Lethal reunifications: two children dead in New York and Florida

Their names were Rashid Bryant and Julissia Battles). She was seven years old and he had lived for only 22 months. He lived in Opa-Locka, Florida, and she lived in the Bronx. They were both taken into state care at birth. Julissia had a life of safety and love with her grandmother, occasionally punctuated by disturbing visits with her mother, until the age of six, when she was dropped off for a visit that ended in her death. Rashid knew 14 months of safety and care starting at birth, before the months of torture began. An inexplicable drive to reunify families, regardless of the lack of change in the parent’ ability to care for their children, is behind both of these tragic stories.

The 694 days of Rashid Bryant

By the time Rashid Bryant was born, on December 13, 2018, his parents were already known to the Florida Department of Children and Families, according to Carol Miller of the Miami Herald, whose articles from May 10 and July 8 are the basis of this account. Rashid’s parents, Jabora Deris and Christopher Bryant of Opa-Locka, had first come to the attention of the Florida Department of Children and Families (DCF) in 2013 and were reported at least 16 times to DCF. The allegations included parental drug abuse, physical injury, domestic violence, and inadequate supervision of their many children. The reports alleged that Deris smoked marijuana with her older children, that most of her children did not to school, that her home had no running water and that the children were hungry and losing weight. An allegation that Bryant had thrown one of his children into a car when escaping from police finally resulted in court-ordered in-home supervision of this family by DCF. When Deris and her newest child tested positive for marijuana, all of the children were removed but were soon returned to the family in August 2018.

By that time, Deris and Bryant had eight children including two younger than two and a hotline report said that the couple were leaving a 15-year-old in charge of several younger siblings, including a two-year-old who was seen outside naked. In October and November 2018, DCF received seven new reports, including drug abuse, inadequate supervision and “environmental hazards.” The couple’s children were taken into custody around Nov. 22, 2018 and were placed with relatives and foster parents. Less than a month later, their ninth child, Rashid, was born and was immediately taken into state care.

The 14 months from his birth in December 13, 2018 until his return “home” on February 2 may have been the only time that Rashid received the love and care he deserved. But the system had reunification on its mind. By August 2019 the parents were given unsupervised visitation, which was revoked after they suddenly moved without notifying the court, but was restarted again in January 2020. That same month, a supervisor with a private case management agency handling the case for the state of Florida stated that conditions for the children’s return had been met. But records reviewed by the Herald show that DCF did not agree, stating that “This determination was not supported, given that the reason for removal had not been remedied.”

On February 28, 2020 14-month-old Rashid and three brothers were returned to their mother by the court, despite the fact that DCF had asked the judge to return the children gradually, starting with one older child. According to agency records reviewed by the Herald, the children were sent home without supportive services to assist the mother with her four young children. As if that were not enough, the judge also saw fit to give “liberal, unsupervised visitation” to Deris with her other five children.

About a month later, Deris’ tenth child was born, to the “complete surprise” of caseworkers, who reported that she had denied in court that she was pregnant. Three weeks after the birth of her tenth child, the judge saw fit to return her remaining four children, leaving the new mother with the custody of ten children including five that were younger than five years old. Oversight of Rashid and the three brothers sent home with him ended in August of 2020, and all monitoring of the family end by October of that year at the judge’s order.

We don’t know when Rashid’s suffering began. We do know that he injured his leg around June 2020, but his mother waited two days to seek medical help, leaving the hospital with Rashid after refusing to allow an X-Rray. It appears Rashid spent the last five months of his life mostly in bed. At a June 22 pool party at the house of an aunt, Rashid and his father never left the car, according to the aunt. When she tried to pick him up from his car seat, she reported that Rashid began to cry. She never saw him again. Rashid’s maternal grandfather, who frequently visited the home, reported not seeing Rashid for about two months. (Why these family members did nothing in view of these red flags is another question.) Rashid’s brother, then 16, told police that he noticed something wrong with Rashid’s leg two months before he died because the little boy cringed and cried when it was touched. The teen described another incident where Rashid vomited all over his bed and then lay still and shaking with his legs up in the air. The teen could not remember if his mother sought medical attention after either of these incidents. After that incident, reported the teen, Rashid could not move his right arm. Four days before he died, a sister saw Rashid vomit after eating. She reported that the right side of his body appeared limp and his eyes were moving in different directions.

On November 6, 2020, two weeks after DCF closed the case on the family by court order, Rashid was dead. He had lived 694 days. The arrest warrant said that Rashid had suffered two seizures in the month before his death but his mother had never bothered to take him to a pediatrician. On the morning of Rashid fatal seizure, Deris called her sister saying he was unresponsive and “foaming from his nose and mouth.” Her sister told her to take him to the hospital. Deris did call for an ambulance–83 minutes later.

The Medical Examiner reported that in the months before his death Rashid had suffered two cracks to his skull — one healing, the other fresh. He also had a healing rib fracture and a recently broken leg. The cause of Rashid’s death was “complications of acute and chronic blunt force injuries.” The contributory cause was “parental neglect.” Deris and Bryant were arrested within a week of Rashid’s death and are awaiting trial on manslaughter and aggravated child abuse.

But somehow, DCF has not decided whether Rashid died of abuse or neglect–so they refuse to release the case files that they are required to release by law when a child dies of abuse or neglect by a caregiver . That requirement is in a state law that was passed requiring such revelations in the wake of the Miami Herald’s publication in 2014 of, Innocents Lost, detailing the deaths of about 500 children after DCF involvement. The Herald has filed suit against DCF and has been joined in the suit by a dozen media companies and advocacy groups.

Julissia Batties: from home to hell

On August 10, police and medics were summoned to the 10th-floor Bronx apartment where Julissia Batties lived with her mother, Navasia Jones, her 17-year-old half-brother, and one-year-old brother, as reported by the New York Times and many other media. Her mother gave inconsistent accounts to the police but it appears that after finding Julissia “vomiting and urinating on herself” at 5am, she waited three hours, and went to the store and the bank, before she called for emergency services shortly after 8:00 AM. Julissia was pronounced dead shortly after 9am. Julissia’s 17-year-old half-brother later told police that he had punched Julissia in the face eight times that morning because he thought she had taken some snacks. But those were not the injuries that killed Julissia. The medical examiner found injuries all over her body. On Friday her death was ruled a homicide caused by blunt force trauma to the abdomen. There have been no arrests so far.

Records show that Julissia’s mother had a long history of involvement with ACS and police. In 2013, the year before Julissia was born, Jones lost custody of her four older children. When Julissia was born in April 2014, she was immediately removed from her mother’s custody and placed with her paternal grandmother, Yolanda Davis. A family court judge initially granted Jones’ motion for custody of the new baby, but ACS appealed, and the appeals court stayed enforcement of the custody transfer pending their decision on the appeal. In 2015, the appellate court agreed with ACS, stating that “the mother had failed to address or acknowledge the circumstances that led to the removal of the child.” The court stated that although the mother complied with the services required by her case plan, “she was still prone to unpredictable emotional outbursts, even during visits with the children, and she was easily provoked and agitated. Indeed, the case planner testified that she had not seen any improvement in the mother’s conduct even after the mother participated in the mandated services.” The court concluded that “until the mother is able to successfully address and acknowledge the circumstances that led to the removal of the other children, we cannot agree that the return of the subject child to the mother’s custody, even with the safeguards imposed by the Family Court, would not present an imminent risk to the subject child’s life or health.” Wise words indeed. Julissia remained with her grandmother, Yolanda Davis, until being returned to her mother on March 2020, when she was almost six years old.

It appears that the COVID-19 pandemic had some role in the transformation of a weekend visit into a custody change that resulted in a child’s death. Davis told a local TV station, PIX-11, that a caseworker told her the visit had been extended due to the pandemic, and the extension never ended. Sources told the New York Post that the mother was officially granted custody in June 2021, though the circumstances are unclear. The decision to return Julissia to her mother appears to have been made at the recommendation of SCO Family of Services, a foster care nonprofit that was managing the case for ACS. After the first month or so, Julissia was not even granted visits with her grandmother, which would have been a much-needed respite and could have saved her, had the grandmother seen or reported injuries or other concerns. The New York Daily News reported that in May 2020, Davis was denied visits with Julissia because she had allowed the child to see her own father, Davis’ son. The motivation behind denying a child visits with the only parent she had known for six years are truly hard to understand.

There were many indications that all was not well in Navasia Jones’ household in the months before Julissia’s death. A neighbor told the Times that “there was always a lot of commotion, always yelling, always screaming” in the apartment. As recently as August 6, his girlfriend had called authorities to report that Julissia had a black eye. The neighbor told the Times that he had spoken to police and ACS staff about the family several times. Police reported to the Times that officers had filed at least nine domestic abuse reports on the family and responded to five reports of a person needing medical attention.

