The new Child Maltreatment 2021 Report: Did child maltreatment really decrease?

The federal government’s annual maltreatment report for 2021 was released on February 9, 2023, and the child welfare establishment is celebrating. New Child Maltreatment Report Finds Child Abuse and Neglect Decreased to a Five-Year Low, crowed the Administration on Children and Families (ACF). “Number of Abuse and Neglect Victims Declines Again,” trumpeted The Imprint, a journal that typically reflects the prevailing voices in child welfare today. Left for the body of the ACF press release (and totally omitted by The Imprint) was the fact that in 2021 the nation was still in a pandemic that kept many schools closed for much of the year, and that child maltreatment “victimization” reflects jurisdictions’ policy and practice much more than it reflects actual maltreatment. Thus, there is no reason to celebrate a decrease in child maltreatment based on this report.

Child Maltreatment 2021 , the latest edition in the annual series from the ACF, combines data from the 50 states, the District of Columbia and Puerto Rico about the number of reports or children involved in each stage of the child welfare system in Federal Fiscal Year (FFY) 2021, which ran from October 1, 2020 to September 30, 2021. The data are obtained from the National Child Abuse and Neglect Data System (NCANDS), a national data collection program run by the Children’s Bureau under ACF. Arizona did not submit data in time to have its data included in this report, so only 49 states are included in this year’s report, along with the District of Columbia and Puerto Rico. Commentaries from most of the states regarding policies and conditions that may affect their data are attached in an appendix. The report’s findings are summarized in Exhibit S-2. All of the figures in this post are taken from the report.

A family’s journey through the child welfare system starts with an initial report, known as a “referral.” Figure 2-D below shows that the total number of referrals (the purple line) rose between 2017 and 2019, dropped sharply in the wake of the Covid pandemic in 2020, as schools closed and many families isolated at home, and increased only slightly in FFY 2021. It is important to remember that in FFY 2021, which began in October 2020, many schools were still closed. Most schools opened over the course of FFY 2021, but some remained closed the entire year. Thus, reporting from school personnel was suppressed for the federal fiscal year.

The rate of referrals as a portion of the child population varied greatly by state. Table 2-1 of the report shows that the total referral rate per 1,000 children in 2021 ranged from a low of 17.8 in Hawaii to a high of 137.0 in Vermont in 2021. Such differences exist every year and reflect factors such as public opinion and knowledge of child maltreatment reporting, as well as state practices. Some states do not even report most referrals to NCANDS, as described in the state commentaries. Pennsylvania has a unique system in which most reports that are not for abuse are classified as “General Protective Services” and not reported to NCANDS. Similarly, Connecticut does not report referrals receiving an alternative (non investigation) to NCANDS. In 2021, state-to-state differences may also reflect how soon in-person schooling resumed in the state after the pandemic. Vermont reported in its commentary that it has been receiving more referrals for concerns that do not reflect maltreatment. Vermont also included several reasons for its high referral rate, including the fact that reports on multiple children in the same family are counted separately. Kansas reported a decrease in reports due to “engaging communities to focus on prevention.”

Once a referral is received, it can be screened in or out by agency hotline or intake units. In general, agencies screen out referrals that do not meet agency criteria, which vary by jurisdiction. Reasons for screening out a referral may include that it does not meet the definition of child abuse or neglect, that not enough information is provided, that another agency should more appropriately respond, or that the children being referred are over 18. Despite receiving slightly more referrals than the previous year, child welfare agencies screened out a larger proportion of them in FY 2021, resulting in a slight decrease in screened in referrals (known as “reports“), from 2020 to 2021 – the blue line in Exhibit 2-D. In the 46 states that provided both data points, 51.5 percent of referrals were screened in and 48.5 percent were screened out.

There is great diversity in the proportion of referrals accepted by states. The percentage of referrals that was screened-in ranged from 15.3 in South Dakota to 98.5 percent in Alabama.1 There are many reasons for these variations, mostly associated with differing policies and practices between jurisdictions. For example, Georgia mentioned in its commentary that after hotline calls increased in 2021, it adjusted screening criteria to screen out more of them. Indiana tried to reduce its screen-in rate by changing criteria related to sexual behavior among teens and preteens, marijuana use by children, and educational neglect. Kansas reported a decrease in reports due to a change in the screening process for educational neglect. Missouri, on the other hand, changed screening criteria to screen in more referrals out of concern for children isolated because of the pandemic.

In FFY 2019, teachers were the most common source of referrals, submitting 21 percent of all referrals. They lost that position in FFY 2020 with the pandemic school closures, while legal and law enforcement personnel increased their share of reports. Perhaps it is not surprising that teachers did not recoup their leading role in 2021, since many students were still attending school virtually for some part of the year. Teachers actually submitted a smaller proportion of referrals in 2021 (15.4 percent) than in 2020 (17.2 percent). It is possible that teachers were making more calls but that more of these calls were being screened out than in the year before. But since ACF does not show the distribution of all referrals by reporting source, one cannot use this data to test that hypothesis.

Investigations

In Chapter 3 of Child Maltreatment 2021 the focus shifts from the referral or report to the child. ACF estimates that 3.016 million children or 40.7 children per 1,000 in the population received an investigation or alternative response2 in 2021. This was a slight decrease over 2020, when 42.0 per 1,000 children received an investigation or alternative response. These rates varied greatly by state, from a low of 12.8 per 1,000 in Pennsylvania to a high of 129.8 in West Virginia. The low in Pennsylvania is not surprising due to its unique system in which most neglect referrals are not reported to NCANDS. But Maryland and Hawaii also investigated small proportions of children– 15.7 and 15.9 per 1,000. These investigation rates reflect the number of referrals and how many were screened in, as well as the number of children per referral.

ACF found that of the children who received an investigation or alternative response, 16.7 percent were found to be victims of child abuse or neglect, as shown in Exhibit 3-B.3 The remaining children were not determined to be victims or received an alternative response. Estimating for missing data from Arizona, ACF calculated a national “victimization rate” of 8.1 per 1,000 children. As Exhibit 3-C shows, this rate has been decreasing since 2018 but the greatest decrease was in 2020 with the arrival of the pandemic.

ACF’s use of the term “victimization” can be misleading. An investigator’s decision about the truth of an allegation is based on limited information and is constrained by available time and staff, and evidence indicates that many referrals are unsubstantiated when maltreatment actually exists. Moreover, these rates are dependent on state policies and practices. Because of the misleading nature of the term “victimization,” the term “substantiation” is used for the rest of this commentary. State substantiation rates per 1,000 children ranged from 1.6 in New Jersey (even lower than Pennsylvania’s 1.8) to 17.0 in West Virginia, suggesting that these rates reflect much more than the prevalence of child abuse and neglect.

Among the many factors that can influence state substantiation rates are:

  • Differences in referral rates and screening practices, as decribed above;
  • Different policies about what is considered child maltreatment and different levels of evidence required to substantiate an abuse allegation;
  • Whether and how much a state uses an alternative (non-investigation response);
  • Natural and social disasters that may vary in their impact between states. Some states went back to in-person schooling for the entirety of 2021, others opened midyear, and others were virtual almost all year. West Virginia, with the highest substantiation rate, has been particularly hard-hit by the opioid epidemic. The state has the highest overdose mortality rate in the nation;
  • Differences in the messages coming from an agency’s leadership about the relative importance of child safety versus family preservation;
  • Variations in the use of kinship diversion, the practice of placing children with a relative without court involvement or case opening. If this happens before the investigation is completed, it may result in an “unsubstantiated finding.

All of these factors can change over time, affecting substantiation rate trends from year to year. It is clear that nationwide, the COVID-19 pandemic continued to suppress reports to CPS hotlines, and therefore investigations and maltreatment findings, in 2021. But the effect of the pandemic differed greatly between states: it appears that some states had more in-person days of school in 2021 than in 2020, and others had less. Additionally, several states described changes in their screening practices in 2021, usually to screen in fewer referrals. Delaware and Washington mentioned an increase in reports diverted to differential response as a reason for declining substantiation numbers in FFY 2021. The emphasis on prevention as an alternative to intervention has been increasing in most states, perhaps affecting the likelihood of substantiation. It is possible also that increases in kinship diversion may have reduced substantiation rates: there is no data to prove or disprove this, but concern over this practice is certainly growing.

To state that maltreatment decreased between 2020 and 2021 is to ignore that “maltreatment victimization” is not a measure of actual abuse and neglect. It is the result of a winnowing process that starts even before a referral arrives. At each stage, the numbers remaining may depend on a wide variety of factors, including policy, practice, natural and man-made disasters and more. The vast differences between state data on referrals, reports, investigations and substantiations shows how unlikely it is that the total number of children found to be victims of maltreatment reflects the actual number of maltreated children, and how irresponsible it is to suggest this might be the case.

A note on Child Fatalities

Last year, ACF used a decline in fatalities due to child maltreatment to headline its press release, Child Fatalities Due to Abuse and Neglect Decreased in FY 2020, Report Finds. This year, the number of child abuse and neglect fatalities reported by states increased slightly, a rise that was not the subject of a headline by ACF. Whether there is a small increase like this year or a decrease like last year means very little, for several reasons. As ACF explains, these child fatality counts reflect the federal fiscal years in which the children were determined to have died of maltreatment, which may be different from the year the child actually died. Such determinations may come much later due to the time it takes to complete a death investigation. For example Alabama reported that for the fatalities reported in FFY 2021, the actual dates of death were between FFY’s 2016 and 2021. Michigan even reported that its child fatality data included the child abuse death of twins in 2003 which was revealed by a cold case investigation.

A second problem with the fatality estimates is that they are widely believed to be too low. One reason is that many states report only on fatalities that came to the attention of child protective services agencies. As the report’s authors point out, many child maltreatment fatalities do not become known to agencies when there are no siblings or the family was not involved with the child welfare agency. Moreover, some fatalities resulting from abuse or neglect are labeled as due to accident, “sudden infant death syndrome,” or undetermined or unknown causes because insufficient evidence was found. I recently reviewed the child fatality review report produced by the District of Columbia’s Child and Family Services agency (CFSA). CFSA relied on the decisions of the medical examiner, which chose not to classify as maltreatment deaths an infant who died after a mother who was high on PCP rolled on top of him when sleeping with him in the same bed (counted as “unknown); a baby left on his stomach with a bottle in his mouth when his mother left the apartment (counted as “undertermined); a child who was shot to death by gunmen trying to kill her father, involved in the violent drug trade, outside a liquor store at 11:00 PM (“non-abuse homicide”), and a child who died of an untreated bacterial infection and had beating injuries diagnosed by doctors as due to abuse (“undetermined”). The total number of maltreatment fatalities was estimated at only three for the District in CY 2021, not including those four deaths. Some researchers suggest that the actual number of abuse and neglect fatalities may be as much as twice or three times that given in the Child Maltreatment reports,4 and the District of Columbia data suggest this may well be the case.

Notes

  1. This leaves out three states that are listed as screening in 100 percent of referrals: Illinois, New Jersey and North Dakota. Both Illinois and New Jersey explained in their state commentaries that reports must meet certain criteria to be accepted for investigation, so it is not clear why they responded that they screen in 100 percent of referrals. North Dakota actually screens in all referrals, but that is more semantic than real. Reports that do not meet agency criteria for a report of suspected chlid abuse or neglect are categorized as receiving an “administrative assessment,” and are not investigated. North Dakota does not report the number of referrals receiving an “adminnistrative assessment;” hence the reports that 100 percent of cases are screened in. It is unclear why New Jersey and Ilinois provided this figure of 100 percent but the reason may be similar.
  2. Alternative response is, as defined in NCANDS, the “provision of a response other than an investigation that determines if a child or family needs services. A determination of maltreatment is not made and a perpetrator is not determined.”
  3. NCANDS defines a “victim” as “a child for whom the state determined at least one maltreatment was substantiated or indicated, and a disposition of substantiated or indicated was assigned for a child in a report.” “Indicated” is defined as a disposition that concludes that maltreatment could not be substantiated under state law or policy, but there is a reason to suspect that at least one child may have been maltreated or is at risk of maltreatment.”
  4. Herman-Giddens, M. E., et al. (1999). Underascertainment of child abuse mortality in the United States. JAMA , 282(5), 463-467. Available from http://jama.jamanetwork.com/article.aspx?articleid=190980. Also, Cotton, E. E. (2006). Administrative case review project, Clark County, Nevada: Report of data analysis, findings and recommendations. Crume, T. L., DiGuiseppi, C., Byers, T., Sirotnak, A. P., & Garrett, C. J. (2002). Underascertainment of child maltreatment fatalities by death certificates, 1990-1998. Pediatrics, 110(2). Abstract available from https://pubmed.ncbi.nlm.nih.gov/12165617/. Herman-Giddens et al. estimate actual child abuse and neglect deaths to be as high as three times the national reported amount; Cotton et al. and Crume et al. found the actual number of deaths to be twice that reported.

