When ideology can kill: the death of Noah Cuatro

Image: KTLA.com

As many of my regular readers know, I have been fearful that the current climate emphasizing family preservation and racial and ethnic disparities in the child welfare involvement might end up inadvertently harming children. Well, it has happened in California, where a child is dead after the Department of Child and Family Services (DCFS) disregarded a court order to remove a child from a lethal home, motivated in part by hypersensitivity to concerns of possible bias and an exaggerated focus on family strengths that blinded agency staff to glaring problems.

On July 5, 2019, the parents of four-year-old Noah Cuatro called 911, saying their son had drowned in the pool at their apartment complex. But Noah did not look like a drowning victim. He had signs of strangulation, old and new rib fractures, and bruises across his chest, arms, and legs, and a large mark on his forehead. The cause of death was ruled as suffocation. His parents are facing trial for murdering and torturing him.

In August 2019, the Los Angeles Office of Child Protection (OCP) issued a flawed report that exonerated the Department of Child and Family Services of any responsibility for Noah’s death. Fortunately, the Los Angeles Times and the Investigative Reporting Program at UC Berkeley went to court to gain access to documents that would tell them what really happened. They reviewed juvenile court files, emails, and testimony from a grand jury proceeding that led to the indictment of Noah’s parents. In a harrowing article describing the results of their investigation, the journalists document the role of errors, misjudgments, bureaucratic conflict, bias accusations, and a flawed practice model that together “blocked multiple opportunities to protect Noah.” My account is based in part on the Times article as well as the OCP report, which contains some dates and other details that help flesh out the timeline of this tragic case.

Noah Cuatro was first removed from his parents in August 2014 when he left the hospital after birth, after his mother, Ursula Juarez, was alleged to have abused an infant half-sister, causing skull fractures. He ended up in the home of his great-grandmother, Eva Hernandez. At the age of nine months, he was returned to his parents when the agency was unable to prove the allegations against Juarez. But the Times-UC Berkeley investigation found that Noah’s parents always felt that DCFS had robbed them of the first nine months with their newborn. And Hernandez felt that perhaps because they missed his first nine months, they never bonded with Noah and therefore targeted him for abuse.

In November 2016 Kaiser Permanente called the child abuse hotline to report that Noah had missed eight doctor’s appointments over the spring and summer of 2016. An investigation found that Noah had gained only a few ounces between February 2015 and October 2016. His muscles were deteriorating, and he was unable to walk at the age of 27 months. Once again, Noah was removed from his parents and placed first in a facility for medically fragile children and then back with Hernandez.

Two years later, on November 9, 2018 Noah was returned to his parents by a court over the objections of DCFS. Noah had thrived with Hernandez, reaching the appropriate weight and height for his age. He screamed and wet the bed before and after visits with his parents and begged to stay with his great grandmother. Moreover, his parents had not complied with court orders to participate in therapy and visitation with Noah. But the Juvenile Court commissioner, Steven Ipson, saw “substantial progress” by the parents and sent Noah home, requiring that his parents arrange for a visitation schedule with Hernandez, participate in Parent Child Interaction Therapy with Noah, and send him to preschool.

The red flags appeared almost as soon as Noah returned to his parents. On her visits to the family, Susan Johnson, the social worker assigned to the case, learned that Noah’s parents were ignoring the court orders for therapy, preschool and regular visits with his great-grandmother. In April 2019, an aunt made a call to the child abuse hotline, reporting that Noah was losing weight and had thinning hair. Worse, he had changed from an exuberant boy to a scared one. Another relative had told her that during an overnight stay Noah had night terrors and complained of pain in his “butt.”

Johnson went to the home and found Noah with marks on his right arm and neck, a big bruise on his left arm, and lotion covering his back, which his mother attributed to eczema. When Johnson asked what happened when he did something wrong, Noah said “I get hit,” but he quickly retracted. She tried the same question again, and got the same affirmation and quick retraction–characteristic of a scared, abused child. Back at the office, Johnson met with her supervisor and a senior administrator, who told her to file a petition for removal.

