Surprise, surprise! Family First has not reduced the use of congregate care!

by Marie Cohen

A new report from the Government Accountability Office (GAO) has revealed what many of us have expected: implementation of the Family First Prevention Services Act (often called “Family First”) has not reduced the use of congregate care in most states. There is no reason to be surprised. The failure of Family First to achieve this goal was predicted from the start. Requiring states to stop using existing congregate care facilities while making it difficult to provide alternative placements was not only bound but actually designed to fail as a consequence of the revenue neutrality that was built into the law. GAO’s lack of substantial recommendations to solve the problem is disappointing, as is the failure of Senator Wyden to recognize the fundamental flaws in the law he created and pushed through Congress in 2018.

Family First, passed as part of the Bipartisan Budget Act and signed by President Trump in 2018,¹ made two major changes in existing law. Part One extended funding under Title IV-E of the Social Security Act to programs designed to keep children safely at home or with relatives instead of being placed in foster care. Part IV, which is the subject of this post, was to limit funding for all placements that are not foster homes. Such placements are often labeled as “congregate care,” and include group homes, residential treatment centers, and any setting other than a family foster home. While federal funds could be claimed for the placement of any youth in such a setting before Family First, the law limited both the types of congregate care settings that can be funded and the characteristics of the youths who could be placed in these facilities with federal funds. The rationale for these limits was that most children do better in families than in group or institutional settings and that many children were placed in congregate care for lack of an alternative. For those youths who truly need congregate care, the goal was to ensure that these settings are high-quality and truly therapeutic

To reduce the placement of children in congregate care and ensure that such settings are appropriate when used, Family First limited reimbursement for children placed in congregate care facilities after 14 days to four categories (1) a new placement type called a Quality Residential Treatment Program (QRTP) designed for children with “serious emotional or behavioral disorders or disturbances;” (2) a setting designed for pregnant or parenting youth; (3) an independent living setting for youth over age 18; and (4) a setting for children who “have been found to be, or are at risk of becoming, sex trafficking victims.”

As defined in Family First,a QRTP must have a trauma-informed treatment model, have registered or licensed nursing staff available 24/7, have provisions for family involvement in a child’s treatment, be licensed and accredited, and provide “discharge planning and family-based aftercare support for at least six months post-discharge.” To be placed in a QRTP, a youth must be assessed by a “qualified individual” to determine whether his or her needs can be met in a foster family home or with family. If the assessment recommends the placement, it must be approved by a court and reconsidered at every permanency hearing, and the agency head must approve placement in a QRTP for more than 12 months.

Despite Family First’s goal of reducing the use of congregate care, the new GAO Report found that there has been no reduction in the use of such care in the majority of states.² Based on survey responses from 49 states in in the first half of 2025, GAO found that 26 of these states reported that the percentage of their foster youth who were placed in congregate care settings had either increased or remained the same compared to October 2021. Moreover, 26 states reported that the average number of days that youths spent in congregate care either increased or stayed the same in the same period. Forty-two states reported that they continued to use “stopgap placements” like hotel rooms, office buildings, and hotel emergency rooms because other placements were unavailable. More states reported an increase than a decrease in how much time youths spent at stopgap placements and emergency shelters over the period. And 43 states reported using out-of-state placements, with 29 of them reporting that the use of these placements had increased since October 2021.

GAO found that 34 states (more than two-thirds of the states responding) had at least some QRTP’s. But unfortunately, states were not able to open enough QRTP’s (through conversion of existing facilities to QRTP’s or establishment of new ones) to eliminate congregate care placements that did not meet Family First standards. Of those 34 states, half reported that 50 percent or less of their child welfare congregate care facilities were QRTP’s. Thirty states reported that meeting QRTP requirements was challenging. The requirement that states reported was most difficult to meet was providing family-based aftercare support for at least six months after discharge. Of the 15 states that had no QRTP’s, several reported that the time or cost of meeting QRTP requirements was too burdensome; some said that providers could not meet the requirements. Two states reported that they had implemented QRTP’s but that the facilities had closed or implementation had been paused because of difficulties in meeting the requirements.

With the new limitations on congregate care reimbursement and the difficulty of establishing QRTP’s, GAO found that “the majority of states increased their own spending on congregate care as federal funding diminished.” Twenty-nine of the 49 responding states reported increasing the amount of state, county or local funds used to support youths in congregate care. Drawing from its visits to four states, GAO reported that:

An official in one of these states told us that the goal of reducing the use of congregate care was well intended, but noted that in practice, some youth still required congregate care. Officials in another of these states said that in many cases the state must now pay for the same services that it previously paid for with Title IV-E funds to prevent youth from sleeping in offices or other inappropriate settings. Officials also said that a lack of foster homes and youths’ challenging behaviors made placing youth with families difficult. This leaves the state few options but to continue to place youth in congregate care and pay for those placements with state funds…..Officials in three of four states we visited said that Family First shifted congregate care costs to states. State officials noted that the decline in the percent of federal funds for congregate care since the passage of Family First has been quite large.

In open-ended survey responses, several states reported that the need to shift state and local funds to congregate care has reduced funding for other important priorities, including community based and prevention services and workforce support and training.

All 49 responding states reported challenges in securing enough foster care placements in general, including ten states reporting a challenge in finding family foster homes, both relative and nonrelative, and four reporting a challenge in finding therapeutic foster homes. But securing enough congregate care placements was a challenge for almost all the states. Forty-seven states reported that finding “step-down beds”³ for young people in congregate care was at least a moderate challenge and thirty-nine states reported a lack of behavioral health congregate care placements was at least a moderate challenge.

With only ten states reporting a lack of foster homes as a challenge and compared to 39 reporting the lack of behavioral health congregate care placements as a challenge, it is clear that the placement crisis is worst for children who need the intensive services and supervision only congregate placements can provide. Forty-one state child welfare agencies reported that finding placements for youth with significant behavioral challenges, autism, or intellectual disabilities was very or extremely challenging. And these children, often called “high acuity youth,” are becoming more prevalent in foster care caseloads. Officials in all four states that GAO visited reported that the severity of foster youths’ needs had increased.

Recent news from Tennessee shows how desperate the situation can get. The Department of Children’s Services is supporting a bill that would allow foster children to be locked up in detention centers without being charged with a crime. The bill would create a new class of foster children called “Children in Need of Heightened Supervision,” who could be placed in juvenile jails without any charges. The department claims that these children are violent and there is no other facility that can supervise them adequately.

GAO’s findings should not have been a surprise to anyone. The Family First Act was designed to be revenue-neutral, so that any increased costs would have to be balanced out by savings. Since Part I was expected to result in new expenditures for prevention services, there had to be an equivalent amount of savings, and much of that savings would have to come from reduced spending for congregate care. The Congressional Budget Office in its 2016 cost estimate projected that that ” because states would take several years to recruit and retain additional foster parents, many states would not have enough placements for all children eligible under Title IV-E. CBO estimated that about 70 percent of the children residing in group settings other than [QRTP’s] in 2020 would simply become ineligible for any reimbursement under title IV-E.” Thus, states would be paying the entire cost of these congregate care placements rather than close to half the cost as they were before. Over the ten-year period from 2017 to 2026, CBO estimated that the restriction on non-family placements would on net reduce direct federal spending by $910 million, which would offset almost 70% of the costs of extending IV-E reimbursement to family preservation services.⁴

CBO expected that the fraction of children whose placements would not be eligible for funding would decrease in future years as the states recruited and retained more foster parents. The cost estimators apparently assumed the entire “placement gap” created by Family First could eventually be filled by recruiting and retaining more foster parents. Their lack of understanding that many of the youths in need of placements have needs and behaviors that are too severe to be met in a normal foster home is quite surprising.

Anyone who claims to be surprised at the GAO results is either disingenuous or has a memory problem. Family First could have achieved its Part IV goal only with less restrictive standards for QRTP’s or increased financial assistance to help states establish or convert existing facilities into QRTP’s. I called attention to the problem before the law was passed in a post called The Family First Act: A Bad Bill that Won’t Go Away.

Surprisingly, GAO has only one recommendation to improve the situation. That recommendation is based on its finding that some states are taking advantage of the lack of guidance about how to define a setting for children who “have been found to be, or are at risk of becoming, sex trafficking victims,” which is one of four settings for which states are allowed to receive IV-E funds after a child has been there for fourteen days. Because this term is not defined and federal guidance provides no further information on how to interpret it, states have been interpreting this language in different ways. For example, at least one state has designated all of its congregate care facilities as this type of setting and claims IV-E funding for all children in congregate care in the state. Other states believe they can claim IV-E funding for any youth placed in a facility designated for actual or potential victims of sex trafficking. Still other states require that a youth placed in such a facility must be individually assessed as a victim or at risk of sex trafficking to be eligible for Title IV-E funds.

Because these different interpretations can result in disparities in Title IV-E funding between states, GAO recommended that The Secretary of Health and Human Services should direct the Administration for Children and Families to clarify its guidance on the appropriate use of Title IV-E funds for youth in facilities designated as settings “providing high-quality residential care and supportive services to children and youth who have been found to be, or are at risk of becoming, sex trafficking victims.”

GAO’s recommendation is shockingly narrow. Having found that the most challenging requirement for a QRTP was providing family-based aftercare support for at least six months after discharge, it is surprising that GAO did not suggest that Congress modify that requirement. It might be more appropriate and realistic to require that each child receive six months of aftercare after attending a QRTP rather than requiring that the QRTP provide that care.

Another recommendation is strikingly missing in the GAO report: exempting QRTP’s from the “IMD exclusion.” An “Institution for Mental Disease” (IMD) is an facility with more than 16 beds that cares for people with “mental diseases.” The “IMD Exclusion” prohibits states from using Medicaid to pay for care provided in IMD’s. This exclusion dates back to the creation of Medicaid in 1965 and was put in place to prohibit the use of Medicaid funds to pay for large mental institutions. The problem is that QRTP’s of more than 16 beds will probably fall victim to the IMD exclusion. According to a letter to Congress signed by more than 500 organizations, “Many high-quality, licensed, and accredited residential providers are considered to have over 16 beds because the bed count includes all beds on a campus or under common ownership, rather than the number of beds in each separate unit, cottage, or family-style home. Further, FFPSA did not include a size restriction in the QRTP requirements, and there is no evidence that programs with 16 beds produce better outcomes than programs with greater capacity.” The letter calls for Congress to fix this problem by exempting QRTP’s from being classified by Center for Medicare and Medicaid Services (part of HHS) as IMD’s. Bills were introduced in 2021 and 2023 to accomplish this, but they did not advance to the floor.⁵ Senator Ron Wyden, prime architect of the Family First Act, who chaired the Senate Finance Committee from 2021 to 2025, has ignored numerous pleas to fix the IMD exclusion.

It is strange that the term “IMD” does not even appear in the GAO report. The intersection between QRTP’s and the IMD exclusion has been a source of consternation among states and residential providers since the passage of Family First. Over 600 organizations signed the letter to Congress asking it to exempt QRTP’s from this provision. It is quite strange that GAO did not ask about the impact of the IMD exclusion, and it is hard to believe that the states did not mention it in their survey responses or conversations with GAO.

By cynically or naively shifting cost of needed congregate care from the federal government to the states, Congress failed the children most damaged by abuse and neglect. And GAO missed its opportunity to tell Congress that it was responsible for fixing the problems that it created. So it is not surprising that instead of trying to fix the flaws in Family First, like the IMD Exclusion and the overly restrictive QRTP requirements. Senator Wyden chose to criticize ACF for not enforcing its standards, saying “I will continue to hold Alex Adams and the Administration for Children and Families accountable for any action or inaction that allows the intent of the bipartisan Family First Act to be tarnished.” To write a bad bill for which anyone with clear eyes could see the consequences, to refuse to fix it once the effects became clear, and then to demand that it be enforced is betrayal of the most traumatized and needy children in foster care around the nation.

Author’s Note: The same day as I posted this blog, the nonprofit newsroom Searchlight New Mexico published an article reporting that agencies providing treatment foster care (TFC) for New Mexico’s Children Youth and Families Department (CFYD) were turning down referrals of hard-to-place youth. Among those rejected were a teenage girl who had shot and killed her father and another teenager who was currently placed in a psychiatric ward for extreme and aggressive sexual behaviors. As the director of the treatment foster care agency wrote to legislators “These are just two examples of the types of referrals we receive on a constant basis that are not clinically appropriate” for treatment foster care….These are the children that are routinely staying in CYFD offices because TFC agencies say no.” In recent years, CYFD has referred hundreds of children to TFC agencies, and most of them have been rejected. CFYD told Searchlight that all of these children were assessed and approved for TFC by the agency and “managed care providers.” According to the CYFD spokesperson, “The issue isn’t that a child doesn’t meet the clinical need of the TFC, it is that the TFC agency doesn’t have a TFC family that matches to the clinical needs.”

Really? As the Searchlight article explains, these children being turned down have bounced from home to home for years, interspersed with stays in offices and hotels. By the time they are referred to TFC, they need round-the-clock supervision and care, which TFC families are not equipped not provide. These are family homes, after all. Not to mention the fact that no foster home is prepared for children who have killed or displayed extreme and aggressive sexual behaviors. But the needed 24-hour care does not exist in New Mexico. Many residential treatment facilities have shut down, and the state does not have a single QRTP. As the TFC director told Searchlight, “I’m not saying all these kids need to be in residential treatment centers. But what we’ve done is we’ve gone from a system that actually had providers at each level of care to a system that has hardly anything. So there’s nowhere to send these kids.”

And yet CYFD is still trying to force these children into TFC homes. Searchlight reported on a new sense of optimism now that the parties in the Kevin S settlement are setting a new annual target for TFC placements. The power of wishful thinking is great indeed.

