Opioid Crisis: Removing Infants from Mothers on Medication Assisted Treatment is Misguided

MAT
Image: drugabuse.gov

An NPR story (New Hampshire Mothers Struggling with Opioid Addiction Fight to Keep their Children) aired on June 2, 2018, introduced us to Jillian Broomstein, a New Hampshire mother whose two-week-old infant was removed from her by the state’s child welfare agency. Broomstein was on methodone to combat her addiction to heroin and it was working. She had not taken heroin for months.

Methadone is one of the two medications that is used in Medication Assisted Treatment (MAT) for Opioid Use Disorder.  MAT is “the use of medications in combination with counseling and behavioral therapies to provide a whole patient approach to the treatment of substance use disorders.” The medications commonly used to treat opioid addiction in pregnant women include methadone and buprenorphine.

Research has shown that MAT is the most effective treatment for opioid use disorder, at least doubling the rates of abstinence from opioids compared with treatments that use a placebo or no medication. MAT has been recognized by the World Health Organization as the most effective treatment for opioid use disorder. Moreover, MAT is the treatment the American College of Obstetricians and Gynecologists (ACOG) recommends for pregnant women with opioid use disorder.

Concerns about MAT for pregnant women arise from the fact that their infants may experience neonatal abstinence syndrome. But as the lead author of the ACOG guidance states, “Concern about medication-assisted treatment must be weighed against the negative effects of ongoing misuse of opioids, which can be much more detrimental to mom and baby.” MAT increases adherence to prenatal care and drug treatment and reduces the risk of pregnancy complications. Abrupt withdrawal from opiates or safer substitutes means a mother is more likely to relapse, thus making it less likely that she can reunify with her child. Neonatal abstinence syndrome, on the other hand, is treatable and does not appear to have lasting effects.

Bias against MAT among professionals working with substance-abusing families has been documented often. An excellent federal study, discussed in an earlier post, found that MAT is not always understood or accepted by child welfare professionals, judges or even in the substance abuse treatment community. One reason for such bias may be that many professionals have past experience with other types of drugs such as cocaine and methamphetamine, for which MAT is not available

Information on state policies regarding reporting, investigation, and placement of infants exposed to methadone and buphrenorphine is not readily available. A report from the Substance Abuse and Mental Health Administration suggests that New Hampshire is not alone, indicating that child welfare agencies “may use a positive toxicology result for methadone or buprenorphine at birth as a presumptive cause for child removal.”

In some states, on the other hand, these cases may not even be reported or investigated. Pennsylvania law requires reporting only if the drug is illegal, although individual hospitals may choose to report other cases. In Massachusetts, for example, the Department of Children and Family Services can screen out a report involving a substance-exposed newborn if the only substance affecting the newborn was methadone, buprenorphine or naltrexone and if the substance was used as part of a treatment program.

But do we know that methadone and buprenorphine are consistent with safe parenting? Unfortunately, there seems to be  no research evidence on this question. We do know that with stable dosing, methadone and buphrenorphine does not cause the euphoric “high” associated with heroin and prescription painkillers.

Removing infants from their mothers who are participating in MAT has many negative consequence. It disrupts the critical attachment process between infant and mother. It may lead discouraged mothers to go cold turkey in order to get their children back. This may lead to relapse and permanent loss of the children.

Instead of automatic removal of the children, new mothers on MAT should be supervised by CPS for at least six months to ensure that they are capable of safe parenting. During that period they should receive intensive services akin to those provided by Kentucky’s Sobriety Treatment and Recovery Teams (START), a program that has been in municipalities in New York, Indiana, Georgia and North Carolina. Each family is paired with a specially-trained CPS worker and a mentor who is in long-term recovery. Caseloads are limited and each family receives weekly visits from both the CPS worker and the mentor for the first 60 days. START has been rated as a promising practice by the California Evidence-Based Clearinghouse for Child Welfare.

Most states, particularly those ravaged by the opioid epidemic, are reporting critical shortages of foster homes. Preventing unnecessary foster care placements, in addition to the obvious benefits for parent-child attachment and long-term sobriety of the parent, will allow these homes to be available for children who really need them.