The decision to send Julissia home with her mother after six years apart is particularly strange because the Adoption and Safe Families Act of 1997 (ASFA) requires that a state must file for termination of parental rights after a child has spent 15 of the last 22 months in foster care. The requirement was written into law because children were languishing for years in foster care without a plan for permanency. It was recognized that children need permanency and stability and it is hard to understand why ACS and its contractor would want to move a thriving child from the grandmother who had parented her from birth to age six.

Much needs to be clarified to understand how this child was returned to the family that would kill her. ACS and SCO have declined to comment on the case, citing confidentiality. ACS did issue a statement that “its top priority is protecting the safety and wellbeing of all children in New York City.” But it is clear that other priorities took a front seat in Julissia’s case.

Factors Contributing to lethal reunifications

What explains the adamant determination on the part of some agency personnel and judges to return children to biological parents who have shown no sign of changing the behaviors that caused the system to remove them in the first place? To some extent, it reflects an ideology–one that is becoming increasingly dominant in the nation– that is committed to family preservation and family reunification at almost any cost. Child welfare is known for pendulum shifts in the emphasis on child safety as opposed to family preservation and reunification, but the latter is clearly in the ascendant right now. Extreme deference to this ideology can blind agency employees and judges to what is right in front of their faces: the failure of a parent to change the behaviors and attitudes that resulted in the initial removal of a child.

The obsession with family reunification at all costs can be encoded into social worker evaluations. In Tennessee, a recent survey of social workers suggests that they are being judged by whether they close cases in a timely manner, regardless of child safety. As one worker put it, “Children are returned home or exiting custody to relatives quickly to lower the number of cases without regard to whether the children will be truly safe and the parents ready to parent again.”

The current emphasis on family preservation and reunification is often justified as a way to ratify racial imbalances in child welfare involvement. A growing movement urges drastically scaling down or eliminating current child welfare services on the grounds that the overrepresentation of Black children in care compared to White children is a consequence of racism. Supporters call for elimination of the “disproportionality” between removals of Black and White children from their parents, while disregarding higher rates of poverty and historical trauma that result in more child maltreatment among Black families. To say that Black children need to stay with, or return to, abusive parents in order to equalize the percentages of White and Black children in care is to devalue children and reduce them to nothing more than their race, a strange position for an anti-racist movement to take. As described in a document entitled How we endUP: A Future without Family Policing, parts of this movement are fighting for repeal of ASFA, which would eliminate timelines and encourage jurisdictions to reunify children with their birth parents years after they had established parental bonds with other caregivers, such as grandmothers or former foster parents.

Racial considerations are not the only factor driving systems to support reunification at all calls. Lethal reunifications occur in states like Maine, where 88 percent of the children in foster care are White. Maine’s Office of the Child Advocate recently reported that the state’s child welfare system continues to struggle to make good decisions around two critical points–the initial safety assessment of a child and the finding that it is safe to reunify the child with her parents. In its review of seven cases closed through reunification, the OCA found multiple incidents where children were sent home with insufficient evidence that they would be safe. In one case, the parents had not been visited for a year-and-a-half despite the fact that home conditions were a reason for the original removal. In another case, providers were not contacted or given the information they needed to treat the issues that had resulted in the removal. In another case, the parent “failed to understand or agree to the reasons the children entered custody, but this was not considered significant.” In yet another case, the trial home placement started too soon and the parent never completed required substance abuse treatment. The child was sent home two months after the parent had a positive toxicology screen.

In responding to the criticisms of Maine’s OCA, OCFS admitted that “staff have been challenged with the current workload based on the increase in the number of calls, assessments, and children in care.” It is clear that insufficient of resources lead to excessive caseloads around the country, endangering children. In Tennesseee, for example, while caseloads are not allowed to exceed an average of 20 (a very high number in the experience of this former social worker) data obtained by the Tennessee Lookout, indicated that 30% of caseworkers had caseloads of more than 20, and that many had 30, 40 or even 50 cases. Insufficient funding often means low pay and a difficulty in attracting people with the education and critical thinking skills required for the job. High caseloads and poor pay lead to high turnover, resulting in a loss of institutional memory about specific cases that may drag on for years, such as those discussed here. In turn, high turnover leads to high caseloads as social workers have to pick up cases from those who leave. Such factors may or may not have contributed to the deaths of Rashid and Julissia; they have certainly contributed to other child deaths around the country. Most taxpayers don’t want to think about these systems or fund them; it is easy to avoid reading about the consequences when they occur.

And cost considerations drive reunifications in another way as well. Reunifications save money for cash-strapped child welfare systems. Once a child is sent home and the case is closed, the jurisdiction incurs no more expenditures for foster care. If the child is instead placed in guardianship or adoption with a relative or foster parent, the jurisdiction may end up paying a monthly stipend to the caregiver until the child turns 21. Of course, many relatives who step up to the plate like Julissia’s grandmother are not paid, due to the same budget concerns. giving rise to the current outcry and debate around hidden foster care.

Family court problems contribute to lethal reunifications as well. Rashid’s death appears to be primarily due to a judge who insisted against agency protests on the return of nine children in the space of two months, during which the mother also gave birth to a tenth child. The information available suggests that Florida DCF staff proposed a much slower reunification process. We don’t know what influenced the judge’s decision, but we do know that family courts are overwhelmed and in crisis, resulting too often in the deaths of children in both custody and child protection cases. These courts are inundated with cases, judges often lack the training they need, delays are all too frequent and were worsened by the pandemic. Judges rarely see consequences for decisions that lead to an innocent child’s death, and I have never heard of a judge being removed for the death of a child that was placed in a lethal home against all the evidence. The judge who sent Rashid to his death probably continues to endanger other children daily. This judge must be named, punished, removed and never again allowed to send children to their deaths.

The degree to which the pandemic contributed to Julissia’s and Rashid’s deaths is impossible to estimate. Julissia’s irregular reunification was justified to her grandmother on the grounds of the pandemic. Both Rashid and Julissia should have been visited regularly at least monthly once they were placed with their original families, depending on state regulations. Visits to Rashid should have occurred until the judge terminated them in August, well after the leg injury that left him bedridden, and he should have also been seen in the visits to his siblings that terminated in October. Even if the case managers were visiting (virtually or in real life) only the four children whose cases had not been closed, they should have had the curiosity to ask about little Rashid. For Julissia, there should have been visits throughout her 16 months in hell. Were these visits conducted at all, virtually, or in person? What information was gathered at these visits? This information that must be revealed.

This is not my first post about a lethal reunification in Florida. In January 2019, I wrote about Jordan Belliveau, who was murdered by his mother eight months after being reunified with her, even while a agency in Pinellas County was still monitoring the family. A caseworker for the agency and later resigned told News Channel Eight that the system “puts far too much weight on reuniting kids with unfit parents and makes it nearly impossible for caseworkers to terminate parental rights.” It does not appear that the state learned from Jordan’s death.

I could have written about other lethal reunifications in New Mexico, Ohio, and elsewhere. But I often resist writing about the deaths of a specific child or children known to the system that was supposed to protect them. There are so many reports of such cases, and they are only the tip of the iceberg. Why choose one and not another? I cried for Rashid but I did not write about him until I read about Julissia. Then I knew that I had to write about both, because they represent so many others whose names we will never know. Some of these children’s names may never be known to the general public because there was no outraged grandmother to speak out, no determination of the cause of death, no charges by police, or no alert reporter to reads a crime report and ask questions. But others are unknown because they are suffering in silence and darkness. Because death is not the worst thing that can happen to a child whose life is one of unremitting pain.

Taking racialized thinking to its illogical conclusion: a state senator responds to David Almond’s death

Image: WJAR

Last week I discussed the scathing report by Massachusetts’ Child Advocate revealing the many opportunities that the Massachusetts Department of Children and Families (DCF), Juvenile Court, and schools missed to prevent death of David Almond and the serious physical and emotional injuries to his brothers.” All of these agencies were aware of multiple red flags in David’s case but somehow, unbelievably, managed to disregard them all. The report describes seven months of abuse, starvation and denial of their right to education of two autistic boys, as the family systematically lied to school and DCF staff and kept the boys out of their sight. The family’s efforts to use the COVID-19 pandemic to avoid any scrutiny of the boys’ well-being apparently transparently obvious to readers of the Advocate’s report but apparently raised no red flags for those paid to care for and educate these vulnerable children.

On May 4, Massachusetts Child Advocate Maria Mossaides testified about her 107-page report. If her testimony was anything like reading the report itself, it should have been devastating and left little room for questions other than “How could this happen?” and “How can we make sure it never happens again?” But Committee Chair Sen. Adam Gomez did not seem touched by the suffering of the boys and failure of any agency to protect them. As described in Shira Schoenberg’s May 6, 2021 article, Gomez’s first question had to do with race. What he wanted to know was “Did Mossaides’s analysis of the Almond case….incorporate a racial equity lens and consider whether there was a ‘racial difference in the treatment of the Almond family with similarly situated families of color?’”