Notes

See Title VII of Public Law 115–123. ↩︎
It is truly unfortunate that GAO does not list the answers by state. It is the total number of children experiencing these conditions that matters more than the number of states that experienced a decline. ↩︎
This term generally refers to a placement that is less intensive and restrictive than the previous level, but more intensive than traditional foster care. It could be a less restrictive congregate care placement or a therapeutic foster home. ↩︎
This cost estimate was for the Family First Prevention Services Act of 2016. This bill was incorporated and passed, with some changes, in the Bipartisan Budget Act of 2018. The CBO cost estimate for this bill does not contain a detailed narrative about Family First but reduces the estimated savings from the congregate care restrictions to $641. It is not clear why the savings estimate was reduced but it is clear that these provisions were still expected to produce savings. ↩︎
The 2023 bill was included by the House Energy and Commerce Committee’s Subcommittee on Health as part of the SUPPORT Act but was not included in the act that was passed. In its FY 2021 budget, the Trump Administration also asked Congress to exempt QRTP’s from the IMD exclusion ↩︎

To report or not to report?: Misinformation from The Ethicist at The New York Times

by Marie Cohen

I Saw a Child Who Seemed Neglected. Should I Have Done Something? was the title of a column from Kwame Anthony Appiah, who writes the “Ethicist” Column for the New York Times. Appiah is a respected philosopher and writer, but he lacks in-depth knowledge about the child welfare system. In this case, he was relying on misinformation about our child protection system that has become so prevalent that it is taken for truth.

The anonymous writer told The Ethicist about a child she saw in her home town in upstate New York, which she described as a poor rural area that has been hit hard by the lost of industry and the opioid epidemic. On a “bitterly cold day,” she stopped into a local dollar store and saw two young woman who entered with a child under five years old. She noticed the child was wearing only shorts and a T-shirt, with no socks or shoes. The child also appeared extremely dirty, as if the child had not been bathed in days. The writer also noticed that the child’s hair was dyed neon green and he or she had black nail polish on fingers and toes. It seemed odd to her that somebody found time for these “fun touches” while basic care was missing. As the group left the store, she noticed the child stepping barefoot into slush and climbing into a car where the driver was smoking a cigarette. She watched the group drive away and reported, “I couldn’t shake the feeling that I may have seen a child who needed help and I simply walked away. At the same time, I worry that I’m piling assumptions onto a family I know nothing about, a family that might be doing its best. … I also know that calling Child Protective Services can create serious harm for families who don’t deserve it. What should I have done?”

Here is “The Ethicist’s” answer, paragraph by paragraph, followed by my response,:

This probably wouldn’t be a hard call if we all trusted the ability of social services to intervene — and to refrain from intervening — thoughtfully and protectively. After all, child abuse and neglect take place on a distressing scale. In an ideal world, you could note the car’s plate number, report what you’d seen and be confident that you were more likely to help than harm. A widespread concern, though, is that C.P.S. can do a great deal of damage; indeed, some child-welfare experts have concluded that, on net, these programs do more harm than good.

Many of these “child welfare experts” that Appiah is talking about cite statistics showing the abysmal outcomes of youth who age out of foster care, such as low high school graduation and college attendance rates and high rates of teen pregnancy, homelessness and criminal justice involvement. They often talk about “the foster-care-to-prison pipeline.” But we do not know the extent to which these bad outcomes reflect the child’s earlier experiences at home versus the effects of foster care. Many of the children who are removed from abusive or neglectful homes might have fared even worse if they not been removed. It is certainly a shame that we do not have a foster care system that is nurturing and generous enough to erase the disadvantages with which children enter it, but that is not to say that our inadequate foster care system is responsible for the poor outcomes that foster children and youth experience. Moreover, youths who age out of care (the ones who are usually studied) are likely more disadvantaged than the majority of foster youth who return home, go to relatives, or get adopted, and using them to gauge the impact of foster care is misleading.

Whether foster care does more harm than good is a difficult question to research because it is not possible to do a controlled experiment in which abused or neglected children are randomly assigned to stay home or go to foster care. In marginal (lower-risk) cases where the decision to remove a child depends on the investigator assigned to the case, studies have been done using the best available methods (which are not very satisfactory) and different studies have reached different conclusions.¹ These methods cannot be used to estimate the effects of foster care for children who are at higher risk, whom investigators would tend to agree should be removed. But in these cases, it is highly plausible that foster care is likely to do more good than harm. It is impossible to know the risks facing the particular child discussed in this column because we have no idea what a visit to the child’s home would reveal.

A big problem is that C.P.S. [Child Protective Services]’s most powerful instrument is family separation, which can be traumatic for both children and parents. Despite efforts to reduce reliance on it, a built-in asymmetry of blame can lead to overuse. Headlines and public outrage can ensue when a caseworker makes a judgment that leaves a child in a dangerous situation; there’s seldom much notice when a caseworker makes a judgment that unnecessarily separates a family. As one social-policy expert has put it, this imbalance of incentives means that those in the child-protection sector aren’t so much “risk averse” as “risk-to-self averse.”

Appiah is right that CPS’ “most powerful” instrument is family separation, but it is not the most common response to a report or abuse or neglect. First, the report must be screened in to receive an investigation or an alternative esponse. Based on the latest data compiled by the federal government from state submissions, about 4.365 million reports involving 7.693 million children were made to CPS in 2024. Less than half of the calls were screened in for an investigation or an “alternative response” (often called a family assessment) which is a process often used for lower-risk cases and is designed to focus on a family’s service needs rather than determining whether maltreatment occurred. About three million (2,990,234) children received either an investigation or an alternative response. If the social worker doing the investigation or assessment decides that the child cannot be safely maintained at home, that child will likely be placed in foster care. But in cases where maltreatment is found but the child is not deemed to be in imminent danger, it is more likely that the family will receive case management and services (such as parenting education, drug treatment, and mental health services) through the opening of an in-home case.

The total number of children placed in foster care in FFY 2024 was 170,955, which is less than six percent of the three million children who received an investigation or alternative response, and barely two percent of the children who were the subject of a call to CPS. Unfortunately we do not know how many children receive in-home services because the Children’s Bureau does not collect that data.² But clearly the number placed in foster care is small relative to the number of children who are the subject of calls and the number who are investigated.

Appiah seems to be living in another world when he says that “Headlines and public outrage can ensue when a caseworker makes a judgment that leaves a child in a dangerous situation;….. this imbalance of incentives means that those in the child-protection sector aren’t so much “risk averse” as “risk-to-self averse.” That may be the case, but the national conversation in child welfare for at least ten years has been all about keeping families together and kids out of foster care. Every day brings a new report of a child being left in an obviously dangerous home and ultimately dying. Right now, we may have to worry more about children being left in dangerous homes than about them being unnecessarily removed.

When people talk as if all that matters is the “best interests of the child,” they turn an important idea into a simplifying rule. It isn’t as if we believe that billionaires are entitled to take the babies of low-income parents on the grounds that they can promise better life chances. The harm done to parents, along with the harm done to children by tearing their families apart, has to figure into any proper moral accounting.

Here, Appiah has created a straw man. Nobody is saying that children should be removed when they could have a better life in a different family or that the best interests of the child is grounds for removal. Harm to parents? Yes, parents are harmed by the removal of their children. But when the parents have been severely abusing or neglecting their child, I don’t think their well-being should enter into the equation at all.

All of that brings us back to your position in this episode. As you say, you don’t really know much about this situation, and your letter indicates a certain class distance that may add to your uncertainty. What you witnessed was worrisome, but you did not see someone shivering or sick. Nor do you live in the community. Others in the store, townspeople, saw the child, too. The child presumably has neighbors who see the preschooler’s everyday life, and any of them could have reported what they knew (and, for all you know, have done so). They may know the local record of C.P.S. and have a keener sense than you of both the risk to the child and the risk of calling in the state. So you shouldn’t reproach yourself for not reporting this child. That’s not because C.P.S. couldn’t possibly have helped. It’s because you didn’t know enough to decide what was needed and there were others better placed to do so.

A child who is wearing shorts and a tee shirt and no socks, shoes or coat in cold weather is clearly neglected, and some kind of intervention is necessary. But Appiah’s point about residents of the community being in a better position to report is a good one. This child is clearly not being hidden away, so others in the community probably have a better sense of what is going on than a stranger observing this group for the first time. Can one be sure that this child goes to school or is regularly exposed to people in the community who would be inclined to report? Based on my ignorance about the answer to this question, I would probably call CPS, despite my doubts about whether the call would be accepted given that only a license plate could be provided to identify the child and family.

The Ethicist’s final conclusion that the anonymous writer should not reproach herself for not calling CPS about this child is reasonable. But that conclusion stems from the writer’s position as a stranger in the community and is not applicable to the more common scenario in which a potential reporter has longer-term knowledge about a child’s circumstances. What is more important is that the three preceding paragraphs contain misinformation that may discourage people from reporting in situations when they really should do so. It is unfortunate that The Ethicist has fallen victim to the current ideological climate, where right and left agree in opposing government interference in the lives of children, even those who are abused or neglected.

Notes

Joseph Doyle of MIT, in a pathbreaking study, found a way to simulate such an experiment by taking advantage of the fact that children are essentially randomly assigned to different investigators who have different propensities to place children in foster care. Treating assignment to an investigator as an “instrumental variable,” Doyle was able to estimate the effects of foster care in marginal cases, where the assignment of an investigator determines whether the child will be placed in foster care. His results, using data from Illinois, suggested that “children on the margins of placement tend to have better outcomes when they remain at home.” But Doyle’s data are over two decades old and from a state with an atypical foster care system. Use of the same method with data from Michigan, Gross and Baron found that assignment to foster care for children at the margin of placement improved children’s safety and educational outcomes and in the long-term reduced the chances of adult arrests, convictions and incarceration. A similar study in Rhode Island found that found that removal significantly increased test scores and reduced grade repetition for girls and had not discernible impacts for boys. ↩︎
In its Child Maltreatment reports, the Children’s Bureau provides an estimate of the number of children reported to CPS and how many of those children ultimately end up receiving “postresponse services,” which includes both foster care and in-home services. Unfortunately, the numbers are duplicated, so that the same child can be counted more than once if that child is the subject of a new report after leaving foster care or having an in-home case closed. Moreover, the concept of “postresponse services” is quite broad and includes very limited services, such as information and referral, that may not require the opening of a case. ↩︎

The Title IV-E Prevention Services Clearinghouse: Fatally flawed like the law that created it

by Marie Cohen

In Home Visiting: More Hype than Hope, I wrote about the failure of decades of studies to prove that home visiting programs have real-life outcomes for children and families. In this post, I explain how the federal government promotes these and other programs as interventions to prevent foster care despite the lack of meaningful evidence for their success. A “Prevention Services Clearinghouse” established by federal legislation approves programs for reimbursement based on the results of outcome studies, with virtually no attention to the quality of the measures used, the lack of corroboration, the total weight of the evidence, or the logic and size of the impacts. There is little evidence to support the effectiveness of these programs in making it possible for children who are maltreated (or at risk of foster care for another reason) to remain safely in their homes. Congress should consider eliminating the Clearinghouse and changing the type of services services eligible for federal funding.

The stated purpose of the Family FIrst Prevention Services Act (FFPSA),¹ which was signed by President Trump in 2018, was to “provide enhanced support to children and families and prevent foster care placements through the provision of mental health and substance abuse prevention and treatment services, in-home parent skill-based programs, and kinship navigator services.” To achieve this purpose, FFPSA expanded the use of Title IV-E funds from foster care and adoption to what it called “foster care prevention services and programs” designed to prevent the removal of children from their homes.² These programs were nothing new; at the state level, they are often called in-home services, family preservation services, or intact family services. Under FFPSA, these services are available to children who are “candidates for foster care” [meaning the child is at imminent risk of entering foster care but can safely remain at home or with a relative with the provision of services provided under the Act³] and to pregnant or parenting foster youth and the parents or kin caregivers of these children.⁴

Under FFPSA, these “foster care prevention services” must be provided “in accordance with practices that meet the requirements for being promising, supported, or well-supported practices.” Among the requirements, the components of the practice must be described in a book or manual, there must be no evidence suggesting the program does more harm than good, and when there are multiple studies of one program, the “overall weight of the evidence” must support the benefits of the practice. Each practice must be found to be “superior to an appropriate comparison practice using conventional standards of statistical significance in terms of demonstrated meaningful improvements in validated measures of important child and parent outcomes, such as mental health, substance abuse, and child safety and well-being.”

To receive the highest rating of “well-supported,” a practice must have data from at least two randomized controlled trials (RCT’s), or quasi-experimental research designs if RCT’s are not available. At least one of the studies must demonstrate that the practice has a sustained effect lasting at least a year. The requirements are somewhat lower to be a “supported” practice and lower still to be a “promising” practice. In order for a program to be rated as “supported” or “well-supported,” the supporting studies must have been conducted in a “usual care or practice” setting, which is defined as an existing service provider that delivers substance abuse, mental health, parenting or kinship navigator services as part of its typical operations.

At least 50 percent of a state’s foster care prevention services funding must be for “well-supported” programs in order to claim federal support under Title IV-E. Thus it is not surprising that states have chosen to include mostly “well-supported practices” in their Title IV-E Prevention Plans.

In order to further define the requirements and apply them to existing programs, FFPSA created the Title IV-E Prevention Services Clearinghouse (“the Clearinghouse” from now on), which is run under contract by Abt Global, formerly Abt Associates. The Clearinghouse has published a Handbook of Standards and Procedures describing the methodology it has developed to evaluate whether a program meets the requirements established by FFPSA.⁵ Program ratings are based on what the handbook calls “contrasts.” A contrast is defined as “a comparison of an eligible intervention condition to an eligible comparison condition on a specific outcome for a specific posttest measurement.” A “contrast” might be a comparison of the number of substantiated child abuse reports for the experimental vs the control group in one study, for example. A contrast must be statistically significant based on conventional standards in order to be considered favorable.⁶

The Clearinghouse staff has interpreted the requirements written by Congress in a way that sets a very low bar for a program to be judged “well-supported,” “supported,” or “promising.” To be “well-supported,” the Clearinghouse requires no more than two contrasts from different studies that show favorable effects.” At least one of the contrasts must demonstrate a “sustained favorable effect” of at least 12 months. This is a low standard for many reasons.

