Neglect as poverty: the myth that won’t go away

It’s one of those myths that won’t go away and instead is gathering steam–the idea that parents who are found to be neglectful by child welfare agencies are really just poor people being judged for their inability to provide sufficient material support to their children. It doesn’t matter how much evidence is cited against it. The myth continues because it is an essential part of the narrative that is currently dominant in the child welfare arena. Nevertheless it’s been over a year since my last attempt to shed some light on this issue, and some new research has become available, thus it seems a good time to revisit the topic.

It’s Time to Stop Confusing Poverty With Neglect, exhorted Jerry Milner, Children’s Bureau Commissioner and his special assistant David Kelly back in January, 2020, in a typical statement of this myth. “Most of the reasons for child welfare involvement fall into what we call “neglect” rather than physical abuse or exploitation. Our most recent child maltreatment data tell us that 60 percent of victims have a finding of neglect only…More times than not, poverty and struggles to meet the basic, concrete needs of a family are a part of the equation in all types of neglect.” Miller and Kelly now sell their expertise at Family Integrity & Justice Works, an arm of the Public Knowledge consulting firm which has the goal of “replacing child welfare.”

Media outlets have taken this story and run with it. Here is the Philadelphia Inquirer: “A common misunderstanding is that the leading reason kids are taken into the foster care system is because of physical or sexual abuse. But that accounts for only one of six cases. Children far more often are removed from their homes for ‘neglect,’ which often amounts to symptoms of poverty, like food insecurity or unstable housing.”

The Biden Administration has endorsed the idea that most neglect findings reflect nothing but poverty. The Administration on Children and Families (ACF) has solicited applications for a grant of between one and two million dollars “to support the development and national dissemination of best practices to strengthen the capacity of child abuse hotline staff to distinguish between poverty and willful neglect.”

There is no federal definition of child neglect, and state definitions vary. In contrast to abuse, it is usually defined as an act of omission rather than comission. According to the Child Welfare Information Gateway, neglect is “commonly defined in state law as the failure of a parent or other person with responsibility for the child to provide needed food, clothing, shelter, medical care, or supervision to the degree that the child’s health, safety and well-being are threatened with harm.” The most commonly recognized categories of neglect include physical neglect or failure to provide for basic physical needs, failure to provide adequate supervision , educational neglect or failure to educate the child as required by law, and medical neglect.

There is no dispute that more children are found to be neglected than abused. Based on data collected by the federal government and published in Child Maltreatment 2020, three-quarters (76.1 percent) of the children found to be victims of maltreatment in 2020 were found to be neglected. A total of 16.5 percent were found to be physically abused, 9.4 percent were found to be sexually abused, and six percent were found to be victims of some other type of maltreatment.* Of the children who were removed and placed in foster care, according to the 2020 AFCARS Report, 63 percent had neglect listed as a circumstance associated with the child’s removal, compared to 12 percent with physical abuse and four percent with sexual abuse.

But the idea that neglect findings represent nothing but poverty is questionable. First, the neglect deniers would probably agree that most poor parents do not neglect their children but instead find a way to meet their needs, relying on charity, extra work, or subordinating their own wants to the needs of their children. When poor children are deprived of food, clothing or adequate housing, other factors such as substance abuse, mental illness and domestic violence are often involved. Second, more than half of the states exempt from the definition of neglect any deprivation that is due to the lack of financial means of the parents. Third, the definition of neglect is not confined to the failure to provide adequate food, clothing or shelter but instead includes other acts of omission, such as failure to protect a child from dangerous caregivers, or failure to ensure that children go to school and get needed medical care. Lack of supervision, a common form of neglect, can reflect poverty when parents feel they must rely on inadequate arrangements in order to go to work; we just don’t know the degree to which neglect findings reflect such decisions by parents.

But until now we did not have quantitative data concerning the types of neglect being investigated or the importance of risk factors like substance abuse and mental illness. A recent study from California, the nation’s most populous state, begins to fill this data gap. Palmer and colleagues used a representative sample of 295 neglect investigations that took place in California in 2017. They found that only 14 percent of the investigations involved physical neglect–the deprivation of food, clothing, and housing that is most closely connected with poverty. The most common types of neglect that were investigated were inadequate supervision, investigated in 44 percent of the cases, and failure to protect (leaving the child in the care of a known abuser or failure to intervene with known abuse), in 29 percent of cases. Moreover almost all (99 percent) of the investigations of physical neglect included concerns related to substance use, domestic violence, or mental illness; or they involved another type of maltreatment such as physical or sexual abuse or an additional neglect allegation. Thus, the authors conclude that almost no parent was investigated for material deprivation alone, although it is true that they did not separate out any lack of supervision cases that involved the inability to obtain adequate childcare for work or other necessary activities.