Abusive parents are using homeschooling to avoid detection

Hart family
Photo: Associated Press

On April 25, 2018, Connecticut’s Office of the Child Advocate (OCA) issued a stunning report. Using data from six school districts, OCA found that over a third of children removed from school to be homeschooled lived in families that had been reported at least once for abuse or neglect. This is the first publicly released data to suggest the extent to which homeschooling may serve as a vehicle for abusive parents to isolate their children from scrutiny by other adults.

The Child Advocate’s report was a follow-up to its investigation of the tragic death of Matthew Tirado.  On February 14, 2017 , Matthew died of homicide from prolonged child abuse and neglect by his mother. While Matthew was never formally withdrawn from school (though he had not attended for a year), OCA found that his mother was able to withdraw his sister from school after numerous reports by the school district alleging abuse and neglect in the home.

To determine whether other children from families that were the subject of child abuse allegations were withdrawn from school, OCA collected data from six Connecticut school districts, the Hartford District where the Tirados lived and five other districts selected for their diversity. Their analysis showed that over three school years, 2013-2016, 380 students were withdrawn from the six districts to be homeschooled. Of those students, an astonishing 138 (or 36%)  lived in families that were the subject of at least one prior accepted report of abuse or neglect. Most of these families had multiple prior reports, ranging from two to 30 reports. 11% of the withdrawn children belonged to families with four reports or more.

Executive Director Rachel Coleman of the Coalition for Responsible Home Education (CRHE) is not surprised by this percentage. She cites an unpublished study conducted in another state, which produced similar results. Coleman also cites the groundbreaking study of torture as a form of child abuse by Barbara Knox and colleagues. Of the school-aged victims they studied, 47% had been removed from school under the pretext of “homeschooling,” although no education was taking place in these homes. According to the researchers, this “homeschooling” “appears to have been designed to further isolate the child and typically occurred after closure of a previously opened CPS case.”

Like the parents in Connecticut and those studied by Knox, Jennifer and Sarah Hart removed their six children from school as soon as Minnesota CPS closed their last case in 2011. The school had made six reports concerning food deprivation and physical punishment, two of which resulted in findings of abuse. With their withdrawal from school, the children had lost their best advocates. They continued to endure starvation and cruel discipline until their deaths in 2018.

The OCA report suggests that “homeschooling is used to conceal abuse more frequently than has been commonly thought,” as Rachel Coleman puts it. With 1.7 million children being homeschooled today, it is possible that hundreds of thousands are living in abusive situations.

Abusive parents must not be allowed to withdraw their children from school on the pretext of homeschooling them. Legislators must act to require schools to report all withdrawals for the purpose of homeschooling to Child Protective Services (CPS) to be cross-checked for previous reports. Parents with at least one substantiated abuse or neglect report should not be allowed to homeschool. Parents who have been the subject of an unsubstantiated report could be allowed to homeschool, subject to frequent monitoring by the school district or CPS.

The powerful homeschool lobby will object to any such regulation of homeschooling. In California, a massive outcry from homeschooling parents killed a very modest bill to require annual fire inspections of all home schools, prompted by the Turpin case.  The Home School Legal Defense Association has stated that “abuse is horrible and must never be tolerated. But imposing regulations that treat all home-schooling families like criminals is unjust.” Nobody is suggesting that homeschooling parents be treated as criminals. Rather, they should be treated a little more like schools.

Despite DHS Statement, Little Change Apparent in Oregon Child Protection Practice Since Hart Case

Policies and Procedures binders in the office. Stationery on a wooden shelf
Image: Oregon.gov

In a cover letter accompanying the records of its interactions with the Hart family–the six children and their adoptive parents who are all presumed dead after their van drove off a cliff on –the Oregon Department of Human Services (DHS) tacitly acknowledged that it botched an opportunity to rescue the six children from years of suffering and a tragic death. DHS also suggested that such a catastrophic error would not happen today because policy and practice have changed. But available evidence raises questions about whether vulnerable children are any safer in Oregon today than they were in 2013.

The released records show that DHS knew that Jennifer and Sarah Hart had been reported for child abuse six times in Minnesota and two of these reports had been confirmed. Sarah Hart had even pleaded guilty to misdemeanor abuse charges and was placed on probation. At least two women who knew the family reported the Hart withheld food from their children and used excessively harsh punishments. Nevertheless, DHS closed its investigation after concluding it was unable to determine that there was abuse in the home.