A program can be rated “well-supported” with as few as two positive contrasts, even if they are wildly outnumbered by contrasts that fail to show an impact. Even within a specific category (such as parental drug abuse, for example), one favorable contrast is enough, no matter how many other related indicators from the same or other studies show no effect.
Any positive contrast is counted, regardless of whether it is based on objective indicators or subjective ones like self-reports. Improvements on subjective measures are counted even if objective measures fail to find impacts.
Any pattern of impacts (or contrasts) is accepted, regardless of whether it is predicted by the program’s theory or logic model. If a program is supposed to work by changing parental behavior, but it instead changes children’s behavior directly, the outcome is counted. There is no requirement that a program impact be explained by its logic model or theory.
There is no requirement that a specific contrast reported by one study be corroborated by another study. Many of the individual impacts that are reported are supported by only one study, with each study cited providing evidence of a different impact.
Any contrast that is statistically significant is accepted, regardless of whether it is of practical significance. The American Statistical Association has stated that “[S]tatistical significance is not equivalent to scientific, human, or economic significance.” A tiny effect can be statistically significant if the sample size or measurement precision is large enough.
Studies are counted even when the specific populations studied are very different from those eligible for Title IV-E Prevention services.

Examining the Clearinghouse evidence on some of the most popular programs clearly reveals the flaws of its methodology, providing multiple examples of the problems noted above.

Parents as Teachers is the most popular program rated by the Clearinghouse, having been included by 31 states in their Title IV-E Prevention plans as of August 2024. PAT is a home visiting program that describes its mission as “To promote the optimal early development, learning and health of children by supporting and engaging their parents and caregivers.” The rating of “well-supported” was based on only three studies, one of which was not conducted in a “usual care and practice setting” and another of which was conducted in Switzerland–with a very different population from that of the U.S. The Clearinghouse found three favorable contrasts (out of six total contrasts) on child social functioning, all from one study, along with one unfavorable contrast and two showing no effect. They found two favorable contrasts on child cognitive abilities (one from the Swiss study) compared to 10 findings of no effect). And they found two small favorable contrasts on child welfare administrative reports (with two showing no effect) from a comparison group study that was not done in a “usual care or practice setting,” Only one study reviewed looked at the quality of parenting or the home environment, and it found no favorable effects. The authors of that study said that the results “raised questions about the underlying premise of PAT that focusing services on parents to improve parenting knowledge, attitudes, and behaviors is an effective way to benefit children.” They also concluded that their results (including the three positive contrasts on child social functioning and one on child cognitive functioning) “are consistent with the overall research base for family-focused early childhood programs, which have produced ‘modest and inconsistent effects.'” (ee Appendix A for more detail on all the contrasts discussed here).

Functional Family Therapy (FFT) is second in popularity only to Parents as Teachers, being included in the plans of 25 states as of August, 2024. As described by the Clearinghouse, FFT “aims to address risk and protective factors that impact the adaptive development of 11 to 18 year old youth who have been referred for behavioral or emotional problems.” The Clearinghouse rated FFT as “well-supported” based on the results of six studies. The Clearinghouse reported two favorable contrasts, 23 contrasts showing no effect, and one unfavorable contrast on Child Behavioral and Emotional Functioning–the core goal of the program. It showed two favorable contrasts, two unfavorable contrasts, and 16 contrasts showing no effect on child delinquent behavior. No contrasts showed an effect on positive parenting practices and only two out of 13 contrasts showed an favorable effect on family functioning. Ten contrasts showed a favorable impact on children’s substance abuse, compared to eight findings of no effect. But all of these favorable contrasts came from one study of alcohol-abusing youths who resided in a shelter after running away–a very specific population that may not be generalizable to children abusing other substances or those who are living at home.

Like FFT, Motivational Interviewing (MI) is included by 25 states in their Family First plans. MI, according to the Clearinghouse, is a” method of counseling clients designed to promote behavior change and improve physiological, psychological, and lifestyle outcomes.” The Clearinghouse reviewed studies of MI focused on illicit substance and alcohol use or abuse among youth and adults, and nicotine or tobacco use among youth under the age of 18. These programs are typically delivered in one to three sessions with each session lasting about 30 to 50 minutes. The Clearinghouse rated MI as “well-supported” based on results from 21 studies. The contrasts reviewed showed no effects on child substance use, caregiver mental health, caregiver criminal behavior, family functioning, parent/caregiver physical health, or economic and housing stability. The only favorable effects were on parent/caregiver substance abuse, for which there were sixteen favorable contrasts, two unfavorable contrasts, and 91 showing no effect. Eleven of the favorable contrasts came from one study of heavy-drinking college students–a very different population from parents of children at risk of foster care placement; presumably few if any were parents at all. It was also not conducted in a “usual care or practic setting.” It is no surprise that a program of one to three sessions would not lead to major changes in parents’ and children’s lives, but it is strange that serious analysts would accept these results as proof that such a minimal program would change lives.

The Clearinghouse rated the Healthy Families America (HFA) home visiting program (included by 22 states in their Title IV-E Prevention Plans) to be “well-supported” based on the results of six studies. Healthy Families America was developed as an intervention to prevent child maltreatment and is now the signature program of an organization called Prevent Child Abuse America, as I discussed in an earlier post. Yet, HFA’s effects on child maltreatment are decidedly underwhelming. The Clearinghouse found five positive contrasts on self-reported measures of maltreatment and no favorable contrasts on 99 more objective measures like CPS reports, hospitalizations and injuries. Of the 16 remaining favorable contrasts for the entire program, five come from improvements in parental reports of child behavioral and emotional functioning (a self-reported item with possible bias), another was on the child’s self reports about skipping school “often,” and none were corroborated by another study.

Some readers might observe that the standard critiques of the clearinghouse focus on the difficulty, not the ease, of meeting its standards. Critics like The Child Welfare League of America have stated that the “high evidentiary standards for the clearinghouse require rigorous, costly research that many states, Tribes and programs are unable to fund. This barrier is particularly onerous for programs that focus on underserved populations, such as Black and Native families, children of more than one race, and rural communities.” This assertion is not inconsistent with my conclusions about the Clearinghouse. That is because there are two types of standards. The standards for the rigor of the studies themselves may be too high for many programs to meet. But once a study meets the requirements to be reviewed, the requirements for being “well-supported” are almost laughable.

Another problem with the Clearinghouse is that many of the programs included are generally paid for by Medicaid, private insurance, or other state and federal programs, such as the federal home visiting program. And Title IV-E is required to be the payer of last resort for these services so it cannot pay if another source is available. The idea was apparently that Family First could be used to supplement these sources for families without private health insurance or where these funds are not available, but this does not seem to be occurring on a large scale, as I explain below.⁷

Finally, the Clearinghouse does not include what may be the most important foster care prevention service of all–case management. All of the services in the clearinghouse depend on relationships, but it is the relationship with the social worker managing the in-home case that may be the most important intervention for a maltreating parent. It is the case manager who refers the client to the parenting, substance abuse and mental health programs prescribed by the Act and who maintains contact with the programs to monitor the parent’s participation and progress. The case manager is responsible, through home visits, for monitoring the safety of the child or children who have not been placed in foster care. Without such monitoring, there can be no foster care prevention services.

Currently, case management is treated as an administrative cost under Title IV-E, which means it cannot be paid for unless the client is receiving other services that are supported by the Clearinghouse. At least one agency, the District of Columbia’s Child and Family Services Agency, has found a way to adapt one of the “well-supported practices” listed in the Clearinghouse as a case management model, allowing it to claim Title IV-E funding for case management for all children receiving foster care prevention services. CFSA adapted the practice of Motivational Interviewing (MI, discussed above), which is in the Clearinghouse as a substance abuse intervention, as a model for case management for all in-home services. As one account puts it, the approval of this use for MI was “particularly notable because while [MI] was approved by the Title IV-E Clearinghouse for Family First reimbursement only as a substance abuse service, DC received approval to implement and claim for it as an integral component of CFSA’s case management practice for all families.” But it should not be necessary for states to go through this type of charade in order to obtain Title IV-E funding for their case management services.

All of the problems mentioned above may explain why states are not drawing down large amounts of Title IV-E funding for foster care prevention programs. The federal government spent only $182 million reimbursing states for Title IV-E prevention services in FY2024, serving only about 18,300 children per month. A recent federal report showed that reported reimbursement claims on Title IV-E prevention services constituted less than two percent of overall Title IV-E program reimbursement claims in FY 2023, serving about two percent of the children receiving Title IV-E funded services.

What can be done?

Raising the standards for “promising,” “supported,” ‘well-supported” to be meaningful is simply not a viable option. Adjusting the three ratings to incorporate the quality of the measures, the need for corroboration, the weight of the evidence and the logic and size of the impacts, would probably mean that few if any programs would be classified in the top tier. So there is not really a way to classify programs based on evidence that will work well for the purpose of funding foster care prevention programs in Title IV-E.

Perhaps this is not surprising. The concept of evidence-based practice was adapted from medicine. When applied to social services, the concept has many limitations. Research conducted under controlled, small-scale, well-funded conditions, even if conducted in a “usual care and practice” setting is often not applicable to the messy, underfunded world of social services practice. It is well-known that effect sizes often shrink when a small pilot program is expanded to cover a larger population. Moreover, a study conducted on one population may not be generalizable to other groups. The population of parents at risk of losing their children to foster care is distinct from many other populations included in the studies mentioned above. The antecedents of child maltreatment, substance abuse and mental illness are extremely complex and may go back for generations. The idea that a three-session, three-month or even a three-year program can eliminate these problems may be unrealistic.

Finally, in relationship-intensive services like all of those included in the Clearinghouse, the characteristics of the practitioner probably matter more more than the specific model. In psychotherapy, multiple studies have concluded that “who your therapist is matters more than the model they use.” Ordinary people dealing with mental illness or addiction do not usually look for an “evidence-based practice.” They look for the best provider they can find–the one they have heard by word-of-mouth, or by scanning the internet for ratings. As mentioned above, the quality of the therapist matters more than the model, and the same applies to program staff. When I was a foster care social worker, and we had a child who had complex mental health needs, we used available funds to reimburse a top-notch provider who did not accept Medicaid. I don’t think we ever talked about what “model” they offered, and they met with clients for much longer than than program manuals prescribe. Medicaid itself does not require proof that a program is evidence-based.

In light of these issues, Congress should consider eliminating the Title IV-E Clearinghouse, as proposed by the Bipartisan Policy Center’s child welfare working group in its recent Blueprint for Child Welfare Financing and Accountability Reform.” The group of 15 child welfare experts representing different professional experiences and perspectives agreed that the clearinghouse process for approving programs as evidence-based “is cumbersome, is idiosyncratic, and impedes states from meeting the needs of families….” The group recommended replacing the clearinghouse with an expert panel convened by the U.S. Department of Health and Human Services that would consider proposals from the states for programs they want to provide using Title IV-E funds. States would be required to submit “evidence to support the efficacy of the interventions, and data that demonstrates the why states believe that proposed interventions would reduce child welfare involvement or improve outcomes of child welfare-involved children and families.”

Congress should also change the definition of the “prevention” services that can receive federal reimbursement under Title IV-E. Instead of continuing to pay for programs that belong to the field of mental health and substance abuse or are generally funded by Medicaid or private insurance, Title IV-E funds should be used for the critical service provided either directly or under contract by child welfare agencies–case management. Agencies should not have to go through the contortions that DC’s Child and Family Services Agency went through to adapt a three-session substance abuse cessation program into a case management model only to receive reimbursement from Title IV-E. This is the main service that they provide directly and it should be funded. Congress could also add a provision for states to be reimbursed to provide services mental health or drug treatment for the small number of parents who do not have public or private coverage for such services–in other words, where a payer of last resort is needed.

In drafting and passing FFPSA, Congress hoped to make new funds available to programs that would ameliorate the problems that were putting children at risk of being removed from their homes. In its effort to ensure that effective programs were funded, Congress instead created a process that awards ratings to programs based on the mindless and mechanical application of standards that mean little–and that fails to unlock the hoped-for source of funding for foster care prevention. The law must be changed in order to fulfill the intent of its framers.

Notes

See Title VII of Public Law 115–123. ↩︎
There is something odd about the concept of services to prevent foster care. Prevention usually refers to a social problem like child maltreatment or teen pregnancy, not a government policy, which is itself a response to the problem of child maltreatment. It is like talking about preventing hospitalization rather than preventing illness. It would be more natural to think of services to prevent the underlying problem that result in foster care, which is usually child abuse or neglect, but can also be children’s behavioral health problems that are so severe that parents feel compelled to relinquish their care to the state. But this is the term used by FFPSA and I will use it here. ↩︎
A note about foster care candidacy is in order here. In general, children are placed in foster care because they are abused or neglected or are at imminent risk of abuse or neglect. However , there is another group of children entering foster care who have drawn increasing attention. These are children whose parents voluntarily relinquish them because they are unable to care for them at home or obtain needed services–usually care for severe behavioral issues. ↩︎
Federal research has estimated that as many as five percent of all children entering foster care between 2017 and 2019 may have entered care primarily to receive behavioral health
or disability services, not because of maltreatment. ↩︎
The Handbook has already been revised once, but the language on this specific issue has not been revised. ↩︎
See pages 83-84 for more on statistical significance. This author did not find a statement of the required p-level. ↩︎
Also problematic is the failure to include domestic violence services in the clearinghouse. This was always puzzling. Child welfare social workers and academics often speak of the “Big Three” factors that result in child welfare involvement– drug abuse, mental illness and domestic violence. So the omission of domestic violence was strange–especially because domestic violence programs are greatly underfunded and not chargeable to an another program like Medicaid. ↩︎

Appendix

Parents as Teachers Contrasts Cited by Clearinghouse

Two small favorable contrasts from the matched comparison group study, which was not carried out in a usual care or practice setting and two contrasts showing no effect on child welfare administrative reports;
One contrast showing no effect on out-of-home placement;
Three favorable contrasts, two contrasts showing no effect and one unfavorable contrast on child social functioning;
Two small favorable contrasts and ten contrasts showing no effect on child cognitive functions and abilities;
Three contrasts showing no effect on child physical development and health;
One contrast showing no effect on adult parenting practices;
Eight contrasts showing no effect and one showing an unfavorable effect on family functioning;
Nine contrasts showing no effect and one showing an unfavorable effect on adult economic and housing stability.

