who have  no lived experience of foster care. Who are these ivory tower elites to tell anyone that foster care is unnecessary and should be eliminated when they’ve not lived through it themselves?

The child welfare abolitionists have chosen to ignore those of us with lived experience of child abuse and neglect who refuse to endorse their program of eliminating the child protection system. Are they too uncomfortable to talk about the cruel truth of being an abused or neglected child? Do they fear this conversation will thwart their efforts to abolish the system? It’s much easier to ignore the issues of child abuse and child deaths, to avoid engagement with survivors, and to see only the adult perpetrators as victims, than to recognize the reality of child abuse and neglect. It is also much easier to talk about tearing a system down than to grapple with the question of how to build one up that truly promotes child safety, permanency, and well-being. It is  harder to acknowledge the harms of child maltreatment and work together with us to find solutions that ensure our safety, stability, and well-being. Abolitionists are choosing the easy, less messy way out. They argue that foster care is not the answer. But for some of us, it is the only answer after experiencing abuse and neglect without extended family support.

I was born in El Salvador and am a descendant of the Pueblo Pipil, an indigenous group of people in El Salvador. I migrated to the United States as an unaccompanied minor at the age of ten. My background is rooted in a history of civil war and the struggle of oppressed indigenous people to overthrow those in power. In the United States, child welfare abolitionists often label themselves as “revolutionary” or claim to be engaging in “revolutionary” social work, but they are mistaken. True revolution occurs when the community rises up against oppression from those in power, not the other way around. These are the lessons I have learned from my revolutionary ancestors.

Child welfare abolitionists use the term to brand themselves as social justice warriors and  silence those with lived foster care experiences. They discuss child protection and  foster care among themselves, excluding the very people most affected.  It is  an abuse of power for the “abolitionists” to neglect the voices of those with lived experiences in foster care, while enhancing their own prestige within the elite ivory tower. 

Advocates for abolishing the child welfare system (or as they call it, the “family policing system”) argue that collective efforts and community involvement are the solution in cases of child abuse and neglect. Yet nearly five years have passed since the inauguration of upEND, and the child welfare abolition movement has not provided specifics about how this would look in practice. Nor have I heard Dettlaff or other child welfare abolitionists discuss the experiences of young people like me who endured abuse and neglect. Are they afraid of the harsh realities we’ve experienced? How can they even talk about the child welfare system when they refuse to acknowledge our existence?

I keep asking myself these questions: where was the community when I witnessed my mother being violently attacked, with a gun held to her head by my father? Where was the community when Gabriel Fernandez lost his life? Where was the community when Danieal Kelly was starved to death by her mother? Or much more recently, as four-year-old Jahmeik Modlin, slowly starved to death in an apartment stocked with food? Where is the community when children continue to lose their lives at the hands of their caregivers daily? When I’ve spoken to community members about their role in intervening when child maltreatment or violence on the streets occurs (a “solution” prescribed by the “abolitionists”), they’ve expressed fears of retaliation or concerns about getting themselves into dangerous situations where they could be attacked by the perpetrators.

The child welfare abolitionists have manipulated many young people, students, and activists into adopting oversimplified, Black and White narratives that erase other ethnic groups and the intersectionality children like me experience. To support their argument, they assert that the media is responsible for over-emphasizing cases of abuse and deaths, which they contend are infrequent. But when you grow up witnessing so much violence, abuse, and neglect firsthand, you don’t have to watch the stories on the news. In fact, I did not grow up watching any TV. I learned about all this violence because I lived it.

College and university professors who support abolition (and who have never worked in the system) consistently push the narrative that CPS serves only to break Black and Brown families apart. They rarely if ever acknowledge the suffering endured by the over half a million children and youth who are abused and neglected annually and the need for a system of child protection in this country. As a young person with lived experience in an abusive family, I felt compelled to speak up in the classroom. And I did, immediately standing out with my thick accent and visible head tattoos. Fortunately, many of my classmates, including peers with experience in foster care, supported me and together we pushed back against professors’ biases and prejudice. I felt powerless growing up, and I still feel powerless as I navigate the racist, sexist, and classist world of academia.

In Defying Labels: From Negative Credentials to Positive Credentials?, an article I wrote for a newsletter at UC Riverside, I explained that society often shifts blame to the child for revealing family secrets in cases of abuse and neglect. The last thing I want as an adult is to keep being torn down and silenced by those in positions of power – professors, researchers, policy analysts, lawyers, and others. The abolition movement is tearing foster youth apart. Why not actually listen to what we have to say? This is the only way toward a safer world for all.