Since the time of the Harts’ assessment, according to the cover letter, “DHS has shifted practice from incident-based investigations to comprehensive safety assessments” and Oregon has “greatly increased efforts to provide ongoing training…on Oregon’s Safety Model (OSM).” A quick search showed that OSM, in comparison with the previous practice model, indeed was a step toward protecting vulnerable children. Instead of being dependent on confirming the specific allegations of abuse, the decision to act would now be based on the present safety of the children.

But the recent audit of child welfare in Oregon reveals that the OSM was actually rolled out in 2006–and was in place long before the Hart investigation. Unfortunately, it was never fully implemented because of inadequate training and opposition from administrators and staff. There seems to have been a new push to implement the model fully at about the same time as the Harts were being investigated in 2013. But statewide effort to retrain workers in the model was halted in 2014 and the resources reallocated to training in a new model, Differential Response. That model was in turn dropped but training in the OSM never resumed. Managers were still resistant it in 2017, when the audit was conducted.

Moreover, the DHS website shows that the new push to train staff in the Oregon safety model is still in its early stages. In a description of a project called Fidelity to the Oregon Safety Model Part 2, DHS states that “Some caseworkers and supervisors know and use the model well but other caseworkers and supervisors do not.” The website goes on to say that while online training is available, the agency needs more trainings, as well as coaching and quality assurance, to make sure the model is used “consistently.” (And this is a model that has been on the books since 2006!) The project aims to “create new training so that all staff understand and use the Oregon Safety Model and use it correctly.”

The timeline for the Fidelity to the Oregon Safety Model Project Part 2 is dated April 2018. According to the timeline, the project began in “March – May 2017” with the hiring of a project manager. In the intervening year, according to the timeline, the agency has created a work team, developed a project scope, held a kickoff meeting, developed a project plan, developed a scope of work for a consultant, finalized deliverables, assigned tasks and set timelines. It looks like the “active work” begins in August 2018 and the training will not begin until February 2019! So Oregon’s new statewide effort to train staff in the Oregon Safety model does not appear to have begun. Who knows whether this effort too will be dropped before it is implemented, and how effective the training will be if it is actually put into place?

But one part of the OSM seems to have been in use already, despite DHS’s claim that it was not. The DHS letter claimed that things would be different today because “case workers are trained to assess factors that contribute to a child’s vulnerability such as isolation (sic). Children who have no outsiders observing them are considered ‘highly vulnerable’ under the [Oregon Safety] Model and this factor must be considered…when making child safety decisions.” The Hart records show that DHS investigators were already assessing for vulnerability. In a section called “Vulnerability,” the investigator reported that “The children are completely dependent on their caregivers and do not have contact with any mandatory reporters, as they are home schooled.” Despite this understanding, the investigators opted to close the case without protective action.

DHS appears to be manipulating its reporting of the facts in order to suggest that its child welfare system has been reformed to prevent future catastrophic errors. But the recent audit and the case files themselves suggests this is not the case. The subtitle of the audit, “chronic management failures and high caseloads jeopardize the safety of some of the state’s most vulnerable children,” provides further reasons to doubt the capacity of DHS to protect the state’s most vulnerable children.

Multiple System Failures Allowed Hart Children to Die

Hart family
Photo: Associated Press

On March 26, an SUV filled carrying a family plunged off a cliff. The car belonged to Jennifer and Sarah Hart. Their bodies, and those of three of their children, were found on the scene. Three children are still missing although another body found in the ocean may be one of the children. Initial coverage focused on the fact that the family consisted of two white mothers and six adopted black children. The family had had an earlier brush with fame when one of the boys was in a viral photograph hugging a police officer at a Ferguson protest.

As the days passed, disturbing details came to light. Days before the crash, Washington Child Protective Services (CPS) had opened an investigation of the family after a neighbor called the child abuse hotline. We eventually learned the family had a history of abuse reports. Then we learned that the crash appeared intentional, and probably triggered by the CPS report.

With each new discovery, we learned of another systemic failure to protect these vulnerable children. The Hart case brings together several common themes found in many cases of severe child maltreatment. Each of these themes highlights a different gap in the system that is supposed to protect our children.

