Yes, A System Should be Judged by One Case

“A system should not be judged by one case, no matter how sad or sensational,” said Joette Katz, Commissioner of Connecticut Department of Children and Families (DCF) Katz’ words were reported by the Hartford Courant.

Katz was referring to the case of Matthew Tirado. Matthew, a 17-year-old diagnosed with Autism and Intellectual Disability, died on February 14, 2017 from prolonged abuse and neglect by his mother. As revealed by a heartbreaking report from Connecticut’s Office of the Child Advocate (OCA), Matthew had been known to DCF for 11 years, since he was five years old. Yet, DCF missed several opportunities to save Matthew, who was nonverbal and could not speak for himself. Matthew’s interactions with DCF included:

In December 2005, when Matthew was six years old, his school called DCF to report that Matthew had missed more than 30 days of school since the school year began, . DCF investigated and found neglect but later closed the case after Matthew’s attendance briefly improved.
In December 2006, the school again contacted DCF to report that Matthew had missed over 50 days of school. DCF closed the case six weeks later without finding neglect. Matthew’s mother told DCF that her mother was moving in to help her care for the children. This should have been a red flag because agency files documented Matthew’s grandmother’s long history of involvement with DCF, alcohol abuse and mental illness. But repeated risk assessments erroneously noted that Matthew’s mother had no history of being abused or neglected as a child.
In 2009, school officials again called CPS stating that Matthew came to school with bruising on his face that was covered up with makeup. School officials also reported contacting Ms. Tirado on other occasions regarding bruises, which she responded were inflicted by Matthew’s two-year-old sister. Matthew’s mother denied abusing him and the case was closed before requested medical records arrived.
In October, 2014, Hartford Public Schools (HPS) reported that Matthew’s sister, a first-grader, showed signs of physical abuse and reported that her mother hit her. She told school staff that Matthew was also hit, but he was not seen or assessed.
In November 2014, HPS reported to DCF that Matthew was not enrolled in school and may not have been in school for a long time. In fact, Matthew had hardly attended school since 2012. DCF found Ms. TIrado to be neglectful and abusive and opened a case on the family for supervision by the agency.
Matthew attended less than 100 days of school between June 2012 and his death in February 2017. HPS made five reports to DCF between October 2014 and May 2016. about the children’s failure to attend school. After March 2016, Ms. Tirado refused to allow DCF access to her children. In July, DCS iled a neglect petition with the Juvenile Court.
The Court held six hearings on the case between July and December 2016 but Ms. Tirado never appeared. In December 2016 DCS asked the court to terminate the case. No orders were sought to compel Ms. Tirado to produce the children, permit visitation of Matthew’s sister in school, or to remove the children, even though there was legal justification for any of these actions. Unbelievably, after a failed attempt to compel Ms. Tirado to come to court, the court accepted DCS’ request to close the case. DCS closed its own case on the family in January 2017.

After Matthew’s death, the Hartford Courant reported that Commissioner Katz shockingly told legislators that “As horrible as this may sound, there comes a point where you have to make a determination that you have done all that you can legally do. There are 15,000 cases and only so many social workers.”

The Commissioner also said that a system should not be judged based on one case. It’s an old refrain. But is it true? I don’t think so. There are many reasons why a system should be judged by one case.

First, we are not talking about one bad decision. A child suffered for as long as 11 years and agency social workers missed multiple opportunities to protect him. His sister fared a little better since she survived but will probably bear lifetime scars. This is more than a one-time event.

Secondly, for each “worst case, “we don’t know how many children suffer for years and don’t die while the system ignores repeated red flags. At least Matthew is out of his misery. The others are still suffering. We may never know their names.

I’m tired of agency heads who tell us not to judge the system by the worst cases. Lets bury this trope once and for all. A system should be judged–above all–by the worst cases. For each of these cases represents many more children whose daily suffering will lead to lifetime emotional educational and physical damage.

A potentially lifesaving algorithm in Allegheny County, PA

In August 2016, Allegheny County Pennsylvania (which includes Pittsburgh) became the first US jurisdiction to use a predictive algorithm to screen every call to the child abuse and neglect hotline. In a brilliant article for the New York Times Magazine, science writer Dan Hurley clearly explains how the tool works and how it changes current practice. Hurley’s account suggests that Allegheny’s experience is a hopeful one for the county and for children nationwide.