Functional Family Therapy (FFT) Contrasts Cited by Clearinghouse

Two favorable contrasts, 23 contrasts showing no effect, and one unfavorable contrast on Child Behavioral and Emotional Functioning–the core goal of the program. One of the two favorable contrasts is on “Strengths and Needs Assessment: Child Behavioral/Emotional Needs” immediately after completing the program. But another study shows no impact on the same outcome.
Two favorable contrasts, two unfavorable contrasts, and 16 contrasts showing no effect on chid delinquent behavior;
Nine contrasts showing no effect on positive parenting practices;
Two favorable contrasts and 13 contrasts showing no effect on family functioning.
Ten contrasts showing a favorable impact compared to only eight showing no effect on children’s substance abuse. But all of these effects came from one study of alcohol-abusing youths who resided in a shelter after running away–a very specific population that may not be generalizable to children who are living at home.

Motivational Interviewing (MI) Contrasts Cited by Clearinghouse

Thirteen contrasts showing no effects on child substance use;
Five contrasts showing no effect on caregiver mental health;
Sixteen contrasts showing a favorable effect, 91 showing no effect, and two showing an unfavorable effect on parent/caregiver substance use. Among the favorable contrasts, one study shows a favorable effect on the number of drinks per week while there is no effect on the number of drinks per day but the Clearinghouse did not apparently take account of such contradictions.
Seven contrasts showing no effect on parent/caregiver criminal behavior;
One contrast showing no effect on family functioning;
Ten contrasts showing no effect on parent-caregiver physical health;
One contrast showing no effect on economic and housing stability.

Healthy Families America (HFA) Contrasts Cited by Clearinghouse

Forty-three contrasts showing no effect on child safety as measured by child welfare administrative reports, medical indicators of maltreatment risk, or “maltreatment risk assessment” measures.
Five favorable contrasts, 38 contrasts showing no impact, and one showing a negative impact on child safety based on parental self-reports of maltreatment. Clearly these self-reports are less valid than more objective measures, since parents clearly know what answers are expected after having been through the program. A parent’s negative answer to the question of whether she ever used physical abuse in the past year (one of the actual indicators used) cannot be trusted to be accurate.
Seven contrasts showing no effect on child safety as measured by “medical indicators of maltreatment risk,” a strange heading for a group of questions from the Adolescent-Adult Parenting Inventory including “Inappropriate Expectations, Lack of Empathy, and “Belief in Corporal Punishment.”
Eleven contrasts showing no effect on “Maltreatment Risk Assessment” measures such as hospitalizations and injuries needing medical care.
Five favorable contrasts and two showing no effect on parent reports of child behavioral and emotional functioning, also a self-reported item;
Two favorable contrasts, six showing no effect, and one unfavorable contrast on child cognitive functions and abilities.
One favorable contrast on “child delinquent behavior;” The measure was actually “child skips school often,” self-reported by children in first or second grade, according to the study.
One favorable contrast and two showing no effect on child educational achievement and attainment. This was a positive contrast on the percentage of children retained in first grade. However, the percentage of children who performed above or below grad level did not change.
Three favorable contrasts and 24 showing no effect on positive parenting practices. The three favorable contrasts came from observations of “Positive Parenting” from researchers’ observations of parents during a puzzle task, a “delay of gratification” task, and a cleanup task. However observations of harsh parenting during those same tasks did not show a statistically significant change.
Three contrasts showing a favorable impact and 16 contrasts showing no effect on parent/caregiver mental or emotional health;
Fifteen contrasts showing no effect on parent/caregiver substance use;
Three contrasts showing a favorable effect and 28 contrasts showing no effect on family functioning. Twenty-two of the contrasts were measures of intimate partner violence (IPV) or family violencefrom one study only and not corroborated. The positive impacts were on three specific measures based on the perpetrator, the type of violence and the age of the child. Only three of those 30 contrasts showed a positive impact and no effect sizes were provided.
Five contrasts showing no effect on economic and housing stability.

How did peer reviewers let this one get by? A flawed study of foster care removals and child maltreatment mortality

by Marie Cohen

This blog has often focused on the uncritical use of flawed research to support desired conclusions. A good example of this has now become available. The authors of a new study conclude that decreasing rates of entry into foster care are not associated with changes in mortality from child abuse and neglect. Advocates of continuing reductions in foster care or its total abolition have lost no time in sharing the results, undaunted by what should have been obvious to any knowledgeable reader. The study is too flawed by the nature of its data on child maltreatment fatalities to make any conclusions about the presence or absence of a connection between foster care reductions and changes to child maltreatment mortality.

The number of children entering foster care in the United States has fallen from 252,198 in Federal Fiscal Year (FFY) 2019 to 170,955 in FFY 2024. As computed by Frank Edwards, Kelley Fong, and Robert Apel in their new paper, foster care entry rates have decreased from 3.49 to 2.47 entries per 1000 children between 2018 and 2023, a decrease of about 29 percent. This large drop in foster care entries was in large part the result of a growing bipartisan consensus on the federal level and in red and blue states around the need to reduce or entirely terminate the use of foster care to protect children from continuing abuse or neglect.

Some child advocates and media outlets around the country have argued that the reductions in the use of foster care have gone too far. The Seattle Times Editorial Board recently told readers to “Stop dodging and face facts: More kids are dying on DCYF’s watch,” citing a 35% drop in dependency petitions to take kids into foster care since 2021 along with a 67 percent increase in child deaths and near-deaths between 2020 and 2024. A series from Texas Public Radio called When Home is the Danger suggests that a 40 percent reduction in removals of children to foster care, at the same time as in-home services were being curtailed, has resulted in more children dying as a consequence of abuse or neglect. Child advocates across the country have expressed similar fears, but there has been no good data to support or refute this claim.

Edwards, Fong and Apel say their new study shows these fears are baseless. They report that they “found no evidence of a negative association between foster care entries and child maltreatment fatalities at the population level.” They came to this conclusion by estimating the association between child maltreatment mortality rates and foster care entry rates at the state level, using state administrative data from Federal Fiscal Years 2010 to 2023. Even after controlling for variations in population disadvantage, other state features, and national temporal effects they found no association between foster care entry rates and child maltreatment mortality rates.

Advocates of continuing reductions in, or outright elimination of, foster care have been circulating the article widely, using it to counter any claim that excessive foster care reductions may be leading to child fatalities. But a cursory review shows that the study is fatally flawed and would not have been published had the peer reviewers been familiar with the sources of the data used. Four of the leading academic researchers in the field have already posted comments pointing to issues with the data and the model. These comments are summarized and explained below, along with examples from my research on child maltreatment fatality data.

Flawed Data

The Edwards study uses child maltreatment fatality data from the National Child Abuse and Neglect Data System (NCANDS) to represent child maltreatment deaths. These numbers appear in the annual Child Maltreatment reports released by the Children’s Bureau. In a report called A Jumble of Standards: How State and Federal Authorities Have Underestimated Child Maltreatment Fatalities, I summarized the results of my review of ten years of federal Child Maltreatment reports, including all the state commentaries provided in each report. My work points to multiple reasons that these numbers reported by the states should never be used in such a study.

Screening Policies

The number of child maltreatment fatalities a state will find depends first on which deaths it accepts for investigation and which ones it screens out. And when these change, the number of fatalities found will probably change. For example, some states or counties historically screened out cases where there were no other children in the home,¹ because investigations were not considered necessary to protect the other children in the home. West Virginia began investigating cases with no surviving children in the home in FFY 2016. Alaska changed its policy in 2023 so that it will now investigate cases where there are no surviving children in the home, which will affect future counts. We do not know how many states may have made this or similar changes over the span covered by the Edwards paper.

Texas changed its screening policy as of September 2022 so that “reports that involve a child fatality but include no explicit concern for abuse and neglect” are not investigated until the reporter or first responders are interviewed to find out if they had any concerns for abuse or neglect. Only if they had such concerns is the report investigated. DFPS reported that as a result, the number of child fatalities it investigated decreased from 997 in FY2022 to 690 in FY2023 (a 31 percent decrease) due to this new screening policy. And the number of child maltreatment fatalities found fell from 182 to 164.

Changed screening policies can also lead to an increase in reported child maltreatment fatalities. In 2022, Maryland implemented a policy that requires local agencies to screen in sleep-related fatalities, which often involve parental substance abuse. In its commentary, the agency indicated that this was the reason it reported an increase in child deaths from 68 in FFY 2022 to 83 in FFY 2023.

Definitions

NCANDS defines a child maltreatment fatality as “the death of a child as a result of abuse or neglect because either: (a) an injury resulting from child abuse or neglect was the cause of death; or (b) abuse and/or neglect were contributing factors to the cause of death.” So a state’s definition of a maltreatment fatality depends on its definition of child abuse and neglect. And if that definition changes over time, that will affect the trend in child maltreatment fatalities reported. For example, Texas changed its definition of child neglect in 2021 to require “blatant disregard” for the consequences of an act or failure to act. Texas reported a drop of in the number of child maltreatment fatalities from 255 in 2020 to 205 in 2021 to 176 in 2022. The state has attributed that decline in reported neglect deaths to the 2021 law.

A similar decrease in reported child fatalities occurred in Illinois, where “blatant disregard” was already included in the definition of neglect but the requirement was enforced through a new administrative review process for sleep-related deaths. A senior administrator reviews the investigation to ensure that death included evidence of “blatant disregard.” In its 2023 commentary, Illinois links this new policy with a decrease of 24.6 percent in reported child fatalities in FFY 2023.

Data Sources

Experts widely agree that NCANDS underestimates the total number of child maltreatment fatalities, as Edwards et al. acknowledge. One reason is that many states do not use all of the available sources for possible child maltreatment fatalities, which include reports to child protective services, state vital statistics departments, state child death review teams, law enforcement agencies, and medical examiners or coroners. Some states have recently been broadening the sources of data they use, and such changes may have resulted in an increase in reported fatalities. For example, North Carolina originally reported only deaths that the chief medical examiner classified as “homicide” by a parent or caregiver as child maltreatment fatalities. (This does not jibe with the NCANDS definition of child maltreatment fatality, but there is no consequence applied to states who do not use it.) After the agency began to include child deaths that were substantiated as maltreatment by CPS, as well as increasing their collaboration with vital statistics and criminal justice agencies to identify maltreatment deaths, North Carolina’s reported child fatalities increased from 64 in FFY2018 to 111 in FFY2019 (a 73 percent increase).

Historically, Mississippi also reported only deaths that the chief medical examiner had classified as homicide by a parent or caregiver but in 2007 began including fatalities substantiated by CPS as due to maltreatment. In FFY 2014, Mississippi developed a Special Investigations Unit to investigate all reports of child fatality that meet criteria for investigation. Mississippi reported that the having dedicated, specialized investigators resulted in a higher count of maltreatment fatalities in that year and thereafter.² The state also reported that public awareness campaigns to prevent deaths caused by unsafe sleep and children left in hot cars led to an increase in reporting of such fatalities, also contributing to an increase in reported deaths. The number of child maltreatment fatalities reported by Mississippi increased from 17 in FFY 2010 to 76 in FFY 2023.

Reporting Errors

In 2025, a reporter at the Baltimore Banner noticed that Maryland was reporting an alarming rate of child fatalities. With a reported 83 children dying of abuse or neglect in FFY 2023, Maryland had one of the worst child maltreatment fatality rates in the nation. Taken by surprise, state Department of Human Services officials soon realized that they had been reporting incorrect numbers for the past five years. Instead of reporting the deaths for which maltreatment was confirmed, they had been reporting all child deaths that had been investigated for maltreatment. The department now believes that there were 173 child maltreatment fatalities, not the 285 reported, between FFY’s 2020 and 2023. We do not know how many other states have been reporting erroneous numbers, given the little attention that these reports usually receive.

Time Lags

A key flaw of Edwards et al.’s analysis is the assumption that child maltreatment fatalities reported for a specific year reflect the deaths that occurred in that year. That is far from being the case. As the Children’s Bureau explained in Child Maltreatment 2023, “The child fatality count in this report reflects the federal fiscal year (FFY) in which the deaths are determined as due to maltreatment. The year in which a determination is made may be different from the year in which the child died.”³ There is similar language in reports from the previous years. States have explained in their commentaries that the actual dates the children died may have occurred as much as seven years before the year they were reported. As Sarah Font of Washington University and Emily Putnam-Hornstein of the University of North Carolina explain in their comment (posted below the article), “the Edwards et al. analysis largely models whether state foster care entry rates predict past [child maltreatment fatalities] — a nonsensical question with no bearing on whether foster care is a protective intervention. Indeed, if states respond to rising [child maltreatment fatalities] by placing more high-risk children in foster care, one would expect higher past [child maltreatment fatality] rates to be associated with higher current foster care entry rates.”

Even if the fatalities did occur in the same year as they were reported, it would not make sense to expect an increase in deaths only in the same year as a decrease in foster care, Brett Drake of Washington University raises this concern in his comment. Any maltreatment fatality resulting from a failure to remove a child will not necessarily occur in the same year. A foster care removal may save a child’s life in a subsequent year. Many of the most horrific child fatality cases involve child fatalities that could have been prevented by removal in prior years. In some of these cases, the child suffered through years of abuse or neglect before dying. But as Font and Putnam-Hornstein point out, the Edwards model attempts to correlate removal rates with past child maltreatment fatalities. And there is no way that makes sense.