Adoption: All six Hart children were adopted from foster care in Texas: three in 2006 and the next three in 2009. It is not that being adopted makes children more likely to be abused.  Indeed, one Dutch study indicated adopted children were less likely to be abused than children growing up in their biological families. However, anecdotal evidence suggests that adopted children are overrepresented among children who are severely abused or neglected, at least in homeschool settings. Many of these cases involve common elements, including locking children up in a room, withholding food, and isolating the child by homeschooling or other means, all of which were present in this case. One possible explanation for this pattern focuses on the traumatic backgrounds of many adoptive children, which may lead to behaviors that adoptive parents are not prepared to deal with. While they may start out with good intentions, they end up resorting to punitive and eventually abusive parenting to control the undesired behaviors.

Writer Stacey Patton has described a “white savior attitude” among some white parents who adopt black children from the U.S. or abroad. These parents “wear their transracial adoption as a status symbol.” These adoptive parents often post on social media about their extraordinary efforts to deal with their children’s emotional and intellectual challenges that they attribute to the deficiencies of their birth parents.” The Harts fit this pattern. According to the Oregonian, the Harts often said their children suffered a multitude of early childhood behavioral and developmental issues that made parenting a challenge.  Jennifer Hart also polished her image as an ideal mom who gave her underprivileged children a beautiful life. She frequently posted on Facebook portraying an idyllic family life full of trips, celebrations, community service, and events like the Ferguson rally in which Devonte sported a sign offering “Free Hugs.” When adoption is all about the parents, and the children become part of their public image, a bad outcome is not surprising.

There is reason for concern about the vetting process the Harts received when adopting the children. The Hart kids were among the 300 to 400 Texas children adopted each year by out of state foster parents, often because they are harder to place because they are in large sibling groups or have special needs. The Harts would have been vetted by a Minnesota agency, which would have submitted their home study to Texas for approval. After a child visit, the children would have probably moved in with the Harts for a six-month trial period. A Texas agency spokesman told the San Antonio Express-News that during the trial period for out-of-state adoptions, the out-of-state agency would be monitoring the family and reporting back to Texas. But in September 2008, probably during the trial period for the second adoption, Hannah Hart was asked about a bruise in her arm. She reported that her mother hit her with a belt. Police and social services interviewed the mothers, who denied the beating and said she had fallen down the stairs. Nevertheless, the second adoption went through. We need to know whether Texas was informed of this investigation.

Once the adoption was finalized, there was nobody monitoring the Hart children, even though Texas continued to pay for their care. The San Antonio Express-News reports that Jennifer Hart received nearly $1,900 per month in adoption subsidies from the State of Texas. The paper estimates that she collected a total of $270,000 from the state for caring for the six children during the time they lived with her. Unfortunately, children who receive adoption subsidies are not monitored to ensure that they are being properly cared for, are still in the home, or are even alive. Such monitoring has not been imposed even in the wake of cases in which adoptive parents like Renee Bowman and Edward and Linda Bryant have fraudulently collected adoption subsidies after killing–or allegedly killing–their children.

Home Schooling. On April 11, 2011, Sarah Hart made a plea agreement a week after pleading guilty to physical abuse of a six year old child. The next day, all six children were removed from school, never to attend again. The Harts joined a long line of abusive parents that removed their children from school after a brush with CPS. The notorious Turpin family, who gained worldwide attention this winter when one of their 13 malnourished children escaped confinement in their home, who also liked to dress their children in matching tee shirts. As the Coalition for Responsible Home Education points out, Pennsylvania is the only state that bars convicted child abusers from homeschooling, and then only if the conviction is in the past five years. No state has any mechanism to identify cases where parents remove a child from school after a child protective services case is closed, or after a series of child abuse allegations.

Failure to report: At a festival in Oregon, the Oregonian reports that one acquaintance observed the mothers become enraged after she brought Devonte and Sierra back to her parents from a day out, bearing food.  Sarah Hart grabbed Sierra’s arm, inflicting a bruise that lasted for days, and both mothers chastised her for “being selfish” and not sharing. Sierra told the woman that she often got in trouble for talking to people her mothers did not know. But the neighbor did not report the disturbing incident. The Hart family’s neighbors in Washington, Dana and Bruce DeKalb, told reporters that they had suspected that something was not right in the Hart household.  A few months after the Harts moved to Washington, the DeKalbs reported that Hannah Hart came to their door at 1:30 AM. She had jumped out of a second-story window and ran through bushes to their home, begging them to protect her from her abusive parents. The neighbors noted that she was missing her front teeth and appeared to be about seven years old, although she was twelve. The other children also appeared small and thin when the family came over the next morning.