How New York keeps the public in the dark about high-profile child abuse and neglect deaths

Image: WWNY

This essay was originally published on the website of Lives Cut Short, a project to document child maltreatment deaths in the United States since 2022, for which I serve as Senior Project Associate

Jahmeik Modlin was found in a skeletal condition in a Harlem apartment stocked with food. He died the next day, and his three older siblings were hospitalized with severe malnutrition. The family had been on the radar of the Administration for Children’s Services (ACS) since 2019, before Jahmeik was born. But the agency closed its last case with the family in 2022 after determining that the children were safe, a source told the New York Times. A spokeswoman for ACS declined to offer further information, citing state law designed to protect siblings of fatal abuse victims.

According to data states submit to the federal government, about 1800 children die of abuse and neglect every year, but this figure is widely recognized to be an undercount. Among those deaths, studies suggest that between a third and a half involve families who were already known to the child protection system (CPS) through previous reports.  Even in other cases where the family had no prior contact with CPS, other systems may have interacted with the child and perhaps could have intervened. Legislators, advocates and the public must have access to timely information about the circumstances leading up to child maltreatment fatalities so they can identify missed opportunities and policy and practice changes necessary to protect children. For that reason, Congress in 1996 added a provision in federal law that requires all states to provide assurances to the federal Department of Health and Human Services that they have provisions for disclosing findings and information regarding child fatalities and near fatalities from maltreatment.

Lives Cut Short surveyed state laws and policies governing access to information about child maltreatment fatalities and near fatalities. The resulting report, Keeping the Public in the Dark: How Federal and State Laws and Policies Prevent Meaningful Disclosure about Child Maltreatment Fatalities and Near Fatalities, shows that most states have such laws and practices but many of them are vague, and many have provisions that conflict with the purpose of ensuring public access to critical information. Among such provisions are those that prohibit releasing information that might harm surviving children in the families where a child was killed or seriously injured by maltreatment.

New York, at first glance, appears to be more transparent than most states in making information and findings about child maltreatment fatalities available to the public. The New York State Office of Children and Family Services (OCFS), which supervises local agencies such as ACS, is required to review all local investigations of child fatalities reported to the State Central Register and to publish a summary report within six months of the investigation. Disclosure of this information, however, occurs only if the state or local commissioner determines that it is not “contrary to the best interests of the child, the child’s siblings or other children in the household.”  While the law does not provide a comprehensive definition of “contrary to the best interests,” the OCFS website does explain that OCFS conducts what it calls a “best interests determination,” sometimes assisted by “experts” from the agency’s Statewide Child Fatality Review Team.  The process considers “whether publishing a fatality report is contrary to the best interests of a child’s siblings or other children in the household, what effects publication may have on the privacy of children and family, and any potentially detrimental effects publication may have on reuniting and providing services to a family.” 

To understand the impact of the “best interests” determination, one needs to know  the proportion of child fatalities for which New York withholds reports.  The identifying numbers that the state assigns to its child fatality reports provide a useful clue. All these numbers start with a two-letter abbreviation for the region (AL for Albany, BU for Buffalo, etc.), continue with the last two digits of the year, and end with a three-digit number, starting from 001. For example, the first Albany report for 2022 would be identified as AL-22-001. Assuming that all missing numbers represent reports withheld under the “best interests determination,” about one-quarter of reports on 2022 fatalities in New York State were withheld.

The Child Abuse and Neglect Deaths Integrated Database (CANDID), maintained by Lives Cut Short, allows us to determine which child deaths reported in the media had a corresponding fatality report released by New York OCFS. CANDID combines information on child maltreatment fatalities from media reports, official fatality reviews or reports, and other available sources. New York State’s fatality reports do not include names, but they do include the dates of death as well as details about the circumstances. Therefore, one can attempt to match media coverage with the OCFS review of the same fatality. But very few maltreatment deaths occurring in 2022 and covered by the media had an OCFS review released to the public. It appears that the reviews of high-profile deaths that received media coverage were withheld based on “best interest determinations.” 