Hurley introduces the Allegheny Family Screening Tool, an algorithm developed by leading child welfare researchers in concert with DHS policymakers. To develop the algorithm, the authors analyzed all referrals made to the county child abuse hotline between April 10 and April 2014. For each referral, the authors combined child welfare data with data from the county jail, juvenile probation, public welfare, and behavioral health programs to develop a model predicting the risk of an adverse outcome for each child named on each referral. (A more technical description is provided by the authors here.) The end product was an algorithm that calculates a risk score between 1 and 20 for each child included in a referral.

The policymakers and developers chose to use the algorithm to supplement, not supplant, the clinical judgment of hotline workers. Only if the score exceeds a certain threshhold does it trigger a mandatory investigation; below that level the risk score it provides another piece of data to help the hotline worker decide whether to assign the case for investigation.

Among the most important takeaways from Hurley’s article are the following:

Before the development of the new algorithm, Allegheny County had experienced a series of tragedies in which children died after maltreatment reports had been made to the hotline but screened out. The problem was not incompetence or poor training. Hotline workers simply cannot within the 30 minutes to one hour allowed for decision making investigate all the historical data on all family members from numerous agencies with which they may have had contact.
Evaluation data shared with the reporter show that implementation of the Allegheny County Screening Tool resulted in more high-risk cases being screened in and more low-risk cases being screened out. Hurley provides a real case example. A teacher reported that a three-year-old child witnessed a man dying of an overdose in her home. Department records showed numerous reports to the hotline dating back to 2008 about this family, including allegations of sexual abuse, domestic violence, parental substance abuse, inadequate food, physical care, hygiene and medical neglect. Nevertheless, the hotline worker was poised to screen out the case as low risk. The tool, however, calculated a risk rating of 19 out of 20, causing an investigator to go out to the home. Eventually, the mother was found to be unable to care for the children due to her continuing drug abuse, and they were placed with family members, where they are doing well.
County officials were astute in awarding the contract to develop a predictive algorithm. Several other jurisdictions have gone with private companies such as Eckerd Connects and its for-profit partner Mindshare, which has a predictive analytics tool called Rapid Safety Feedback (RSF). The details of RSF are closely held by the companies, and the state of Illinois recently terminated its contract because the owners refused to share its details, even after the algorithm failed to flag some children who later died. The Allegheny Family Screening Tool is owned by the county. Its workings are public and have been published in academic journals. Moreover, its developers, Emily Putnam-Hornstein and Rhema Vaithianathan are acknowledged as the worldwide leaders in their field, with extensive publications and experience in doing similar work.
County officials were also astute in developing and rolling out their model. They held public meetings before implementing the tool, giving advocates a chance to interact with the researchers and policymakers. Choosing to use the tool at the hotline stage rather than a later step such as investigation made it less threatening as the tool is not being used as input on whether to remove the child, simply whether to investigate. In addition, the county commissioned an ethics investigation by two experts before implementing the tool. The reviewers concluded that not only was the tool ethical but that it might be unethical to fail to implement it. The concluded that “It is hard to conceive of an ethical argument against use of the most accurate predictive instrument,”
Many opponents of predictive analytics argue that it institutionalizes racial bias by incorporating data that is itself biased. Supporters have argued that predictive algorithms reduce bias by adding objective algorithms to subjective worker judgments. Preliminary data from Pittsburgh supports the proponents, suggesting that the algorithm has resulted in more equal treatment of black and white families.
Other jurisdictions are already emulating Allegheny County. Douglas County, Colorado has already commissioned Putnam-Hornstein and Vaithianathan to develop an algorithm and California has contracted with them for preliminary statewide work.