The DeKalbs told the Washington Post that they considered calling CPS but “tried to overlook the incident.” In the next eight months, the DeKalbs saw Devonte doing chores but never saw the other children outside.  About a week before the crash,  Devonte began coming to the DeKalbs’ house requesting food and saying that his parents had been withholding food as punishment.  The visits escalated from daily to three times a day. It was only after a week of such visits that they finally called CPS, setting in motion the the escape attempt that ended in the fatal crash.The DeKalbs’ hesitation echoes that of the Turpins’ neighbors, who never reported the many red flags they saw.

Biased Investigative Process: As mentioned above, Oregon CPS was unable to substantiate a report from a family friend that the Harts were punishing the children by withholding food and emotionally abusing them. CPS interviewed the children but told the friend that it appeared they had been “coached” to lie, so there was no evidence to substantiate the allegation. The question is, why were the parents given enough warning that the children could be coached? This is only one example of how the system is biased toward parents’ rights over children’s safety.

Multiple systemic gaps allowed the abuse of the Hart children to continue until it culminated in the deaths of the entire family. A variety of policy changes are needed to address the gaps highlighted by this tragic case. I will discuss these in my next post.

 

 

 

 

Why Kansas let Adrian and Evan die

 

Dianne Keech, a former Kansas child welfare official and currently a child safety consultant, was asked by the Wichita Eagle and Fox News to analyze case files regarding the highly-publicized deaths of Adrian Jones and Evan Brewer.  I asked Ms. Keech to prepare a guest blog post about the factors contributing to the deaths of Evan and Adrian. She prepared a ten-page document, which you can access here. Below, I highlight some of her conclusions. 

Calls to the Kansas child abuse hotline began when Adrian Jones was only a few months old. There were 15 screened-in reports for Adrian before he was six years old. Out of 15 reports in total that KCF investigated, Keech found that there was only one substantiated allegation of abuse, and that was based on an investigation by law enforcement.  After Adrian was removed from his mother’s custody due to lack of supervision and placed with his father and stepmother, calls alleged that there were guns all over the house, that the stepmother was high on drugs, that Adrian had numerous physical injuries, that he was being choked by his father and stepmother, and that he was beaten until he bled.  Adrian’s father and stepmother consistently denied every allegation and the agency did nothing to verify their stories.  Adrian’s body was found in a livestock pen on November 20, 2015. It had been fed to pigs that were bought for this purpose. It was later found that Adrian’s father and stepmother had meticulously documented his abuse through photos and videos. They are serving life terms for his murder.

DCF received six separate reports of abuse of little Evan Brewer between July 2016 (when he was two years old) and May 2017. These reports involved methamphetamine abuse by the mother, domestic violence, and physical abuse of Evan. Only three of these reports were assigned for investigation and none were substantiated.  In the last two months of Evan’s life, the agency received two reports of near-fatal abuse, one alleging that he hit his head and became unconscious in the bathtub and the other alleging that his mother’s boyfriend choked Evan and then revived him. The first of these reports received no response for six days and the investigator apparently accepted the mother’s claim that the child was out of state. The investigator of the second report also never laid eyes on Evan.  On September 22, a landlord found Evan’s body encased in concrete on his property. Horrific photos and videos documented Evan’s months of torture by his mother and her boyfriend. His mother and her boyfriend have been charged with first-degree murder. 

Looking at Root Problems

Keech believes that there are three root problems that led to Adrian and Evan’s deaths: a dangerous ideology, the pernicious influence of a well-heeled foundation, and faulty outcome measures used by the federal government. These are discussed in order below.

Dangerous Ideology: Signs of Safety is a child protection practice framework that was never officially adopted by Kansas. But Keech alleges that its philosophy has permeated all aspects of child welfare practice in the state. The Signs of Safety framework, according to its manual, seeks to avoid “paternalism,” which “occurs whenever the professional adopts the position that they know what is wrong in the lives of client families and they know what the solutions are to those problems.” Signs of safety links paternalism with the concept of subjective truth, citing  “the paternalistic impulse to establish the truth of any given situation.” According to Keech, this implication that all truth is subjective  means that investigating “facts” is a worthless task.  Workers are encouraged to “engage” parents, not investigate them.  Keech gives numerous examples of how this practice approach left Evan and Adrian vulnerable to further abuse. When Adrian’s younger sister was brought to the hospital with seizures, she was diagnosed with a subdural head trauma that was non-accidental. But when Adrian’s stepmother insisted that Adrian inflicted the injury with a curtain rod, DCF believed her and did not substantiate the allegation–not even finding her neglectful for letting the child be hurt. When DCF received a report that Evan’s mother was using methamphetamine and blowing marijuana in his face, they accepted her denials and closed the case with no drug test required.