These cases included:

  • The death of Bryleigh Klino, a profoundly disabled 17-year-old whose parents have been charged with endangering her welfare. Hospital employees observed numerous signs of abuse and neglect on Bryleigh’s body;
  • The drowning of six-month-old Dalilah Crespo, whose death was ruled a homicide;
  • The death from abusive head trauma of four-month-old Cairo Dixon-Sanchez, for which his father pleaded guilty;
  • The fentanyl poisoning death of 11-month-old Liam Sauve, who ingested 23 times the amount of fentanyl that could kill an adult and whose mother pleaded guilty for his death;
  • The death of three-month old Genevieve Comager, whose father was charged with shaking her to death;
  • The beating death of nine-year-old Shalom Guifarro, whose mother has been sentenced to 16 years for her killing;
  • The death of two-year-old Ermias Taylor-Santiago of a fentanyl overdose, which was ruled a homicide;
  • The death of blunt force trauma of Xavier Johnson, whose mother’s boyfriend was charged with beating him to death;
  • The fatal heroin overdose death of six-month-old Denny Robinson, found with a heroin bag in his mouth in a house that was connected with a major drug trafficking operation;
  • The drug and alcohol poisoning of 14-year-old Hailey Hasbrouck, allegedly by her father and his girlfriend, who allegedly gave her the “toxic cocktail;”
  • The “suspicious” death of seven-year-old Hunter DeGroat, found unresponsive in his home;
  • The death of two-year-old Aniyah Wyatt-Wright, allegedly punched to death by her father;
  • The murder of three-year-old Shaquan Butler, beaten to death in a Queens homeless shelter after being reunified with his parents after being removed from them by ACS.

It is probably not a coincidence that OCFS has elected not to release information on most of the egregious fatalities that were covered in the media. Many of the published state fatality reviews concern deaths due to unsafe sleep factors, accidental drownings, and other fatalities that do not result in criminal charges and are therefore never known to the public. It is possible that OCFS is trying to shield the surviving children in the cases listed above because readers may be able to identify them by putting together the reports and the media coverage—as we did. But these are the very cases for which the information is most urgently needed. The nature of these cases suggests the existence of serious and chronic conditions that might have resulted in previous reports and involvement with CPS. Any harm that public release of the report would cause when the incident has already been covered in the media is dubious.  
It’s hard to avoid wondering if the exclusion of these cases from disclosure protects the agency more than the children. And to avoid guessing that Jahmeik’s death will join the list of those cases for which reports are never published.

We cannot make progress in the prevention of severe and life-threatening child maltreatment unless legislators, advocates and the public have access to comprehensive information about what led up to these tragic events. Congress tried to provide this access through a provision in federal legislation, but states have couched this requirement in vague language or hedged it with qualifications that prevent the release of critical information—or any information at all in some cases—as in New York. Only Congress can fix the gaps in the federal law, but state legislatures can act in the meantime to ensure their disclosure laws serve the purpose of improving child welfare in their states. 

To learn about current law in your state, see the new report: Keeping the Public in the Dark: How Federal and State Laws and Policies Prevent Meaningful Disclosure about Child Maltreatment Fatalities and Near Fatalities. 


School shootings and fentanyl overdoses: the uncounted costs of neglecting maltreated children

Colin and Colt Gray: TMZ
Maylia Sotelo: Fox 11

A fourteen-year-old boy and a fifteen-year-old girl are charged as adults, one for a mass shooting and the other for selling a fentanyl tablet that killed an older teenager. These two young people had something in common–a long history of neglect (and sometimes abuse) by their parents and a failure to intervene by child welfare services despite multiple reports that children were in danger. Ignoring chronically maltreated children when they could have been saved and then locking them up for life is both inhumane and costly. We must intervene to help maltreated children before they are irrevocably damaged by years of abuse and neglect.

On September 4, 2024, fourteen-year-old Colt Gray shot and killed two teachers and two students at Apalachee High School in Winder, Georgia with an AR-15 style rifle given to him by his father. He has been charged as an adult and is awaiting trial. It did not take long for the media to uncover that Colt had grown up in a chronically abusive and neglectful home. As the Washington Post put it in a devastating article, “Colt’s parents, each addicted to drugs and alcohol, were perpetually inattentive, often cruel and sometimes entirely absent, according to family members, neighbors, investigators, police reports and court records.” In November 2022, Colt’s mother, Marcee Gray, left his father, Colin Gray, and moved to southern Georgia with her two younger children. It appears that DCFS had opened a case at some point because In October of 2023, a spot drug-test revealed Marcee’s renewed drug use. Colin Gray was ordered to retrieve the other children, or they would be placed in foster care. Shortly thereafter, it appears that the case was closed.