How could this be the first question asked by the legislator tasked with protecting the most vulnerable Massachusetts children? As I stated in an op-ed published by Commonwealth Magazine, Gomez appears to be in thrall to a dominant narrative that has taken over the child welfare world with the help of some very wealthy foundations. in this view, CPS workers take children away from their capable and loving parents, especially parents of color, and often refuse to give them back. In this narrative CPS is likened to the police, interfering in families of color based on racial bias. Some of these advocating this view argue that both the police and CPS should be abolished.

It is true that Black and indigenous children are more likely to be placed in foster care than White children. National data indicate that Black children represent 23 percent of the children in foster care, compared to only 14 percent of children in the general population. Native American children are approximately two percent of the children in foster care compared to one percent of the child population. Latino children are actually underrepresented in foster care at the national level, though they are overrepresented in some states, including Massachusetts, as Commonwealth Magazine recently reported. 

There is considerable evidence that the disparities in foster care placement between Black, Indigenous and White families are due to differences in the underlying rate of child abuse and neglect. However, that is actually beside the point that Senator Gomez was making. He was asking if David Almond would have been reunified with his family had he been Black. Studies do indicate that families of color wait longer to reunify with their children.  But new research indicates that after adjusting for other relevant factors (like the cause of removal and the length of stay in foster care), there are no differences in the likelihood of reunification with their families for Black or multiracial children and White children. Hispanic children are more likely to reunify with their families, and indigenous children do have lower odds of reunification than White children. Moreover, a state’s degree of disproportionality in representation of Black and Hispanic children in foster care  did not affect its reunification rates for these children.  So there is no evidence that David would not have been reunified with his father had he been Black or Hispanic.

But let us set aside the research and follow Gomez’ thinking to its logical condition. Let us say he is right, and David would not have been returned to his parents had he been Black, Indigenous or of color (or “BIPOC,” as he put it). In that case, David would have been saved. The only logical conclusion is that Massachusetts ought to take steps to ensure that White children receive the same level of protection from deadly parental abuse as is currently afforded “BIPOC” children.  Yet somehow this does not appear to be the point Senator Gomez was attempting to make. 

Perhaps one key to Gomez’ apparent paradoxical thinking is that he and other child welfare “racialists” like to focus on the rights of parents, not children. According to this thinking, David’s parents benefited from White privilege by being given the benefit of the doubt over and over again. Perhaps if David’s parents had been Black, they would have lost custody of David earlier- before he had been removed from them and returned to them four times. But thanks to their White privilege, David’s parents got to keep (and kill) their child while Black parents would not have been afforded the same privilege.

Of course taking a child-oriented perspective flips the script, so to speak. Where David was allowed to die, a Black child in his his shoes might have been saved by a system that Gomez believes is harder on parents of color. But Gomez is not worrying about Black children dying at the hands of their parents. He and his allies are worried about the unfair treatment of Black parents who might not be extended the privilege of keeping their children long after compassion and common sense dictated a removal to a safe place.

I’m not sure why Gomez and his friends have chosen to focus on the treatment of parents rather than children. Perhaps the answer is that if they talked about children instead, they would have to make clear that they want lower standards for how children of color can be treated compared to White children. And that would hardly be a compelling argument for for anyone who cares about children of any race.

This is an expanded version of an op-ed published in Commonwealth Magazine on May 13, 2021.

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

Image: Family Connects Durham

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Detroit Prevention Project: Preventing child maltreatment by supporting at-risk families

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The current mainstream discourse in child welfare is all about prevention: reaching families before maltreatment occurs instead of intervening afterwards. Many jurisdictions pay lip service to this mantra by making services available to high-risk communities but not targeting these services to the families who need them most. The Detroit Prevention Project, launched by the Michigan Department of Health and Human Services (DHHS) in conjunction with an innovative organization called Brilliant Detroit, is different. It reaches out to families at risk of child maltreatment with an intensive case management and peer mentorship intervention aimed at preventing child abuse and neglect.

“One of the top priorities of the new administration when it comes to the child welfare system is to connect with families and provide them with support and resources before there is a need for Children’s Protective Services to file court petitions,” said JooYeun Chang, who served previously as the head of the Children’s Bureau and Managing Director of Casey Family Programs and came to Michigan in 2019. “We believe children are better off when they are with their families as long as we can work with families to make sure the children are safe.”

Interest in preventing child maltreatment before it occurs has been increasing in child welfare. But the drop in CPS reports under virtual schooling, which deprives the current system of its main trigger for action, has led to even more interest in prevention.  In Michigan, DHHS had already begun to formulate plans for shifting toward a more proactive approach but COVID-19 accelerated those efforts, according to a recent article from Second Wave Media.

The new program, called the Detroit Prevention Project, pairs families at risk for child maltreatment with two workers, each performing a different function. Peer mentors, also known as “parent partners,” are community members who have experience in navigating the child welfare system in Detroit. They receive training in mental health peer support and how to work within MDHHS systems. Benefits navigators connect families to community resources such as food, housing assistance, education, and employment. The use of peer mentors or counselors is a newer approach in child welfare that has been shown to produce positive effects on outcomes associated with reduced child maltreatment. While many other programs use either peer mentors or benefits navigators, combining the two is an innovative approach.

DHHS decided to pilot its new approach in two of the zip codes with the highest rates of referrals of child abuse and neglect in the state. They chose to work with Brilliant Detroit, an organization founded in 2015 to “provide a radically new approach to kindergarten readiness in neighborhoods,” according to its website. The program has created family centers in neighborhoods which attempt to provide families of children aged 0 to 8 with all the services (emphasizing health, family support and education) needed to ensure school readiness and provided needed family support. Co-Founder and CEO Cindy Eggleton was awarded a 2021 Purpose Prize from AARP for her work in founding and directing Brilliant Detroit.

Families are also given access to a variety of programs already offered by Brilliant Detroit. These range from anger management and GED classes to nutrition workshops and fitness activities. Also offered are community based playgroups, intensive tutoring for the kids, family literacy programs, “parent cafes” to help parents connect, workforce and financial literacy training, free sports for children, and more.

The program is strictly voluntary and is being offered to a group of families drawn from two sources. DHHS is referring families that were the subject of a child protective services investigation in the past year based on their score on its Structured Decision Making (SDM) Tool. SDM is an actuarial assessment system, used by many states, to assess risk and make decisions about how to handle a case. Families that had an investigation closed with a score of III (evidence of abuse or neglect but a low or moderate level of risk to the child) or IV (insufficient evidence to show that abuse occurred but future risk of harm to the child) are normally referred to community services. These families will be invited to participate in the Detroit Prevention Project. Brilliant Detroit is also offering the program to families that it already knows from its neighborhood work.

The goals of the program are as follows, according to the document provided by Brilliant Detroit:

  • Reduce the number of at-risk families in zip codes 48205 and 48288 that are reported from child abuse and neglect;
  • Align existing MDHHS programs with Brilliant Detroit’s network of partners to create a comprehensive continuum of services.
  • Provide data on the efficacy of the model
  • Construct a model that can be scaled up through additional funding and community based partnerships.

The Detroit Prevention Project was jointly developed with leadership from the Skillman Foundation and Casey Family Programs. Skillman suggested that MDHHS talk to some of their partners on the ground, including Brilliant Detroit, to flesh out the ideas, which led to the partnership. The funding is being provided by MDHHS, Casey and Skillman. When it reaches full scale, the program will serve 400 families.

The Detroit Prevention Project embodies the prevailing sentiment in child welfare in favor of preventing abuse and neglect before they occur. This push has been led from the top by the Children’s Bureau, where Chang’s successor Jerry Milner has been a forceful advocate for this approach. Many states have responded with enthusiasm and new programs. However, some states have created new programs (like the Family Success Centers recently opened by the District of Columbia based on New Jersey’s model) without targeting them to children that are at risk of child abuse or neglect. Without a systematic effort to reach out to the families who need these services most, there is no assurance that these families will receive the services.

DHHS might want to consider using the Detroit Prevention Model to reach further upstream, following the example of Allegheny County, Pennsylvania. Allegheny County’s Hello Baby program reaches out to parents of new babies to offer them a tiered set of services. Families with the most complex needs based on a predictive risk model are offered the most intensive approach which, similar to the Detroit Prevention Program, matches each family with a peer counselor and a case manager. Given Brilliant Detroit’s mission of focusing on children from zero to eight and DHHS’s focus on prevention, this would be a natural step for both partners.

Participation in the Detroit Prevention Program is strictly voluntary, which means that some of the most troubled families will refuse to participate. Research indicates that it is difficult to engage the highest-risk families in voluntary services. We hope that the program will collect and report on the number of families refusing to participate and track their future maltreatment reports, in order to assess the extent of this problem. If it is extensive, leaders may need to consider using a family’s refusal to participate as the trigger to initiate an investigation.