Did child maltreatment fall under COVID-19?

As the Covid-19 pandemic took hold, stay-at-home orders were declared, and school buildings closed, many child advocates voiced fears that child abuse and neglect would increase but would remain unreported as children were locked in with their maltreaters. But some newly available data has led to a spate of commentaries announcing triumphantly that rather than increase, child maltreatment has actually decreased during the pandemic, suggesting to some that we may not need a child welfare system after all. In fact, while the data provides no definitive evidence of either an increase or decline in child maltreatment, there are some concerning indicators from emergency room visits, teen self-reports, and domestic violence data that there may have been an increase in child abuse and neglect after Covid-19 closed in.

There are many reasons to think that the Covid-19 pandemic and our nation’s response to it would have led to a spike in child abuse and neglect. Research indicates that income loss, increased stress, and increased drug abuse and mental illness among parents (all associated with the pandemic) are all risk factors for child abuse and neglect.* On the other hand, the expansion of mutual aid networks and the influx of new government assistance programs with few strings attached may have protected children against abuse and neglect. Data on hotline calls, emergency room visits, child fatalities, teen self-reports of abuse, and domestic violence are being cited as indicators of what happened to maltreatment during the pandemic. I examine the evidence below.

Child maltreatment referrals

As soon as stay-at-home orders were imposed, child advocates warned of the likely drop in reports to child abuse hotlines as children vanished into their homes. And indeed, this is exactly what happened. Individual jurisdictions began reporting large drops in reports starting in April 2020 But national data did not become available until the publication of Child Maltreatment 2020, the compendium and analysis of data the US Children’s Bureau received from states for the fiscal year ending September 30, 2020. According to the report, there were 484,152 screened-in referrals (reports to hotlines) between April and June 2020, following the declaration of emergencies at the national and local levels and the closure of most schools buildings and subsequent transition to virtual operation. This compares to the 627,338 referrals in the same period of 2019–a decrease of 22.8 percent.** For July through September, referrals decreased from 553,199 in 2019 to 446,900, or 19.2 percent. So even in the summer when schools are mostly out anyway, referrals decreased.***

Despite the concerns among child advocates about the drop in hotline calls as a natural consequence of lockdowns and school closures, some parent advocates, such as Robert Sege and Allison Stephens writing in JAMA Pediatrics, have argued that these decreases in hotline calls show that “child physical abuse did not increase during the pandemic.”**** Similarly, In her article entitled An Unintended Abolition: Family Regulation During the COVID-19 Crisis, Anna Arons argues that the decline in hotline reports during the first three months of pandemic shutdowns in New York City relative to the same period the previous year reflects an actual decline in maltreatment rather than the predictable effects of lockdowns and school closures.

Interpreting the decline in hotline reports to suggest a decline in child maltreatment during the pandemic is either naive or disingenuous. The drop in reports was predicted by experts as soon as schools shut down because school personnel make the largest share of reports in a normal year–about 21 percent in FY 2019. The number of reports from school personnel dropped by 58.4 percent in the spring quarter and by 73.5 percent from July through September.** Exhibit 7-B from Child Maltreatment 2020 shows the drastic decline in reports from school personnel, as well as smaller decreases in reports from medical and social services professionals. To claim that this drop in reports reflects reduced abuse and neglect is to disregard the most obvious explanation-that children were seeing less of teachers and other adults who might report signs of abuse or neglect.

Source: Child Maltreatment 2020, https://www.acf.hhs.gov/sites/default/files/documents/cb/cm2020.pdf

In her article about New York City, Anna Arons cites the absence of an oft-predicted surge of child maltreatment reports when schools reopened in September 2020. Far from such a surge, she states, reports did increase, but only “at a rate in line with the typical increase in a non-pandemic fall, rather than a more dramatic leap.” But the grounds for predicting a surge in reports are far from clear. First, only 25 percent of New York City children returned to school buildings in September, as Arons reports. Moreover, is not obvious that the concept of a backlog makes sense in reference to abuse and neglect reports, as it does with tax returns, for example. Bruises may heal, a hungry child may be fed when there is money in the house; living situations may change. Many of the most troubled families are the subject of multiple reports of maltreatment over the course of a year; a child who would have been reported in the spring and again in the fall will not necessarily receive an “extra” report in the fall.*****

Emergency room visits for suspected maltreatment

As the pandemic closed in, child advocates feared that hospital emergency rooms would see an influx of maltreatment-related injuries among children. To address this question, Elizabeth Swedo and colleagues at the Center for Disease Control and Prevention used a platform that provides information on approximately 73 percent of all Emergency Department (ED) visits in the United States. The authors did not find the increase that these advocates feared, reporting that the total number of ED visits related to child abuse and neglect decreased sharply during the early part of the pandemic as compared to the analogous period in 2019, though ED visits for all causes increased even more during that period. Despite the decreases in the number of ED visits for maltreatment, the number of such visits ending in hospitalization stayed the same, which suggests there was no decrease in maltreatment severe enough to result in hospitalization.

Using an administrative database from 52 U.S. children’s hospitals, Kaiser et al. found a sharp decline in all ED visits and hospital admissions, and in visits and admissions for child physical abuse (not including admissions related to sexual abuse or neglect) during the first six months of the pandemic period compared to previous years. Moreover, they found no increase in the severity of the child physical abuse cases resulting in ED visits or hospitalizations. They concluded that coronavirus aid programs and eviction protections might have resulted in reductions in child physical abuse.

To disentangle the effects of reduced healthcare usage during the pandemic changing levels of child maltreatment, Maassel et al. looked at hospitalizations for abusive head trauma (AHT), arguing that it is more difficult for caregivers to forego medical care for such life-threatening injuries. They found a significant decrease in admissions for AHT among 49 children’s hospitals during the COVID pandemic compared to the three previous years.****** They hypothesize that the marked increase in job losses for women, along with more adults working from home, may have led to more children being cared for by two or more caregivers, and specifically fewer being cared for by sole male caregivers, who are the most common perpetrators of AHT.

Swedo et al’s finding that the number of ED visits for abuse or neglect that ended in hospitalization stayed the same contrasts with Kaiser et al and Maassel et al’s findings that hospitalizations for child abuse (and specifically) AHT declined during the early period of the pandemic. One explanation may be that abuse decreased but neglect did not; it may also be relevant that Swedo et al used a different database than did the other two teams. More research is needed to explain these differences.

Child Fatalities

One might argue that child maltreatment fatalities are best indicator of maltreatment rates during the pandemic because fatalities are less likely to avoid being reported than non-fatal maltreatment. Child Maltreatment 2020 contains estimates of child fatalities due to abuse and neglect from all states but Massachusetts, plus the District of Columbia and Puerto Rico. These jurisdictions reported a total of 1,750 fatalities, for a population rate of 2.38 per 100,000 children, compared to 1,825 or 2.50 per 100,000 children in FFY 2019. But to say that the maltreatment fatality rate went down in 2020 as compared to 2019 would be incorrect, because the fatalities counted in one year did not necessarily occur in that year. Rather, the authors indicate that “the child fatality count in this report reflects the federal fiscal year … in which the deaths are determined as due to maltreatment,” which may be different from the year the child actually died.” Such determinations may come a year or more after the fatality occurred. So it is not possible to make inferences from this small decrease in the child maltreatment fatality rate in FY 2020. Moreover, it is not not implausible that the pandemic affected reporting, so that year-to-year comparisons between pandemic years and non-pandemic years are particularly problematic.

Teen Self-Reports of Abuse

Results from a nationwide survey of 7,705 high school students conducted in the first half of 2021 and reported by the New York Times revealed disturbing indications that abuse, at least of teens, increased during the pandemic. Over half (55.1 percent) of adolescents reported being emotionally abused by a parent, and more than one in 10 (11.3 percent) reported being physically abused by a parent. Black students reported the highest rate of physical abuse by a parent–15 percent, compared to 9.8 percent for White students. Students who identified as lesbian, gay or bisexual, and those who identified as “other or questioning” experienced the highest rate of emotional abuse (74.4 percent and 75.9 percent respectively). Female students were more likely to experience emotional abuse by a parent than male students (62.8 percent vs. 46.8 percent). While using a different sampling frame, methodology and wording, a survey of a nationally representative sample of children aged 14 to 17 conducted in 2011 (as quoted by the authors of the new survey) found much lower estimates of abuse–13.9 percent for emotional abuse by a caregiver in the past year and 5.5 percent for physical abuse. The change in these percentages, even if accurate, is not necessarily due to the pandemic, but it is a troubling indicator nonetheless.

Trends in Domestic Violence

Domestic violence is highly correlated with child abuse and neglect, and the same risk factors, heightened by the pandemic, contribute to both of these problems. A systematic review of 12 US studies, most including multiple cities, concluded that domestic violence incidents in the US increased by slightly over eight percent after jurisdictions imposed stay-at-home orders. The authors speculated that the increase in domestic violence was driven by factors such as increased unemployment and financial insecurity and stress associated with childcare and homeschooling–the same factors that might contribute to increased child maltreatment.

I have written often about the propensity for wishful thinking in child welfare, whether it relates to home visiting programs, “race-blind removals,” or other programs and issues. Unfortunately, this propensity is on full display in the commentaries that try to portray reduced calls to child abuse hotlines as showing that child maltreatment did not rise during the pandemic. But it is certainly true that emergency room and hospitalization data do not provide evidence of a surge in child abuse and neglect, and there are even some suggestions that abuse may have declined perhaps due to fewer children being left alone with male caregivers. Overall, the data we have so far do not conclusively demonstrate that maltreatment rose or fell. Some children who lived through this period will eventually share their memories of life at home during the period. But these memories of course will be impossible to generalize. We may never know what really happened to maltreatment during the covid-19 pandemic.

This commentary was revised on May 18, and May 19, 2022 to incorporate new findings on ER visits and hospitalizations by Kaiser et al and Maassel et al.

*How neglect would be affected by a pandemic is somewhat less straightforward than with abuse. Many neglect cases involve lack of supervision, which may have increased with parents leaving children alone to work, with schools and childcares closed. Increased drug and alcohol abuse by parents might have also increased the occurrence of neglect. On the other hand, with more parents unemployed or working at home, lack of supervision may have become less prevalent during the pandemic.

**Unfortunately, the Bureau did not provide the total number of referrals including those screened in and screened out, by quarter. For the whole year the report shows that 54.2% of referrals were screened in, compared to 54.5% in FY 2019.

***The continued suppression of hotline calls could be due to fewer children in summer camps, summer schools, and childcare, as well as fewer attending health appointments and family gatherings in the first summer of the pandemic.

****It is not clear why Sege and Stephens refer to physical abuse only, as they data they discuss concern all types of child maltreatment,

*****However, it is interesting that even in September 2022, when almost all NYC children returned to school, reports did not return to their 2022 level. There are several reasons this could be the case, including a decline in child maltreatment and a decrease in reporting due to changes in messaging coming from ACS and advocates.

******Maassel and colleagues compared AHT admissions between March 11 and September 30 in 2020 to admissions during the same period over the previous three years.

New data show drop in foster care numbers during pandemic

Source: US Children’s Bureau, AFCARS Report $28, https://www.acf.hhs.gov/sites/default/files/documents/cb/afcarsreport28.pdf

A long-awaited report from the federal government shows that most states saw a decrease in their foster care population during the fiscal year ending September 30, 2020, which included the onset of the COVID-19 pandemic. Both entries to foster care and exits from it declined in Fiscal Year (FY) 2020 compared to the previous fiscal year. These results are not surprising. Stay-at-home orders and school closures beginning in March 2021 resulted in a sharp drop in reports to child abuse hotlines, which in turn presumably brought about the reduction in children entering foster care. At the other end of the foster care pipeline, court shutdowns and a slow transition to virtual operations prolonged foster care stays for many youths. One result that is surprising, however, is the lack of a major decrease in children aging out of foster care, despite the widespread concern about young people being forced out of foster care during a pandemic.