The evidence from California is very suggestive, but as the authors caution, it is possible that other states receive more reports that focus on unmet material needs, are less likely to screen out such reports, or emphasize them more during the investigation. This is possible because California, according to a recent study of state neglect definitions, is one of five states that have adopted an “expanded” definition of child neglect, including more neglect types and allowing for the threat of harm, rather than actual harm, in neglect findings. Studies similar to the Palmer study from other states with more limited neglect definitions would be useful.

While the California study is not sufficient to negate the presumption that findings of neglect represent nothing more than poverty, it is important to note that there are no studies supporting this viewpoint. So why does the myth that child welfare treats poverty as neglect persist despite the lack of evidence supporting it, and the many reasons for skepticism? It persists because it supports the narrative and associated policy prescriptions of the child welfare establishment today–child welfare leaders, administrators, legislatures, and influential funders like Casey Family Programs. The dominant narrative describes a racist family policing system that persecutes people only because they are Black, Indigenous or poor. The policy prescriptions involve radically shrinking or even abolishing child welfare systems.

According to the prevailing view, if omissions that are labeled neglect are strictly due to poverty, there is no need to intervene with social services or child removal. Instead, governments should provide economic benefits to neglectful parents. There is a body of research suggesting that economic support for families does help reduce maltreatment, perhaps not only by helping parents meet their children’s financial needs, but also enabling them to provide better childcare and improving parents’ mental health through stress reduction. Independent of their impact on maltreatment, I strongly support increases in the safety net for families and children. But available information suggests that it will take more than financial assistance to cure neglect in most cases. Improved economic supports will not be a replacement for services to help parents address challenges with substance abuse, domestic violence, mental health, and parenting, and for child removal when there is no other option.

What can be done to alleviate the confusion and misinformation around child neglect and poverty? Collecting better data from the states would be helpful. In its annual Child Maltreatment reports, the Children’s Bureau uses data from the National Child Abuse and Neglect Data System (NCANDS). When reporting on the type of maltreatment alleged and then found, states must pick up to four out of eight categories, including physical abuse, “neglect or deprivation of necessities,” medical neglect, sexual abuse, psychological or emotional maltreatment, sex trafficking, no alleged maltreatment, other or “unknown or missing.” It is not clear whether the “neglect” category is supposed to indicate all types of neglect or just those involving “deprivation of necessities,” but there is no way for states to clarify what they mean or to distinguish between the most common types of neglect. The same problem exists with the AFCARS data used to compile federal reports on foster care and adoption.

Clearly, a reform of the data elements that states are required to submit is needed so that resesarchers can see the types of neglect that are being alleged and found for each child. However, such an improvement would not substitute for careful research like the California study cited above because it will never be possible to rely on the thoroughness of database entries by overworked social workers. We cannot be sure they will enter all of the applicable categories, for many reasons, including that not all the applicable categories may be substantiated for a particular case. Moreover, while states are required to report on some caregiver risk factors contributing to abuse and neglect, such as alcohol and drug abuse, emotional disturbance and domestic violence, these seem to be vastly understated by the social workers who enter these factors in state databases. For example, only 26.4 percent of caregivers of maltreated children were found to have the risk factor of drug abuse and only 36 percent of removals involved parental drug abuse, according to federal data. Yet anecdotal reports from states and localities tend to indicate a much higher percentage of cases that involve substance abuse.

Thus, a reform of data collection might help, but would not solve the problem, especially considering that that many child welfare leaders and funders seem inclined to maintain the hypothesis that CPS confuses poverty with neglect. Ideally, the federal government and other funders would support more studies like that of Palmer et al, and more academics would consider performing such studies.

The myth that CPS confuses neglect with poverty is pernicious because, like other myths currently prevalent in child welfare, it runs the risk of hurting abused and neglected children. It is being used to justify dismantling child protective services, eliminating mandatory reporting, or more modest proposals to hamper these critical protections for children. The federal government should improve data collection on child neglect and associated risk factors as well as supporting additional research to provide more accurate estimates of their prevalance.

*According to the report’s authors, “other” could be anything that does not fit into the categories offered by the Child Abuse and Neglect Reporting System and includes threatened abuse and neglect, drug addiction, and lack of supervision according to state comments submitted with the data.

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

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.

Opioid Crisis: New federal report shows child welfare impact

After more than a decade of decreasing, the national foster care caseload rose by 10% between 2012 and 2016. Many public officials and commentators have blamed this increase on parental substance use, especially due to to the opioid crisis, but evidence has been lacking on the national level to support this conjecture. A new report from the Assistant Secretary for Planning and Evaluation (ASPE) of the U.S. Department of Health and Human Services provides new evidence linking substance abuse with increasing foster care caseloads. It also highlights the daunting challenges facing those professionals at the interface of child welfare and substance abuse in hard-hit areas, and highlights the urgency of helping them meet these challenges..