Along with a new practice framework, Kansas adopted a new definition of safety. As in many other states, safety in Kansas has been redefined as the absence of “imminent danger.” This is in contrast to “risk,” which connotes future danger to the child. As a result, children can be paradoxically found to be at high risk of future harm but safe–which happened twice with Adrian. (He was found to be at “moderate” risk three times.) As long as a child is deemed “safe,” the child cannot be removed from home. The decoupling of risk from safety explains why both Adrian and Evan were found to be “safe” 18 times in total, when they were anything but. This is a common situation in many other states. “Risk,” on the other hand, triggers an offer of services, which can be refused, which is what Adrian’s father and stepmother did when he was found to be at risk. I’ve written about the case of Yonatan Aguilar in California, who was found four times to be at high risk of future maltreatment but “safe.” His parents refused services. He spent the last three years of his life locked in a closet until he died.

Pernicious Influence: Casey Family Programs is a financial behemoth with total assets of $2.2 billion. Its mission is to “provide and improve, and ultimately prevent the need for, foster care.'”Over a decade ago, Casey set a goal of reducing foster care by 50% by the year 2020.  Casey works in all 50 states, the District of Columbia, two territories and more than a dozen tribal nations.  It provides financial and technical assistance to state and local agencies to support its vision. It conducts research, develops publications, provides testimony to promote its views to public officials around the country.  As Keech puts it, “There is not a corner of child welfare in the United States where Casey is not a highly influential presence.” Keech has experienced firsthand Casey’s efforts to pressure Kansas to reduce its foster care rolls.  At a meeting in that Keech attended in 2015, Casey used “peer pressure” to “shame one region for having a higher foster care placement rate.  Casey adopted and promoted the Signs of Safety approach discussed above.

Faulty Federal Outcome Measures: The Child and Family Services Review (CFSR) is an intense federal review of the entire child welfare system.  If a state does not pass the review (and no state has passed, to date) then the state must agree with the federal government on a Program Improvement Plan (PIP) or lose funding. Keech feels that the federal reviews can be manipulated by states to improve their outcomes at a cost to child safety.  For example, one of the two measures of child safety is timely initiation of investigations. When a hotline screens out a report (as was done three times with Evan)  or a case manager fails to report a new allegation (which was done three times while Adrian had an open services case) the agency does not need to worry about timely initiation of an investigation. Another CFSR outcome is “reduce recurrence of child abuse and neglect, ” which is measured by calculating the percentage of children with a substantiated finding of maltreatment who have another substantiated finding within 12 months of the initial finding. This outcome can be improved by failing to investigate reports, or investigating them but failing to substantiate. Only one of the allegations involving Adrian was substantiated; three of the allegations involving Evan were not even investigated and the other three were not substantiated. By not substantiating allegations, Kansas reduces its recurrence rate. 

The factors that Keech discusses are not unique to Kansas and are occurring around the country, in states including most of America’s children. All of these states should consider Keech’s recommendations for protecting Kansas’ children from the fate of Adrian and Evan.  Most importantly, states need to prioritize the safety of children over and above any other consideration.   The primary goal of child welfare must be the protection of children, not reducing entries to foster care. The artificial division between risk and safety should be eliminated and risk should be allowed to inform safety decisions. States must treat substance abuse, domestic violence, criminal activity, mental health issues, and parental history of maltreatment, as real  threats to child safety. Workers must be empowered and required to gather all of the information needed to determine the truth of allegations, not rely on adults’ self-serving denials. And they must be allowed–and required–to request out of home placement when there is no other way to protect a child.  

 

 

Childhood trauma: Let’s invest in prevention as well as treatment

Oprah childhood trauma
Image: jsonline.com

In the past decade, the world has discovered trauma. More and more “trauma-informed” models of care have been developed, and more and more institutions and government agencies have adopted these models, making a lot of money for their developers. Awareness of trauma and trauma-informed care took a big leap with its discovery by Oprah Winfrey, who highlighted in a 60 Minutes segment the adoption of the approach by her home town of Milwaukee.