Michigan DHHS should be commended for the implementation of the Detroit Prevention Program. We hope that child welfare leaders in other states are watching this initiative carefully. We also hope that DHHS will subject this program to intensive evaluation so that we can learn from this experiment experiment.

Hello Baby: Innovative child maltreatment prevention program launches in Allegheny Co., PA

On September 21, 2020, the Allegheny County (Pennsylvania) Department of Human Services (DHS) began rolling out a “first of its kind” parenting initiative called Hello Baby. The program aims to support and strengthen families of newborns who are at risk of abuse and neglect, so as to prevent the occurrence of maltreatment rather than responding after it occurs. This new program is an innovative approach that attempts to avoid the flaws of many other programs that aim to prevent child maltreatment.

Hello Baby is a “voluntary program for parents of new babies, designed to strengthen families, improve children’s outcomes, and maximize child and family well-being, safety and security.” As described in a Frequently Asked Questions document and a Methodology Report on the Allegheny County Analytics website (which contains. many other relevant documents as well), the program combines a universal entry point with differentiated services in a three-tiered approach, as described below:

  • Universal Tier: Services available to all new parents in the county include a “warmline,” the Hello Baby website, and a texting service staffed by volunteers to answer questions about newborns and parenting issues.
  • Family Support Tier: Families with “moderate needs” will be served through the existing network of 27 Family Centers located around the county. These families will have access to the rich array of services offered by these centers, including home visiting, family support, and child care subsidies.
  • Priority Tier: Families with the most complex needs are offered the support of a two-person team employed by Healthy Start Pittsburgh, which was selected through a Request for Proposals. The teams are made up of a family engagement specialist, who functions as a peer counselor, and a social worker who plays the role of case manager. In the pandemic environment, they will meet with families both virtually and in home visits. These teams work with families to learn about their needs, connect them to resources, and provide wraparound assistance, which will be available until the child turns three years old. This wraparound assistance can include concrete goods, transportation assistance, and connections to community resources. The priority tier model is based on the COACH Model of the Camden Coalition, a behavior change intervention for people with complex needs.

Every new mother in the county receives information about the program through her birthing hospital, OB/GYN, or pediatrician and may receive an initial visit from a nurse to talk about the program in more detail. A few weeks later, each family receives a postcard informing them of the universally available services and giving them the opportunity to opt out of further contact. Families with moderate and higher levels of need who have not opted out of services will be contacted by the Family Centers or two-person teams, respectively.

The placement of newborns into three different risk groups will be based on a predictive risk model (PRM), another unique part of this program. The model is designed to identify the families with the highest likelihood of having a child removed to foster care before the age of three. The model uses data already available from birth records, child protective services, homeless services, and justice system records to calculate a risk level for each child. Model development was led by Rhema Vaithianathan and Emily Putnam-Hornstein, along with the data science team based at the Centre for Social Data Analytics (Auckland University of Technology, NZ). Vaithianathan and Putnam-Hornstein are world leaders on the use of PRM in child welfare, and they have been working with Allegheny DHS since developing the county’s child abuse hotline screening tool in 2015. While most Priority Tier slots will be filled through PRM, some slots will be reserved for parents who request intensive support or those referred by clinical providers.

The program planners made extensive efforts to address potential concerns about privacy, coercion to participate, or involvement with child protective services (CPS). Hello Baby is not connected to CPS. The risk scores will not be shared beyond program staff, used after the initial screening, kept on file, or used for any child welfare purpose. No family will be reported to CPS for refusing to participate in the program. DHS estimates that 40 percent of the families assigned to the most intensive service tier will already be involved with child welfare. These families will be eligible for the program except when safety issues are so grave that the baby is removed right after birth by CPS. If the family agrees, Hello Baby staff can work directly with the child welfare caseworker to make sure the family receives the best services to meet their needs.

The FAQ document cites several reasons for the development of Hello Baby. For one, agency leaders recognized that the county was rich in programmatic resources but that the resources were not reaching those who needed them both. Second, they realized that the historical practice of targeting high-poverty areas for prevention efforts (like the county’s Family Centers) leaves out many families in need because the root causes of child maltreatment (such as substance abuse, mental illness and intimate partner violence) cut across economic lines. Finally, even within a community with a Family Center, evidence suggests that those who need it most may not access the services.

The focus on ages 0 to 3 was chosen because infants and children are most at risk of serious abuse and neglect–and most likely to die of such maltreatment. Almost 80 percent of Allegheny County children who suffered fatalities connected with abuse or neglect were under the age of three. And half of them were unknown to the child welfare system, which means that there had been no earlier opportunity to protect the child.

According to an account on the county’s DHS website, Allegheny’s child welfare leaders began thinking about a child maltreatment prevention program using a tiered approach supported by predictive risk modeling (PRM) in 2015, when they were developing the Allegheny Family Screening Tool (AFST) for screening hotline calls to determine their relative risk level. If they could use PRM to screen child maltreatment reports, DHS leaders asked, would there be a way for them to use these methods to reach families “BEFORE they reach the breaking point?”

The fact that Allegheny County DHS is already using PRM to screen hotline calls is a testament to the vision and courage of its leadership. Few other jurisdictions have implemented PRM in child welfare in part because of the controversy surrounding the use of an algorithm in decisions about case opening.[1] But DHS Director Marc Cherna is one of the longest-serving human services directors, having served in the position since 1997 and has won nationwide recognition for his innovative initiatives. He was was the first director of DHS, a mega-agency that was the outcome of a merger between several discrete departments. As described in a case study, Cherna took the opportunity to create a “data warehouse” integrating information from the formerly separate agencies. This integrated database in turn provided the opportunity to improve decision-making using PRM. In response to a Request for Proposals, DHS chose the team led by Vaithianathan and Putnam-Hornstein to develop the AFST and later the Hello Baby tool as well.

Hello Baby is the outcome of many years of research and planning by DHS leadership working together with community members, according to the FAQ document. The process included an extensive literature review focused on how to engage and retain families with intensive and complex needs. In addition to the internal literature review, DHS commissioned two independent ethical reviews. The developers also met with families receiving services, service providers, clinical experts, judges, Family Court advocates, peer support agencies, national experts, local funders; and civil liberties, civil rights and social justice organizations to identify service gaps and concerns. Finally they conducted case reviews with social workers and child development experts in order to understand the population they were seeking to reach.

Hello Baby was launched on September 1, 2020 and is being piloted at a subset of sites before being rolled out statewide after a year. DHS anticipates providing Priority Tier service to five percent of families with new babies or about 650 families per year when the program is fully implemented. The County has contracted with two respected social science research institutes–Chapin Hall and the Urban Institute–to conduct process and impact evaluations of Hello Baby.

As Vaithianathan and Putnam-Hornstein explain in their methodology document, we know very little about what works, and for whom, to prevent child maltreatment. Therefore, new approaches are needed. Hello Baby’s combination of universality and targeting is appealing based on logic. As DHS. explains in an implementation brief provided to Child Welfare Monitor, universal services have many benefits, like reduced stigma, wider reach and no need for eligibility requirements. But when resources are limited, services are stretched thinly across many families. Families with the greatest needs may not get the intensity of services they need, while families with lesser needs may receive support disproportionate to their needs. Hello Baby addresses this problem with its tiered service array.

DHS has undertaken an elaborate process to protect privacy and self-determination and prevent the use of risk scores in any context other than assigning families to Hello Baby tiers. However it must be recognized that there is a tradeoff between parental self-determination and protecting children. Prior research indicates that it is difficult to engage the highest-risk families in voluntary services. By ruling out the possibility of reporting these families to CPS, DHS may be condemning some children to years of neglect, abuse, injury, or even death. We hope that DHS will collect and report on the number, risk scores, and future maltreatment reports, of those who decline to participate in order to assess the extent of this problem.

We congratulate Allegheny County for the implementation of Hello Baby. The lack of attention to the rollout by prominent child welfare organizations, thought leaders and media is surprising. We hope that child welfare leaders are are paying attention to this important initiative and thinking about options for similar programs.

[1]: Much of the controversy around PRM centers on fears that it will exacerbate racial disparities in child welfare decision making. But an evaluation of the AFST has suggested that it has reduced, rather than increased, racial disparities in the rate of case opening between White and Black children, thus assuaging fears that it would increase such disparities.

Child protection in the time of Covid-19: what we know and what we can do

Every year when school resumes after summer vacation, child welfare agencies brace themselves for an onslaught of reports as teachers see children after the entire summer and flood hotlines with reports of suspected abuse or neglect.  Earlier in the year, many officials and advocates expressed concern that this fall would see any even greater surge of calls than usual and that child welfare agencies would be overwhelmed. But as more and more schools and systems opted for a virtual opening this year, policymakers and advocates began to worry about the opposite problem–a continued dearth of reports to child abuse hotlines and a continued fear that children are suffering unseen.