The ASPE researchers obtained data on drug overdose deaths and hospitalizations and child welfare indicators for all of the counties in the US. They conducted quantitative analysis and statistical modeling to assess the relationship between substance abuse and child welfare. They also conducted interviews and focus groups with child welfare administrators and practitioners, substance use treatment administrators and practitioners, judges and other legal professionals, law enforcement officials, and other service providers who work with families affected by substance abuse in counties that are being hard-hit by the opioid crisis. Their key findings include:

Caseloads: There is a correlation between the severity of a county’s drug crisis and the burden on its child welfare system. The researchers found that when related factors are controlled, counties with higher rates of overdose deaths and drug hospitalizations had higher child welfare reports, substantiations, and foster care entries.
Nature of Cases: The researchers also found that higher rates of substance abuse overdoses corresponded to more “complex and severe child welfare cases,” as measured by a greater proportion of children with maltreatment reports that were removed from their homes. Substance abusing parents have multiple issues including domestic violence, mental illness and extensive history of trauma. Professionals in hard-hit areas described great difficulty in reunifying families due to the multigenerational nature of the epidemic (reducing the availability of kin caregivers) as well as the weakening and loss of community institutions including churches over time.
Treatment Challenges: Several major challenges affect agencies’ ability to get treatment for substance-abusing parents. These include cursory and delayed assessments resulting in treatment delays; misconceptions about Medication Assisted Treatment (MAT), which has been found to be the most effective treatment for opioid use disorder; and lack of treatment options matching parents’ needs, including family-friendly treatment options.
Systemic Barriers: Agencies are struggling to meet families’ needs due to multiple systemic factors including inadequate staffing leading to unmanageable caseloads, shortages of foster homes, and difficulty coordinating between systems and states (in the many counties that border other states).

This study has many policy implications. Unfortunately, all of them involve the need for increased financial resources both within the child welfare system and beyond it. The nation’s supply of effective drug treatment needs a major boost. Child welfare systems need financial help to improve assessments, hire new staff and train all staff on substance abuse and treatment, and increase the availability of high quality placement options for the children affected by the substance abuse crisis.

Treatment. More treatment programs are needed to meet the needs of parents involved with child welfare. In particularly, the study documented shortages of MAT and family-friendly treatment options. Clearly the opioid crisis is much broader than its impact on child welfare and requires a much broader response. In a full-page editorial on April 22, the New York Times stated that Congress has taken only “baby steps” so far in addressing this crisis by appropriating only a few billion dollars over the past few years. The Times quotes Andrew Kolodny, co-director of opioid policy research at Brandeis University, that “at least $6 billion a year is needed for 10 years to set up a nationwide network of clinics and doctors to provide treatment with medicines like buprenorphine and methadone.” Supporters of the recently–passed Family First and Prevention Services Act, which allows Title IV-E foster care funds to be used for drug treatment and other services to keep families together, have exaggerated its potential to help parents obtain treatment. If the treatment slots do not exist, money to purchase treatment won’t help. Moreover, many or most parents involved with child welfare already have Medicaid or other insurance that could pay for treatment if it existed.
Assessment. It is crucial that parents involved with child welfare receive thorough assessments of their substance abuse and other needs. The lack of proper assessments is a also problem for parents and systems not affected by the opioid crisis. A change in the standards of child welfare practice requiring a thorough assessment, conducted by a licensed professional, for each parent with a child in foster care, is necessary. Of course this would require additional funding.
Training. Lack of knowledge among professionals about the efficacy of different treatment options can prevent parents from obtaining the most effective treatment. Child welfare and court staff need training in substance abuse and treatment options just as they need training in mental health, domestic violence, and other issues facing many of their clients.
Staffing. In areas that are overwhelmed by cases due to the substance abuse crises, staff shortages lead to burnout, which in turn leads to more departures and increased shortages. These staff shortages are dangerous to children and to staff themselves and should not be allowed to continue.
Foster placements. More placements are clearly needed in some hard-hit areas, but it is not likely that enough traditional foster homes can be found, especially in light of the widespread nature of the substance abuse epidemic in some of these areas. That’s why we may need to look at new placement options, including family-style group homes and professional foster homes for four to six children, including large sibling groups.

The new study from ASPE has received a shocking lack of attention. It adds new, more rigorously collected evidence to the avalanche of media reports that have documented the impact of the substance abuse crisis on children and families. So far, the nation has not responded to this crisis with the urgency it demands. We will pay a high cost in the future–in broken families and damaged children–if we don’t provide the needed resources now.