There is no information from media reports about whether DCFS evaluated Colin Gray for his fitness to take care of his three children or to monitor their well-being in his care before closing the child welfare case. Yet, relatives reported to the New York Post that Colin Gray relentlessly bullied his son, calling him names like “sissy” and “bitch.” The Washington Post reported that Colt first came to the attention of authorities at the age of 11, when his school flagged him for searching the internet for ideas on how to kill his father. In Colin Gray’s custody, Colt never attended eighth grade and was not even registered for school until February 2 of that year. That Christmas, Colin Gray gave Colt his own AR-15 style rifle, in an attempt to “toughen him up,” as relatives told the New York Post. By his fourteenth birthday in January, Colt’s grandmother reported that he was searching the internet for what was wrong with him; she offered to pay for therapy and take him there but his father never signed him up. In July of 2023, Marcee returned from rehab and Colin allowed her to move back in. Colt’s mental health deteriorated even further after his mother’s return, and he talked of hurting himself or others. He registered for high school two weeks late and rarely attended. “Colt was like the thrown-away child,” said his grandmother, who tried in vain to get his father and the school to help him. Five days after his father failed to take him to a crisis mental health center despite his grandmother’s plea, Colt brought his rifle to school and took four lives.

Also charged as an adult was 15-year-old Maylia Sotelo of Green Bay, Wisconsin, the subject of a devastating article by Lizzie Presser of Pro Publica.  Maylia’s home had been a “hangout for users and dealers.” Her three older sisters had all been kicked out or left due to their mother’s violence. Maylia’s had been referred to child protective services 20 times before she was finally removed from her home at the age of 14. In a pattern typical of chronic maltreatment, the reports concerned multiple types of neglect, sexual abuse, and physical abuse. Before Maylia turned one, CPS documents show that her mother overdosed on cocaine and Adderall with seven children in her home. When she was five years old, a caller reported that her mother was “high as a kite” and her boyfriend was violent. The next year, another report indicated that there was no food in the home and that the mother was using heroin in front of her children.

When Malia was seven, CPS substantiated a report that a man “opened his pants, pulled out his penis and masturbated” in front of one of Maylia’s sisters. That same year, a woman overdosed on crack in the house and Maylia’s mother “would not call rescue or the police because [she] did not want her children removed,” according to a social worker’s notes. And a school employee reported that Maylia missed half the school year. When Maylia was 14 and her mother became psychotic, Maylia and her sister were finally removed from the home and placed with relatives. But they were given no counseling or assistance with school, according to Pro Publica. Maylia had been smoking weed since fifth grade, then began selling it. By the beginning of tenth grade, she was selling “blues,” pills that were billed as percocet but actually contained filler and fentanyl. She sold a pill to an 18-year-old named Jack McDonough. When he died of an overdose, Maylia was arrested for first-degree reckless homicide.

It is obvious that both Colt Gray and Maylia Sotelo were chronically maltreated children who suffered from multiple types of maltreatment over a period of years. It is also obvious that the systems designed to protect them failed both of these young people. Both families clearly required intervention that did not come when it was needed, though we do not have enough details to make an informed critique of the system’s response. When the child welfare system finally intervened in Malia’s case, it may have been hard to change her trajectory, and it appears that she was left with relatives and received monitoring or services to address her traumatic history. In Colt’s case, the intervention may have also come too late to prevent serious psychological damage. And once they became involved, caseworkers appeared to be focused on his mother and ended the case with the placement of all three children with their father, a parent who had been equally neglectful and failed to take action to protect the children from his wife’s abuse.

Perhaps more intensive in-home services provided earlier could have helped Colt’s and Maylia’s parents address the issues that led them to abuse or neglect their children. If not, perhaps Maylia’s earlier removal from her toxic home, and Colin’s removal to a better environment than either of his parents could provide might have saved these children from the sad fate that awaited them. The approach that is currently in fashion – exemplified by the much touted Family First Prevention Services Act (FFPSA) of 2018 – prescribes the avoidance of foster care at almost any cost. It does, however, promise that parents receive support in parenting their children, whether it is mental health, drug treatment, or parenting training. Child welfare systems have long been providing such support to families in the form of in-home services, and FFPSA was supposed to provide the resources to improve these services. Unfortunately, FFPSA did not acknowledge or support the crucial role of frequent home visits to ensure the children are safe and that they can be removed into foster care if the parents do not cooperate with their plans for addressing their issues and improving their parenting.