A chorus of media reports from all over the country last spring documented drastic drops in calls to child abuse hotlines following school closures due to the coronavirus pandemic. As Child Welfare Monitor reported, almost every state reported declines in hotline calls last spring, with calls dropping often by half and sometimes by as much as 70 percent since schools shut their doors. A survey of children’s advocacy centers, which work with victims of physical and sexual abuse nationwide, found a 21 percent drop in the number of children served in January through June of 2020 compared to the same period in 2019; the drop would probably be much greater if only March through June were considered.

The loss of reports from schools was the primary explanation for the drops in reports of child maltreatment. And indeed the shift to online education delivered a double-whammy to any attempts at child protection. For children who did attend virtually, it was harder for teacher to see signs of trouble, like bruises or hunger. And many students who did did not show up for virtual education regularly or at all. The New York Times heard from many teachers around the country that fewer than half of their students were participating in online education. The School Superintendent in Los Angeles has reported that only 60 percent of students participated daily in online learning last spring. A child’s failure to participate may reflect the lack of a dedicated computer or internet access, difficulties in accessing platforms, a child too busy watching siblings or even working, or lack of engagement in virtual education.  Whatever the explanation for their absence, these children were not being seen by teachers, counselors or other school staff, often the ones who notice red flags. Other reporters, like doctors and extended family members, were also less likely to see children under the Covid-19 quarantine. 

More detailed data from Allegheny County Pennsylvania and two Colorado counties (shared in a webinar from Mathematica Policy Research) and from Maine (shared in a Child Welfare League of America webinar) shed some light on changes in reporting trends in the last school year and what they might mean.  The number of calls to child abuse hotlines (also called reports or referrals), as compared to the previous year, fell dramatically in all three states. The decline in reports was especially marked among teachers and other school staff such as counselors. In all the jurisdictions  the lower-risk referrals tended to drop off the most. In the data for Colorado and Allegheny County, where predictive risk modeling is used to screen hotline calls,  the average risk scores of the children being referred rose, suggesting that the lower-risk referrals tended to drop off more than the higher risk referrals. Maine officials found that reports were generally more severe and that they were getting fewer reports that were screened out as inappropriate or because there were multiple reports from the same family. Participants in both webinars suggested that in normal times schools make too many unnecessary reports for minor issues, and that many of these reports were being suppressed by the school closures.

It is encouraging that less serious referrals are more likely to be dropped than more serious ones, but it is equally clear that higher-risk referrals are being lost as well. Another important indicator is the percentage of referrals that result in a substantiation–or a finding that abuse or neglect has occurred. If the missing referrals were mainly frivolous,  we would expect a big increase in the percentage of reports that was substantiated. That did not occur in at least one state–Michigan–spurring its child welfare director to design an initiative discussed below. Unfortunately, substantiation data on a national level for last spring will not be available for another year from the federal government. 

At the same time that reports dropped, many child advocates have expressed fear that child maltreatment has actually increased. Based on past research, family violence increases in times of natural or economic disasters, probably in large part due to parental stress. In addition to the stress imposed by job loss and health concerns, parents who are cooped up in close quarters for months with their children may be more prone to respond with violence. And parents who need to work despite school closures may leave their children uncared for or with caregivers who are unprepared.

Despite these reasons to suspect that child maltreatment may be increasing, we do not have any national data to confirm or deny it. Data from individual hospitals in various locations around the country has been cited to demonstrate that cases of severe child abuse are increasing. Hospitals around the country have reported increases in serious injuries and even deaths compared to previous years. Reports of such excessive child abuse injuries and deaths have come from hospitals in Fort Worth, Texas, Orlando, Florida, Colorado Springs, Colorado, Washington, DC, and Pennsylvania. But without systematic data from hospitals, we really cannot know if this represents a national trend.

Last Spring, child advocates worried about the unseen children who would have to wait until schools reopened after the summer to have their situation discovered. But as more and more districts abandoned plans to open school buildings, it became clear that the anticipated onslaught of hotline calls would not occur in these jurisdictions. What can be done to ensure that children are safe? Several different approaches have been tried or suggested.

Public awareness campaigns: Some jurisdictions have instituted publicity campaigns encouraging members of the community to  report child abuse and neglect. For example,  the New Jersey Department of Children and Families launched a ‘Social Distancing Shouldn’t Mean Social Isolation’ campaign to raise awareness about child abuse, domestic violence and other dangers facing residents while homebound. It include a flyer about warning signs of child abuse as well as a more general resource that includes telephone numbers for the child abuse, domestic violence, mental health, and other hotlines. In a Call to Action for State Governors, CHILD USA, a national think tank focused on child protection, suggests that Governors should add to all their COVID updates a reference to the need for all adults to be alert for signs of abuse and neglect, along with how to reach the child abuse hotline.

Providing new guidance to traditional reporters: Some agencies have created new resources to share with educators and other traditional reporters of child abuse and neglect.  Maine issued guidance for educators, medical personnel, and community members to help them identify warning signs of child abuse and neglect in a time of virtual education.  CHILD USA released a useful list of Tips for Teachers on Child Welfare and Online Safety during COVID-19 which suggests questions for teachers to ask that are targeted at elementary, middle and high school students. The questions focus on food, physical safety and online safety. The document also includes tips on what to look for in the home environment as perceived through a computer screen. The Zero Abuse Project has published Responding to Child Abuse During a Pandemic: 25 Tips for MDT’s, which provides tips that might be useful for child welfare agencies as well. The authors included some valuable advice, such as a reminder to teachers that abuse has been shown to increase after a child receives a bad report card. They suggest that teachers. contact parents in advance of giving out a bad grade, promise to follow up (with the hope of defusing any violence) and call authorities if parents indicate a plan to punish the child physically,.

Reaching Out to Nontraditional Reporters: Some child advocates like family violence researcher Andrew Campbell have urged states to reach out to nontraditional reporters, such as postal workers, garbage collectors, and home repair agencies, who are continuing to see children as they move through homes and neighborhoods. A simple postcard listing the warning signs of child maltreatment and the phone number of the child abuse hotline could be distributed to businesses and agencies employing such workers. Animal protection agencies are another potential community partner for child welfare agencies, as Campbell also suggests. Animal control officers could be trained and enlisted to check up on the wellbeing of humans as well as animals in homes where animal abuse has been reported.

School Based Approaches: Schools have a critical role to play in ensuring that children can be protected in a time of virtual schooling. Districts must make sure that all students have access to a computer and high-speed internet service. It is critical that they adopt a policy of checking in with all students they have not been able to reach for a specified period of time, whether a day or a week.  Clearly this is easier said than done in schools serving largely disadvantaged populations. Media outlets have reported on the herculean efforts of dedicated school staff who have spent months trying to locate students who were missing from virtual education. Schools can also provide training to their teachers in how to spot red flags in virtual meetings, as Pueblo County Colorado has done. Schools should also consider adding to their virtual platforms an option for children to indicate that they are in trouble at home and need help. 

Reaching out to at-risk families known to the system: Noticing the precipitous fall in calls to the hotline without a corresponding rise in substantiation rates, Michigan’s child welfare director JooYeun Chang feared  that some children in need were “simply invisible,” as she explained to the editor of The Imprint. Before the pandemic arrived, the agency had commissioned an assessment from Chapin-Hall, a child welfare think-tank, which had identified 14,000 families that had been involved with the agency and had a high risk of children entering foster care without receiving additional preventive services. About 1,000 child protection workers freed up by the decline in hotline calls were assigned to reach out to these families to find out if they needed any type of assistance. Data provided to Child Welfare Monitor indicate that workers spoke with 8,267 of the 14,162 families on the list, and 80 percent of the families received a text, email, or mailing. Workers provided general support, information and referrals. Many parents expressed great appreciation for the calls; some conversations lasted 45 to 90 minutes. One worker was able to contact a cash assistance worker and rectify the erroneous closing of a case, another provided referrals to a father struggling with physical and mental health problems who thanked the worker several times just for listening. The agency is now reaching out to another 10,000 families that were investigated since the Covid-19 shutdowns began.

Inspired by Michigan, Allegheny County, Pennsylvania DHS is using staff and community partners to connect with higher-risk families involved in child welfare cases that closed six months earlier, to check in and find out whether they need help with food, housing or other services. Checking in with families to offer assistance is not designed to identify ongoing abuse or neglect. However, it may reduce the probability of child maltreatment recurrence by helping families meet concrete needs for food, clothing and shelter and even by offering them a friendly ear and reducing their social isolation.