But it was not Johnson’s job to assess the truth of the allegations. She was a “Continuing Services Children’s Social Worker” (CS-CSW) in DCFS lingo, whose job was to monitor and assist the families in their journey toward a safe home and case closure. The duty of investigating the allegations fell to an “Emergency Response Children’s Social Worker (ER-CSW often known as a Child Protective Services or CPS worker in other states) named Maggie Vasquez Ducos. When Vasquez Ducos visited the family, Juarez told her that Noah got his injuries by falling off a bunk bed. She also told her, in tears, that Johnson and DCFS had been persecuting her. Noah denied abuse, and a medical exam found that his injuries could have been caused by falling from a bunk bed.

Vasquez Ducos consulted with the social worker who worked with the family before Johnson, Lizbeth Hernandez Aviles. Hernandez Aviles reported that “she had always had concerns for Noah, was opposed to his return home, and felt that the parents are habitual liars who present well,” according to the OCP report. She expressed concern about the existence of bonding between Noah and parents and believed he was the child in the family targeted for abuse.

Nevertheless Vasquez Ducos made a finding of “inconclusive” on the new allegation, meaning that there was insufficient evidence to determine that child abuse had occurred, on May 9, 2019. There is no indication in the records reviewed by the Times and UC Berkeley that Vasquez Ducos reached any of Noah’s relatives, an essential component of any serious child abuse investigation. The police investigation after Noah’s death found text messages between relatives revealing their rising concern during the same time period about the parents’ treatment of Noah.

While Vasquez Ducos was investigating, Johnson was writing and submitting her petition for the removal of Noah and on May 15 it was granted by the court, along with the requirement that Noah be taken for a medical exam. On the same day, a new referral came in alleging domestic violence in the home and sexual abuse of Noah. Assigned to investigate the new referral, Vasquez Ducos learned of the removal order and immediately began to question the need for it. Parroting the words of Noah’s parents, she told her supervisor that Johnson was “harassing them.” She argued that Johnson was biased against the parents and overly influenced by great-grandmother Hernandez.

Investigating the new allegations, Vasquez Ducos visited the family on May 20, 2019, accompanied by the previous social worker, Hernandez Aviles, who had voluntarily taken a demotion to be a Human Services Aide due in part to the stress of managing Noah’s case, according to the Times-UC Berkeley investigation. They found Noah with an injury to his cheek, for which three explanations were given, along with plenty of coaching by Mom for Noah to endorse her explanation. During the visit, Hernandez Aviles reported that Noah “randomly” ran up to her stating ““They feed me a lot,” “They take good care of me,” and “They love me.” It’s hard to imagine better evidence of coaching, and indeed Hernandez Aviles noted that many of Noah’s responses appeared coached.

But Vasquez Ducos was unmoved. In a May 22 meeting with higher management, she argued against the removal order and the top administrator in the room took her side, telling Johnson not to execute the order.* It was agreed that DCFS would facilitate a “child and family team meeting” with the family. Johnson testified that when she tried to state her case, a supervisor elbowed her to be quiet. But she was heard to state, “that she didn’t want a dead kid on her watch,” according to an email quoted in the Times article. Ironically, the new allegation was cited as a reason not to remove Noah until the investigation could be completed. To make matters worse, Johnson, Noah’s main advocate, was removed from the case. It appears that the top administrator who made the decision not to enforce the court order also wanted a Spanish-speaking case manager, although such a person was never appointed and the job of managing the case for the rest of Noah’s life was left to Vasquez-Ducos, who was an investigator, not a case manager.