Ever since the COVID-19 pandemic resulted in lockdowns and shut down schools around the country, child welfare researchers have been speculating about the pandemic’s impact on the number of children in foster care. While many states have released data on foster care caseloads following the onset of the pandemic, it was not until November 19, 2021 that the federal Children’s Bureau of the Administration of Children and Families (ACF) released the data it received from the 50 states, the District of Columbia and Puerto Rico for Fiscal Year 2020, which ended more than a year ago on September 30, 2020. The pandemic’s lockdowns and school closures began in the sixth month of the fiscal year, March 2020, so its effects should have been felt during approximately seven months, or slightly over half of the year. The data summarized here are drawn from the Adoption and Foster Care Analysis System (AFCARS) report for Fiscal Year 2020 compared to the 2019 report as well as an analysis of trends in foster care and adoption between FY 2011 and FY 2020. State by state data are taken from an Excel spreadsheet available on the ACF website.

The nation’s foster care population declined from 426,566 on September 30, 2020 to 407,493 children on September 30, 2021. That is a decline of 19,073 or 4.47 percent. According to the Children’s Bureau, this is the largest decrease in the past decade, and the lowest number of children in foster care since FY 2014.* Forty-one states plus Washington DC and Puerto Rico had an overall decrease in their foster care population, with only seven states seeing an increase. The seven states with increases were Arizona, Arkansas, Illinois, Maine, Nebraska, North Dakota and West Virginia. The change in a state’s foster care population depends on the number of entries and the number of exits from foster care. And indeed both entries and exits fell to historic lows in FY 2020. The reduction in entries was even greater than the fall in exits, which was why the number of children in foster care declined rather than increasing.

Entries into foster care fell drastically around the country, from 252,352 in FY 2019 to 216,838 in FY 2020 – a decrease of 14 percent. This was the lowest number of foster care entries since AFCARS data collection began 20 years ago. Foster care entries dropped in all but three states – Arkansas, Illinois, and North Dakota. These three states were also among the seven states with increased total foster care caseloads. It is not surprising that entries into foster care dropped in the wake of pandemic stay-at-home orders and school closings. While we are still waiting for the release of national data on child maltreatment reports in the wake of the pandemic, which are included in a different Children’s Bureau publication, media stories from almost every state indicate that calls to child abuse hotlines fell dramatically. This drop in calls would have led to a fall in investigations and likely a decline in the number of children removed from their homes. Monthly data analyzed by the Children’s Bureau drives home the impact of the Covid-19 pandemic on foster care entries. More than half of the decrease in entries was accounted for by the drops in March, April, and May, immediately following the onset of stay-at-home orders, which were later relaxed or removed, as well as school closures.

Source: Trends in Foster Care and Adoption, FY 2011-FY 2020, https://www.acf.hhs.gov/sites/default/files/documents/cb/trends_fostercare_adoption_11thru20.pdf

Reasons for entry into foster care in FY 2020 remained about the same proportionally as in the previous year, with 64 percent entering for a reason categorized as “neglect,” 35 percent for parental drug abuse, 13 percent for physical abuse, nine percent for housing related reasons and smaller percentages for parental incarceration, parental alcohol abuse, and sexual abuse. (A child may enter foster care for more than one reason, so the percentages add up to more than 100.)

Exits from foster care also decreased nationwide from 249,675 in FY 2019 to 224,396 in FY 2020 – a decrease of 10 percent – a large decrease but not as big as the decrease in entries, which explains why foster care numbers decreased nationwide. Only six states had an increase in foster care exits: Alaska, Illinois, North Carolina, Rhode island, South Dakota and Tennessee. Along with the decrease in exits, the mean time in care rose only slightly from 20.0 to 20.5 months in care, while the median rose from 15.5 to 15.9 months in care. Again, it is not surprising that the pandemic would lead to reduced exits from foster care. In order to reunify with their children, most parents are required to participate in services such as therapy and drug treatment, to obtain new housing, or to do other things that are contingent on assistance from government or private agencies. Child welfare agency staff and courts are also involved the process of exiting from foster care due to reunification, adoption, or guardianship. All of these systems were disrupted by the pandemic and took time to adjust to virtual operations. Monthly data shows that about 68 percent of the decrease in exits was accounted for by the first three months of the pandemic, when agencies and courts were struggling to transition to virtual operations. It is encouraging that the number of exits was approaching normal by September 2020; it will be interesting to see if the number of exits was higher than normal in the early months of FY 2021.

Source: Trends in Foster Care and Adoption, FY 2011-FY 2020, https://www.acf.hhs.gov/sites/default/files/documents/cb/trends_fostercare_adoption_11thru20.pdf

Most exits from foster care occur through family reunification, adoption, guardianship, and emancipation. The proportions exiting for each reason in FY 2020 remained similar to the previous year, while the total number of exits dropped, as shown in Table 3 below. Children exiting through reunification were 48 percent of the young people exiting foster care in FY 2020, and the number of children exiting through reunification dropped by 8.3 percent from FY 2019. Children exiting through adoption were 26 percent of those leaving foster care, and the number of children exiting through adoption fell by 12.6 percent. Exits to guardianships fell by 11 percent and other less frequent reasons for exit fell as well. The drop in reunifications, adoptions and guardianships is not surprising given court delays and also the likely pause in other agency activities during the pandemic. However, nine states did see an increase in children exiting through adoption.

Table 3

Reasons for Exit from Foster Care, FY 2019 and FY 2020

Exit ReasonFY 2019
Number
FY 2019
Percent
FY 2020
(Number)
FY 2020
(Percent)
Decrease
(Number)
Decrease
(Percent)
Reunification117,01047%107,33348%9,6778%
Living with another relative15,4226%12,4636%2,95919%
Adoption54,41526%56,56825%7,84712%
Emancipation20,4458%20,0109%4352%
Guardianship26,10311%23,16010%2,94311%
Transfer to another agency2,7261%2,2631%46317%
Runaway6080%5280%8013%
Death of Child3850%3600%256%
Source: US Children’s Bureau, AFCARS Report $28, https://www.acf.hhs.gov/sites/default/files/documents/cb/afcarsreport28.pdf

It is surprising that the number of foster care exits due to emancipation or “aging out” of foster care fell only slightly, to 20,010 in FY 2020 from 20,445 in FY 2019, making emancipations a slightly higher percentage of exits in FY 2020–8.9 percent, vs. 8.2 percent in FY 2019. There has been widespread concern about youth aging out of foster care during the pandemic, and a federal moratorium on emancipations was passed after the fiscal year ended. At least two jurisdictions, California and the District of Columbia, allowed youth to remain in care past their twenty-first birthdays due to the pandemic. It is surprising that this policy in California, with 50,737 youth in care or 12.45 percent of the nation’s foster youth on September 30, 2020, did not result in a bigger drop in emancipation exits nationwide. California’s foster care extension took effect on April 17, 2020 through an executive order by the Governor and was later expanded through the state budget to June 30, 2021. And indeed, data from California via the Child Welfare Indicators Project show that the number of youth exiting through emancipation dropped by over 1,000 from 3,618 in FY 2019 to 2,615 in FY 2020. Since total emancipation exits dropped by only 435 nationwide, it appears that the number of youth exiting care through emancipation outside of California actually increased. This raises concern about the fate of those young people who aged out of care during the first seven months of the pandemic.

In December 2020 (after the Fiscal Year was already over), Congress passed the Supporting Foster Youth and Families Through the Pandemic Act (P.L. 116-260), which banned states from allowing a child to age out of foster care before October 1, 2021, allowed youth who have exited foster care during the pandemic to return to care and added federal funding for this purpose. But this occurred after the end of FY 2020 so it did not affect the numbers for that year. Moreover, The Imprint reported in March 2021 that many states were not offering youth the option to stay in care despite the legislation, raising fears that the number of emancipations in FY 2021 may not have been much lower than the number for FY 2020.

Among the other data included in the AFCARS report, terminations of parental rights decreased by 11.2 percent in FY 2020. This is not surprising given the court shutdowns and delays. Perhaps this decline in TPR’s explains why the number of children waiting to be adopted actually decreased from 123,809 to 117,470, contrary to what might be expected from the decrease in adoptions.

It is disconcerting that some child welfare leaders and media outlets are portraying the reductions in foster care caseloads during FY 2020 as a beneficial byproduct of the pandemic. Despite the fact that maltreatment reports dropped by about half after the pandemic struck, Commissioner David Hansell of New York City’s Administration for Children’s Services told the Imprint that “It was just as likely that the pandemic was ‘a very positive thing’ for children, who were able to spend more time with their parents.” Based on an interview with Connecticut’s Commissioner of Children and Families, an NBC reporter stated that ‘With the pandemic, the last two years have been difficult, but something positive has also happened during that time span. Today, there are fewer kids in foster care in Connecticut.”

Even In normal times, I take issue with using reductions in foster care numbers as an indicator of success. Certainly if foster care placements can be reduced without increasing harm to children, that is a good thing. But in the wake of the pandemic, we know that many children were isolated from adults other than their parents due to stay-at-home orders and school closures, and we have seen a drastic decline in calls to child abuse hotlines. Thus, it is likely that some children were left in unsafe situations. Moreover, the pandemic caused increased stress to many parents, which may have led to increased maltreatment, as some evidence is beginning to show. So when Oregon’s Deputy Director of Child Welfare Practice and Programming told a reporter that “Even though we had fewer calls, the right calls were coming in and we got to the children who needed us,” one wonders how she knows that was the case, and whether her statement reflects wishful thinking rather than actual information.**

There have been many predictions of an onslaught of calls to child protective services hotlines once children returned to school. And indeed, there have been reports of a surge of calls after schools re-opened in Arizona, Kentucky, upstate New York, and other places, but we will have to wait another year for the national data on CPS reports and foster care entries after pandemic closures lifted.

The FY 2020 data on foster care around the country provided in the long-awaited AFCARS report contains few surprises. As expected by many, foster care entries and exits both fell in the first year of the pandemic. Since entries fell more than exits, the total number of children in foster care fell by over four percent. These numbers raise concerns regarding children who remained in unsafe homes and those who stayed in foster care too long due to agency and court delays. The one surprise was a concerning one: the lack of a major pandemic impact on the number of youth aging out of care. The second pandemic fiscal year has already come and gone, but it will be another year before we can get a national picture of how child welfare systems adjusted to operating during a pandemic.

*Our percentages are slightly different from those in the federal Trends report because the Children’s Bureau calculated their percentages based on numbers rounded to the nearest thousand.

*There is evidence that maltreatment referrals from school personnel are less likely to be substantiated than reports from other groups, and this may reflect their tendency to make referrals that do not rise to the level of maltreatment, perhaps out of concern to comply with mandatory reporting requirements. Data from the first three months of the pandemic shared in a webinar showed that referrals which had a lower risk score (measured by predictive analytics) tended to drop off more than referrals with a higher risk score. However as I pointed out in an earlier post, that low-risk referrals dropped off more does not mean that high-risk referrals were not lost as well.

The death of David Almond: a perfect storm, or the tip of the iceberg?

Image: WJAR

I have been trying to avoid writing more posts about children failed by state systems that exist to protect them. No matter how many reports are written, these fatalities continue to occur with devastating regularity, and I’m not sure if my posts do any good. But despite my resolution to avoid such stories, I feel compelled to write about David Almond, a fourteen-year-old boy with Autism Spectrum Disorder who died of abuse and neglect on October 21, 2020. I have to write about David for many reasons, including the sheer number of red flags that were disregarded by child welfare, schools and courts in his case; the light his death sheds on risks to children with special needs, and what it shows about the peril posed to abuse victims by the quarantines due to COVID-19.

The Massachusetts Office of Child Advocate (OCA) issued a scathing report in March that revealed “multiple missed opportunities for prevention and intervention prior to the death of David Almond and the discovery of the serious physical and emotional injuries to his brothers.” David’s family was under the supervision or monitoring of the Department of Children and Families (DCF), the juvenile court, the education system and many service providers at the time of David’s death. Reading OCA’s account of the family’s involvement with DCF alone, it is hard to comprehend the many misguided actions and missed opportunities that allowed David to be returned to a family patently unable to care for him and then to deteriorate physically and emotionally over a period of seven months, culminating in his death. The attachment to this blog lays out the sad chronology assembled by OCA, which I summarize more briefly below..