Other flaws in the model

Font and Putnam-Hornstein, as well as Richard Barth of the University of Maryland, draw attention to another problem. Children under age five account for 82 percent of reported child maltreatment fatalities but less than half of foster care entries. But proportional decreases in foster care entries were largest among older children: there was a 49 percent reduction in entries of 17-year-olds versus an 18 percent reduction in infant entries. It might have been more sensible to focus on younger children only, though fixing this problem would not address all the other problems with the analysis.

Barth suggests another problem with the model. Placing a child in foster care may prevent that child dying from other causes, not just maltreatment. And indeed, we have learned that maltreatment is correlated with deaths from all causes, not just from child maltreatment. Research shows that children who have been reported for maltreatment are more likely to die of accidents in their first five years, sudden infant deaths and medical causes as infants, and suicide as teenagers. It is also obvious from my personal experience reviewing child fatalities in the District of Columbia that children who die of homicide as teenagers and young adults are likely to have a family history of child abuse and neglect reports. Child maltreatment mortality is only one type of child mortality we should care about.

It is unfortunate that so many child welfare leaders and commentators are so quick to grab hold of any research that supports their point of view without critically examining the methodology and considering whether the findings justify the claims. I hope that the peer reviewers for this study were as unfamiliar with state child maltreatment data as the study authors themselves; otherwise their motives in approving the study are suspect. As Font and Putnam Hornstein put it, “[t]he conclusions of Edwards et al. rest on a mis-specified model and deeply-flawed data; deficiencies unaddressed by the authors’ numerous sensitivity analyses.” These findings have no relevance to the discussion of whether the decline in foster care removals is putting children at risk of dying.

Notes

Some jurisdictions still do this, including the District of Columbia (as I learned from requesting child fatality information) and some counties in Ohio, as described in Child Maltreatment 2022. ↩︎
Child Maltreatment 2014, Child Maltreatment 2015, and Child Maltreatment 2016. ↩︎
Like many statements in the CM reports, this is not exactly true. A few states (including California) do attempt to capture only the deaths that occurred in the reporting year. This involves reporting on only deaths that occurred in the reporting year and then amending the numbers in future years. See A Jumble of Standards. In their eAppendix 1, Edwards, Fong and Appel note that they include the most recent revisions into their estimates. But as I describe in A Jumble of Standards, it appears that only a few states make such revisions. ↩︎

The Trump Administration is separating families again

by Marie Cohen

The last time Evgeny and Evgenia saw their eight-year-old son Maksim was on May 15. That’s the day that the couple refused to board a commercial flight taking them back to Russia, from which they had fled fearing persecution for their opposition to Valdimir Putin. On August 24, Maksim will turn nine years old in foster care. He has not seen his parents since May 15 and has given up hope for a reunion. Maksim’s family is not unique. The New York Times found a total of nine cases in which parents have been separated from their children after refusing to comply with deportation orders in this new version of the family separation policy that generated such a strong backlash in the first Trump Presidency.

As reported by Hamed Aleaziz in the New York Times and its podcast, The Daily, Evgeny and Evgenia, who prefer not to have their last name revealed, fled Russia because of their political activism. As supporters of Putin’s murdered enemy Alexei Navalny, they felt that they were at risk of losing their freedom, their livelihood or even their lives if they remained in Russia. They fled to Mexico, with the hope of getting an appointment to apply for asylum in the US through a cellphone app created by the Biden Administration to enable asylum-seekers to schedule an appointment from outside the country. But Trump shut down that program when he took office. Seeing no other option, the family went to a port of entry on the southern border and explained that they were there to seek asylum. But asylum applications had been shut down completely at the southern border, and the family was detained in Border Patrol custody. After two weeks, they were taken to JFK airport to be deported.

At the airport, ICE officials told Maksim’s parents that they would be separated from their son if they did not board the flight to Russia. But Evgeny was trying to prevent a longer separation in Russia since he expected to be detained there. With many tears on all sides, Evgeny and Evgenia were taken to detention and Maksim was taken to a shelter for unaccompanied immigrant children. It was May 15, 2025.

In the first Trump administration, thousands of families were separated at the border as a way to deter people from entering the country illegally. Parents were arrested and criminally charged for illegally entering the country and their children were taken away. This policy created a massive outcry worldwide and Trump ended it in 2018. Today, border crossings have slowed to a trickle and the new administration is focused on deporting those who have already crossed. Migrants from many countries can be shackled, cuffed, and loaded onto chartered flights. But for those who came from countries like Russia that do not accept deportation flights from the US, the government must use commercial flights to deport unwanted migrants. And commercial airlines do not accept passengers in restraints or who make a scene. Hence the choice offered to Maksim’s parents.

As Aleaziz puts it for the Times, “the new cases suggest that the administration has decided to use family separation as a tool, at least in some instances, to persuade families to leave and to create a powerful deterrent for those who might come to the United States illegally.” He found nine families who have refused deportation and been separated. But he does not know how many families have faced this choice, including those who have agreed to return to the countries from which they came. A spokeswoman for the Department of Homeland Security told him that there is no family separation policy and that “these families had the right and the ability to depart the country as a family and willfully choose to not comply.”

Evgeny and Evgeniia have not given in–a fact which lends credence to their fear of persecution in Russia. Since Maksim was taken from them, they have passed the rigorous screening for the validity of their asylum claim. Now the government cannot deport them to Russia but can send them to a third country if one can be found. Maksim has been transferred to foster care. His conversations with his parents are heartbreaking; At first he was counting the days that he has been apart from his parents but has now stopped. At this point, he has given up hope that he will see his parents again. Maksim will turn nine on August 24 and it looks like he will not be with his parents on that special day.

My regular readers know that, unlike some people who want to abolish foster care, I support the separation of children from their parents when there is abuse or neglect that is so severe that the child cannot be protected without removal. But perverting these practices in order to deter asylum-seekers is state-committed child abuse. Allowing Maksim to spend his ninth birthday in foster care as a lesson to families with valid asylum claims not to enter the United States is heartless beyond belief. Can a groundswell of opposition be generated and end this family’s ordeal and that of others in a similar situation? I certainly hope so.

Teaching abuse: how some adoptive parents are being taught to maltreat their children

Image: Yadkin Ripple

by Marie Cohen

At a glance:

Reactive Attachment Disorder (RAD) is a diagnosis that is included in the DSM and often applied to foster and adopted children. While RAD refers to a pattern of inhibited, withdrawn behavior, some controversial therapies (often described as varieties of “Attachment Therapy”) are based on a distorted definition of RAD, or on an unauthorized diagnosis of “attachment disorder” that includes a deep-seated rage that if unaddressed will result in antisocial and even criminal behavior.
Among the practices included these controversial therapies are severe disciplinary methods including the establishment of total parental control over children’s actions, including eating, drinking and using the toilet.
Many of these Attachment Therapy technique include a component that involves forcing the child to express underlying rage through physically coercive methods that may include being held down by several adults for as much as three to five hours. Several child deaths have been attributed to such methods.
In order to prevent more damage to children, it is necessary to adequately vet prospective adoptive parents for their readiness to parent children with challenging behaviors due to early trauma and deprivation. Even for parents who are able to meet the challenge, training and continued support are necessary.
Unbelievably, some adoptive parents have not been charged even when their parenting techniques have led to the deaths of their children. It is absolutely necessary for parents who use abusive parenting techniques to be charged and tried in court. Adequate investigations are necessary in order to ensure that the conditions that lead to such cases are identified and remedied.

On January 5, 2023, according to a police warrant filed in Surry County, North Carolina, Joseph Wilson received a text from his wife telling him that something was wrong with their four-year-old adopted son Skyler after he was “swaddled.” She attached a picture of Skyler lying face down on the floor, wrapped in a sheet or blanket with duct tape attaching him to the floor. “Swaddling” is a practice used in many cultures to comfort infants, but Wilson told police he was referring to a parenting technique learned from a parenting expert named Nancy Thomas. (Court documents also state that one of the Wilsons’ former employees described recorded Zoom counseling sessions the couple had with Thomas.) Skyler died at Brenner Children’s Hospital in Winston-Salem on Jan. 9 of a “hypoxic, anoxic brain injury,” meaning that oxygen was unable to reach his brain due to the “swaddling.” Skyler’s adoptive parents, Jodi and Joseph Miller, have been charged with murder and felonious child abuse and are awaiting trial, which has recently been postponed–for the second time–from June 2 to December 1, 2025.

After Skyler’s death, police recovered surveillance cameras and arm and ankle restraints that Wilson had told them his wife used on Skyler during “swaddling.” A former foster parent of Skyler and his brother told police that Jodi Wilson had told her about using practices like “food restriction, the gating of Skyler in a room for excessive ‘alone’ time, and the exorcisms of both children.” The former foster parent was concerned enough to call Child Protective Services a month before the incident that killed Skyler.

Nancy Thomas, mentioned as the source of the swaddling technique and as a counselor to Skyler’s parents, is perhaps the most prominent exponent of a group of approaches to that the American Professional Society on the Abuse of Children (APSAC) described in a 2006 report as “controversial attachment therapies.” These therapies are generally directed at children with “attachment disorders.” The only such disorder that is officially recognized by the mental health community is “Reactive Attachment Disorder” (RAD), a diagnosis that is included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This diagnosis involves “a consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers” as well as a “persistent social and emotional disturbance characterized by behaviors like minimal responsiveness to others, limited positive affect, and “episodes of unexplained irritability, sadness or fearfulness.” To be diagnosed with RAD, the child must have “experienced a pattern of extremes of insufficient care,.” which explains why this diagnosis is often applied to children who were adopted from orphanages abroad or foster care in the US. Some practitioners of these controversial attachment therapies, like Nancy Thomas, prefer to speak of children with “attachment disorder,” which is not included as a diagnosis in the DSM. Others use the term RAD but ascribe to that term a variety of symptoms that are not part of the DSM definition.

Whatever term they use, practitioners of controversial attachment therapies tend to believe that children who experience early adversity become “enraged at a very deep and primitive level.” This suppressed rage is said to prevent the development of attachment to caregivers and others and to lead to severe behavioral problems, such as violent behavior. These children are described as failing to develop a conscience, not trusting others, seeking to manipulate and control others, and at risk of developing criminal and antisocial behaviors. According to Nancy Thomas, some famous people with “Attachment Disorder” who did not get help in time include Adolph Hitler, Saddam Hussein, Jeffrey Dahmer, and Ted Bundy.

As described in the APSAC report, these controversial attachment therapies suggest that “parenting a child with an attachment disorder is a battle, and winning the battle by defeating the child is paramount.” Parents are often counseled to start by establishing total control over all the child’s actions, and requiring immediate obedience to parental commands. Nancy Thomas’s book, When Love Is Not Enough: A Guide to Parenting Children with RAD-Reactive Attachment Disorder, includes advice like “In the beginning, your child should learn to ask for everything. They must ask to go to the bathroom, to get a drink of water, EVERYTHING. When it starts to feel that they must ask to breathe, you are on the right track.” Another quote: When given directions it is unacceptable for the child to ask ‘”‘why?” or ‘what?’ NEVER answer these questions….Remember, have a consequence ready when a rule is challenged.” Thomas also recommends putting an alarm on a child’s bedroom door, and the window if necessary. Other techniques that have been recommended by attachment therapists include keeping the child at home (even counseling home schooling), barring social contact with others, assigning hard labor or repetitive tasks, and requiring prolonged motionless sitting.

Many proponents of controversial attachment terapies also believe that a child’s rage must be “released” before he or she can function normally. This release is often provided through physically coercive methods that may include being held down by several adults for as much as three to five hours. These techniques can be traced to “holding therapy,” a technique developed by a child psychiatrist named Foster Cline, who was ackhowledged as a mentor by Nancy Thomas in her book. Cline was admonished and restricted from using parts of his holding therapy model by the Colorado Board of Medical Examiners after members saw video of an 11-year-old being subjected to physical and verbal abuse while being restrained.

“Holding therapy” and similar methods designed to address “attachment disorder” have been implicated in the deaths of several adopted children, including that of three-year-old Krystal Tibbets, who died in 1997 when her adoptive father “applied the full weight of his body on the girl by lying across her and pressing his fist into her abdomen,” a technique he said he was taught by a therapist; four-year-old Cassandra Killpack, who in 2002 was forced to guzzle two quarts of water while her arms were bound, and 10-year-old Candace Newmaker, who suffocated in 2000 by a “therapist named Connell Watkins during a 70-minute “rebirthing ceremony” that was supposed to treat her attachment disorder. Nancy Thomas was working for Watkins at the time of Candace’s death. The “swaddling” technique that killed Skyler Wilson is an example of such a method.

Advocates of controversial attachment therapies have come to the defense of Skyler Wilson’s parents. The President of the Board of a nonprofit called Attach Families, Inc. shared an article on Facebook about Skyler’s death with the following preface: “These tragedies are always written one sided with no Investigative reporting, sadly…They obviously were using a swaddling technique that some Professionals promote for Attachment. This is a tragedy. But before these parents are “burned at the cross” our Families want more information.” The Page also posted this: “As we have seen hundreds of others making our Families look like monsters. When the truth is we try and will try ANYTHING to help our children. This is what we are trying to help them heal from before they get too big for us to physically handle their rages. Rages in which they inflict self harm. Rages where they slam their heads over and over on purpose. Rages in which we try to protect them from themselves and others around them. If you don’t live it 24 hours a day you have no idea what it is like.” Attached was an article about a Kansas teen who was arrested in the killing of his mother. The article contained no details about the teen or his mother. It is hard to understand how this talk of rage would apply to four-year-old Skyler. His former foster parent told a reporter that Skyler “was so tiny and small but had a heart three times bigger than he was…”

In some cases, the parents themselves, after reading misleading literature about children with RAD may invent their own disciplinary practices or use those inherited from their own upbringings or family traditions. The Denver Post recently wrote about Isaiah Stark, a seven-year-old who died in 2020 from ingesting too much sodium, likely from drinking olive brine. The newspaper learned that Isaiah’s adoptive parents were forcing him to eat olives and drink olive brine as a form of punishment for his behavior. According to a report from the state’s Child Fatality Review Team, the mother blamed all of Isaiah’s difficult behaviors on RAD and both parents attributed his actions to “manipulative behaviors and wilfulness.” At the funeral, she described Isaiah’s death as “God rescuing him.”