On June 6, Juarez, who had repeatedly denied being pregnant, gave birth to a baby boy. She had received no prenatal care and initially claimed to be a surrogate, despite lacking any paperwork, and tried to “sneak out of the hospital.” A Kaiser social worker informed DCF about the birth. She also told Vasquez Ducos that Kaiser’s psychiatric exam showed that Juarez had traits of a sociopath and indicated that she was worried about Juarez’ contradictory accounts of her pregnancy. Nevertheless. Vasquez Ducos and her supervisor decided to let Juarez go home with her newborn.

During the month of June, the family seemed to turn against Vasquez Ducos as well, apparently obstructing all her attempts to visit him before the end of the month. Her last visit with Noah was on June 28, 2018. According to the OCP report, Noah was described as “in good spirits and reported that he was doing well.” Vasquez Ducos reported that Noah’s father dismissed her attempt to schedule the long-delayed meeting with DCFS that was agreed at the May 22 meeting, saying they wanted no further involvement with the agency–a strange thing for a social worker to accept as the prompt scheduling of the meeting should have been a condition for keeping Noah at home.

In the final week of Noah’s life, Vasquez Ducos (perhaps sensing impending disaster and seeking justification) set her sights on the people who tried to protect Noah, stating in emails that Johnson was biased towards Noah’s family, that great-grandmother Hernandez (the only person who treated Noah like a mother) was at fault for biasing Johnson, and that Noah’s parents were victims of DCFS. “I feel like as a Department we have been picking on this family,” she wrote on July 3. Three days later Noah was dead.

A close reading of the Times-UC Berkeley article and the OCP report shows that DCFS disregarded numerous red flags that should have been obvious to any competent social worker with a modicum of training: the parents’ repeated failure to comply with the terms of their custody order; the admissions of abuse and subsequent retractions by Noah; his unsolicited comment that his parents treated and fed him well and other obvious signs of coaching; the assessment indicating that the mother had traits of a sociopath; and the comments by the previous social worker, among many others. There were multiple failures in case practice including the ignored removal order, the disregarded court order for a medical exam, the lack of response to the parents’ repeated failure to comply with the terms of their custody (a reason in itself for removal of the child); and the failure to schedule a family meeting which was an essential component of the plan to leave Noah at home.

But what makes this more than yet another story of missed red flags and bad case practice is the explicit evidence of the impact of two factors—bias accusations and “strength-based practice–in the death of Noah Cuatro.

Bias accusations

From the beginning of her involvement, Vasquez Ducos seemed to be convinced by Noah’s parents that Susan Johnson was biased against Noah’s parents. The charge of bias took place in the context of a state and national reckoning with racial and cultural bias against people of color. As I’ve written, there is a growing focus on the disparities in child welfare involvement between different racial and ethnic groups. These disparities are evident as they relate to Black and Native American children, who are much more likely to be reported to CPS, found to be abused or neglected, and placed in foster care, than White children. But this is not the case for Latinos like Noah, who actually are underrepresented in foster care nationally, constituting 25.4 percent of the child population but only 20.8 percent of those in foster care. In California, Latino children enter foster care at the same rate as all children–5.3 per thousand in the population, and in Los Angeles County they enter foster care at a slightly lower rate. Yet, “people of color” who are said to be over-represented in foster care and child welfare services are often assumed to include Latinos.

The extent to which Vasquez Ducos and her supervisors believed that Johnson (a Black woman) was biased against Latino families is unclear. The previous social worker, who had argued for removal, was Latina. The great-grandmother, who Vasquez-Ducos accused of influencing Jackson against Juarez, was also Latina. Yet, the Times reported that the administrator who quashed the removal order also wanted Johnson replaced with a Spanish-speaking social worker, even though the entire family was fluent in English except for one person in the extended family. Whatever the cause, the facile use of the bias label seemed to blind Vasquez Ducos to the evidence that should have been apparent to any minimally-trained investigative social worker.