David, Michael and Noah Almond were triplets born in February, 2006 in Syracuse, NY and diagnosed with Autism Spectrum Disorder at the age of about two. Between 2006 and 2013, the triplets were removed from their parents three times by the New York State Office of Children and Family Services (OCFS) due to substance abuse, mental illness, “deplorable living conditions,” medical neglect, inadequate supervision, and “a general lack of basic care.” After working toward termination of the parents’ rights, OCFS inexplicably shifted gears and a New York Family Court awarded full custody of the boys, now aged ten, to Almond, who was living in Massachusetts, in September 2016.

Upon receiving custody, Almond moved the boys to the one-bedroom apartment in Fall River, Massachusetts, which he shared with his partner, Jaclyn Coleman, and his mother, Ann Shadburn. Almond had been removed as a child from Shadburn, whose parental rights to all her children had been terminated due to abuse and neglect. Almond and Coleman were both in DCF custody for part of their childhoods due to abuse and neglect, mental illness, physical violence, and substance abuse. By August 2017, Coleman had a new baby (Aiden) and three reports had already come into Masachusetts’ child abuse hotline concerning the family.

In October 2017, all four children were removed from Almond and Coleman because of abuse and neglect, parental substance abuse, unsanitary home conditions, medical neglect, and the triplets’ excessive absences from school. In the words of OCA, “This was the fourth time in the triplets’ young lives that they were removed from Mr. Almond for the identical pattern of abuse and neglect.” But four strikes was not enough. The parents agreed to a plan requiring them to engage in therapy to address longstanding substance abuse and mental health issues, submit to random drug tests, participate in family therapy with the triplets, complete psychological evaluations, and complete parenting classes. Aiden was placed in foster care and the triplets were eventually placed in a residential facility specializing in autism spectrum disorder and intellectual disability.

While the triplets thrived in their residential facility, Coleman and Almond displayed minimal compliance with their plans, and the children’s permanency goal was changed to adoption in January 2019. But in July 2019, the children’s goal was changed back to reunification based on the parents’ improved compliance with their case plan, and Aiden was returned home the next day. This occurred, as OCA put it, “despite Mr. Almond’s failure to engage with therapy, despite Ms. Coleman’s limited engagement with therapy, and despite the lack of any documentation of any change in Mr. Almond and Ms. Coleman’s ability to parent, specifically their ability to parent children with special needs.” OCA attributes this decision mainly to a parenting evaluation conducted by a contractor that did not adequately assess the caregivers’ ability to care for the children.

In December 2019, DCF Fall River area office management decided to begin the reunification process for the triplets. This decision was made despite concerns raised by the family support provider and the case management team (social worker and supervisor) that the parents were canceling appointments, and more generally regarding their ability to care for the triplets. Management set a target date of January 2020 for the reunification. They disregarded requests for a delay from the case management team, the residential facility and the boys’ school. These requests were based in part on the need of children for a slower transition given the children’s disability, the logic of waiting until June to eliminate an extra change of school, the limited engagement the parents had demonstrated with services, the difficulties inherent in having seven people in a one-bedroom apartment, and the threat of eviction by the landlord if the boys returned home.

As the reunification date grew nearer, Almond and Coleman canceled scheduled visits with the boys, canceled appointments with the parenting support provider, and failed to take steps to secure larger housing. During the first day visit of the boys to the home on January 10, 2020, Coleman stated that reunification was moving too fast and that the family was not yet ready for overnight visits because the apartment was too small. At the first overnight visit on February 7, Almond and Coleman reported that Noah became aggressive, and he was returned to his facility that night. After this home visit, Noah refused to return to the apartment and was allowed to remain at his residential facility. The goal of reunifying him with his parents was dropped. This young autistic boy’s self-advocacy may have saved his life.

On February 11, 2020, the residential care facility took the “extraordinary” step of sending DCF a letter opposing the reunification of David and Michael with Almond and Coleman, citing the inadequate physical environment of the home to meet the children’s therapeutic needs; the fact the parents were facing eviction; and the need for a slower, more appropriate transition plan. The reunification was delayed, but by one month only. The case management team referred the family for Applied Behavioral Analysis (ABA) Services, an evidence-based approach used in both the residential program and school that the boys attended. This service was considered essential for a successful reunification, but there was a waiting list of at least six months for ABA services. Instead of delaying the reunification, DCF chose to secure “continuum services” for the family even though these services targeted one child only (Michael) and were not a substitute for ABA’s services, which are specific to the needs of autistic children.

David and Michael were returned to Almond and Coleman on March 13, 2020, barely two months after their first day visit. Four days after the reunification, the state’s COVID-19 restrictions went into effect. Starting within days of the boys’ return home and continuing until David’s death, OCA states that Almond and Coleman “deliberately avoided contact with the DCF case management team, the Fall River Public Schools, the continuum service provider, and the parenting support service provider.” They often claimed to have phone or internet access issues that prevented them from responding or being on video. When offered help in dealing with these issues, they refused or provided conflicting information.

Between March and September 2020, the case management team conducted monthly virtual visits with the family and received many communications from providers and schools. During this period, the team missed multiple red flags and opportunities to prevent the tragedy that eventually occurred. The team disregarded evidence from their own virtual visits, such as Coleman’s berating of David for his alleged behavior and her coaching of the boys to provide the desired responses to the case manager’s questions. But they never sought to interview David and Michael outside the presence of the adults. Exactly two months before David’s death, DCF received received a new CPS report about conditions in the home and substance abuse by Coleman and Almond. But the case management team accepted Coleman’s attribution of the report to a malicious neighbor and did not request drug tests for Coleman and Almond.

The team ignored concerning reports from providers and schools. These included the termination of services by the parenting services provider due to Coleman and Almond’s failure to engage with services; consistent reports from the continuum services provider that Coleman refused to allow them to speak to Michael, the targeted child for these services, and were resistant to the support and the strategies offered to address the boys’ behaviors; and David was never allowed to see the therapist obtained by DCF. DCF heard from Fall River Public Schools that Coleman and Almond refused the Chromebooks offered by the school in May but never submitted the paper packets they had chosen to complete instead. Instead, DCF learned that that the boys were not logging into school in the fall semester (a report Coleman denied, as she was logging into the schools’ electronic attendance system to falsely mark the boys “present.” ). They learned that David had missed his physical in July and two subsequently scheduled appointments.

David’s school, despite making multiple concerning reports to DCF case management, also missed many chances to save David. In one striking example, a school attendance officer came to drop off Chromebooks for David and Michael only 20 days before David was found dead. Coleman met the officer outside, refusing him entry in the apartment, and the offer did not attempt to see the boys. Apparently he was there solely to drop off the devices and not to see David or discuss with this family his lack of engagement with school since the previous March. If that officer had seen David and noticed his physical state, David might be alive today.

On the morning of October 21, 2020, emergency medical personnel responded to a 911 call regarding David; he was bruised, emaciated, and not breathing. He was transported to Charlton Memorial Hospital and pronounced deceased. Michael was found emaciated but responsive, and Aiden was well nourished and appeared physically unharmed. Substances believed to be heroin and fentanyl were found in the apartment. Michael and Aiden were immediately removed from Almond and Coleman, who are in jail and facing criminal charges.

OCA found that DCF missed multiple opportunities to protect David and his brothers. DCF gathered insufficient information from service providers and failed to analyze the information they did get; underestimated the impact of Almond and Coleman’s substance use; failed to recognize that Almond and Coleman were using access to technology as a tactic to avoid participation in services for themselves and their children; misinterpreted the “successful” reunification of Aiden (a non-disabled child) as a predictor of a successful reunification for the triplets; disregarded the triplets’ need for a gradual transition to the home; failed to secure the recommended essential services for David and Michael to be stable and successful at home; made David responsible for his own physical safety rather than teaching him to distinguish between appropriate and inappropriate interactions how to to communicate concerns to a trusted adult; and failed to adequately identify and adjust to the complications imposed by the COVID-19 pandemic.

OCA found that DCF management failed to understand that the physical environment of the home, a small one-bedroom apartment, did not meet the needs of the triplets. This is despite hearing this concern from the DCF case management team, Almond, Coleman, Almond’s legal counsel, legal counsel for David and Michael, and several provider agencies.  Incredibly, it appears that DCF management interpreted concerns from the various professionals as “an inappropriate consideration of the family’s financial means.” They seem to have disregarded the importance of physical space in the therapeutic management of autistic children and also the fact that Coleman and Almond seemed uninterested in finding a larger apartment and provided multiple excuses for not following up on housing applications.

As OCA states, “It is widely recognized that in times of crisis and economic stress there is an increase in child abuse and neglect.” Yet, OCA found that DCF did not treat the COVID-19 pandemic as a cause for reevaluation of the appropriateness of David and Michael’s reunification and did not consider the implications of the pandemic for the safety or well-being of the children. DCF seemed oblivious of Coleman and Almond’s use of the pandemic to isolate the children. Bizarrely, DCF case management staff urged school staff not to hold Coleman accountable for David and Michael’s complete absence from school, arguing that the problem was lack of technology access in the home. Case management staff also advised Coleman repeatedly to contact the school to explain that technology was the barrier to David and Michael’s participation, in order to prevent the school from filing a child neglect report against her.

Amazingly, DCF did not categorize David and Michael as high-risk children to receive in-person home visits during COVID-19. DCF appeared not to understand that that the boys’ disability, the long history of abuse and neglect in this family, the caregivers’ avoidance of contact with providers, and their reports about David’s behaviors, injuries and illnesses were all signs of children at risk. Moreover, the DCF administration has not issued statewide guidance that provides DCF personnel instructions about how to assess safety and risk during virtual home visits.

And perhaps most shockingly, DCF missed the deterioration in David’s physical and emotional state between March 13, 2020, and his death on October 21. The residential program and school where David lived and studied until March 2020 described him as having good social interaction skills, as being communicative, as having no significant behavioral issues or self-injurious behaviors, as having no aggression toward others and as having the ability to take care of his own activities of daily living. Yet within weeks of reunification Coleman was reporting that David was noncompliant, aggressive, harmed himself, and needed assistance with activities like toileting. During virtual home visits with DCF, David was always quiet and minimally communicative, while Coleman often berated and shamed him for behaviors and defiance. The case management team accepted her account and disregarded the conflict with his observed behavior and past accounts. David was a healthy weight when he left residential care. At his death, David had lost approximately 60 pounds from his last recorded weight in December 2019. It is hard to understand how anyone could have missed such a drastic change, even through a video screen.

OCA found that the Juvenile Court, including the attorney for David and Michael, did not serve as a check on the many egregious decisions of DCF. Instead, perhaps because they all agreed to return the boys home, the court and attorneys relied too heavily on DCF to determine the direction of the case. They accepted DCF’s interpretation of Aiden’s “successful” reunification as an indication of the likelihood of a similar outcome for the triplets, disregarding the differences between Aiden and the autistic triplets; failed to require a submission of a realistic reunification plan despite the judge’s statement that such a plan would be needed; accepted DCF’s narrative of the triplets’ “successful” reunification even though court reports contained information from service providers about the family’s failure to participate in services; disregarded multiple concerns about the small size of the family’s apartment and the stress it caused, based on the apparent belief that it was inappropriate to consider inadequate housing as a barrier to reunification; and never requested an analysis of the effects of the COVID-19 pandemic on the family’s ability to care for these high-needs children.

The education system’s failure of David and Michael was almost as egregious and shocking as that of DCF and the court. OCA found that the state Department of Elementary and Secondary Education (DESE) did not have the resources to monitor the provision of a free and appropriate public education in real time by local school districts during the COVID-19 pandemic. Despite their policy of prioritizing high-risk students for in-person learning, DESE “allowed families to choose the fully remote option for any reason and without a stated reason. In fact, districts were instructed not to counsel families of high risk students to choose in-person learning even if the district felt that remote learning would not be successful for a particular student.” DESE did not set higher standards for monitoring or support for high-risk students, such as those with disabilities and those involved with DFS, regardless of their choice of learning option. DESE issued no guidance to school staff on how to recognize abuse and neglect in a virtual environment. Nor did they address mandatory reporting of attendance issues until January 2021.