Recognizing the impacts of trauma on human development and incorporating this knowledge into education, social services and other areas is important. But I wish we could devote as much attention to preventing trauma as we do to treating its effects.

Oprah’s story started with the case of Alisha Fox. She was removed from her mother at the age of one and placed in foster care. At the age of four, she was placed with her father, “a sometimes construction worker prone to heavy marijuana use and violent bouts of depression, “according to an article in the Milwaukee Journal-Sentinel which inspired Oprah’s story.  For the next ten years, Alisha endured sexual abuse by her father. By the time she revealed the abuse and was removed from her father, she had a full-blown case of Post Traumatic Stress Disorder (PTSD).

Whether Alisha’s trauma could  have been prevented is not clear. The child welfare system may have erred in placing her with a deeply troubled and drug-abusing father. Alisha told the Journal Sentinel that she covered up the abuse until age 14. It is common for abused children not to report their abuse. One can’t help but wonder if there were warning signs that were disregarded. There is more awareness now of the signs of child sexual abuse than there was when Alisha was a child. So we just don’t know if Alisha’s years of trauma could have been cut short or if other children in her situation can nowadays be protected better than she was.

But we do know that many other children are abused for years while numerous red flags are disregarded. Nobody called the authorities about the 13 Turpin children as they were beaten, starved and chained for years in two states, even though family and neighbors in two states noted numerous warning signs. Texas neighbors considered reporting but had seen Turpin with a gun and feared “repercussions.” California neighbors perceived a peculiar and private family but claimed not to draw the conclusion that abuse was occurring.

Other traumatized children are reported numerous times but the system never intervenes to help them. We we often hear about these children only after they die.  Evan Brewer was killed by his mother’s boyfriend after the Kansas child welfare agency had received eight reports that Evan was living in a home of chronic meth users and that the mother’s boyfriend was choking him until he blacked out. For every Evan Brewer who is finally killed, there must be many more Alisha Roths, who escape after years of suffering. Or like Congressional intern Tonisha Hora who wrote:

At 14 years old, my twin sister and I were removed from a kinship care placement and put in foster care after experiencing severe physical and verbal abuse for ten years…Child Protective Services often visited our home, sometimes multiple times a year, after they received reports from neighbors and teachers who we often asked for food to keep from being hungry or saw our bruises. We were scared children who wanted to run away every day in hopes of escaping. We were aware of how the system continued to fail us by never removing us from our home when they should have. To us, the signs were obvious, yet CPS workers always left us there. The abuse worsened after every CPS visit. That was the problem: they always left without us. Every time. For ten years.

There are things we can do to save the Alishas, Tonishas and Evans of this world before they end up with PTSD or die. We need universal mandatory reporting accompanied by a massive public education campaign about the signs of child abuse and the duty to report even a suspicion of maltreatment. We need enough funding to ensure that CPS workers are qualified and have time to make good decisions. And we need to ensure that the current bias by agencies around the country toward  preserving and reunifying families does not go too far and leave children to suffer in silence.

It is great that cities, states and the federal government are investing in trauma-informed care. Lets hope that with the help of citizen input, they soon decide to allocate equal resources to save traumatized children before they suffer as long as Alisha did.

Child Welfare Myths: Foster Care Is Worse than Remaining Home

removed kids
Image: Fox 26 Houston

As a field, child welfare seems to be particularly vulnerable to myths and misconceptions, which are often backed up by inaccurate interpretations of research. Unfortunately, these myths and misconceptions, when promoted by powerful and wealthy advocates, can be perpetuated and enshrined into policy.  This is the beginning of an occasional series in which I attempt to deconstruct some of the most common myths. We start with one of the most common and potentially destructive–the myth that children left with their families always do better than they would if placed in foster care.

This myth was recently exhibited in all its glory by the Arizona Star as part of a major series on child welfare in that state. Here is how reporter Emily Bregel describes a frequently quoted study.

Research indicates that children left with their own troubled families fare better than those brought into the foster care system. A 2007 study found children whose families were investigated for abuse and neglect but remained home were less likely to become teenage parents or juvenile delinquents than similarly abused children who were removed from home. Those left at home were also more likely to have jobs as young adults, compared with children of similar backgrounds who were put in foster care.