Isaiah Stark’s parents were never charged for his death. Since there was no trial, the public never learned whether the parents received any sort of parenting advice from an “expert.” The failure to charge parents who have tortured and killed adoptive children is all too common: witness the case in Florida of Begidu Morris, whose parents were not charged after starving, confining and beating him for years, ostensibly because the person who actually killed him could not be determined. As developmental psychologist Jean Mercer writes, plea bargains and the failure of investigators to follow up on the development of abusive parenting practices mean that we often don’t know whether abusive parents drew on outside influences or their own family histories or imaginations for the practices that led to a child’s injury or death.

Concern about controversial theories and methods of “Attachment Therapy” about twenty years ago prompted the formation of a task force of the American Professional Society on the Abuse of Children, the leading professional society of professionals who deal with child abuse and neglect. Its 2006 report, mentioned above, concluded that “attachment parenting techniques involving physical coercion, psychologically or physically enforced holding, physical restraint, physical domination, provoked catharsis, ventilation of rage, age regression, humiliation, withholding or forcing food or water intake, prolonged social isolation, or assuming exaggerated levels of control and domination over a child are contraindicated because of risk of harm and absence of proven benefit and should not be used.” The report cautioned child welfare systems not to tolerate any such techniques by foster or adoptive parents. It also stated that “[p]rognostications that certain children are destined to become psychopaths or predators should never be made based on early childhood behavior.” It also condemned “intervention models that portray young children in negative ways, including describing certain groups of young children as pervasively manipulative, cunning or deceitful.”

Some adults are simply not suited to raise challenging children. Yet, agencies desperate to get children adopted, especially children with special needs in foster care, have placed children with such parents despite red flags, or even returned them after abuse was uncovered. In an extreme case in 2016, the 12-year-old adopted daughter of Eugenio and Victoria Erquiaga ran away from home. Neighbors found her with her hands zip-tied and her feet bound. She reported that she was locked inside a small playhouse for long periods of time with no bathroom. The story became national news and it became known that the parents had sought help from a mental health counselor who oversaw a program called “Radical Healing,” which no longer exists. The state charged the parents with child abuse. However, they then offered to drop all of the charges and expunge their records if the Erquiagas agreed to take their daughter back into their home, which they did. The girl ended up in a group home after she turned 18.

Twenty years since the APSAC report, children continue to suffer and die because they have been diagnosed by “experts” or parents with RAD or “attachment disorder.” To prevent more damage to children, state governments must adopt policies to ensure that all adoptive parents are adequately vetted. Agencies must be prepared to screen out potential adoptive parents who lack the patience, self-control and emotional intelligence to raise challenging children, and those who might be susceptible to practitioners offering controversial methods involving harsh discipline and physical restraint to cope with behaviors stemming from previous trauma or deprivation. In 2012, a committee led by Washington’s child welfare agency and children’s ombudsman published a Severe Abuse of Adopted Children Committee Report, which made several recommendations for improving assessment of assessing prospective adoptive families. These included strengthening qualifications for individuals conducting adoption home studies and post-placement reports and enhancing minimum requirements for these home studies and reports.

Training and ongoing support must also be provided to those adoptive parents who are deemed capable of accepting the challenge of raising children with histories of trauma and deprivation. These parents must be prepared to understand the needs and possible behaviors of the children they adopt, given their backgrounds. They also must be educated about the existence of parenting practices and therapies which are not supported by research and potentially harmful to children. And finally, they need ongoing support. The need for a greater investment in post-adoption services has been publicized by authorities like the Donaldson Adoption Institute (now closed) in its major report, Keeping the Promise: The Critical Need for Post-Adoption Services to Enable Children and Families to Succeed. Even RAD parent advocacy organizations like Attach Families Inc. are also asking for ongoing support.

Parents caught confining, starving, or otherwise abusing their children through adherence to “attachment therapies” must receive a criminal trial. This is, not only to ensure that justice is done, but also to provide an understanding of the factors that allow such tragedies to occur. The failure to try cases of parents who were obviously responsible for the torture and death of a child is a national stain and must be addressed.

That vulnerable children who have already been traumatized or deprived in early childhood in have met suffering or even death in licensed foster or adoptive homes should be a source of shame to all Americans. It is time to put an end to the suffering of children who have suffered enough. These tragedies can and must be prevented.

Just before this article went to press, the author became aware of media reports about the arrest of the adoptive parents of a 15-year-old boy, who for the past ten years has been locked in his bedroom for most of the day with no access to food, water or a bathroom. The adoptive father is a former employee of the El Paso County, Texas sheriff’s office. So far there has been no information about the genesis of the situation and whether a diagnosis or behavioral problem was involved. But it seems that hardly a week goes by without news of an egregious case of abuse against and adopted child. There is no time to waste in taking action to prevent more such suffering and damage to children.

This post was edited on June 24, 2025 to add a reference to the Washington report on severe abuse of adopted children and its recommendations and again on June 26 and 27 to correct several small errors and typos.

A Reality Check on Family First: It Has Nothing to Do with the 50% Decline in Indiana’s Foster Care Caseloads

by Emily Putnam-Hornstein (University of North Carolina at Chapel Hill), Sarah Font (Pennsylvania State University), and Brett Drake (Washington University in St. Louis).

I am honored to publish this post by three of the leading academic researchers in child welfare. As often is the case in this blog, they are writing about the flawed use of data to support the user’s claims about a policy or program. In this essay, the authors discuss last year’s testimony by Indiana’s deputy director of child welfare services claiming success for the state’s family preservation program in reducing foster care caseloads without compromising child safety while also reducing racial disparities.

On May 22, 2024, the U.S. Senate Committee on Finance held a hearing titled “The Family First Prevention Services Act (FFPSA): Successes, Roadblocks, and Opportunities for Improvement.” The testimony was striking for its still-aspirational tone 6 years after the law passed and its sanitized depiction of why children enter foster care. As researchers, however, the statistics offered by Indiana’s deputy director of child welfare services, David Reed, caught our attention. Reed’stestimony indicated that FFPSA and associated investments in intensive family preservation services and concrete supports had produced: (1) a 50% decline in the state’s foster care caseload, alongside improved child safety; and (2) a two-thirds decrease in racial disparities among children entering foster care.

These claims are striking and beg the question: How?

On their very face, such dramatic numbers should invite skepticism. Despite continued efforts to move “upstream,” empirical studies of maltreatment prevention programs generally generate null or small effects. But one way for an agency to achieve a rapid reduction in foster care caseloads is to increase the threshold for intervening, leaving children in environments from which they would have been previously removed.

Below, we review data for Indiana and conclude that available evidence does not support the testimony offered.¹ This is problematic not only for Senate Committee Members, but also the field at large. Bold causal claims based on flawed interpretations of data too often lead policymakers, and the public, to conclude that there are easy fixes to complex problems.

Reducing Entries to Foster Care and Improving Child Safety

The ideal way to reduce foster care entries is by reducing the community incidence of child abuse and neglect. Other than a brief drop during the COVID-19 pandemic, and despite investments in voluntary programs such as Healthy Families Indiana, referrals to Indiana’s child maltreatment hotline were largely stable pre- and post-FFPSA implementation (i.e., 168,919 in 2017 vs. 172,077 in 2023). There is no evidence of a decrease in suspected maltreatment identified by community members.

Of note, data indicate that Indiana is now screening in a smaller percentage of referrals (75.0% in 2017 to 57.9% in 2023). Certainly, it is possible that Indiana was responding to allegations of maltreatment that were unwarranted. Indiana issued guidance in 2021 designed to change the state’s response to allegations of “educational neglect.” But if such changes led to the reduction, one would expect that as more “low-risk” referrals were screened out, children who were screened in would have higher risk and a greater share would be identified as victims requiring services.

Yet that is not what the data show. Among children who were screened in, the number of substantiated victims declined by roughly 30% between 2017 and 2023. This decline is particularly notable, given that during this same period, overdose deaths in Indiana were increasing and parental substance abuse is one of the most well-established risk factors for child maltreatment. It would appear that in addition to reducing the number of children who received a response, Indiana also increased its threshold for substantiating maltreatment. Importantly, changes in substantiation thresholds affect not only overall child victim counts, but also the federal measure of repeat maltreatment, which is the indicator of safety cited in Reed’s testimony. The easiest way to document improvements in child safety is to raise the bar for substantiation, thereby reducing both the initial victim count and the likelihood of identifying repeat incidents.

Short of successful efforts to reduce the incidence of maltreatment in the community at large, a second way an agency could theoretically—and safely—reduce the number of children in foster care is by expanding efforts to prevent placement by providing more families with effective services and resources. Yet once again, Indiana’s data show that fewer rather than more children reported for maltreatment have received in-home services. State data suggest a reduced number of children receiving in-home services in absolute numbers (Figures 1 and 2, Table 1) and no change in the proportion (Figure 3). Moreover, as depicted in all three figures and consistent with screening and substantiations, steep declines in in-home services and foster care caseloads began in 2017, before FFPSA was implemented.

A third possibility is that the services provided have become more effective, thus reducing the rate of children entering foster care. Yet the major program touted by Reed in his FFPSA testimony—an intensive family preservation program called Indiana Family Preservation Services—appears to have no effect on removal and a near-zero effect on repeat maltreatment.² Indeed, the program is described as having “0 favorable effects” by the federal clearinghouse for evidence-based programs. There is simply no way to attribute a 50% foster care reduction to Indiana’s prevention services.

Finally, because the number of children in foster care is a function of the number of children entering care relative to the number of children exiting care, an additional possibility is that Indiana found ways to transition children out of its foster care system faster or in greater numbers. However, foster care entries declined from 12,826 in 2017 to 6,212 in 2023. underscoring that the bulk of the 50% caseload reduction likely stemmed from fewer entries.

Decreasing Racial Disparities

Senate committee members also heard about data suggesting that Indiana’s Black–White disparity in foster care entries declined by two thirds. The statistics presented, however, were quite unusual. The typical approach—both in the health literature and as a longstanding practice in child welfare—is to measure disparities as a ratio of rates (known as relative risk). In the context of the testimony presented, this would have been presented as the Black foster care entry rate divided by the White foster care entry rate.

But this is not what was used.

Rather, Indiana’s numbers were presented as the subtracted difference: the Black foster care entry rate minus the White foster care entry rate. The problem with this approach is that it is very sensitive to base rates. Imagine that rates of removal were 10 per 1,000 Black children and 1 per 1,000 White children, then those rates decreased to rates of 1 per 1,000 for Black children and 0.1 per 1,000 for White children. In both cases, the relative risk of removal is 10 times higher for Black children than White children (a 0% change in disparity). But using Indiana’s subtraction-based measure, it would appear that the disparity declined from 9 to 0.9: a 90% reduction.

Using the conventional disparity ratio formula, the Black–White removal rate disparity declined only slightly in 2021–2022 compared with 2016–2017—a reduction of roughly 12%, not the “66.9% decrease” indicated in Reed’s testimony (see Table 2).

Summary

Available data do not support testimony that FFPSA implementation and Indiana’s Family Preservation Services program led to a 50% decline in foster care cases. Likewise, any reported improvements in child safety are likely an artifact of changed thresholds for classifying child maltreatment victims. We also believe that this testimony indicating dramatic reductions in racial disparities is quite overstated.

Of course, it is always possible that we have misunderstood the numbers Reed referenced—which is why we contacted him almost a year ago and shared our analysis. We received no response. If there is additional data that supports the testimony provided, we hope it will be made available. Until then, it is only reasonable to conclude that the striking claims made do not hold up to even modest scrutiny.

Note: On June 3, 2025, the IndyStar published an op-ed by Emily Putnam-Hornstein and Sarah Font summarizing the analysis in this post.

Notes

Regarding data published by Indiana’s Department of Child Services, we relied on publicly available information published as of June 2024 to align with what would have been available at the time this testimony was prepared. We also used data submitted by Indiana and found in the annual Child Maltreatment Reports. We focused on trends from 2017 (before FFPSA) through 2023 (the most recent year available).
↩︎
To elaborate, the intervention produced no “direct effect” on children entering foster care (i.e., no statistically significant reduction occurred in placements among families who were served). Published research has indicated that the intervention may have led to a small reduction in repeat maltreatment. To be generous, Indiana officials might argue that despite no direct effect on removals, the reduction in repeat maltreatment led to reduced removals over time. However, the estimated reduction in repeat maltreatment is only 4%, meaning that any indirect effects on removals cannot be more than this 4%. It is also worth noting that the declines in foster care caseloads began long before the program was implemented at any scale in Indiana. ↩︎

Figures and Tables

Child Welfare Monitor DC: 65 percent of investigations closed as “incomplete” in the second quarter of FY 2025

by Marie Cohen

In a post dated January 10, 2025, I reported that 40 percent of investigations conducted by the District of Columbia’s Child and Family Services Agency (CFSA) in Fiscal Year(FY) 2024, which ended on September 30 2024, were “incomplete.” But by annual rather than quarterly data, that post actually understated the magnitude of the problem, which has worsened in the first half of FY 2025. The percentage of investigations that were terminated with a finding of “incomplete” increased to 65 percent in the second quarter of FY2025. The number of substantiated investigations has increased, while foster care placements and in-home case openings have not kept up with the apparent need for services.