In addition to the failures of DESE, Fall River Public Schools (FRPS) missed multiple opportunities to save David. The shift to remote learning, coinciding exactly with the transfer of David and Michael to FRPS, meant that David was never seen by, or spoken to, by any school employee from March 2020 to the time of his death in October 2020. To their credit, school staff made numerous attempts to communicate with the parents and resolve alleged technology problems. Yet, David and Michael’s teachers never attempted to make contact with the boys directly via telephone. While they raised concerns about the boys’ lack of participation to the DCF case management team, school staff never elevated this concern by filing a neglect or truancy report. Moreover, FRPS set no attendance or participation requirements, and David was incredibly promoted to high school after being completely disengaged from his school since being transferred there in March. DESE and FRPS guidance for the fall 2020 concerning attendance tracking, contact, and grading never filtered down to school staff, perhaps preventing an intervention in the last month of David’s life.

There was another entity that could have intervened to raise concerns about the safety of the children, and that was the Massachusetts Probation Service (MPS). Massachusetts children in child welfare cases are assigned a probation officer whose role is to verify compliance with court orders, report to the court on the status of these orders and monitor the well-being of the children. The officer in this case had regular contact with the family and seemed to have a much more clear-eyed view of their problems than did DCF, which did not act on his expressed concerns. However, he did have a worrisome conversation with Coleman only days before David’s death in which she reported on the deterioration of both boys, that they had regressed to wearing adult diapers, that David was picking at his skin causing sores and bleeding, and that Michael had to be hospitalized for self-injury. The officer could have brought these concerns to the attention of the court before the next hearing but did not do so–possibly due to a culture discouraging such communications–and missing the last opportunity to save David.

Several questions remain even after the comprehensive review by OCA. First, what explains the New York Court’s decision to reunify the triplets with their father after taking steps toward terminating his rights? It is very concerning that OCA was not able to obtain this information in its review of court data. A court decision like this would have to be documented and would presumably been based on recommendations from Onondaga County (NY)’s Office of Children and Family Services (OCFS). It is not clear whether OCA requested documents from OCFS, and whether such a request was refused. It is necessary to understand what occasioned this about-face by New York. One cannot help wondering if the agency realized the boys would not be adopted was trying to avoid the expense of caring for the boys into adulthood.

OCA was also unable to explain the DCF area management’s unwillingness to reconsider the appropriateness of the reunification plan in the face of objections from their case management team and almost everyone else involved. OCA states that there was no pressure from the Juvenile Court, Almond, Coleman, their attorneys, nor the children’s attorney to rush a transition home. DCF administration also confirmed during this investigation that there were adequate funds in the Fall River Area Office’s budget to continue the triplets residential placement. Once again, as in New York, one has to wonder whether, despite the existence of “adequate funds” for the boys’ placement, there was in fact pressure on the local DCF office to return the boys due to the financial costs of their placement. Such budget concerns might have explained the unseemly rush to reunify despite the unavailability of a crucial service and adequate housing and the clear logic of waiting until the triplets completed their educational program in June 2020.

It is hard to avoid speculating about whether Almond and his paramour actually wanted custody of David and Michael. It appears that Almond and Coleman wanted Aiden back (not surprising as he was Coleman’s son and not disabled) and that is why they began to cooperate somewhat with services after an initial period of total noncompliance. There is no evidence that the couple were pushing for the return of the triplets and many indications that they tried to delay it as long as possible. Canceling visits to the boys and appointments with providers and failing to take steps to find a larger apartment could all be taken as signs of reluctance to receive the boys at home. Caring for triplets with autism plus a baby is not easy for anyone, it is hard to imagine a troubled couple like this one doing it, especially without the help that was recommended by the expert.

There is no excuse for the sheer inhumanity displayed in this household. Nevertheless, the case does call to mind the reports that are coming from all parts of the country regarding our national failure to help parents care for their mentally ill or developmentally disabled children–a crisis that is leading good parents to consider relinquishing custody of their children in order to obtain the services they need. It is possible that Almond and Coleman (not being good parents in the least) were trying hard to relinquish custody but were unsuccessful in unloading their unwanted triplets onto New York and Massachusetts. The eagerness of agency management to shed this burden and the reluctance of Almond and Coleman to take it on made for a toxic mix that killed David Almond, and left both of his brothers with lifelong wounds.

The OCA report contains many pages of recommendations for DCF, which include improving supervision, reviewing and revamping agency policies on contacts with collaterals, clients with disabilities, reunification; revamping the safety assessment process; setting standards for when and how virtual visits can be conducted, establishing a robust quality assurance system with additional monitoring at critical decision-points in a case and for higher-risk cases, and creating a “culture of continuous learning” where the “identification and correction of errors, miscalculations, or misinterpretations is encouraged and commended.” Many more recommendations targeted the juvenile court, the Probation Services, and the public schools.

While this report is unique due in its exploration of the complications due to the COVID-19 pandemic, we have seen too many similar reports from all of the country over many years. Most recently, Maine’s child welfare ombudsman found that the system continues to struggle with making an informed decision about whether to send a child home from foster care and whether to end agency supervision of reunified children. In a review of 82 cases closed in the past year, they found 20 cases where reunification practices were at issue.

Commonwealth Magazine notes that OCA conducted comprehensive investigations in 2013 and 2015, following three high-profile child deaths. Since 2015, the Legislature and Gov. Charlie Baker’s administration have increased funding for DCF by more than $200 million, added more than 650 positions, reduced caseloads, and introduced numerous reforms. Yet, Fall River State Representative Carole Fiola pointed out that many of the same patterns of agency malfunction were found in the earlier reports. This is indeed discouraging. Perhaps stronger measures are required.

A “three strikes law” for abuse and neglect might be one such stronger measure. Perhaps parents should not be given another chance after three or more removals. And this question brings up the role of ideology, especially as it might be expressed by managers who are unfamiliar with the actual details of the case. In the current child welfare climate, it often seems that parents can do no wrong. As noted repeatedly in the this case, there was too little focus on the problems that brought the children into care, and too little assessment of whether these problems were truly solved before the children were returned. This may not be atypical or surprising, given the current emphasis on family preservation and “strength-based” approaches to working with families, which ask social workers to minimize problems and find strengths wherever they can. There is certainly value in this perspective as a corrective to an earlier focus exclusively on problems, but taken too far it can be deadly.

The reluctance of the agency, lawyers and court personnel to consider housing adequacy as a prerequisite to reunification was another dysfunctional intrusion by ideology into case practice. Today’s dominant narrative asserts that children are being removed from families due to poverty that is being couched as neglect by intrusive child protective services systems. Poverty should not be a reason for removal nor should it be a barrier to reunification. But this case was not so simple. Almond and Coleman took no steps to apply for larger housing, despite being offered many opportunities to do so. It is possible that their reluctance to apply stemmed to their hope that they would not be saddled with the three boys. But the reigning narrative may have blinded agency management, court and lawyers to this concerning lack of action by the boys’ father and his paramour.

David’s case warns us to beware of the blanket statements often pushed by the child welfare establishment. It is often accepted as common knowledge that children do best with their family of origin, that in rare cases where children cannot remain at home the best placement is a relative (like Ann Shadburn?), and that congregate care is always the worst placement for children. None of these “truths” were correct for David and his brothers. Perhaps David’s story will lead some leaders and commentators to ask themselves what a home really is, and to understand that it is the presence of love, not the type of setting, that matters to a child.

“It is tempting to characterize this case as resulting from a ‘perfect storm,'” says the OCA, while not expressing an opinion on whether that is an apt characterization. The “perfect storm” explanation is often used by governments to argue against placing significant weight on individual cases, no matter how egregious. “A system should not be judged by one case, no matter how sad or sensational,” said Joette Katz, Commissioner of Connecticut Department of Children and Families (DCF) as reported by the Hartford Courant. Katz was talking about the death of Matthew Tirado, an autistic 17-year-old, on February 14, 2017 from prolonged abuse and neglect by his mother. Matthew had been known to Connecticut’s Department of Children and Families since the age of five, as revealed by a heartbreaking  report from Connecticut’s Office of the Child Advocate. Yes, A System Should be Judged by One Case was my answer to Katz. If David’s death was the outcome of a perfect storm, it was also the tip of the iceberg. If professionals are capable of making the kind of mistakes they made over and over again in this case, similar mistakes are obviously occurring in other cases. For every David Almond or Matthew Tirado, there must be many other children left in abusive and neglectful homes who never come to our attention because they are not actually killed albeit suffer lifetime damage. But the cost in current suffering and future damage is incalculable.

Certainly the COVID-19 pandemic was a large part of the “perfect storm” leading to David’s death. Thankfully, the pandemic appears to be easing and schools should be open full time next fall. However many jurisdictions plan to retain a virtual option next fall. OCA expressed concern that even though an in-person option was offered to the boys in Fall 2020, parents were allowed to choose virtual education without any stated reason and even if the district felt that remote learning would not be successful for a particular student. OCA made many recommendations for improving the oversight of children in virtual education but did not make a recommendation that addressed this finding. It is my view that jurisdictions should establish guidelines for approval of virtual education for each student and require a waiver for any student whose guardians request virtual education for reasons that are not included in these guidelines. Many advocates for children and domestic violence victims, such as Andrew Campbell, have warned from the outset of the pandemic of the dangers facing people who locked in with abusers. David’s case showed how right they were and that planning for future emergencies needs to include better provisions for such vulnerable people, including school-aged children.

COVID-19 will end, but I will continue to write about the Davids, the Matthews and all of the children who are failed by the agencies that exist to protect them. I will continue to write about them until we learn to value our children more than money or ideology, and until we decide as a nation that children will no longer be collateral damage in the pursuit of other goals, whether pandemic containment, “family preservation,” or budget savings.

Attachment: Chronology of the case of David Almond, from the Office of the Child Advocate Report

February, 2006: David, Michael and Noah Almond were born in Syracuse, NY to Sarah and John Almond, as described in OCA’ s devastating report. The triplets were all diagnosed with Autism Spectrum Disorder at the age of about two.

2006 to 2013: the triplets were removed from their parents three times by the New York State Office of Children and Family Services (OCFS) due to substance abuse, mental illness, “deplorable living conditions,” medical neglect, inadequate supervision, and “a general lack of basic care.” Their mother had no contact with them after the final removal, and their father moved to Massachusetts. OCFS began steps to terminate the parents’ rights to the boys, but never completed the process.

September 2016: A New York Family Court awarded full custody of the boys to Almond, who was living in Massachusetts, in September 2016, after years of minimal or no contact. Almond moved the boys to the one-bedroom apartment in Fall River, Massachusetts, which he shared with his partner, Jaclyn Coleman, and his mother, Ann Shadburn. All three had a history of abuse and neglect as a victim or perpetrator. Shadburn’s parental rights to all of her children, including John Almond, had been terminated. Almond and Coleman were both in DCF custody for part of their childhoods due to abuse and neglect, mental illness, physical violence, and substance abuse.

June 2017: The first two abuse or neglect reports were called into the Massachusetts hotline concerning the children. Another report came in that August, citing Coleman’s substance abuse and questions about the parents’ ability to meet the needs of their newborn son, Aiden, as well as of the triplets.

October 2017: All four children were removed from Almond and Coleman because of abuse and neglect, parental substance abuse, unsanitary home conditions, medical neglect, and the triplets’ excessive absences from school. In the words of OCA, “This was the fourth time in the triplets’ young lives that they were removed from Mr. Almond for the identical pattern of abuse and neglect.” But four strikes was not enough. The parents agreed to a plan requiring them to engage in therapy to address longstanding substance abuse and mental health issues, submit to random drug tests, participate in family therapy with the triplets, complete psychological evaluations, and complete parenting classes. Aiden was placed in foster care and the triplets were eventually placed in a residential facility specializing in autism spectrum disorder and intellectual disability.

January 2019: While the triplets thrived in their residential facility, Coleman and Almond displayed minimal compliance with their plans, and the children’s permanency goal was changed to adoption.