Given the Allegheny County algorithm’s promising results, one cannot help wondering whether a similar algorithm should be used at later stages of a case as well. A similar tool could be very useful in aiding investigators in making a decision about the next step in a case. Such a proposal would of course trigger an outcry if used to decide whether to remove a child from home. But like the Allegheny County screening tool, such an algorithm can be used to supplement clinical judgment rather than replace it. Policymakers need not set any level that would trigger a mandatory removal. However, they could set a risk level that requires opening a case, be it out-of-home or in-home. Many children in many states have died when agencies failed to open a case despite high risk scores on existing instruments. Algorithms can also be used to monitor ongoing in-home cases, as Rapid Safety Feedback has demonstrated. Perhaps if and when predictive algorithms are proven to be effective at protecting children they will be integrated into multiple stages and decision points, like the actuarial risk assessments that many states use today.

Identifying the children most at risk of harm by their parents or guardians has been one of the knottiest problems of child welfare. Allegheny County’s experience, as portrayed by Dan Hurley’s excellent article, provides hope that emerging predictive analytics techniques can improve government’s ability to identify these most vulnerable children and keep them safe.

Secrecy in child welfare: cover up or get better?

Kansas-Kids- — Evan Brewer, Caleb Blansett, Adrian Jones: From http://www.crimeonline.com

Clint Blansett’s 10-year-old son had been dead just a few days when a social worker from the state knocked on the family’s door in south-central Kansas . She wasn’t there to offer condolences after Caleb’s death or ask about his sister, Blansett said. She wanted him to sign a form saying he wouldn’t talk about his son’s death or the Kansas Department for Children and Families. No details about contact the agency had with the family before Caleb’s mom smashed his head with a rock while he slept and then stabbed him seven times.

So begins a story by the Kansas City Star entitled Secrecy inside child welfare system can kill: ‘God help the children of Kansas. In it. reporter Laura Bauer describes an agency that chooses to protect itself at the expense of fulfilling its mandate to protect kids. Among the examples included in the story are

A DCF deputy director resigned after she was asked to shred notes of meetings about critical cases. Furthermore, her attempt to implement a systemwide review process for such cases was refused because administrators did not want mistakes documented in writing lest they would be used in court against the agency.
For a year and a half, DCF refused to release information about its repeated interactions with the family of Adrian Jones, who was killed by his father and stepmother and fed to their pigs. It was only after the murderers were sentenced to life in prison that DCF reduced 2,000 pages of records that were haphazardly thrown together in what looked like a purposeful attempt to baffle readers. The records, once put in order, revealed multiple investigative errors, particularly three that probably cost Adrian his life.
A Wichita television station reported that DCF received several reports of mistreatment of Caleb Blansett, beginning in 2012 and continuing in the months before his death. On August 3, 2017, the Star requested information about these calls and any ensuing investigations. Three months later, DCF responded that it did not have the staff to respond to the request.
Just this past September, the body of three-year-old Evan Brewer was found in a cement structure outside the house where his mother and boyfriend were living. He had been missing at least since the previous March. His father claims to have made multiple reports to DPS alleging abuse of Evan. DCF denied a request from a local TV station for the records relating to these reports.

Kansas law requires that “in the event that child abuse or neglect results in a child fatality or near fatality, reports or records of a child alleged or adjudicated to be in need of care received by the secretary, a law enforcement agency, or any juvenile intake and assessment worker shall become a public record and subject to disclosure.” But unfortunately, the law does not define “reports and records.”

To receive federal money under the Child Abuse Prevention and Treatment Act (CAPTA), a state must allow “public disclosure of the findings or information about the case of child abuse or neglect which has resulted in a child fatality or near fatality.” Unfortunately, the vagueness of this language allows states to avoid releasing information necessary to identify how the agency failed. In a report entitled State Secrecy and Child Deaths in the U.S., two child advocacy groups found that all states have some sort of public disclosure policy regarding child abuse deaths. However, the report gave 20 states (including the three most populous states) a grade of C or below on these policies based on a variety of criteria, including whether they were encoded in statute, whether the disclosure is mandatory, and the scope and specificity of the information that must be disclosed.

Kansas was actually in the better half of states. It received a “B” from authors of the state secrecy report, mainly because it has a policy, the policy is encoded in statute, and is mandatory, despite the vagueness of the information that must be released. It is worth noting that only 14 states got higher than a B grade. Moreover, the report’s authors also found that states often fail to abide by their own disclosure policies–as when Kansas claimed to lack staff to respond to the request for information about the death of Caleb Blansett.