The reporters found something very telling in Vasquez Ducos’ notes. She quoted Juarez as saying “Why would we hurt our baby when we just got him back? I have had this case open for four years, and I have been told I’m good enough to only have my two kids but not Noah. How does that make sense?” Apparently Vasquez Ducos agreed. She must have never learned about the well-known phenomenon of one child in a family being targeted for abuse, as well as the attachment problems that can ensue when an infant is apart from its mother from birth, information that one hopes is included in training for child protective services workers everywhere.

Strength-based practice

Perhaps even more important than the bias issue is the role that a “signature” DCFS policy played in Noah’s death. In telling testimony reported by the Times, Vasquez Ducos’ supervisor reported that “DCFS management wanted to follow the core “practice model” that requires workers to remain focused on the positive, taking a better look at a family’s strengths and less at its weaknesses.” Similarly, Hernandez Aviles told the grand jury that colleagues decided not to remove Noah in line with the agency’s “strength based approach.”

According to Los Angeles DCFS website, its social workers use a “Core Practice Model that prioritizes child safety while emphasizing strengths over deficits, addressing underlying needs over behaviors, and instilling empowerment over helplessness.” This Core Practice Model is an example of what is generally called “strength-based practice,” a theory of social work practice that emphasizes clients’ self-determination and strengths.

I am familiar with this approach because I was trained in a similar model by the District of Columbia’s Child and Family Services Agency. We learned that in the past, child welfare practice was characterized by an emphasis on deficits, telling parents what is wrong with them and what they must fix. This approach, we were told, created hopelessness among parents and interfered with the development of good relationships with social workers. We were told that strength-based practice empowers families to make positive self-directed change.

It makes sense find a family’s strengths, emphasize them to the family and build on them. I certainly tried to do this when I worked with families that were trying to get their children back from foster care. But to disregard problems that could lead to harm to a child in no way “prioritizes child safety” as DCF claims to do. Noah’s case shows how disregarding family problems despite numerous red flags can lead to tragedy.

But strength-based practice is in line with a national movement focusing on parents’ rights and stressing the importance of keeping families together, with removals eliminated or drastically restricted. This movement has been reinforced by the current racial reckoning, which has produce arguments that child protective services is nothing more than a “family policing system.” Noah’s case shows what can go wrong when this philosophy goes unchecked.

Bobby Cagle, the Director of DCFS, told the reporters that he saw no problems with his agency’s policies or its handling of Noah’s case. He refused to say if any employee was disciplined as a result. Firing people is not a solution to such unnecessary deaths as that of Noah. However, it seems likely that one or more people in the Lancaster office of DSS are so unsuited to their jobs that they pose a danger to children. Keeping them on the job is unacceptable on child protection grounds, not to mention the need for accountability.

The death of Noah Cuatro was a tragedy. The fear and suffering that he endured starting from the time he was returned to his parents at the age of four was also a tragedy. We cannot know many children are suffering at this very moment because social workers or their bosses miss the most obvious red flags due to ignorance, overwork or because their ideology or training does not allow them to see the glaring faults of their parents. DCFS’ Office of Child Protection tried to cover up this horrendous failure that cost the life of a child. The Los Angeles Times and UC Berkeley deserve kudos for providing the answers that OCP tried to cover up.

*According to OCP, a removal order authorizes, but does not require removal of a child. However the court must be notified within ten days if the child is not removed. Nobody notified the court that the removal order obtained by Johnson was not carried out until the hearing on June 25, more than 45 days after the order was approved. The ordered medical exam had never been carried out.

The power of wishful thinking: the case of “race-blind removals” in child welfare

Wishful thinking is a very human pattern of thought that can even be functional at times. Thanks to wishful thinking, a placebo can actually cure an illness. Great ideas can gain support even if we don’t know they will succeed. But when wishful thinking is used to distort available data to support a given theory or policy, it becomes a problem. Such is the case with “race-blind” removals. The story of how this simple concept became viewed as a solution to the disproportional share of Black children in foster care, in relationship to their share of the general population, is a case study in the misuse of data to promote a particular viewpoint.