Sadly, there is no evidence that increases in family support or child safety monitoring are forthcoming. States are proudly citing drops in their foster care caseloads, with no reporting on what is happening to the children left at home. States are not required to release data on the number of cases opened for in-home services, so we have no idea whether the abused and neglected children who are not being removed are getting any supervision or their parents receiving services. But as I have written, data from the states with the largest and third largest foster care caseloads indicates that the number of children receiving in-home services has not increased to make up for the drop in children removed to foster care; instead it has decreased along with foster care placements, resulting in a decline in the number of children being served overall.

Studies have documented the connection between child maltreatment and crime.1 Failing to intervene with at-risk children before they resort to crime and subsequently incarcerating them results in unnecessary human suffering, not to mention greater financial costs, than intervening early. If we do not want to remove more children, we must provide intensive services to parents and close monitoring of their children’s safety–and be ready to remove the children as soon as it becomes clear that parents are not going to change before the children are irreparably harmed. Such monitoring is key, because we really do not know what, if anything, works in preventing future maltreatment among parents who have maltreated their children.

This is not the first time that the failure of CPS has been noted in the wake of a heinous crime. I previously wrote about Lisa Montgomery, who was executed on January 12, 2021. She murdered a pregnant woman, cut out the baby, and took it home. It turned out that Lisa Montgomery had a long and horrific history of physical and sexual abuse throughout her childhood, including beatings and bizarre punishments by her mother, rape by her stepfather, and prostitution by both. Sadly, it seems that we have not made much progress since Lisa’s childhood, and current ideological trends run the risk of leaving even more children unprotected in the future.

Notes

  1. See Janet Currie and Erdal Tekin, Does Child Abuse Cause Crime? NBER Working Paper 12171, https://www.nber.org/digest/jan07/does-child-abuse-cause-crime and Todd I. Herrenkohl et al., Effects of Child Maltreatment, Cumulative Victimization Experiences, and Proximal Life Stress on Adult Crime and Antisocial Behavior, https://www.ojp.gov/pdffiles1/nij/grants/250506.pdf.

Reposting: Torn apart: A skewed portrait of child welfare in America

The MacArthur Foundation has announced its new class of Fellows, the recipients of what are commonly called the “Genius Awards.” Among the recipients is Dorothy Roberts, the self-styled popularizer of the term “racial disproportionality” and creator of the term “the family policing system.” According to the Director of the Program, “The 2024 MacArthur Fellows pursue rigorous inquiry with aspiration and purpose. They expose biases built into emerging technologies and social systems….” It’s hard to understand how this term can be applied to an author who wrote that the “family-policing system terrorizes Black families because that’s what it is designed to do ” despite also stating that child welfare systems excluded Black children from their inception until the second half of the twentieth century. The choice of Roberts only exposes the bias and lack of rigor–or alternatively the sheer ignorance– of the MacArthur Foundation. As an illustration, I am reposting my 2022 review of Roberts’ most recent book, Torn Apart: How the Child Welfare System Destroys Black Families–and How Abolition Can Build a Safer World.

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. [Update added October 2024: A newer study, reflecting current foster care policy and the more typical state of Michigan, found the opposite result.] But focusing on marginal cases* leaves out the children suffering the most severe and obvious maltreatment. In a recent 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.

New Jersey’s claim of declining child maltreatment: ingenuous or disingenuous?

Officials of New Jersey’s Department of Children and Families (DCF) are congratulating themselves on what they call the decline of child abuse and neglect in their state and attributing this ostensible decline to their department’s preventive services. The number of reports of child child maltreatment has actually increased over this period. DCF’s claims are based on a decline in the number of children with substantiated reports–a number which reflects DCF policy and practice much more than it reflects actual abuse and neglect. Whether agency officials are ignorant or attempting to manipulate the data for naive readers, this is no way to keep the public informed about how well New Jersey is protecting its children.