Investing in Prevention: Interest in preventing child maltreatment before it occurs as was already growing before the Covid-19 pandemic. The drop in CPS reports under virtual schooling has led to even more interest in prevention.  Particularly relevant are secondary prevention approaches, which target families that are at risk of child maltreatment. Michigan DHHS under Jooyeun Chang is working on a new pilot that will be run by a nonprofit in two of the five Detroit zip codes from which the bulk of Detroit’s foster youth were removed. The program will target 400 families (chosen based on the previous calls), who will each receive a peer counselor with similar “lived experience” and a benefits navigator, who will connect the family to needed resources in the community. Combining peer counseling and benefits navigation is an innovative approach that may enhance the value of each of these components when provided together. In addition to the peer navigators, group activities will provide needed information and help participants build their social networks.

The Allegheny County (Pennsylvania) Department of Human Services (DHS) is launching the Hello Baby prevention program in partnership with local Healthy Start and Family Centers. The program, which is voluntary and not affiliated with child protective services, is an interesting hybrid of universal and targeted prevention. It will be offered to all families with a new baby but will offer three levels of services to families depending on how they score based on a predictive risk model using integrated data from multiple sources. The families with the most profound needs will be offered intensive services through Healthy Start Pittsburgh while others will be welcomed to their neighborhood Family Center and/or offered a variety of web-based and “warmline” supports and resources. While the program has not yet launched officially, DHS has soft-launched in some communities with a high density of vulnerable families.

The approaches outlined above fall into two broad categories: initiatives to enhance detection and reporting of child abuse and neglect and those designed to prevent it. These approaches are often supported by different groups in the child welfare space. However, both approaches are valid and important. We cannot go back in time and prevent the abuse and neglect that are already occurring, so we must have a robust system of reporting and investigation to find the children who need protection. On the other hand, to the extent that we can prevent future abuse and neglect before it starts, the benefits would be enormous.

 

America loses champion for a child-centered child welfare system

GellesRichard Gelles, one of the nation’s leading child welfare experts, died late in June of brain cancer, as reported by the Chronicle of Social ChangeGelles’ death deprives the nation of one of its leading child welfare scholars, and one of the few remaining spokespersons for a child centered approach to child welfare.

Richard Gelles played an important role in the passage of the Adoption and Safe Families Act (ASFA) of 1996 through the publication of  The Book of David: How Preserving Families Can Cost Children’s Lives. This book told the  story of a 15-month old boy who was murdered by his abusive mother. David’s parents had an open child welfare case when he was born, due to their severe abuse of his sister Marie when she was six weeks old that left her with lifelong disabilities.  While Marie was still in foster care, the parents were reported to the child abuse hotline twice for abusing David. In closing their investigation without removing David or opening a case, agency workers ignored two huge red flags–the grievous injury to six-week-old Marie and the failure by her parents to comply with the agency’s reunification plan, resulting in the termination of their parental rights to their daughter. Three and a half months after the case was closed, David was dead.

According to Gelles, David’s death could be traced to the doctrine requiring that agencies make “reasonable efforts” to keep or reunite abused and neglected children with their parents. Without any definition or timeframe, efforts to keep children like David with their birth parents often cross the line separating reasonable from unreasonable. Gelles argued that David’s death could also be traced to “the larger ideology behind ‘reasonable efforts,’ ‘the sacrosanct belief that children always (or nearly always) are better off with their biological parents.”

In his testimony at a 1995 Congressional hearing, Gelles argued that the current obsession with family preservation should be replaced for a “child centered child welfare system” where abused and neglected children would longer remain for years in abusive homes, nor would they languish for years in foster care. Instead, the goal of a child-centered child welfare system would be “to terminate parental rights, when appropriate, quickly enough so that (1) children are not permanently harmed, physically or psychologically, and {2) make children available for adoption earlier enough in their lives so that they are ‘adoptable.'”

Gelles’ perspective was incorporated into several changes made by ASFA, as described by  former Hill staffer Cassie Statuto Bevan in an Urban Institute compilation on ASFA ten years after its passage. The requirement for “reasonable efforts” was moderated by requiring that such efforts must maintain the child’s health and safety as the “paramount concern.” Moreover, a  deadline was placed on reunification efforts, requiring a state to file for termination of parental rights after a child had been in foster care for 15 of the previous 22 months. ASFA also allowed states to bypass reasonable efforts altogether in extraordinary cases, such as when parents have committed a felony assault resulting in serious injury to the child or another child–clearly an exception that could have been applied in David’s case.

While it appears that ASFA has resulted in shorter stays in foster care as Gelles hoped, the impact of the provisions designed to protect children from dangerous parents appears to have been less than their authors hoped. Agencies make frequent use allowable exceptions to the 15-month time limit for termination of parental rights and rarely use the provisions that allow them to forego reunification plans. In order to make the system more child-centered, these provisions should be strengthened. Unfortunately, we seem to be going in the opposite direction.

There is a groundswell of attacks against ASFA,  with critics claiming that 15 months is not enough time for with problems like drug addiction to address them, especially if services are not immediately available. Some critics even denounce the law as racist because they say it penalizes black parents, ignoring the needs of black children for safety and permanency. Contrary to the child-centered perspective Gelles promoted, these advocates prioritize parents’ rights over children’s needs to be placed in a loving home quickly enough to avoid permanent damage and early enough in their lives to be likely to be adopted.

In The Book of David and in his testimony, Gelles also criticized the investment of a billion dollars in unproven “intensive family preservation programs” to keep families together. These new programs, such as the well-publicized Homebuilders, were intensive, short term, crisis intervention services designed to address parental behaviors that are putting their children at risk. Gelles pointed out that there was no research evidence to support the success of intensive family preservation programs at preventing foster care placements, let alone keeping children safe–which was not even evaluated. And from a theoretical perspective, Gelles pointed out that intensive family preservation programs would be effective for only those families with a low level of risk and a high level of readiness to change. To assume that these services could work for all maltreating families was unrealistic. 

Sadly, the same programs that were supported without evidence in the 1980’s are being supported again with more baseless claims of research support. As reported in a recent post, Homebuilders is once again being promoted as effective in keeping families together, although the research is no more convincing than that of the 1980s. Recently Homebuilders was approved as a best practice that can be funded by the Family First Act, based on only two studies. One of the studies focused on a program that did not follow the Homebuilders model and worked only to reunify families already separated by foster care—not prevent foster care placement which is the main purpose of Family first. The second was a study of Homebuilders family preservation programs and according to its authors failed to demonstrate any favorable program impacts. 

Why invest in a program that has failed to document success over several decades of research? The renewed push for family preservation has once again taken over the child welfare world. With the passage of the Family First Act, allowing billions in funding for programs that keep families together, there is a desperate need for programs to spend that money on. The federal clearinghouse established to approve programs for this purpose has demonstrated that its standards for calling a program “well-supported by the evidence” are low indeed. And that is not surprising, since there are few such programs that have been shown to be effective in helping abusive and neglectful parents change longstanding and often intergenerational patterns. And so the story starts again.

As we face increased backlash against ASFA and increased incentives to spend billions of dollars on unproven family preservation programs, Richard Gelles’ keen analysis and advocacy for children will be greatly missed.

 

 

Around the country, states face shortage of placements for youth with greater needs

Red Rock Canyon
Image: Salt Lake Tribune

Around the country, young people in foster care–especially those with greater needs– are being housed in facilities not designed for them because appropriate placements are not available. Children who are already traumatized by abuse or neglect are being warehoused in agency offices, hotels, emergency shelters, out-of-state facilities, and even detention centers, resulting in further harm to these most vulnerable children and high present and future costs for taxpayers.

Many youth in foster care have serious emotional and behavioral issues. Many have endured years of trauma, including physical and sexual abuse, severe neglect, and living in dangerous and chaotic conditions. Some have cognitive or neurological issues caused by drug exposure in utero or severe neglect. Some have violent outbursts, many are verbally aggressive, and many have difficulty in making attachments. Around the country, these youths are being placed in inappropriate settings because the right ones are not available.