July 2019; the goal for all of the children was changed back to reunification after reports that Coleman and Almond’s compliance with their plans had improved, and Aiden was returned home the next day. This occurred, as OCA put it, “despite Mr. Almond’s failure to engage with therapy, despite Ms. Coleman’s limited engagement with therapy, and despite the lack of any documentation of any change in Mr. Almond and Ms. Coleman’s ability to parent, specifically their ability to parent children with special needs.” OCA attributes this decision mainly to a parenting evaluation conducted by a contractor that did not adequately assess the caregivers’ ability to care for the children.

December 2019: DCF management decided to begin the reunification process for the triplets. This decision was made despite concerns raised by the family support provider and the case management team (social worker and supervisor). DCF management set a target date of January 2020 for the reunification. They disregarded independent requests for a delay from the case management team, the residential facility and the boys’ school.

January 10, 2020. The boys had their first day visit to the home and Coleman stated that reunification was moving too fast and that the family was not yet ready for overnight visits because the apartment was too small.

February 7, 2020: At the first overnight visit on February 7, Almond and Coleman reported that Noah became aggressive, resulting in a physical altercation. As a result, Noah was returned to his facility that night. After this home visit, Noah refused to return to the apartment and was allowed to remain at his residential facility. The goal of reunifying him with his parents was dropped.

February 11, 2020: The congregate care provider took the “extraordinary” step of sending DCF a letter opposing the reunification of David and Michael with Almond and Coleman, citing the inadequate physical environment of the home to meet the children’s therapeutic needs; the fact the parents were facing eviction; and the need for a slower, more appropriate transition plan. The reunification was delayed, but by one month only.

March 13, 2020: David and Michael were returned to Almond and Coleman, barely two months after their first day visit, while remaining in the legal custody of DCF. Four days after the reunification, the state’s COVID-19 restrictions went into effect.

April 2020: At the monthly virtual DCF visit Ms. Coleman reported that there were no concerns regarding the children’s behaviors and the children had access to a laptop for the purposes of schooling. The DCF case management team did not recognize that Ms. Coleman provided contradictory information to the continuum service provider. 

May, 2020: Ms. Coleman rescheduled a DCF virtual home visit supposedly due to technology access issues. During this phone call, Ms. Coleman reported to the DCF case management team that David was vomiting from having too many snacks and was lying in his own vomit. The DCF case management team did not follow up with Ms. Coleman about how David was feeling or the possibility that David could be sick another reason. When the virtual home visit happened ten days later, Coleman took a “strong and controlling role in the communication between the DCF case management team and the children.” She prompted the children to provide specific answers to the DCF case management team questions. In the same month, the parenting support service provider cancelled the service with Almond and Coleman due to their lack of engagement with the service. Also in May, the school offered Chromebooks to David and Michael. This offer was turned down by Coleman in favor of having the boys complete paper packets. But paper packets were never submitted for either of the boys, and the school took no action.

June 2020, the continuum service provider shared with DCF Coleman’s report that Almond physically restrained David due to David’s aggression and that David was completing his chores, which included scrubbing the floor with a toothbrush. Later in the month, the continuum service provider informed DCF that Ms. Coleman reported being fearful that David and Michael would both attack her at the same time and that David refused to take his medication. The provider reported that Coleman refused an outdoor visit and was not using the provider’s emergency service line that they repeatedly urged her to use.

June 2020: In the monthly virtual DCF visit, Coleman tried to stop the boys from answering a question about whether they wanted to visit with their brother Noah, whom they had not seen since March. OCA believes that “Ms. Coleman intentionally prevented David and Michael from virtually visiting with Noah to isolate them from Noah and isolate them from the congregate care program staff that knew them well and might have identified concerns.”

June 17, 2020: A foster care review panel was held and reviewers found that “Mr. Almond and Ms. Coleman were meeting the needs of the children and participating in the continuum services. According to OCA, “It is unclear if the foster care review panel was aware that the parenting support service provider closed the case in May due to a lack of responsiveness from Mr. Almond and Ms. Coleman, and it was unclear also if the panel knew of the continuum service provider’s description of the challenges facing the family.” 

July 17, 2020: The Court returned legal custody to Almond despite the lack of improvement in his and Coleman’s participation in services and no change in Coleman’s description of the boys’ behavioral challenges . Almond was not present at the hearing. On the same day Coleman refused both an outdoor and an indoor visit. According to OCA, “The DCF case management team did not observe the children, the home, or Mr. Almond or Ms. Coleman between June 19, 2020 and July 17, 2020 when David and Michael were legally returned to Mr. Almond’s care.” 

July 22, 2020: At the monthly DCF virtual visit, Coleman berated David in front of the case management team for his behavior. When Michael contradicted Coleman’ account of David’s behavior, she said he was “making her look like a liar.” But at no point did the case managers seek to interview David or Michael outside Ms. Coleman’s presence.

August 2020: The continuum service provider informed the DCF case management team that Ms. Coleman had reported David scratched his collar bone until it had become raw. The DCF case management team did not follow-up with Almond or Coleman about this injury. The continuum service provider also expressed that the family was not fully engaging with the service and that the children needed Applied Behavioral Analysis (ABA) services. 

August 21, 2020: DCF received a report about conditions in the home and substance abuse by Coleman and Almond. The case management team conducted a virtual home visit three days later. Coleman attributed the report to a malicious neighbor and denied the substance abuse. The team accepted her self-report and did not request drug tests for Coleman and Almond. Coleman attributed a bandage on David’s nose to self-injury and when David was asked, he followed Coleman’s prompting to corroborate her account. As OCA points out, the team neither considered the significance of self-injury as a sign of distress nor considered the possibility of parental violence as the cause of the injury.

September 14, 2020: On September 14, 2020, Michael was brought to an out-of-state hospital emergency department for an injury that Coleman reported was self-inflicted. Michael was admitted for overnight observation and discharged home the next day. This injury was not reported to DCF.

September 25, 2020: The DCF case management team had its last virtual home visit with the family. Ms. Coleman described David as having behavioral issues, and David refused to speak. Between September 20, 2020 and October 3, 2020, the family canceled or did not attend all their scheduled appointments with the continuum service provider. 

On October 1, 2020, a school attendance officer came to drop off Chromebooks for David and Michael. Coleman met the officer outside and he did not attempt to see the boys as he was there solely to drop off the devices and not to see David or discuss with this family his lack of engagement with school since the previous March. If that person had seen David and noticed his physical state, David might be alive today. Twice in October, a teacher contacted DCF to report that the boys were not logging into school. The OCF team contacted Coleman, who denied that report.

October: The DCF case management team was made aware that David’s individual therapist had only been successful in contacting the family one time since August. Ms. Coleman told the case management team why that therapist was not appropriate for David. 

October 5 and October 14, 2020: A teacher from Fall River Public Schools contacted the DCF case management team and reported that David and Michael were not logging into school virtually. The DCF case management team contacted Ms. Coleman, who denied this report and reported both David and Michael were attending school virtually 

On October 7, 2020, the team learned that David had missed his physical in July and two subsequently scheduled appointments. A case review was held on October 14, 2020. Almond and Coleman did not attend. The review panel “inexplicably found that Mr. Almond and Ms. Coleman were meeting all the children’s needs in the home. This determination was made despite concerns regarding the family’s lack of consistent engagement and utilization of services, that David and Michael had not attended school or received any special education services since their reunification in March, and despite Ms. Coleman’s reports of David engaging in serious self-injurious behaviors.”

October 14, 2020: Another foster care review meeting was held in the absence of Almond and Coleman. In OCA’s words, “The foster care review panel inexplicably found that Mr. Almond and Ms. Coleman were meeting all the children’s needs in the home. This determination was made despite concerns regarding the family’s lack of consistent engagement and utilization of services, that David and Michael had not attended school or received any special education services since their reunification in March, and despite Ms. Coleman’s reports of David engaging in serious self-injurious behaviors.” 

October 21, 2020: Emergency medical personnel responded to a 911 call regarding David; he was bruised, emaciated, and not breathing. He was transported to Charlton Memorial Hospital and pronounced deceased. Michael was found emaciated but responsive, and Aiden was well nourished and appeared physically unharmed. Substances believed to be heroin and fentanyl were found in the apartment. Michael and Aiden were immediately removed from Almond and Coleman, who are in jail and facing criminal charges.

New Jersey to foster parents: thanks but no thanks!

Foster Parents Needed As COVID-19 Pandemic Strains Families is a typical headline these days, as illustrated in an article from Illinois. The pandemic has imposed new impediments to recruiting and retaining foster parents, including fears of exposure to COVID-19, loss of employment and income, and concerns about supervising virtual schooling. But these issues do not seem to be affecting New Jersey, where prospective foster parents are told that they are not needed, thank you very much! While the state credits its efforts at child abuse prevention and family preservation for its lack of need for foster parents, the explanation seems to lie elsewhere. Over the course of five years, the state has cut in half its rate of confirming allegations of abuse and neglect–resulting in a similar fall in the number of children entering foster care. This is a big change, and one that demands explanation in order to ensure that the agency is continuing to fulfill its mission of ensuring children’s safety in New Jersey.

Would-be New Jersey foster parents who click on “Be A Foster Parent” on the website of the Department of Children and Families (DCF) are greeted with the following message: “Thank you for your interest in becoming a resource parent to children and youth in state care.  Due to the COVID19 Pandemic and its impact on operations, DCF has suspended all new inquiry submissions at this time. Please continue to check our website for any updates.” This is an odd message indeed, as it seems to imply that the pandemic has made recruitment and licensing impossible. But agencies around the country have adapted quickly to move vetting and training online in order to enable new foster parents to enter the pipeline. Not so New Jersey.

When we asked DCF why foster parents are being turned away, we received the following reply from DCF Communications Director Jason Butkowski. “[W]e did experience a 19.17% reduction in out-of-home placements from 2019 to 2020.  This is attributable both to New Jersey’s statewide prevention network and our ongoing work to preserve families and keep children and parents together in their homes while receiving services.”

Interestingly, a message sent earlier to prospective foster parents gave a different answer. In May, 2020, would-be foster parents received a message saying, “In New Jersey, the number of youth in foster care continues to be reduced each year because we are focusing first on kinship placements,” as quoted in an article by Naomi Schaefer Riley. We asked Mr. Butkowski which explanation was more accurate–prevention and family preservation or kinship placements–but received no answer.

So what is going on in New Jersey? Certainly, foster care numbers have been decreasing. According to the data portal maintained by Rutgers University, annual entries to foster care fell from 5,504 in 2013 to 2,525 in 2019, as shown in the chart below. The rate of decrease in foster care entries became even steeper between 2018 and 2019, with a decrease of 23.7 percent in the number of entries in that one year alone. The total number of children in foster care dropped from a high of 7,775 in May 2014 to 4,463 in February 2020–before the pandemic closures occurred. So what could be causing this drastic decline in foster care placements and caseloads?

Source: NJ Child Welfare Data Hub, available from https://njchilddata.rutgers.edu/portal/entering-placement-reports#

One possibility might be a decline in child abuse and neglect, which Butkowski is implicitly assuming by attributing part of the fall in foster care cases to DCF’s “statewide prevention network.” In that case, one might expect reports to child abuse hotlines to decline significantly. But according to monthly state reports, calls to child abuse hotlines hardly changed between 2014 and 2019, decreasing very slightly from 165,458 to 164,417. Of course we cannot be sure that reports are an accurate measure of child maltreatment; but one might expect a significant reduction in hotline calls if a large reduction in maltreatment were occurring.

DCF’s Butkowski also credited the agency’s work to “keep children and parents together in their homes while receiving services” as a reason for declining foster care entries. It is true that most substantiations of abuse or neglect do not result in foster care. Instead, DCF works with many families in their homes to help them avoid future maltreatment. But DCF has been emphasizing in-home services for years. Of all the children who were under DCF supervision in foster care or in-home services, the percentage receiving in-home services rather than foster care was 84.7 percent in May 2014 and 90 percent in February 2020. So children were somewhat more likely to receive in-home services in 2020 than in 2014, but the difference was small and not likely to explain the big fall in the foster care rolls.

So with hotline calls basically unchanged, and only a slight increase in the emphasis on in-home services, how did New Jersey manage to reduce its foster care entries by almost half in six years? One can think of the child welfare process as a funnel, starting with referrals, the child welfare term for hotline calls. As we discussed, those have fallen only slightly. Only some referrals are screened-in and accepted for investigation; many are rerouted or receive no action because hotline workers determine that they do not concern abuse or neglect. But a reduction in screened-in referrals is not part of the explanation for New Jersey’s drop in foster care placements. New Jersey reported that 60,934 referrals were screened in in FFY 2019, compared with 59,151 in FFY 2013–a slight increase.