Two DCF officials, Laura Jamey, Director of the Division of Child Protection and Permanency and Sanford Starr, Director of the Division of Family and Community Partnerships, say they have some good news for New Jerseyans. They announce it in an op-ed titled “Maltreatment of NJ kids is decreasing. Here’s wow [sic] we’re preventing it,” which was published in the Asbury Park Press. “By using evidenced-based [sic] prevention strategies and practically addressing families’ needs, we’re happy to report that over the past decade, there has been a steady decline in the number of confirmed cases of child abuse and neglect in our state. In 2016, there were more than 8,000 substantiated and established cases of Child Abuse and Neglect in New Jersey. Last year, that number was only 2,641.”

Wow! sounds impressive, right? But it turns out the authors took as much care with the substance of their commentary as with their capitalization and spelling. That much is clear to anyone who bothers to look at the data that New Jersey shares with the federal government through the National Child Abuse and Neglect Data System (NCANDS) and which the federal Children’s Bureau shares through its annual Child Maltreatment reports. The data for 2023 have not yet been published by the Bureau, but the figures below represent what New Jersey reported for Federal Fiscal Years (FFY) 2016 to 2022, which ended on September 30, 2022.

Federal Fiscal YearReferralsChildren Receiving an Investigation or Alternative responseChildren receiving a “substantiated” disposition/percent of referrals
201656,01473,8898,264 (11.2%)
201757,02674,3936,614 (11.6%)
201859, 42877,6616,008 (10.1%)
201960,93478,7415,132 (8.4%)
202052,85370,1793,655 (6.9%)
202148,78166,3213,188 (6.5%)
202257,06874,7663,146 (5.5%)
Sources: Child Maltreatment 2016-2022, Children’s Bureau, Administration on Children and Families

Jamey and Starr cited only the number of substantiated cases of maltreatment. But that figure has meaning only in the context of two figures that represent earlier steps in the process, which are always discussed first in the Child Maltreatment reports. “Referrals” is the child welfare system’s term for reports to the state child protective services hotline. As you can see, those reports increased slightly in New Jersey from 56,014 in FFY2016 to 60,934 in FFY2019. There was a significant drop in referrals during the COVID pandemic in FFY2020 and FFY2021, and then a rebound to 57,068 in FFY 2022, just slightly higher than the number in 2016.

The number of children who were the subject of an investigation also dipped during COVID (in response to the drop in referrals) and bounced back up to a level that was slightly higher than that of 2016. But the number of cases that received a disposition of “substantiated” (which means an investigation concluded that a preponderance of the evidence indicated that abuse and neglect occurred) fell every year, with especially large drops in 2017 and during the COVID pandemic. And according to Jamey and Staff, that number fell even further to 2,641 in 2023, which means the number of children with substantiated referrals had dropped by 68 percent since FFY2016. And the number of children receiving a substantiated disposition as a percent of all referrals fell by half–from 11.2 percent to 5.5 percent, in that period.

So what explains this large drop in children with substantiated dispositions during a period of nine years? In its commentary in Child Maltreatment 2017 (CM2017), New Jersey attributed the one-year drop in children with substantiated dispositions from FFY 2016 to FFY2017 to a revised disposition model it adopted in April 2013.1 But after FFY2017, DCF provided no explanations other than regularly repeating its statement in 2018 that “the decrease in the number of substantiated victims “remains consistent with prior years and shows a continued trend in the decrease of victimization rates.” In CM2022, DCF simply acknowledged without explaining that “[d]espite the number of CPS referrals increasing from FFY 2021 to FFY 2022, the number of child victims continues to decrease. The rate in which New Jersey substantiated reports also decreased from FFY 2021 to FFY 2022.”

Research suggests that substantiation decisions are not very accurate and that a report to the hotline predicts future maltreatment reports and developmental outcomes almost as well as a substantiated report.2 So it just does not seem plausible that child maltreatment could have dropped by over half while the number of reports increased. There is one possible explanation for this decline, which I raised in a 2021 blog. New Jersey is one of many states that is increasingly using a practice called “kinship diversion.” Kinship diversion occurs when social workers determine that a child cannot remain safely with the parents or guardians. Instead of taking custody of a child, the agency facilitates placing the child with a relative or family friend. If this occurs in the context of an investigation, kinship diversion may result in a finding of “unsubstantiated” (or in New Jersey, “unfounded” or “not established”) even when abuse or neglect has occurred, on the grounds that the child is now safe with the relative. We have no idea how widespread kinship diversion is in New Jersey or how often it results in an “unfounded” or “not established” finding. However, the system of informal kinship care created by kinship diversion has been called America’s hidden foster care system and nationwide it appears to dwarf the provision of kinship care within the foster care system.