  • In the letter accompanying his annual budget request, The head of Washington‘s Department of Children Youth and Families has acknowledged the scarcity of “therapeutic group home and facility-based placements for children with severe behavioral issues that don’t enable them to be successful in private foster homes.” As a result, he states, children are being placed in foster homes that are unequipped to handle them, resulting in further damage to the child and often a loss of the foster parent to the system. The lack of appropriate placements also led to over 2000 instances last year of children staying overnight in a hotel or office accompanied by a caseworker; and “excessive use of expensive one-night placements at extraordinary cost and detriment to the child.”
  • In 2016, the discovery that some Oregon children were sleeping in hotels or offices due to a lack of other options resulted in a public outcry and a class action lawsuit. In response, the state drastically reduced its practice of sending foster kids to hotels. But at the same time, according to an investigation by Oregon Public Broadcasting (OPB), the state began sending more foster kids requiring a higher level of care to out-of-state residential treatment facilities.  The majority of these children were housed in facilities run by one for-profit company called Sequel, as reported by OPB in a second installment of its investigation. After reports of abuse and neglect by staff resulted in the closure of five Sequel Facilities, Oregon began bringing its children home. There are now 30 children (down from 84 in February 2019) at out-of-state facilities, all of them run by Sequel, according to OPB.
  • Texas has projected that by 2021 it will have only 90% of the foster homes or other facilities it needs for youths with “specialized” or “intensive” needs (including 24-hour supervision from specially trained caregivers. ) And in some regions of the state the shortages will be much more severe, meaning that children will have to be sent far away if a spot can be found at all..
  • Illinois has had a longstanding problem of children being left in psychiatric hospitals after they have been cleared for release, a practice labeled as  “Beyond Medical Necessity (BMN). The Inspector General for the Department of Children and Family Services has reported that there were approximately 308 episodes of BMN during FY 2019 involving 297 individual youths. Such long stays in such an inappropriate setting result in further damage to children’s mental health. Moreover, the state cannot receive Medicaid reimbursement for such hospitalizations, leaving the state to foot the bill. In FY 2019, children left in psychiatric hospitals BMN ranged in age from 3 or 4 to 19 or 20 with the largest number being between 14 and 16. In FY 2019, 94 youths were hospitalized between 31 and 60 days and 154 youths were hospitalized from 61 to 120 days. The longest BMN hospitalization involved a fifteen-year-old who was hospitalized for 279 days.
  • As I discussed in an earlier post, an alarming report last March indicated that New York City children with behavior problems or mental illness were staying for months at an intake center where they are supposed to be no longer than a few hours until a real placement can be arranged. Instead they were staying as long as a year in this center, where social worker have described an atmosphere of chaos, violence, weapons in plain sight, feces-smeared walls, overcrowding and “a dangerous mix of babies and young children with special needs living alongside troubled teens and even adults straight out of jail.”
  • In my own jurisdiction of the District of Columbia. a special hearing was recently held in a longstanding class action case to discuss the current placement crisis. The Judge, referring to a letter that is not available to the public, reported that 31 children, including seven children between eight and ten years old, experienced a total of 60 overnight stays at the Child and Family Services Agency between April and November of 2019. All of these children had challenging behaviors that excluded them from existing placements. The agency director acknowledged that the District needs more therapeutic placements (either in family or group settings) for these children. The District is in the process of developing some new therapeutic placements but it is not clear that they will be enough to meet the need.

As many are already beginning to do, states must expand their array of placements for the young people with the most serious needs. There is increased interest in developing a cadre of highly trained professional foster parents for whom caring for hard-to-place youths is a full-time job. This may be the best option for many children, but these programs, where they exist, are very small both due to cost and to a small pool of people willing to take on this difficult job. So there will still be a need for more therapeutic group settings. In states including California and Florida there have even been calls for secure therapeutic settings to be established for the most disturbed youths. Child welfare agencies should coordinate with other agencies serving the same youths. such as developmental disabilities, mental health, and juvenile justice agencies, to develop a continuum of appropriate residential placements for all the youths who need them.

Leaders from Washington State to Washington, DC have already begun increasing budgets for therapeutic options including professional foster care and therapeutic group homes. But unfortunately the task of expanding the placement array to accommodate foster youth with greater needs will be made more challenging due to the new Family First Prevention Services Act. This Act was based on a false narrative that nearly all children can succeed in foster homes and that congregate (or non-family) care is always harmful to youth. Believers in this narrative combined with legislators who supported the law because it would reduce government spending. Family First makes it more difficult to place children in congregate care facilities and requires these facilities to meet a number of criteria, such as accreditation, a trauma-informed model, and 24-hour nursing staff in order to be eligible for funding under Title IV-E.

California is one indicator of what might happen under Family First because it is deep into a similar state-level reform called Continuum of Care. So far, many group homes have been closed or have been denied a license to care for foster kids. One veteran service provider in California writes that “there are fewer kids in group homes, but only because there are fewer group homes and counties have inappropriately been pushing challenging, difficult-to-manage youth into lower levels of care.” Family First will result in a replication of the California situation around the nation. At a time when we need more therapeutic facilities, Congress has made it more difficult for those in existence to continue and for new ones to be established.

As in many other areas, America has been penny-wise and pound-foolish in its reluctance to spend money on therapeutic placements for the most damaged young people in the foster care system. The new federal funding framework makes it even more difficult to fund the placements that the hardest to place children need. Let’s hope that states recognize that failing to provide therapeutic placements for these most fragile children now will only result in much greater costs later.

 

 

Family First Act: no funding for important drug treatment and mental health services

Family First ActPassage of the Family First Prevention Services Act as part of the Bipartisan Budget Act early in 2018 was hailed as a game changer in child welfare.  For the first time, according to the celebrants, Title IV-E funds could be used to pay for services to keep families intact rather than place children in foster care. But the more we learn about Family First and how it is being implemented, the less cause for celebration there seems to be. In my last post, I discussed the problems caused by the decision to make Title IV-E the payer of last resort for foster care prevention services. In this post, I discuss the surprising omission of important mental health and drug treatment programs from the list of programs that have been approved or proposed to be paid for under Family First. The paucity of useful programs in the clearinghouse certainly will detract from the utility of Family First in preventing foster care placements.

In expanding the use of federal IV-matching funds beyond foster care through Family First, Congress wanted “to provide enhanced support to children and families and prevent foster care placements through the provisions of mental health and substance abuse prevention and treatment services, in-home parent skill-based programs, and kinship navigator services.” Family First allowed federal Title IV-E matching funds to be used for programs in these categories that meet criteria for being “evidence-based” as defined by the Act.

The categories  of mental health, drug treatment and parenting programs make sense in light of what we know about why children come into foster care. Anyone who has worked in foster care knows that parental drug abuse and mental illness are two of the major circumstances behind child removals, while a third major factor, domestic violence, was inexplicably left out of the Act. The inclusion of parenting programs makes sense because abuse in particular is often related to parents’ lack of knowledge about child development and appropriate disciplinary practices.

Family First established a Title IV-E Prevention Services Clearinghouse, which is being developed under contract by Abt Associates, to review and approve programs for reimbursement using Title IV-E foster care prevention funds. So far, the clearinghouse has approved nine programs for inclusion and is in the process of considering 21 more. A careful look at the programs that are included, under review, and not on either list raises some questions.

Take substance abuse treatment, the most common single factor behind child removals according to federal AFCARS data, which indicates that drug abuse was a factor in 36% of the child removals that took place in Fiscal Year 2018. The opioid crisis, often cited as a reason to pass Family First, seems to have peaked in most areas but is still wreaking havoc in many states and their foster care systems. Medication-assisted treatment is often called the “gold standard” for treating opioid addiction and is vastly underutilized. But strangely that Abt Associates chose to include in the clearinghouse only Methadone Maintenance Therapy and not the newer buprenorphine treatment, which is not even on the list of programs to be considered for clearinghouse listing.  According to the National Institute on Drug abuse, “Methadone and buprenorphine are equally effective at reducing opioid use.” And there are reasons to prefer the newer medication. As the federal Substance Abuse and Mental Health Administration (SAMHSA) states, unlike methadone treatment, “which must be performed in a highly structured clinic, buprenorphine is the first medication to treat opioid dependency that is permitted to be prescribed or dispensed in physician offices, significantly increasing treatment access.”

Let’s turn to mental health. It is clear that mental illness is the major factor behind many removals into foster care. AFCARS data indicate that 14% of child removals are associated with a “caregiver’s inability to cope,” but that percentage sounds small to this former social worker. It is likely that many more removals where other factors (like child abuse and substance abuse) are cited are also related to parental mental illness. Parents suffering from untreated depression, bipolar disorder, post-traumatic stress disorder (PTSD), and other mental health disorders often have difficulty providing appropriate care to their children. So it is not surprising that mental health was included as a category of services to prevent foster care under Family First.

What is surprising is the nature of the services that have been chosen so far. The clearinghouse has approved four mental health programs: Functional Family Therapy, Multisystemic Therapy, Parent Child Interaction Therapy, and Trauma-Focused Cognitive Behavior Therapy. All of these programs are geared at addressing the issues of children–not their parents. It is very odd that the clearinghouse did not include any services to address common mental disorders, such as depression and PTSD, that afflict many parents who come to the attention of child welfare agencies. After all. the California Evidence-Based Clearinghouse for Child Welfare (CEBC), the leading repository of evidence practices in child welfare, lists nine programs meeting Family First criteria as well supported, supported or promising  for treating depression and 11 programs meeting those criteria for trauma treatment for adults. Even odder, among the six mental health programs being considered for inclusion in the Title IV-E clearinghouse, only one (Interpersonal psychotherapy) could be used to treat adults although there is also a version for adolescents and the clearinghouse does not specify which one is under review.