New Jersey’s child welfare agency, under the guise of protecting children’s privacy, in 2013 adopted a rule that the child welfare agency must release information only “to the extent it is pertinent to the child abuse or neglect that led to the fatality or near fatality.” Even the under the new tightened rules the agency should have disclosed information about its past interactions with the family of JoJo Lemons after he became the third sibling in his family to die while sharing a bed with other family members. His parents were charged with reckless manslaughter and child endangerment, and each pleaded guilty to a count of child endangerment. Nevertheless, CPS concluded that JoJo’s death was not caused by abuse or neglect. Therefore, the agency was not required to release information about its interactions with the family.

In Cleveland, 5-year-old Tenasia McCloud was beaten to death by her mother and her girlfriend on March 17, 2017. At the time of her death, the child welfare agency had an open case on the family, according to News 5 Cleveland. A social worker had visited the home eight times, including three days before Tenasia was brought to the hospital in cardiac arrest. The paper tried to find out how the agency did not see that the child was in danger. But Cuyahoga County Children and Family Services refused to provide records of agency contacts with the family, citing a rule prohibiting disclosures that might jeopardize a criminal investigation or proceeding. Only five other states have a similar rule, according to the State Secrecy study, suggesting that it is not a necessary requirement. Moreover, two states conversely allow disclosure only if a person is criminally charged or would have been criminally charged if they had not died.

Congress and the states must strengthen disclosure requirements in the event of child maltreatment fatalities or near-fatalities. Congress should amend CAPTA to define specifically what data states must release in the event of a child maltreatment fatality or near fatality. Until that happens, states should amend their own laws to strengthen the disclosure requirements. These disclosures should be required with no exceptions to any member of the public. The information required to be disclosed should include a summary of all past reports on the family or household, whether these reports were investigated, results of all past investigations and reasons for the determinations made; as well as a summary of all cases opened for the family or household, what services were provided, when the cases were closed and the reasons for closure.

Congress and states should also require that a commission of experts review every death or near-death of a child in a family known to the child welfare system. As I stated in a previous post, the death or severe injury of a child in a family known to the child welfare system should be treated like a plane crash or the loss of the space shuttle Challenger. All such deaths or severe injuries should be reviewed immediately and exhaustively by experts of the highest caliber with access to all agency records regarding contact with the family or household. The report should include recommendations to avoid similar tragedies in the future and should be released to the public with names redacted when necessary to preserve the privacy of innocent children and adults.

The point of requiring release of information and analysis of case history is not mainly to allocate guilt or punishment, although practitioners guilty of egregious errors should be retrained or let go. Rather it is to identify policies or practices that can save children in the future. As the authors of the state secrecy report put it:

Abuse and neglect deaths represent child welfare agencies’ most tragic failures. Unfortunately, it is often only through such cases that lawmakers and the public learn of systemic inadequacies in child welfare systems. If improvements and reforms are to be achieved, it is vital that the facts about these cases reach the public in a meaningful way.

Domestic violence and child abuse: a lethal combination

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It did not take long for the press to discover that Devin Kelley, the the perpetrator of the recent mass shooting in Texas, had repeatedly assaulted his first wife and fractured the skull of his infant stepson in 2012. He was court-martialed for those offenses, pled guilty, and was imprisoned for a year.

I could not help noting the parallel to the case that I wrote about in my last post–that of Antoine Flemons, who at two months old was beaten to death by his father, Antoine Petty. The post focused on one aspect of this case–the fact the father was known to have abused many other children. I argued that baby Antoine might have been protected by a broader policy to identify at birth babies born to parents with such a record.

But the revelations about the Texas shooter reminded me of another important aspect of Antoine’s family that put the baby in grave danger. In an interview with the Washington Post, Antoine’s grandmother stated that her daughter Geneice Petty loved her son but suffered from “battered women’s syndrome.” In other words, she was a victim of domestic violence.

The connection between domestic violence and child abuse is well-documented. Research suggests that “in an estimated 30 to 60 percent of the families where either domestic violence or child maltreatment is identified, it is likely that both forms of abuse exist.”

In the 40 states providing domestic violence data to the Administration Children and Families for its Child Maltreatment 2015 report, 25% of child maltreatment victims were found to have a caregiver who was either a victim, perpetrator or witness of domestic violence.