The number of reports to child abuse hotlines varies by season, with reports tending to drop off during the summer when schools are closed and then increase again when schools re-open, along with fluctuations during the school year. Thus, data for part of a year should be compared to the same period of the preceding year. As shown in the table below, the number of reports to the CFSA hotline increased by from 11,945 in the first half of FY 2024 to 12,342 in the first half of FY 2025. The number of reports accepted for investigation actually decreased from 2,197 to 1,973, mostly because the hotline was screening out more of them. Nevertheless, the number of investigations conducted increased from 1,774 to 2,089. Thus, there were more reports, fewer reports accepted, and more reports investigated in the first half of FY 2025 than in the same period of the previous year. The reasons for these changes are unknown.

Table 1: Data for First Half of 2025 Compared to First Half of 2024

	October-March 2024	October-March 2025
Hotline Calls (referrals)	11,945	12,342
Referrals Accepted for Investigation	2,197	1,973
Investigations	1,774	2,089
–Incomplete	456 (26%)	1,305 (62%)
–Unfounded	949 (54%)	327 (16%)
–Substantiated	267 (15%)	377 (18%)
–Inconclusive	94 (5%)	74 (4%)
In-Home Cases Opened	125	169
Children Placed in Foster Care	110	96

Source: CFSA Data Dashboard

An investigation can have several findings. “Substantiated” means that the investigator (with approval from their supervisor) has concluded that the allegation of maltreatment (or risk of maltreatment) is supported by the evidence. “Unfounded” means there is insufficient evidence to support the allegations. “Inconclusive” means there is some evidence that maltreatment occurred but not enough evidence to support it definitively. “Incomplete” is defined as “an investigation finding for referrals in which there were barriers to being able to complete every aspect of the investigation. This could include obtaining confirmation during the investigation that the family was a resident of another state outside D.C., the parent refusing the social worker access to the home to complete a home assessment, or inability to locate the family.” (For the complete definitions, see the Investigations Page on the CFSA Dashboard). It is important to note that “Incomplete” refers to a finding upon closure of an investigation. It is not refer to an investigation that is ongoing.

The total number of investigations increased from 11,945 in the first half of FY 2024 to 12,342 in the first half of Fiscal Year 2025, as Table 1 shows. And there were some big changes in the numbers of investigations that were incomplete, substantiated and inconclusive. The number of incomplete investigations skyrocketed from 456 to 1,305. The number of unfounded investigations dropped from 949 to 327. And the number of substantiated investigations increased from 267 to 377, which is a large increase of 41 percent. This reflects both an increased number of investigations conducted and an increase in the percentage substantiated from 15 percent to 18 percent.

Chart I shows how the percentage of investigations by disposition has changed over the past nine quarters. The percentage of investigations that was incomplete (see the orange segments in the chart below) began to rise in the first quarter of 2024, when it jumped to 20 percent from 13 percent in the previous quarter. It rose to 30 percent in the third quarter of 2024, 45 percent in the third quarter, and 54 percent in the fourth quarter, 60 percent in the first quarter of 2025, and 65 percent in the second quarter of the current fiscal year.

Source: CFSA Dashboard, Investigations of Abuse and Neglect

As the percentage of investigations that are incomplete has increased, the percentage that are unfounded (dark blue in the above chart) has decreased–from 57 percent in the first quarter of 2024 to 13 percent in the first quarter of 2025. That drop of 44 percentage points happened at the same time as the percentage of investigations that were incomplete rose from 21 percent to 65 percent–an increase of 43 percentage points. It appears that investigations that would formerly have been closed as unfounded are now being closed as incomplete. CFSA did not respond to a request for the reasons for this change. The percentage of investigations that are substantiated has changed little since the first quarter of FY 2024.

Once an investigation is substantiated, CFSA may open a case for in-home services, or less often for foster care. As shown in Table I above, 169 in-home cases (each involving one or more children) were opened in the first half of FY 2025, compared to 125 in the first half of FY 2024. And 96 children were placed in foster care in the first half of FY 2025 compared with 110 in the first quarter of FY 2024. Unfortunately these two sets of numbers are not comparable as each in-home case can involve more than one child. But with substantiated reports increasing by over 100, in-home cases increasing by only 44, and foster care removals decreasing, it appears that some of the families with substantiated reports in 2025 are not receiving any CFSA services at all, and that is concerning. Perhaps some of these families are being referred to the collaboratives for services, which are less intensive and delivered by staff with lower credentials. And it is possible that some of these investigations may culminate in an informal kinship placement, but that means no services are provided to the parents or the children.

Clearly the staffing crisis with which CFSA (along with other agencies around the country) is struggling is responsible for the increase in incomplete investigations, and perhaps for the reduced percentage of substantiated cases receiving services as well. At the oversight hearing on February 13, 2025, Interim Director Trice pointed out that the number of investigative social workers has dropped from 100 to below 40. It is no surprise that CFSA’s oversight responses documented that most investigative workers had caseloads above 15. the maximum caseload allowed by CFSA’s Four Pillars Performance Framework. Average caseloads for the 38 investigative workers in the first quarter of FY 2025 were 30 or higher for 10 workers and 20 or higher for a total of 20 workers.

Director Trice reported that the agency is making do by diverting workers from the In-Home units to Investigations, but that is not a good solution. Families with in-home cases are often deeply troubled, with long histories of chronic neglect. According to CFSA’s 2023 Child Fatality Report, two children died while their families had open in-home cases. We cannot afford to divert these critically needed workers. Moreover, it is possible that the diversion of in-home workers to investigations may be part of the reason that in-home case openings did not increase more given the increase in substantiations. With workers not available to handle these cases, the agency may be more reluctant to open them.

What can be done? Creative solutions are needed. It may be necessary to temporarily reduce licensing or degree requirements through a special waiver due to the staffing crisis. Former Director Robert Matthews spoke of obtaining permission from the Board of Social Work Examiners to use workers with Bachelor of Social Work degrees to help investigators (not carry cases), but this plan was not mentioned in this year’s oversight responses. The agency might consider recruiting federal workers who have lost their jobs for these positions. Recruiting retired police officers and military veterans is another idea that has potential. A partnership with local schools of social work, as Maryland and other states maintain, is long past due. Those who agree to take jobs and remain for a given amount of time should receive loan forgiveness and perhaps housing as well. In a housing-hungry citizen, this could be a game changer. CFSA needs to think outside the box to resolve the staffing crisis.

CFSA’s Dashboard data for the first half of FY 2025 raises more questions than it provides answers. The most striking trend is the continuing explosion in the percentage of investigations that were incomplete–which was 65 percent in the second quarter. Also concerning is the failure of in-home case openings and foster care placements to keep up with increased substantiations. Like many other child welfare agencies, CFSA has been devoting much time and attention to programs outside of its core functions, like the warmline and family success centers. In this time of budget stringency and looming recession, it is time for CFSA to focus on its ability to perform its most basic and important function–child protection.

The rejection of child protection

by Marie Cohen

Source: https://www.youtube.com/watch?v=BjwC0xh0afk

Proposed federal budget cuts to child welfare services might hurt New Jersey’s recent progress in child welfare, the Commissioner of New Jersey’s Department of Children and Families told state legislators last month. The anticipated reduction of more than $100 million would force the department to “revert to its most basic role — that of child protection — not prevention, not support or empowerment, just surveillance and foster care,” DCF Commissioner Christine Norbut-Beyer told members of the state Senate’s Budget Appropriations Committee. The relegation of child protection–or “surveillance and foster care”–to the “most basic” version of child welfare is telling. DCF’s Commissioner, like many other progressive child welfare administrators, no longer views child protection as the primary purpose of child welfare services.

For those who regularly read this blog, the devaluation of child protection and foster care by a high-level administrator over child welfare will not be a surprise. There has been a sea-change in child welfare over the past decade. The mainstream view of the purpose of child welfare has shifted from responding to child abuse and neglect to “upstream prevention.” And why not? Why wait until children are abused and neglected if we can prevent the maltreatment altogether?

There is no denying that ideally, it is better to prevent maltreatment than to respond to it. But the services that are discussed as prevention are mainly in the province of other agencies. In seeking to broaden child welfare services through the Family First Act, Congress added mental health, drug treatment, and parenting training. While the latter can be seen as a function of child welfare, drug treatment and mental health are separate systems. There has been increased emphasis on cash and housing and other antipoverty benefits as child maltreatment prevention; we have large programs to address these problems–much larger than the child welfare system. Even some of the “prevention services” that DCF and other state agencies have adopted, like “Family Success Centers,” provide a wide array of place-based services, most of which do not fall into the traditional orbit of child welfare and would be most appropriately funded jointly with other agencies.

If “prevention” could abolish the need for child protection, then there would be no need for child protection agencies. But we know that no amount of “prevention” (at least as envisioned by today’s child welfare establishment) will eliminate child abuse and neglect. We are often talking about patterns of mental illness, drug abuse, family violence, and poverty that have persisted over generations. And then there are families that are not poor or characterized by generations of dysfunction but where a parent’s mental illness or disordered personality makes them incapable of safely raising children. As Jedd Meddefield describes in his brilliant essay called A Watershed Perspective for Child Welfare, “As critical as it is to fully consider upstream factors, it would be wrong not to do all we can to help children who lack safe families today.

But the fact is that many of today’s child welfare leaders like Norbut-Beyer appear not to be interested in child protection and foster care. They often disparage the “reactive” role of child protective services in contrast to the “proactive” nature of prevention. Many agencies have reactive missions–police, firefighters, emergency rooms–and one could argue these are the most important services of all because they save lives. The analogy with the police is revealing. Police react to allegations of crime just as child welfare agencies react to allegations of child abuse and neglect. To prevent crime, we must not rely on the police, who are overburdened already and not trained and equipped to provide the services needed. Instead we must turn to a whole host of agencies dealing with education, public health, mental health, housing, income security and more–the same agencies that we must mobilize if we want to prevent child abuse and neglect. Nobody is saying that the police need to address the underlying causes of crime.

Norbert-Beyer’s use of the word “surveillance” as a synonym for child protection is telling indeed. She clearly doesn’t see CPS investigators as heroes who go out in sometimes dangerous and certainly uncomfortable circumstances to protect children–and maybe even to save them. It’s not surprising because we have all been told that saving children is not what child welfare is about.¹ And foster care? Norbert-Beyer boasts that New Jersey has the lowest rate of child removal in the country, and children who are removed more often than not go to relatives. She’s not very interested in the quality of care these vulnerable young people receive or in all the things her agency could do it improve it, like establishing foster care communities (like Together California) to house large sibling groups or investing in cutting-edge models of high-quality residential care.

When the person who is in charge of child protective services in a state that is acknowledged as a leader in the field calls it “surveillance,” and relegates it along with foster care to “basic” functions that hardly deserve mentioning, it’s hard to have faith that the crucial mission of child protection will be implemented with the passion it deserves. Norbert-Beyer’s comments illustrate the prevalent thinking that leads to the diversion of resources from crucially needed child protective services and foster care to “prevention services” that are and should be provided by other agencies.

See for example this statement from Casey Family Programs, which includes the words “We must continue to evolve from an approach that seeks to “rescue” children from their families to one that invests in supporting families before abuse and neglect occur.” One of the first messages I was given as a CPS trainee is that my job was not to save children.
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A Fatal Collision: The Opioid Epidemic and the Dismantling of Child Protection Services in Washington State

by Marie Cohen

“B.B.” was born in 2022 and died of fentanyl poisoning in March 2023. During the ten years before B.B.’s death, DCYF had received 30 reports on B.B.’s family (many before B.B. was born) for issues including use of heroin, marijuana and alcohol in the home; lack of supervision of the children; domestic violence; an unsafe caregiver living with the family; an unsafe and unclean living environment unsecured guns in the home “out-of-control” behaviors by B.B.’s older siblings at school, with the mother described as “out-of-it” and unresponsive to school concerns; concerns about the children’s hygiene; and the mother driving under the influence of marijuana. An in-home services case that had been open since January 2023 was closed days before B.B.’s death.

On August 24, 2024, the Washington Department of Children, Youth and Families (DCYF) proudly announced in a press statement that it had reduced the number of children in out-of-home care by nearly half since 2018. Specifically, the number of children in foster care had fallen from 9,171 in 2018 to 4,971 as of August 14, 2024. “Outcomes like this demonstrate our agency’s commitment to keeping families together and children and youth safe,” DCYF Secretary Ross Hunter said. “Although the number of reports we are receiving remain [sic] consistent, we are seeing fewer children and youth in out-of-home care as families are being referred to support services rather than having children removed from their homes. Indeed, “safely reduce the number of children and youth in out of home care by half” (without a baseline date from which this can be measured) is one of DCYF’s six strategic priorities. But treating the decline in foster care (the direct result of government actions) as a desirable outcome in itself can contribute to a disregard of actual child welfare outcomes like safety and permanency.

How did DCYF reduce foster care by nearly 50 percent?

How did DCYF manage to slash its foster care rolls so radically in such a short time? Without providing specifics, the press release cites DCYF’s implementation of the Family First Prevention Services Act (FFPSA) and its emphasis on “supporting and collaborating with families by providing access to services and programs.” A DCYF spokesperson told the Seattle Times that the department was using services to avoid removing children or to reunite families sooner, citing efforts to connect parents to substance use or mental health treatment programs, bring a social worker into the home to “problem solve,” or “offer practical items, like diapers, car seats and beds.”

Apparently not satisfied with the changes implemented by DCYF, the Washington legislature in 2021 passed the Keeping Families Together Act (KFTA, also known as HB 1227), which took effect on July 1, 2023. Among other provisions, KFTA increased the standard for the court to order removal of a child from the home, which previously required the agency to demonstrate that “reasonable grounds that the child’s “health safety or welfare will be seriously endangered if not taken into custody and that at least one of the grounds set forth demonstrates a risk of imminent harm to the child.” As amended by KFTA, the law now requires the agency to demonstrate “that removal is necessary to prevent imminent physical harm to the child due to child abuse or neglect.” The petition for removal is required to contain “a clear and specific statement as to the harm that will occur if the child remains in the care of the parent, guardian or custodian, and the facts that support the conclusion.” Moreover, the court must consider whether participation by the parents or guardians in “any prevention services” would eliminate the need for removal. If so, they must ask the parent whether they are willing to participate in such services and shall place the child with the parent if the parent agrees.