As reported in The Imprint and the Los Angeles Times, the Los Angeles Board of Supervisors has voted to support a project testing “race-blind removal” or “blind removal” of children into foster care. Blind removal was pioneered in Nassau County, New York in 2011 and “discovered” (as they describe it) by a team of researchers headed by Jessica Pryce of Florida State University, who were investigating the practices of two counties that were credited by New York’s Office of Child and Family Services (OCFS) with reducing racial disparities. Before the inception of blind removal, county investigative workers were presenting cases to a committee made up of supervisors, managers, and an attorney before a child could be removed and placed in foster care. Under blind removals, the members of this committee were no longer given information that might give a clue as to the race of the child and family. According to an email from a county official, the information that is withheld includes race, ethnicity, first and last names, addresses, the location of the reporter if that reflects the community where the child lives, and any other information (such as socioeconomic status or receipt of government benefits) that is not deemed to affect safety or risk.

Nassau County adopted the blind removal policy as a way to address its high rate of racial disproportionality in foster care, with Black children being much more likely to be removed and placed in foster care than White children. According to data provided by New York State, Black children were over 14 times more likely than White children to be placed in foster care in Nassau County in 2010. The blind removals policy is based on the belief that implicit racial biases affect the decision to remove a child and that removing this information from the process will remove the bias.

Unless there is strong evidence in support of such a program, one might worry about a practice that relies on people who know so little about a family. One might wonder if such a meeting is the best use of time for overburdened social workers and supervisors. Perhaps it would be better to make sure investigators have enough time to interview everyone who might be able to give them information about the family under consideration rather than burden them with another meeting. And what about emergency situations, where a child cannot be safely left in the home? An article in Children’s Bureau Express documents concerns from social workers who fear that blind removals would make it harder to do their jobs for these and other reasons. Another concern is whether race-blind removals might provide more of an opportunity for investigative workers to express any racial bias they have, since they control the information that is presented to the committee.

But if blind removal truly does cause a significant reduction in racial disparities, perhaps it is worth implementing despite the costs. And if one can believe a TED Talk by Jessica Pryce that has been viewed 1.3 million times, the practice has been spectacularly successful. According to Pryce, “In 2011 57 percent of the kids going into foster care were black, but after five years of blind removals, that is down to 21 percent.”  (At which point the audience broke into applause). Such a simple idea and such a huge impact! Casey Family Programs, the nation’s most influential child welfare funder, highlighted this program in an article on its website, stating without providing numbers that “within five years, the number of Black children removed from their families was reduced considerably, representing the most significant decrease in racial disproportionality within the county system ever.” New York State was so excited that it required all counties to develop a blind removal process effective October 14, 2020, offering a strikingly vague and yet broad description of what information must be kept from the committee: “all demographic and identifiable information (race, gender, language needs, zip code, etc. sic)).” Several other jurisdictions have expressed interest, including Los Angeles County, which is proceeding with its pilot.

Such a great result should be documented and the data made available to the public and researchers, preferably online, so it is surprising that Pryce was unwilling or unable to provide the source of the percentages at the heart of her popular talk. Instead, she referred me to the data team at Nassau County, who did not respond, nor did did the Commissioner’s Office. Nor was Casey Family Programs able or willing to provide the document referenced in their footnote to their statement about the program’s stellar results. Happily, I was able to obtain data from the New York State Office of Child and Family Services showing the percentage of children removed into foster care who were Black every year from 2009 to 2020. Those percentages are shown in Chart One.