Among the evidence based practices included in the CEBC and not included or under review by the Title IV-E clearinghouse are some well-established programs known to be effective, such as Cognitive Behavioral Therapy for adult depression and  Mindfulness Based Cognitive Therapy.  Both of these have the top rating of “well-supported” from CEBC for treatment of depression in adults. Another mindfulness-based treatment called Mindfulness Based Stress Reduction is becoming increasingly popular and supported by research for treatment of depression and anxiety. Because it is not generally covered by insurance, using Family First funds could make this treatment available to parents who could not otherwise get it. Eye Movement Desensitization and Reprocessing (EMDR), a popular trauma treatment, is also given the top rating from the California clearinghouse and not included or being reviewed by its Title IV-E counterpart.

On the other hand, the inclusion of two out of three “in-home parent skill based” programs in the Title IV-E Clearinghouse is somewhat surprising. The inclusion of Healthy Families America (HFA) raises questions because it has not yet been able to demonstrate an impact on the prevention of child abuse and neglect. There is one study with a promising result but this study was criticized by CEBC due to a very small sample size, limitation to one region, reliance on parent self-report and other factors. CEBC gave HFA as a rating of “4” (“evidence fails to demonstrate effect”) for the prevention of child abuse and neglect.

Another home visiting program, Nurse Family Partnership (NFP), has limited potential to prevent foster care among the Title IV-E eligible population. NFP is the only home visiting program given the top rating for prevention of child abuse and neglect by the CEBC; however it is approved only for first-time teenage mothers. It cannot by definition be used to prevent a recurrence of abuse or neglect. NFP can be provided under Family First in jurisdictions, like the District of Columbia, that have defined all children of teens in foster care as foster care candidates. But it is not applicable to most families eligible for prevention services under Title IV-E.

In sum, the list of programs that have been cleared by the Title IV-E clearinghouse as well as those that are being reviewed contains some disconcerting omissions and surprising entries. While some of the most exciting and promising mental health and drug treatment programs are not included, some home visiting programs with very limited applicability to the purposes of the Act have been included. When added to the decision to make Medicaid the payer of last resort, these decisions by the clearinghouse make the utility of Family First as a vehicle of foster care prevention even more dubious. Those who agree should join me in requesting that the Title IV-E Clearinghouse review and approve some of the effective practices mentioned in this post.

 

 

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

ChapinHallIllinois’ child welfare services to families that are allowed to keep their children have major systemic flaws that put children at risk. Most importantly, there is extreme reluctance to remove children from their homes and place them in foster care. Those are the findings of a review from Chapin Hall at the University of Chicago that was commissioned by the Governor in the wake of several deaths of children whose families were being supervised by the state.

This report follows an earlier one, discussed in a  previous post,  by the Inspector General (OIG) for the Illinois Department of Children and Family Services (DCFS) stating that child safety and well-being are no longer priorities for the agency.  One problem area identified in that report was Intact Family Services, which are the services provided to families in order to prevent further abuse or neglect without removing the child. OIG’s 2018 annual report included an eight-year retrospective on the deaths of children in Intact Family Services cases, which concluded that in many of these cases the children remained in danger during the life of the case due to violence in their homes, when DCFS should have either removed the children or at least sought court involvement to enforce participation in services,

Increasingly, child welfare systems around the country have been relying on services to intact families (often called in-home or intact family services) in order to avoid placing children into foster care. In 2017, according to federal data, only 15% of children who received services after an investigation or assessment were placed in foster care; the other 85% were provided with services in their homes. These services may become even more predominant with implementation of the Family First Prevention Services Act, which allows federal Title IV-E funds to reimburse jurisdictions for the cost of such services.

It is important for child welfare agencies to be able to work with families that remain intact. This allows the agency to monitor the children’s safety and avoid the trauma of placement in foster care while working to ameliorate the conditions that might lead to a foster care placement. But agencies must be cognizant that not every family can be helped this way, keep a close watch what is going on in the home, and be ready to remove children when necessary to ensure their safety. The deaths of children who have received Intact Family Services in Illinois have raised questions about whether the agency is accomplishing these tasks.

In Illinois, Intact Family Services (referred to below as “Intact”)  are provided mostly by private agencies under contract with DCFS. The Chapin Hall  report found systemic issues that create barriers to effectively serving intact families.

Avoiding foster care placement: Perhaps the most important issue observed by the researchers was the high priority that Illinois places on avoiding placement of children in foster care. As a result of many years of such efforts, Illinois now has the lowest rate of child removal in the country. Intact staff expressed the belief that “recommendations to remove children based on case complexity, severity, or chronicity will not be heard by the Division of Child Protection (DCP) or the Court.” As a result, Intact supervisors are reluctant to reject referrals of families even when they believe a family cannot be served safely in the home.  They are also reluctant to elevate cases for supervisory review when they have not been able to engage a high risk family.

Supervisory Misalignment: In the past, negotiations between DCP and Intact over the appropriateness of a referral occurred on a supervisor-to-supervisor level, allowing Intact to push back against unsuitable referrals. An administrative realignment that placed investigators and Intact under different administrations eliminated this ability of Intact to contest inappropriate referrals. According to the researchers, this resulted in the opening of Intact cases for families with “extensive histories of physical abuse” that Intact staff believed they could not serve effectively.

High Risk Case Closures:  Intact service agencies are expected to work with a family for six months and then close the case with no further involvement by DCFS. The researchers learned that there was no clear pathway for intact staff to express concerns when they been unable to engage a family. As a result, some providers told the researcher that they may simply close the case when a family will not engage.

Staffing Issues: Caseload, capacity and turnover.  The researchers found that DCP investigators are overwhelmed with their high caseloads and are desperate to make referrals to Intact to get families off their caseload as soon as possible. The prescribed caseload limit of 15 cases per worker is very hard to manage, and some workers carry even more cases. Moreover, DCP workers tend to stop managing safety plans and assessments as soon as a referral is made to Intact, which leaves children in limbo until services begin. For their part, Intact workers’ caseloads are often over the prescribed limits and are not adjusted for travel time or case complexity. Moreover, the difficulty of their clientele makes the current caseload of 10:1 difficult to manage. High turnover among Intact workers, investigators and other staff can also contribute to the information gaps and knowledge deficits mentioned below.

Role Confusion: DCP workers and Intact workers seem to have different views of the role of the DCP worker, according to the researchers. DCP workers view their role as making and justifying the decisions about whether to substantiate the referral and remove the child. However, the Intact Family Services policy calls upon them to engage the family and transmit all necessary information to the Intact staff. Cultural differences between the two sets of workers compound the problems.

Information Gaps: Because of the role ambiguity mentioned above, investigators often fail to pass on crucial information to Intact workers. Yet, these workers often cannot access investigators notes or key features of the case history. Moreover Chapin Hall’s reviews of the two recent deaths of toddlers in intact cases found that much of the family’s history was inaccessible because cases were expunged or purged. DCFS expunges most unsubstantiated reports and shreds investigators files and appears to be more aggressive about such expungements than most other states, according to a previous DCFS Director, George Sheldon.

Service Gaps: The researchers also mentioned gaps in service availability, especially long waiting lists for substance abuse prevention, which make it very difficult to engage families as well as providers.

The authors made a number of recommendations for addressing these problems they identified.  These include:

  • Work with courts and State’s attorneys to refine the criteria for child removal in complex and chronic family cases;
  • Develop and refine protocol for closing Intact cases;
  • Direct attention to cases at greatest risk for severe harm; revisit the use of predictive models which should be transparent, based on broad input and be supported by ethical safeguards’
  • Clarify goals and expectations across staff roles;
  • Utilize evidence-based approaches to preventive case work;
  • Improve the quality of supervision;
  • Adjust the preventive services offered through Intact to meet the needs of the population;
  • Restructure Intact Services to address the supervisory mismatch with DCP; and
  • Redesign the assessment and intake process to reduce redundant information, improve accuracy or assessments to support decision-making and improve communication across child serving systems.

We would have liked to see a recommendation to modify Illinois’ policy of expunging and purging all unsubstantiated investigations. At a hearing in May, 2017, the DCFS Director, George Sheldon, expressed his support for allowing DCFS to keep records of all investigations, even if they are unsubstantiated. Research suggests that it is very difficult to make accurate decisions about whether maltreatment has occurred; moreover, unsubstantiated reports are as good as substantiated ones in predicting future maltreatment. Examples of children killed after families have had multiple unsubstantiated reports have been observed all over the country.

This report should be a must-read for all child welfare agencies.  Children in many states have died of abuse or neglect after intact cases have been opened for their families. (Think about Zymere Perkins in New York or Anthony Avalos and Gabriel Fernandez in Los Angeles.) Many of the issues identified by the Chapin-Hall report may have contributed to these deaths as well, particularly the extreme avoidance of child removals that has condemned so many innocent children to death ever since the widespread push to reduce the foster care rolls, supported by a coalition of wealthy and powerful foundations and advocacy groups.