Co-occurring domestic violence and child abuse can take several forms. In many cases, one parent (usually the father) abuses both the other parent and the child or children. There are other configurations, such as families in which the abused parent in turn abuses the children.

In baby Antoine’s case, no information has been released to the public. One can speculate in view of the father’s extreme violence that Geneice Petty was afraid to protect her children and that her husband bullied her into covering up his killing of their son.

The key question is what could have been done to prevent the death of Antoine. Historically, child welfare systems have had not responded effectively to domestic violence. Common and problematic patterns have included ignoring or minimizing the domestic violence and, conversely, giving women an ultimatum to leave the abuser or leave their children–a response which often leads women to fear and avoid child protection authorities rather than seek their help.

One study found that “[Domestic violence]appears to have only a minor role in influencing the decisions of child welfare workers; yet, children exposed to [domestic violence] often have multiple contacts with [child welfare services] due to the higher number of repeat allegations of maltreatment.”

The Children’s Bureau has has published a useful manual about how to handle child maltreatment cases in which domestic violence is present or suspected. The manual’s many recommendations provide alternatives to the problematic practices mentioned above.

Unfortunately, we don’t know if Maryland child welfare workers even identified domestic violence in earlier cases involving Antoine’s parents, let alone how they responded. That’s why, as I have said over and over again about all child maltreatment deaths and serious injuries, there needs to be a thorough investigation, a public report, and a proposal for changes in policy and practice to protect future baby Antoines.

Would a broader birth match have saved Antoine Flemons?

Antoine Flemons 3 — Photo from GoFundMe fundraiser by Geneva Flemons

Little Antoine Flemons never had a chance. Prince George’s County Maryland Prosecutors described how his father, Antoine Petty, “dangled the infant by the arm and repeatedly struck him before handing the baby to his mother to feed. When the baby continued to cry, Petty dealt another round of blows, quieting the child forever.”

Antoine’s parents left his body in the car for over 24 hours before burying him, according to police. The Judge sentenced Petty to 40 years in prison for his son’s murder. Antoine’s mother pleaded guilty to involuntary manslaughter and will be sentenced in December.

Information shared by the prosecutors revealed that Petty, the father of nine, had a long history with Child Protective Services dating back until at least 2007. He was reported for carving a three-inch cross into a five-year-old daughter’s arm, pushing a five-year-old down stairs, giving a ten-year-old a black eye, forcing a daughter to watch him having sex with a girlfriend, and failing to adequately nourish an eleven-month-old. One of his children was found at age 11 months to have rib fractures which were found by a doctor to be ‘not accidental.”

How could this father be allowed to mistreat child after child and this mother to fail to protect them for close to ten years when so many acts of maltreatment were reported to CPS? It would be more appropriate to ask how such a parent can be stopped. When an abusive parent has a new child, there is no mechanism in most states to trigger protection for that child.

Interestingly, Maryland is one of the few states that does have such a mechanism– a “birth match” program. Under birth match, birth records are matched against a list of parents who had their parental rights terminated within the last five years due to abuse or neglect. Parents thus identified receive a visit from a social worker to assess the child’s safety. If the parents refuse the visit, a case can be opened if there is reason to expect abuse or neglect.

But Maryland’s birth match law did not protect little Antoine. It is unlikely that his parents had their rights terminated in the past. Perhaps Antoine would have been protected by a broader law, such as Minnesota’s, which triggers an investigation or family assessment under a broader set of circumstances. These include when a parent has subjected a child to “egregious harm,” has failed to protect a child from such harm, has committed child neglect endangering physical or mental health, and has committed first second or third degree assault among others.

We don’t know if a broader birth match law would have protected little Antoine because no information has been released about the results of the prior investigations against Antoine’s parents.

As I discussed in an earlier post, all deaths of children in families known to CPS should be investigated immediately and the results made available to the public. Only with such an investigation can we know how and why the system failed little Antoine.

There has been a shocking lack of calls for such an investigation from Maryland legislators and child advocates. Only the Washington Post broke the silence, asking, Could this 2-months old’s death have been prevented? Nobody who cares about children in Maryland should rest until they know the answer, and until measures have been put in place to prevent similar tragedies in the future.