Chart One

Source: Data provided by New York State Office of Children and Family Services

The first fact that emerges from the New York data is that Jessica Pryce’s percentages were not accurate. The 57 percent (56.7 percent) that she cites as the percentage of Black children removed in 2011 was actually the percentage of Black children removed in 2010. As for the 2016 data (the endpoint of the five-year-period cited by Pryce), 37.1 percent of the children removed in 2016 were Black, rather than 21 percent cited by Pryce–rather a large difference. There was a sharp increase in the Black share of children removed, from 45.2 percent in 2009 to 56.7 percent in 2010, the year before the program was implemented. With the implementation of blind removals, the percentage of children removed who were Black declined for two years to 45.5 percent in 2012, then rose for two years to 57.4 percent in 2014, fell to its all-time low of 37.1 percent in 2016, then rose to 49.7 percent in 2018, dipping slightly back to 45.1 percent in 2019, then popping back up to 49.5 percent in 2020–higher than it was in 2009 before the program was implemented. With such large fluctuations from year to year, as well as changes in direction, it is hard to imagine drawing any conclusions from the difference between any particular two years.

It is also important to note that the total number of children placed in foster care in Nassau County dropped precipitously from 429 in 2009 to 91 in 2020, as shown in Chart 2. This drastic drop in removals of Black and other children means that there was a lot more going on than the effort to make removals race-blind; cutting removals by three-quarters requires major changes in policy and/or practice. So it is hard to attribute any change with confidence to the race-blind policy. It also means that the numbers of children removed became smaller and smaller, resulting in a larger margin of error.

Chart Two

Source: Data provided by New York State Office of Children and Family Services

OCFS also provided data on Nassau County’s “Black Admissions Disparity Rate.” This rate, which New York State collects for all its counties, is defined as the “ratio of unique Black children admitted to foster care per 1000 Black children under 18 relative to comparable rate for White children.” According to OCFS, the disparity rate for foster care admissions went down from 14.30 (meaning Black children were 14 times more likely to be removed than White children) in 2010 to 12.60 in 2020. But it fluctuated to a surprising degree (between 24.4 and 6.16 between 2011 and 2019) that is not consistent with the percentages shown above and casts doubt on the correctness of the ratios provided. Assuming the 2020 ratio is correct, Nassau County currently has the highest disparity in foster care placement for Black children in the entire state. According to its ranking of counties based on this ratio, Nassau County was at the bottom in 2020 of all counties listed* with its disparity rate of 12.6, compared with 3.34 for the state as a whole. Hardly a role model for New York or the nation! Now this doesn’t mean we should blame Nassau County’s child welfare system for its abysmal disparity ranking. Other factors are probably behind that large disparity compared to other counties, such as the socioeconomic status of the Black and White populations in a given county. Which raises the question, how much can we expect blind removals to change racial disparities in foster care?

New York State recognizes the weaknesses of its data but focuses on the positive overall trend between 2010 and 2020. As John Craig of OCFS put it in his email to Child Welfare Monitor, “While Nassau County has seen fluctuations in the rate of Black children entering care over the past 10 years, overall, the trend has been very positive. OCFS commends Nassau County for recognizing the disproportionality of children of color in the child welfare system and implementing this innovative approach.” 

Despite OCFS’ valiant attempt to portray Nassau County’s data as “very positive,” the data do not provide a strong justification for expanding the program. While the Black percentage of children taken into foster care in 2020 was 49 percent compared to 57 percent in 2019, there were changes in both directions in the years between those two dates, and the 49 percent was actually higher than the Black percentage in 2009, two years before program implementation. There is reason to wonder whether New York, Los Angeles and others were really concerned about what the data showed. Instead, they may have proceeded in part based on the inherent logic of the approach, which addresses racial disparities directly in a way that is appealing to those who seek a relatively simple solution. Most importantly, they wanted it to work, so they decided that it did, regardless of the highly equivocal findings.

It would be wonderful if we had easy solutions to racial disparities in child welfare, but evidence suggests that higher reporting, investigation and removal rates among Black children stem from their greater needs, rather than bias among social workers. LA County would be better off studying how to make CPS decisions more accurate rather than imposing a cumbersome and unproven hurdle on social workers trying to protect endangered children.

* Certain counties were excluded because of very small number of Black children or Black children taken into foster care.