The next step in the child welfare funnel is investigation, and here the count shifts from the number of referrals to the number of children. According to data submitted to New Jersey to the Administration for Children and Families (ACF) and published in Child Maltreatment 2019, the number of children receiving an investigation in New Jersey increased slightly from Federal Fiscal Year (FFY 2015) to FFY 2019–from 74,546 to 78,741. However there was a stunning drop in the proportion of these children who were found to be abused or neglected (known as “substantiation” in the child welfare world). In FFY 2015, 13.0 percent of the children who received investigations (or 9,689 children) were found to be abused or neglected. In FFY 2019, only 6.5 percent of the children receiving investigations (5,132 children) were found to be victims of maltreatment. In other words, among the children who were involved in investigations, the proportion who were found to be maltreated dropped by half. Similarly, the number of children found to be maltreatment victims dropped by 47 percent. (This is very similar to the 44.6 percent decrease in foster care entries between those years shown in the Rutgers data portal cited above).

Note: The substantiation rate is the number of children found to be maltreatment victims divided by the number of children who were the subject of CPS investigations. Data are from Child Maltreatment 2019, available at https://www.acf.hhs.gov/sites/default/files/documents/cb/cm2019.pdf

It turns out that aside from Pennsylvania, which is not comparable to other states because it does not report on most neglect allegations, New Jersey had the lowest rate of substantiation per 1,000 children of all the states in FFY 2019. Only 2.6 children per 1,000 were found to be maltreated, compared to a national rate of 8.8 children per 1,000. In FFY 2015, this rate was 4.9 per 1,000 children in New Jersey–almost twice as high.

How did the number and percent of children found to be victims of child maltreatment drop so much in New Jersey over a four-year period, despite little decline in hotline calls? We asked DCF this question but received no reply. In the notes it submitted to ACF with its 2019 data, DCF acknowledged a decrease in the number of substantiated victims of maltreatment and stated that this is consistent with a continued trend–but provides no explanation. Perhaps policy or practice has changed to make it more difficult to substantiate abuse or neglect, through a change in definitions or in the standard of proof, or perhaps in training or agency culture. But such a change was not mentioned either by Butkowski or in DCF’s submission to ACF.

Let us revisit DCF’s previous message to foster parents saying that “In New Jersey, the number of youth in foster care continues to be reduced each year because we are focusing first on kinship placements.” This is an interesting statement because it implies that these kinship placements are not through the foster care system. It is important to understand that children can be placed with relatives in two ways. A child can be found to be a victim of maltreatment and placed with a relative, who becomes licensed as a foster parent. In New Jersey, 1,619 foster children (or 41 percent of the 3,951 children in foster care) were living with licensed kinship foster parents in November 2020. But these children are included in the state’s count of children in foster care, so they cannot account for the caseload drop. DCF must have been referring to something else.

Perhaps DCF’s earlier message to foster parents referred to the agency’s increasing use of a practice called “kinship diversion.” As described in an issue brief from ChildTrends, kinship diversion is a practice that occurs during an investigation or an in-home case when social workers determine that a child cannot remain safely with the parents or guardians. Instead of taking custody of a child, the agency facilitates placing the child with a relative. If this occurs in the context of an investigation, kinship diversion may result in a finding of “unsubstantiated” even when abuse or neglect has occurred, on the grounds that the child is now safe with the relative. We have no idea how widespread this practice is in New Jersey or nationwide since neither New Jersey nor other states report the number of these cases. However, the system of informal kinship care created by diversion has been called America’s hidden foster care system and nationwide it appears to dwarf the provision of kinship care within the foster care system.

There are many concerns about kinship diversion, as described in an earlier post: caregivers may not be vetted or held to the same standards as foster parents; they and the children they are caring for do not receive case management and services; they do not receive a foster care stipend and may have to depend on much-lower public assistance payments; there is nothing preventing caregivers giving children back to the parents without any assurance of safety; and parents are not guaranteed the due process rights and help with reunification that come with having their children in foster care. Because of the various concerns around kinship diversion, litigation has been filed in several states challenging this practice.

There is one other possible explanation that comes to mind for DCF’s foster parent surplus–dropping foster care rolls due to the COVID-19 pandemic. We removed data from the time of the pandemic from the above discussion to avoid confounding its effects with those of policy and practice changes but we need to ascertain whether the pandemic’s impact on calls to the hotline has affected entries into foster care. As in most states, hotline calls in New Jersey fell sharply in the aftermath of school closures and other pandemic measures. The number of child maltreatment referrals between March (the onset of school closures and quarantines) and November 2020 (the last month for which data are available on the DCF website) was 98,306, compared to 131,344 in the same period of 2019–a drop of 25 percent, based on monthly reports from DCF. It is likely that fewer calls from teachers now teaching virtually were a major factor behind this drop in hotline calls.

Entries into foster care also fell sharply in the wake of the pandemic. Foster care entries dropped from 1,949 in March through November 2019 to only 1,211 in the same months of 2020–a drop of 37.9 percent–which may have reflected in part the reduction in hotline calls and in part the continuing decrease in foster care entries that we have described. But the number of children in care did not drop nearly as much as entries into care. Between February and November 2020, the total number of youth in care decreased only 11 percent from 4,463 to 3,951. This drop is surprisingly low–in fact it is less than the decrease in the foster care caseload during the same months of 2019 (16.1 percent). The small size of this caseload decline reflects the fact that foster care exits dropped even more than foster care entries. Exits from foster care dropped from 2,754 in March through November 2019 to 1,661 in the same months of 2020. That is a drop of over 1,093, when the drop in foster care entries was “only” 738.[1] As a result, it appears that the number of children in foster care was higher, rather than lower, due to the pandemic. Therefore, it does not appear that the pandemic contributed to the decline in demand for foster parents.

One might expect to hear expressions of concern, or at least interest, in the recent precipitous drop in the number and rate of substantiations and in the foster care caseload from the court-ordered monitor charged with ensuring that New Jersey’s child welfare system is fulfilling its mission of protecting children. Since 2006 New Jersey has been operating under a settlement agreement in a lawsuit filed in 1999. The Court Monitor is Judith Meltzer, Executive Director of the Center for the Study of Social Policy (CSSP). In its most recent report, CSSP praised DCF for maintaining its progress toward meeting all the benchmarks required to exit the lawsuit, despite the challenges posed by COVID-19. Ironically, the report mentions DCF’s progress in “Prioritizing Safety.” The report does not mention the precipitous drop in foster care entries or substantiations before the pandemic or the fact that the state is turning away prospective foster parents.

New Jersey may be the first state to have stopped accepting applications for foster parents, and the reasons cited by DCF do not seem to explain this unusual event. Careful study of DCF data shows that the rate at which allegations of abuse or neglect are substantiated has been cut in half, and that there has been a similar reduction in entries into foster care. This cut in the substantiation rate could be due to policy or practice changes making it harder to confirm child maltreatment or it could be due to an increased tendency to place children with relatives without establishing officially that maltreatment has occurred. Without an adequate explanation from the state, the extent to which either of these factors is driving these trends is unknown. It is imperative to know the explanation of this trend to ensure that DCF’s new policies and practices are not compromising its mission of keeping children safe.

[1]: Reasons for this drop in foster care exits may include court shutdowns and delays and suspension of services parents need to complete their reunification plans.

Hidden child maltreatment: One more reason to vaccinate teachers and open schools

With the end of the holiday break, about half the nation’s public students are not returning to school buildings but instead are continuing with virtual education. The impacts of school building closures on education, the economy and student mental health have been widely covered. But there is another consequence of virtual education that has not been as widely reported–the loss of the protective eye on children that their teachers and other school staff provide. Now that the COVID vaccine is becoming available, it is urgent that we get teachers vaccinated and students back to school.

In the wake of the coronavirus emergency beginning last March, almost all public school buildings in the nation closed, with few if any reopening before the end of the term. Many systems reopened buildings for fully in-person education or “hybrid” (partially virtual) models in August or September, and others opened their buildings later. As of Labor Day, 62 percent of U.S. public school students were attending school virtually, but only 38 percent were still online-only by early November, according to a company called Burbio, which monitors 1,200 school districts around the country. However, a spike in COVID cases beginning in November resulted in many systems returning to virtual education, with 53 percent of students attending virtually by January 4, 2021. Burbio expects a decrease in this percentage over the next six weeks as systems open up again after the virus spikes abate.

Almost immediately after the school closures last spring, reports began rolling in about the failure of online education to reach many students, especially those who were poor and most at risk of school failure. Some students lacked computers or internet access; others were unable to engage remotely in education. There is deep concern about the long-term impact of school building closures on young people’s academic performance, particularly for those at most risk of poor outcomes. With the passage of time, more information began to flow in about other consequences to children of missing school, such as worrisome impacts on their mental health.

But many child welfare professionals and advocates have long shared another concern. They worried about unseen abuse and neglect among the children stuck at home with increasingly stressed parents and not being seen by teachers and other adults. This is especially concerning for younger children, who are less likely to seek help on their own. And indeed, as soon as schools closed around the country last March due to the COVID pandemic, almost every state reported large drops in calls to their child abuse and neglect hotlines. The loss of reports from teachers (who make one in five of reports nationwide) was probably the major contributor, combined with the loss of reports from other professionals, friends, and family members seeing less of children due to stay-at-home orders and physical distancing.

After the academic year ended, data became available that that allowed comparison of reports, investigations, and findings of maltreatment in the pandemic spring compared to the spring of 2019. These analyses showed a large difference between reports, investigations, and substantiations of maltreatment in 2020 relative to 2019, followed by a convergence in data during the summer when schools are normally closed. In our local blog, we analyzed data from the District of Columbia Child and Family Services Agency (CFSA). For this post we used our DC data and information from three other jurisdictions for which data was readily available: New York City, Los Angeles, and Florida.[1]

In the District of Columbia, schooling has remained virtual since the onset of the pandemic, with a small number of students joining their virtual classrooms from school buildings while supervised by non-teaching staff. Figure One shows the number of reports received at the CFSA hotline in January through September 2019 and 2020. The contrast between the two years is obvious. In the “typical” year of 2019, the number of reports increased every month until May,[2] dropped to a much lower level in July and August when schools were closed, and then bounced up in September after schools reopened. The pandemic year of 2020 looked very different. The number of calls fell from February to March with the closure of schools, followed by a much larger drop in April, and stayed fairly flat until a modest rise in September with the opening of school. It’s as if summer vacation started in March, with a slight increase of reports when virtual school started again. In every month of the pandemic, the number of hotline calls in 2020 was considerably less than its counterpart in 2019. The total number of hotline calls received between March and June and in September (roughly the period affected by COVID-19) fell from 7916 in 2019 to 4681 in FY 2020, a decrease of 40.8 percent.

Source: CFSA Data Dashboard, https://cfsadashboard.dc.gov/, data analyzed by Child Welfare Monitor DC.

New York City data show a similar picture, as shown in a report from the Administration for Children’s Services (ACS) comparing hotline calls in 2020 to those in previous years. It is clear that 2020 is the outlier, with reports in 2017 through 2019 displaying similar seasonal patterns. In contrast to the previous years, reports fell in March 2020 with the schools closing on March 16 and then plunged in April during the first full month of school closure. There was a slight uptick in May and then reports remained basically flat before jumping up in October (when school buildings reopened) and falling again in November after schools closed again on November 19. ACS does not provide the numbers for each month but for January through November of 2020, there were 46,375 reports compared to 59,539 during that period in 2019. That is a difference of 22 percent; this difference would clearly be greater if we were able to look only at the weeks when schools were closed due to COVID-19.

Figure Two

Source: NYC Children, Flash Monthly Indicators Report, December 2020, available from https://www1.nyc.gov/assets/acs/pdf/data-analysis/flashReports/2020/12.pdf

Data from Los Angeles, where school buildings have not yet reopened, tell a similar story–a decline in reports in March after the pandemic emergency and school closures and then a big drop in April, the first full month when schools were closed. Referrals remained below the previous year for the rest of 2020, though the difference narrowed. The total number of referrals was 44,959 in March through November of 2020, compared to 61,515 in the same period of 2021–a decrease of 26.9 percent, and the decrease would be greater if only the weeks of school were included.