On a page dedicated to KFTA implementation, DCYF explains that it has implemented the law by adopting new policies and procedures to determine whether to remove a child and by training and supporting staff to implement the new procedures and determine whether there is an imminent risk of serious harm to the child. DCYF reports that internal reviews show that staff are “taking additional steps to prevent removal of a child and to support a safety plan for the family.”

Shortly before KFTA took effect, DCYF, along with the Department of Health, the Health Care Authority, and the Washington State Hospital Association issued new guidelines to birthing hospitals and mandatory reporters. These guidelines stated that infants born substance exposed, but for whom there are no other safety concerns, can receive “voluntary wrap-around services from a community organization” without being reported to CPS. These voluntary services are being provided through federally-mandated “Plans of Safe Care (POSC).” Healthcare providers identifying a substance-exposed infant are instructed to access an online portal where they are directed to call DCYF if safety concerns are identified and to complete a POSC referral if not.

DCYF has been issuing quarterly data updates to assess the impacts of the KFTA. According to the most recent (October 2024) update, the law is having the intended impact of further reducing removals to foster care. DCYF reports a 16 percent decrease in the number of children removed in the July through September quarter of 2024 compared to the same quarter of 2022, before passage of KFTA. However, comparing foster entries for all ages in July through September 2024 to those in the same quarter of the previous year, the data indicate that foster care entries actually increased! Will this be the beginning of the end of the foster care reductions? That remains to be seen.

A longer-term view raises questions about the difference KFTA made, compared to the previous and ongoing efforts by DCYF to reduce foster care placements. Entries into foster care in Washington have decreased annually from 2017 to 2024, as shown in the chart below. The rate of decrease remained about the same between 2019 and 2024, while KFTA was not implemented until July 2023. Perhaps more children would have entered care if not for KFTA, but there is no way to assess the impact of KFTA as compared with DCYF’s ongoing effort to reduce removals.

Source: DCYF, Child Welfare Agency Performance Dashboard, Children Entering Care in SFY, https://dcyf.wa.gov/practice/oiaa/agency-performance/reduce-out-of-home-care/cw-dashboard

The reduction in foster care placements was supposed to be accompanied (and made possible) by an increase in in-home services (which DCYF calls Family Voluntary Services or FVS), and DCYF reports that the number of cases receiving FVS increased by nine percent from 1,809 in SFY2023 to 1,994 in SFY2024. This increase in FVS cases cannot be compared to the 17-percent decrease in children placed in foster care over the same period, as the unit of analysis is different (families rather than children). But the key question is the nature and intensity of these services and whether they really kept the children safe.

The cost of foster care reductions

The purpose of foster care is to keep children safe when they cannot be protected at home. So the essential question is whether the reduction in foster care placements has occurred without any cost to children. Trends in child fatalities and “near fatalities”¹ due to child abuse or neglect can provide a clue. These deaths and serious injuries are the tip of the iceberg of abuse and neglect. For each child who dies or is seriously injured, there are many more that are living in fear, pain, or hunger, and incurring lifelong cognitive, emotional, and physical damage. There are troubling signs of an increase in child fatalities and near fatalities over the past several years. In its most recent quarterly update, DCYF reports on the number of “critical events” or child fatalities and near fatalities that met its criteria for receiving an “executive review.” These include the deaths of any minor that had been in DCYF custody or received services within a year of the death that were suspected to be caused by child abuse or neglect.² They also include near fatality cases in which the child has been in the care of or received services from DCYF within three months preceding the near fatality or was the subject of an investigation for possible abuse or neglect. DCYF reports that the number critical events it reviewed increased from 23 in 2019 to 51 in 2023 and projects that it will increase to 61 in 2024.³

Source: DCYF, Keeping Families Together Act Quarterly Date Update, October 2024, https://dcyf.wa.gov/sites/default/files/pdf/DataUpdate_HB1227_October2024.pdf

The increase in critical events reflects, in part, the growing opioid crisis in Washington, as well as decisions Washington has made regarding how it intervenes to protect children. Opioid related emergencies have “dramatically increased for the entire population (adults and children) in Washington,” and children have not been immune. Fentanyl is particularly dangerous to young children because it takes only a tiny amount to kill a baby or toddler, who can mistake the pills for candy or put straws or foil meant for smoking the drug in their mouths. The number of fatalities and near fatalities reviewed by DCYF that involved fentanyl climbed from four in 2019 to a projected 35 in 2024. Since 2018, Washington’s Office of the Family and Children’s Ombuds (has observed an annual increase in child fatalities and near fatalities involving accidental ingestions and overdoses. Fifty-seven (or 85 percent) of the 67 incidents examined in 2023 involved fentanyl. Over half of these incidents involved children under three years old and a shocking 14 out of the 85 infants were 12 months old or less. As Dee Wilson and Toni Sebastian point out, the limited mobility and motor skills of infants suggests that some of these infants may have been given a small amount of fentanyl as a means of sedation.

The Washington Legislature was concerned enough about the possibility that KFTA is contributing to an increase in child fatalities and near fatalities in the context of the fentanyl epidemic that it passed a new law (SB 6109) in 2024. The law provides that a court must give “great weight” to the “lethality of high-potency synthetic opioids.….in determining whether removal is necessary to prevent imminent physical harm to the child due to child abuse or neglect.” However, it appears that there is confusion about exactly what that means.

Has DCYF given up on protecting children?

“We know that supporting and collaborating with families by providing access to services and programs increases their number of protective factors, leading to better outcomes,” said DCYF Assistant Secretary Natalie Green. “Giving families the tools they need to thrive and safely parent means more children and youth remain safely at home.”

DCYF, Washington Reduces the Number of Children in Out-Of-Home Care by Nearly Half, August 14, 2024.

But the work of DCYF’s own analysts, in their quarterly KFTA updates, raises doubts about whether DCYF is adequately performing its child protection function. These updates acknowledge that the agency is not removing as many children with a high risk of future encounters with child welfare (in other words, those who have a high risk of being harmed). And they also report that the department has seen “an increasing percentage of moderately high to high risk cases being re-referred to CPS within 90 days of the risk assessment. DCYF also reports that the overlap between KFTA and Plan of Safe Care (POSC) is resulting in fewer screened-in intakes involving substance-exposed newborns because these infants are now being referred to voluntary services under POSC.

There has been a chorus of voices alleging that DCYF is abdicating its child protection responsibilities. One foster parent told the Seattle Times that “she and other foster parents are finding children who now come into their care are in worse shape than they used to be, with more serious mental health conditions or greater exposure to lethal drugs like fentanyl.” She contends they’ve been left too long in unsafe conditions because of the heightened legal standard for removal. In The Erosion of Child Protection in Washington State, Toni Sebastian and Dee Wilson have cited the weakness of the management of Family Voluntary Services, which is often employed as an alternative to foster care.

A survey of executive reviews of 2023 and 2024 child maltreatment child fatalities with DCYF involvement within a year provided examples of problems with screening, investigations, and case management, including the following:

Hotline issues. Reviews documented multiple intakes screened out on the same family even when the family had been the subject of multiple calls. The reviews also suggest that too many cases may be assigned to the Family Assessment Response (FAR) pathway, an alternative to a traditional investigation designed for lower-risk cases. In FAR cases, a social worker assesses the family and refers it to voluntary services. There is no finding about whether maltreatment has occurred and no child removal unless the case is transferred to the investigative track.
Premature closure of FAR cases. Reviewers noted instances in which FAR cases were closed after parents failed to cooperate, without caseworkers considering a transfer to the investigative track or before determining that the parent had followed through with services.
Assessment failures: Reviewers noted multiple failures to adequately assess parents for domestic violence, mental health, and substance abuse; failures to contact collaterals (relatives and friends) and instead relying on parental self-reports; lack of recognition of chronic maltreatment; ignoring evidence of past problems if not included in the current allegation; and failing to anticipate future behavior based on historical patterns.⁴
Inadequate understanding of substance abuse: Reviewers noted the failure to conduct a full assessment of substance abuse including history, behavioral observations, and collateral contacts; disregarding the unique danger to children posed by fentanyl; downplaying the significance of marijuana use, particularly as an indicator of relapse from harder drugs; and disregarding alcohol abuse because it is legal.
Failure to obtain information from treatment and service providers. The failure to communicate with service providers about clients’ participation in services like drug treatment and relying on clients’ self-reports was noted by more than one review team. Sometimes the providers refused to cooperate. Staff told the team reviewing one case about a substance abuse treatment provider that routinely refuses to cooperate, even when parents sign release forms, and routinely tells clients not to cooperate with DCYF.
Lack of subject matter expertise. Reviewers pointed to the lack of deep knowledge about domestic violence, substance use disorder, and mental health among staff doing investigations, assessments, and case management and the need to provide access to subject matter experts when needed.
Failure to remove a child despite safety threats. The team reviewing the case of a four-year-old who died after ingesting fentanyl reported that there were at least two different times where an active safety threat was present that would have justified filing a petition in court to place the child in foster care. However, the staff believed, based on past experience, that the court would have denied the petition and therefore did not file.
Delayed Reunifications: “P.L,.” a toddler allegedly beaten to death by his mother, was in foster care for over three years but his mother’s rights were never terminated. He was on a trial return to his mother for just over five months when he was found dead with bruises and burns all over his body.

Staff shortages and high turnover were mentioned as contributing to the observed deficiencies in case practice in almost every fatality review. In B.B.’s case, the reviewers noted that the office had been functioning with a 50 percent vacancy rate for the last several years, stating that such a vacancy rate leads to high turnover, high caseloads, caseworkers with little experience, and supervisors forced to carry cases rather than support their caseworkers. Even caseloads that comply with state standards may be too high. The standard of 20 families per caseworker in FVS was noted to be unmanageable by one review panel, which noted that FVS cases are often discussed as high risk cases and require multiple contacts per month with family members, services providers, and safety plan participants. As Dee Wilson and Toni Sebastian put it, “[b]etting young endangered children’s lives on in-home safety plans developed and implemented by inexperienced and overwhelmed caseworkers is reckless, ill-advised public policy.”

Conclusions and Recommendations

Treating the decline in foster care as a desirable outcome in itself, as Washington and other states have done, is both disingenuous and dangerous. Any government can slash the foster care rolls reducing or ending child removals, as many “child welfare abolitionists” recommend. The central purpose of child welfare services, including foster care, is to protect children from child abuse and neglect. A reduction in foster care placements that results in the failure to protect children is no kind of success.

DCYF told King5 that “the increase in child fatalities and near fatalities in Washington is not being driven by the change in removal standards under House Bill 1227 or the reduction in the number of children in foster care. It is being driven by the increased availability of a highly addictive and hazardous drug and a lack of substance use disorder treatment in our communities.” But whether the agency’s policy or the drug epidemic is more at fault is not the right question. It is DCYF’s job to protect children given the circumstances that exist, including the drug epidemic and the lack of sufficient treatment, keeping in mind that treatment often does not work the first, second, third or subsequent times.

What can be done? DCYF needs to address the workforce crisis, which will probably require increasing pay and improving working conditions, or even possibly relaxing requirements for employment as a caseworker in investigations, assessment, and FVS. DCYF should consider policy and practice changes such as reducing the FVS caseload cap from 20 cases per worker; Instituting a chronic neglect unit, with expert caseworkers and even lower caseloads, for chronic cases; finding a way to limit the use of FAR to cases that are truly low-risk; and promoting the use of dependency petitions for court supervision when children remain in the home, as suggested by two fatality review committees.⁵ DCYF should request and the legislature should fund a variety of ancillary services for families, starting with therapeutic childcare for all preschool aged children with FVS cases as well as those who have been reunited with their parents. Such childcare would give parents a break and parenting support, keep children safe for a large part of the day, and ensure another set of eyes on the child, among other benefits. Also needed are more residential drug treatment centers where parents can live with their children.

Finally, more transparency is needed so that legislators, advocates and the public have access to the findings of DCYF’s executive review teams. Washington deserves credit for sharing its executive child fatality reviews. But there is no reason that the DCYF should not share its near-fatality reviews as well. We know something about how DCYF failed B.B. and the other children who died. But the public needs access to the reviews of those children who narrowly escaped death as well as those who did not. It is only through such transparency that the public can see the actual impact of all the self-congratulatory proclamations about “safely reducing the number of children in out-of-home care.”

Notes

A “near fatality” is defined by state law as “an act that, as certified by a physician, places the child in serious or critical condition.”
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DCYF relies on the Office of the Family and Children’s Ombuds (OFCO) to determine whether the fatality appears to have been caused by abuse or neglect, therefore requiring DCYF to conduct a review.
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Data collected by OFCO are more confusing. OFCO reviews all fatalities and near fatalities in which the child’s family was involved in Washington’s child welfare system within 12 months of the fatality. There number of near-fatalities reviewed by OCFO increased annually from 21 in 2018 to 70 in 2023, according to its most recent annual report on Child Fatalities and Near Fatalities in Washington State. But fatalities reviewed by OFCO did not show the same pattern. They reached a peak of 87 in 2018 and fell sharply in 2019, then rose yearly until they reached 85 in 2022 and then dropped to 79 in 2023. Nevertheless, adding fatalities and near fatalities together shows an alarming increase in critical incidents from 108 in 2018 to 149 in 2023.
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For example, in the case of “R.W.,” a child who died at age four after ingesting fentanyl, an investigation was closed because the children were staying with relatives, despite the mother’s history of repeatedly removing the children from relatives with whom she had left them. A month later the child was found dead at a motel in the custody of the parents.
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See https://dcyf.wa.gov/sites/default/files/pdf/reports/mk-cfr-final-redacted.pdf and https://dcyf.wa.gov/sites/default/files/pdf/reports/ecfr-os-24.pdf ↩︎