This oft-misquoted study was published by Massachusetts Institute of Technology’s Joseph Doyle in 2007. Doyle’s study has been used relentlessly–and often inappropriately–by advocates of reducing foster care placements. Doyle used a creative method to estimate the effects of foster care on Illinois children ages 5 to 15 who were receiving welfare and who were investigated for maltreatment for the first time between July 1, 1990 and June 31, 1991. He compared long-term outcomes (delinquency, teen motherhood, and employment)  for the children assigned to investigators with higher removal rates to outcomes for those assigned to investigators with lower removal rates.

By comparing the outcomes for the two groups, Doyle could estimate the effects of being placed in foster care for children who were on the margin of placement–those who might have been placed by one investigator and not by another. For those children, Doyle found large differences favoring those children who were not removed from their homes. Doyle’s results say nothing about the children whose cases were unambiguous and who would have been placed (or not placed) regardless of the investigator.1

Obviously, we cannot do a controlled experiment in which the same child is both placed and not placed in foster care to get at the true difference that it makes in children’s lives. Perhaps the best we can do is ask the children themselves. Researchers at the University of Chicago’s ChapinHall research center surveyed 727 sixteen and seventeen year olds who had in foster care in California for at least six months. When asked about their treatment by their parents or other caregivers before entering foster care, 36% reported that they were hit hard with a fist, kicked or slapped; 32.4% reported that a caregiver threw or pushed them; 28.4% reported missing school to do chores or care for a family member; 28.3% reported having to go without things they needed because the parent’s paycheck was spent on “adult interests,” 26.4% reported that their caregiver beat them up; and 24.9% reported that their caregiver failed to protect them from harm by someone else. A shocking 29.7% reported sexual molestation and 20.7% reported rape. Horribly, 18.6% reported that their caregiver tried to choke, smother or strangle them and 16.9% reported being locked in a closet or room for several hours or longer.

When asked about characteristics of the parent or caregiver they lived with before entering foster care, 48.8% reported inadequate parenting skills, 49.7% a criminal record, 48.3% drug abuse, 48.8 alcohol abuse, 33% reported that a caregiver was abused by or abused a spouse or partner and 25.6% said a caregiver had mental illness. In addition, a total of 56.9% reported that they either agreed, strongly agreed or very strongly agreed with the statement, “All in all I was lucky to be placed in the foster care system,” while only 17.6% disagreed.

The California survey suggests that more often than not, foster care is an improvement over families where children are unsafe, fearful, hungry, unsupervised, or unloved. However, I have learned from my own experience as a social worker that, while some children make the miraculous journey from hell to heaven when they are placed in the best foster homes, many foster homes are only slightly less chaotic and more nurturing than the homes from which the children have been plucked. The beatings, rapes, and hunger may be over but many children and youth continue to be neglected emotionally, educationally, and in other ways in foster care. When combined with the trauma caused by separation from family, it is not surprising that young people whose home lives were on the border between acceptable and unacceptable to an investigator may do worse in foster care than they would have done at home.

Neglect of children in foster care is inexcusable: these children need more than the usual nurturing in order to make up for the trauma and deprivation they may have already suffered in their birth homes. That’s why we need to increase the number of children placed with kin as well as other alternatives to traditional foster care, such as residential schools and hybrid arrangements that combine features of foster and group homes. But what we don’t need to do is abandon children in homes where they are not safe.

The misuse of Doyle’s article has supported the ideas that it is always better to reduce the number of children in foster care and that reduced care numbers are a prima facie indicator of improvement. It has led to many systems, like that of my home town of Washington DC, using reduction of foster care numbers as an outcome in itself–independent of trends in actual maltreatment. Using foster care reduction as an indicator of success fails to recognize that some placements are needed to keep children safe. It also means that jurisdiction, like New York City for example, may be claiming partial credit for the results of gentrification.

The misuse of research and data, especially when translated into policy, should disturb everyone regardless of their feelings about the particular issue. Doyle’s research suggests that when the case for removal is marginal, the default option might be to keep the child at home–with supervision and services by the state. It does not suggest that removal of a child from home is always the wrong decision or that programs should be rated solely on the ability to cut foster care rolls.


  1. Another problem with making inferences from Doyle’s study about foster care today is the age of his data, which are from 1990 and 1991. Child welfare culture and practices have changed greatly since that time and the relevance of research from 25 years ago is questionable.