Figure Three

Data from Los Angeles Department of Children and Family Services, https://dcfs.lacounty.gov/resources/data-and-monthly-fact-sheets/, analyzed by Child Welfare Monitor

It is interesting to look at Florida, where the governor mandated that school buildings open in the fall semester. Florida data for last spring looks a lot like that for DC, New York City, and Los Angeles. But referrals almost matched 2019 during June and July, with the onset of summer break. August 2020 referrals were slightly lower than those in August 2019, perhaps because many schools opened virtually, but the gap narrowed again in September, October and November as more schools opened in person. And the shape of the fall curves was nearly identical in both years, with referrals rising in October.

Figure Four

Data from Florida Department of Children and Families, https://www.myflfamilies.com/programs/childwelfare/dashboard/intakes-received.shtml?Landing%20Page%20InvRec=2, analyzed by Child Welfare Monitor

Not everybody agrees that the loss of reports from school staff is a problem. Teachers have sometimes been criticized for making too many reports, and some analysts have suggested that the COVID closures might serve a useful function by eliminating frivolous or inappropriate reports. Indeed, some analyses have shown that the reports that are being made tend to be more serious or high-risk, suggesting that more of the less serious reports are being suppressed. If there was a large increase in the percentage of reports accepted for investigation or found to be substantive, there might be less reason to worry. But this does not appear to be the case.

  • In the District of Columbia, as shown in Table One at the bottom of the article, the percentage of reports accepted for investigation was slightly greater in 2020 than in the previous year. But as Figure Five shows, this percentage increase in accepted reports was not enough to substantially narrow the large gap between the number of accepted reports in the two years. Both the number of hotline calls accepted for investigation and the number of substantiated investigations showed the same sharp decrease as the number of reports to the hotline.
  • Similarly, the number of investigations in New York City showed the same precipitous drop from 2019 to 2020 as did the number of reports, as Figure Seven shows. And the percentage of investigations that “showed some credible evidence of abuse or neglect” in January through September 2020 was actually one point lower than that in the same period of 2019.
  • In Los Angeles, the percentage of referrals accepted for investigation actually declined during the pandemic, as indicated in Table Two below. So the year-to-year gap in number of referrals accepted for investigation (see Figure Seven) was even greater than the gap in total referrals. (Los Angeles does not provide data on substantiated reports.)
  • In Florida, as indicated in Table Three, there was a very slight increase in the percent of of intakes accepted for investigation during March-May 2020 compared to the same period in 2019. But as Figure Eight shows, the total numbers were much lower than in the previous year. (Florida does not provide data on the number of reports that were substantiated.)

It is clear from data in the four jurisdictions described here that reports to child abuse hotlines fell steeply in all four jurisdictions after the pandemic school closures, absolutely and relative to the same months of the previous year. In Florida, where schools reopened in September, reports increased to almost the level of the year before. It seems indisputable that measures imposed to fight COVID-19 were behind these changes and highly likely that school building closures were a large factor behind the reporting reductions. Moreover, as reports decreased, so did the numbers of reports investigated and substantiated, thus dashing any hope that only frivolous reports were being weeded out by the school closures.

Now that a vaccine is available, some Governors in states that have not reopened schools have proposed plans to prioritize teachers for vaccines and finally reopen buildings. Governor Gavin Newsom of California has offered a reopening plan including prioritization of school staff for vaccinations throughout spring 2021. West Virginia Governor Jim Justice has announced his plan to open pre-K, elementary, and middle schools for in-person learning on Tuesday, Jan 19. High school students will return to in-person school only in less-heavily-infected counties. Justice announced that the state will vaccinate all teachers and school personnel over the next two to three weeks as part of Phase One of the state’s vaccination plan.

Data from around the country clearly show that child welfare agencies received fewer reports, conducted fewer investigations, and made fewer findings of child abuse or neglect in times and places where schools were virtual. This fact adds to the many other reasons to open all closed school buildings as soon as possible. Opposition from teachers and their unions has been a major reason for keeping schools virtual. It is understandable that teachers were reluctant to return to buildings. But now, availability of vaccines makes it possible for schools to reopen throughout the country without endangering teachers–as long as all teachers are offered the vaccine before returning to classrooms. The high costs to to students of closed school buildings, among which undetected abuse should be included, mean that we should not wait any longer to bring students back to school in person.

[1]: These jurisdictions were chosen as large state or county child welfare systems that had readily available about reports, investigations and substantiations. Many other large jurisdictions do not post such data.

[2]:DC’s pattern of increasing reports from January through May is different from the other jurisdictions and may be related to its law requiring schools to report educational neglect when a student accumulates ten unexcused absences in a school year.

Table One: Hotline Calls Accepted for Investigation, District of Columbia

Source: https://cfsadashboard.dc.gov/; Data analyzed by Child Welfare Monitor DC

Figure Five

Source: https://cfsadashboard.dc.gov/; Data analyzed by Child Welfare Monitor DC

Figure Six

Source: NYC Children, Flash Monthly Indicators Report, December 2020, available from https://www1.nyc.gov/assets/acs/pdf/data-analysis/flashReports/2020/12.pdf

Table Two

Source: https://cfsadashboard.dc.gov/; Data analyzed by Child Welfare Monitor DC

Figure Seven

Table Three: Intakes Accepted for Investigation, Florida

Source: https://www.myflfamilies.com/programs/childwelfare/dashboard/intakes-received.shtml?Landing%20Page%20InvRec=1; Data analyzed by Child Welfare Monitor

Figure Eight

Data from https://www.myflfamilies.com/programs/childwelfare/dashboard/intakes-received.shtml?Landing%20Page%20InvRec=1; Data analyzed by Child Welfare Monitor

When social distancing can kill: child protection during a pandemic


NJbridgethegapSocial distancing is essential to break the back of  the coronavirus pandemic. But for children who are at risk of abuse and neglect, social distancing means social isolation and the loss of any hope of rescue from their desperate circumstances. It is important for child welfare agencies to reach out to the general public and those workers still seeing children with special messages about warning signs of maltreatment and how to get help.

For children living in abusive or neglectful homes, the pandemic is a perfect storm. On one hand, abuse and neglect are likely to increase due to parental stress and more time spent together in close quarters due to social distancing. Research suggests that child abuse increases in times of economic or natural disasters.

At the same time as families are under increased stress and spending more time together, children are not being seen by mandated reporters, especially teachers and school staff.  One in five reports comes from education personnel, according to the most recent federal data; hence the annual summer falloff in reports and the uptick every October. Today, almost every school building in the country is closed. While many schools are conducting online classes, the New York Times has reported that fewer than half of students are participating in some schools. Absence from virtual classrooms seems to be especially high in schools with many low-income students, who often lack access to computers and the internet. Some students and parents have completely fallen out of touch with their schools. And these are precisely the students who are more likely to be abused or neglected.

Reports about declines in hotline calls have appeared from almost every state, with calls in dropping often by half and in some jurisdictions by as much as 70 percent since schools shut their doors.1 School closures cannot explain this entire decline. Clearly other possible abuse reporters, such as law enforcement, health personnel, neighbors, and family members are seeing less of children as well.

At the same time, there is reason to think that child abuse is increasing during the pandemic.  A three-year-old Fort Worth boy who died from “severe child abuse” on Easter morning was the third child in less than a month to die at Cook Children’s Hospital, according to the hospital. Since March 13, eight children have been admitted to the hospital for severe child abuse and three have died. The hospital normally sees six child abuse deaths in an entire year. The Arnold Palmer Children’s Hospital in Orlando, has seen a spike in child abuse cases. According to the medical director, the hospital normally sees one or two trauma cases a month. But in the last few weeks, eight children were brought to the hospital with severe injuries due to abuse. At Children’s National Medical Center in Washington DC, 86 percent of children coming to the Emergency Room with injuries suggesting child abuse between March 15 and April 20 had to be hospitalized compared to 50 percent in the same period of last year.

Ironically, April is Child Abuse Prevention month, when government and nonprofit agencies work to increase public awareness about child abuse and neglect and the need to report it. Unfortunately, a recent study casts doubt on the effectiveness of public education efforts to date. A nationwide survey conducted during the pandemic found that a large majority of Americans are not willing to report excessive physical punishment to the police or CPS. The New York Society for the Prevention of Cruelty to Children (NYSPCC)  surveyed 1,004 adults nationwide on March 27 to 29, in the midst of the crisis. They found that only 19% of adults say they are “very likely” to report a parent who is “excessively spanking or physically punishing their child” to child protective services. Only 36 percent of adults say they are very likely to contact the police if they see a stranger doing the same thing. Among the reasons given for their unwillingness to report, 68 percent of respondents cite that it might make things worse for the child, 35 percent cite the risk to their own family, and 30 percent say it is “none of my business.”

These survey results, with or without a pandemic, are frightening.  As Mary Pulido of NYSPCC puts it, “If what you see in public is enough to even make you think about calling the authorities, think of what that child could be enduring at home, behind closed doors.” But these results should not be surprising to those who are aware of past cases of egregious child abuse which were not reported despite obvious red flags.  For example, the media has reported on the failure of family and neighbors to report major concerns about treatment of the 13 Turpin children, who were imprisoned, starved, and physically abused by their parents over many years. 

What we know about the reluctance of people to report their concerns about children’s treatment suggests the need for a much more concerted effort for the long-term. Such an effort should be led by the federal government and implemented at the state and local levels. It should aim to increase knowledge of the signs of child abuse and neglect and convince citizens that it is their obligation to report, as described in an earlier post. Such a campaign would be more powerful if all citizens were required to report when they fear that a child is being harmed.

For this time of pandemic, we cannot hope for an immediate sea-change in attitudes, but governments can integrate messaging about child abuse and neglect into their communications with the public about the pandemic. Special efforts should be made to encourage teachers who are interacting with students online and other essential workers who have contact with children and families. Sadly, the federal Children’s Bureau has not issued any guidance to states and and counties resources and suggestions for how to do this. Such leadership has been left to state and local governments and nonprofits.

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. Special campaigns such as  #bridgethegap in New Jersey, may be helpful as well. As shown in the poster above, the public is reminded that “It IS your business. Everyone in New Jersey is a mandated reporter.” Readers should reach out to their government executives to urge them to incorporate such messages into their communications with the public. 

Special materials targeted to teachers and other staff may be helpful as well. New Jersey has produced a special message for education personnel asking them to “try to get ‘eyes on’ every child at least once a week.” Maine’s Office of Child and Family Services, in partnership with the Department of Education, has also issued guidance for educators, health care providers and community members for spotting and responding to signs of child maltreatment.

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CHILD USA has issued a list of Tips for Teachers on Child Welfare and Online Safety during COVID-19. This helpful document lists questions to ask students at the elementary, middle, and high school levels to assess their physical safety, online safety, and whether they are getting enough to eat. It also lists key items for teachers to look for when seeing their students online, such as the appearance of the student and the home, and things that the student might say.  And it suggests special efforts to monitor students with issues with drug abuse, mental illness or domestic abuse in their families. All child welfare agencies should ensure that their local school systems distribute this checklist to their teachers.

The document from CHILD USA does not say what teachers should do when they are unable to reach a child and their family, which is probably the case for many of the children most at-risk of maltreatment. Jurisdictions should consider the possibility of treating the inability to reach a child and family after several tries over several days as grounds for a teacher to call the child abuse hotline.

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States and counties might also try to enlist the only people who are seeing children regularly other than their immediate families–grocery and pharmacy workers and mail carriers. A representative of the Allegheny County Department of Children Youth and Families told a reporter that the agency “plans to pivot its awareness campaign” to focus on these workers. They plan to make sure the workers get the message that “if you see something, say something.” A grassroots campaign run by former child welfare workers in Arizona is also trying to contact the people who are still seeing children, including grocery workers, delivery services, and food banks.

As Angelina Jolie wrote in Time Magazine, “We were underprepared for this moment because we have yet to take the protection of children seriously enough as a society.” This is a major problem which needs to be addressed for the long term, so that next time there is a crisis, we will have a society that is ready to keep its children safe in spite of physical isolation.

This post is being updated daily during the coronavirus crisis include new information.

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