There is no way of knowing how much, if any, of the drop in child maltreatment substantiations is accounted for by kinship diversion. If diversion accounts for a substantial portion of the drop, that points to serious problems with the practice. It means not only that DCF is undercounting incidents of child abuse or neglect but also that a parent who committed serious maltreatment would not show up as having a substantiated report, possibly affecting decisions on future allegations against that parent. I described some of the other problems with kinship diversion, such as the lack of support for the child and relatives, the possibility that the caregiver will return the child to the an unsafe home, the possible placement of children with inadequately-vetted relatives, and the lack of due process and services for the parents, in another post.

Despite their lack of explanation in their annual commentaries designed for federal employees and child welfare specialists to read, DCF officials have offered the public an optimistic explanation for the drop in maltreatment substantiations. “We’ve worked to transform New Jersey’s child welfare system to support and strengthen families who are struggling to meet their basic needs rather than separating them. A family unable to provide clean clothes may need a supportive neighbor who can offer a ride to the local laundromat. A family struggling to put food on the table may need to be connected with a local food bank.” We have already shown that this decline does not indicate a decline in actual maltreatment, but this attempt to tie it to simple casework like finding a family a ride to a laundromat is simply not believable.

The problem is not just an op-ed that few will read. As quoted in NJ Spotlight News, the Commissioner of DCF told a legislative committee that “Working together, we have achieved so much for New Jersey’s families, including the lowest rate of family separations in the country, one of the lowest rates of child maltreatment and repeat maltreatment in the country.” This was quoted as part of a congratulatory article about how New Jersey has become a “national leader in child welfare.” it is unfortunate that this public media outlet simply echoed the Department’s rosy view, making no attempt to verify their claims by consulting the data.

The misuse of data by high officials of New Jersey’s child welfare agency raises an uncomfortable question. Is it really possible that these leaders believe that child maltreatment has declined by 68 percent since 2016? All I can say is that their statement reflects either ignorance or a cynical disregard for the truth. Neither of these options reflects well on the leadership’s moral or intellectual capacity to serve their state’s most vulnerable children and families.

Notes

  1. Before the new framework, New Jersey had only two investigation dispositions: unfounded and substantiated. The new model added two new dispositions: established and not established, which fall on a continuum between “substantiated” and “unfounded.” DCF explains that the cases that receive the “established” disposition are coded as “substantiated” in NCANDS, so it is possible that finding some children who would have been substantiated as “not established” instead contributed to the drop in substantiations. ↩︎
  2. Theodore Cross and Cecilia Casanueva, “Caseworker Judgments and Substantiation,” Child Maltreatment, 14, 1 (2009): 38-52; Desmond K. Runyan et al, “Describing Maltreatment: Do child protective services reports and research definitions agree?” Child Abuse and Neglect 29 (2005): 461-477; Brett Drake, “Unraveling ‘Unsubstantiated,’” Child Maltreatment, August 1996; and Amy M. Smith Slep and Richard E. Heyman, “Creating and Field-Testing Child Maltreatment Definitions: Improving the Reliability of Substantiation Determinations,” Child Maltreatment, 11, 3 (August 2006): 217-236. Brett Drake, Melissa Jonson-Reid, Ineke Wy and Silke Chung, “Substantiation and Recidivism,” Child Maltreatment 8,4 (2003): 248-260; Jon M. Hussey et al., “Defining maltreatment according to substantiation: Distinction without a difference?” Child Abuse and Neglect 29 (2005): 479-492; Patricia L. Kohl, Melissa Jonson-Reid, and Brett Drake, “Time to Leave Substantiation Behind: Findings from a National Probability Study,” Child Maltreatment, 14 (2009), 17-26; Jeffrey Leiter, Kristen A. Myers, and Matthew T. Zingraff, “Substantiated and unsubstantiated cases of child maltreatment: do their consequences differ?” Social Work Research 18 (1994): 67-82; and Diana J. English et al, “Causes and Consequences of the Substantiation Decision in Washington State Child Protective Services,” Children and Youth Services Review, 24, 11 (2002): 817-851. ↩︎