Tag: substance abuse

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

  1. 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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  2. 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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  3. 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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  4. 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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  5. 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 ↩︎

We are not here to save children: abuse and neglect deaths after contact with child welfare services in the District of Columbia, 2019-2021

To my readers: This blog summarizes a report that is the culmination of nine months of work. It is part of my advocacy for children in the District of Columbia, which I share in my blog, Child Welfare Monitor DC. But I think this post and the underlying report will be of interest to child advocates, policymakers and researchers around the country because the findings and issues discussed are widely applicable.

“We are not here to save children.” That is what I was told on the first day of my training as a child protective services worker at the District of Columbia’s Child and Family Services Agency (CFSA). And indeed, the District is on the cutting edge of the current movement in child welfare around the country that considers child protective services as a “family policing system” that unnecessarily harasses and separates families, especially families of color. The problem with this perspective is that some families do not provide a safe environment for children to grow and develop. In some of these families, children die. That is what happened to the 16 children whose cases are discussed in a new report, which is summarized in this post. And indeed, analysis of the limited information provided suggests that CFSA did not take advantage of the opportunities it had to protect children even after long histories of CFSA involvement in their families. As a result, three children were beaten to death, three more were poisoned by opioids, and others died of burns, a car accident, and unknown causes when the deaths might have been preventable if the agency had been more protective.

When a child dies of abuse or neglect after that child’s family has been on the radar of the agency designed to protect children, it is important for the public to know whether and how this death could have been avoided. The essential question is whether the agency could have prevented the death by doing something differently. Did staff miss any red flags, and therefore fail to take action when necessary? If the death was preventable, what factors must be remedied in order to prevent such failures in the future? It is not enough for the agency itself to have access to this information, or to have an internal team review it. Agencies can fail to learn from their mistakes when they are blinded by ideology, self-interest or just inertia.

For those reasons, federal law requires every state to have a law or program that includes “provisions which allow for public disclosure of the findings or information about the case of child abuse or neglect which has resulted in a child fatality or near fatality.” In compliance with this requirement, DC Code requires the Mayor or the Director of CFSA, upon written request or on their own initiative, to provide findings and information related to “[t]he death of a child where the Chief Medical Examiner cannot rule out child abuse, neglect, or maltreatment as contributing to the cause of death.” In March 2023, we requested such findings and information for all the fatalities that met the criteria and were reviewed by CFSA’s internal fatality review team between 2019 and 2021. It took more than six months of meetings and emails to receive the information that is presented in this report. We agreed to restrict our request to cases reviewed in 2019, 2020 and 2021 and to withdraw our request for information on near-fatalities, which CFSA only began tracking in October, 2022.

Not surprisingly, CFSA interpreted the disclosure requirements in a way that restricted the information provided as much as possible. If a medical examiner did not rule the manner of death to be an abuse or neglect homicide or “undetermined,” no information was provided. Therefore, the agency did not release any information on cases where the manner of death was labeled as accidental, even if it found a parent responsible for the death or removed the children. The “accidental” deaths for which information was not provided included one child who died after he was left in a baby swing for two hours, which most ordinary people would consider to be neglect. The death of seven-week-old Kyon Jones, whose mother told police that she threw his body in a dumpster after she rolled over him while high on PCP, was not included because his body was never found and therefore it did not meet the criteria for release of the information–even though CFSA removed the surviving children from their mother.*

In addition to omitting some cases in which neglect or abuse played a role, CFSA heavily redacted the information it did provide, with many pages and large portions of others blacked out. CFSA refused to provide the names of the children, parents and caregivers, providing a rather convoluted interpretation of DC Code, which clearly requires the release of this information. (See the full report for more information about their reasoning). In three cases, the child’s identity was clear from media coverage of the case, and we used the child’s name. A major source of redactions was the exclusion of “personal or private information unrelated to the child fatality.” It appears that CFSA’s legal team interpreted this term much more broadly than a social worker or researcher would, because they redacted almost all information about parents’ history of criminal activity, substance abuse, mental illness, and domestic violence–which are obviously relevant to many of the fatalities we are discussing.

On investigations, it is unfortunate that DC Code requires that the agency release only ”a description of the conduct of the most recent investigation or assessment” rather than all investigations regarding the family in question. It appears that the agency interpreted “the most recent investigation” as the fatality investigation itself rather than the most recent investigation before the fatality, but the law ought to require a description of all previous investigations. The agency also disregarded language that requires it to provide “the basis for any finding of either abuse or neglect.”

For most cases, we received very little information aside from a list of the previous referrals (reports to the CPS hotline) including only the date of the report, the allegation category and the disposition; an account of in-home and foster care case activities for the families that had such cases; and an account of the investigation of the fatality itself. The information about the parents was heavily redacted, and almost the entire history of agency involvement was blacked out in most cases. Despite the limited information provided, the redacted summaries included some new information, some of which was startling and disturbing. The report is based on the 16 case summaries provided by CFSA, occasionally supplemented with information from the agency’s annual fatality reports, which are available to the public. These cases affected 15 families, as one family had two fatalities in one year. Unless otherwise noted, the information is based on the case summaries. The full report, from which this blog is excerpted, contains summaries of each case.

Cause and Manner of Death

CFSA classifies child deaths by cause and manner. “Cause of death” is the specific disease or injury that led to the death. Manner of death refers to the circumstances that caused the death, and falls into five categories: natural, accidental, suicide, homicide, and undetermined. Of the 16 cases for which information was provided by CFSA, three (19 percent) were abuse homicides, six (37 percent) were neglect homicides, and seven (44 percent) were undetermined in manner. The latter were the cases for which CFSA provided information because the Medical Examiner was unable to rule out child abuse or neglect homicide as the manner of death.

The most common causes of death were blunt-force trauma and opioid poisoning, each claiming the lives of three children, as shown in figure below. The remaining children died from a variety of causes, including drowning, asphyxia, thermal and scald injuries, injuries from a car accident, and unknown causes.

Abuse deaths: Blunt Force Trauma

Three of the children died of blunt force trauma–one of the two most common causes of death in the sample. The murders of two of these children – Makenzie Anderson and Gabriel Eason – – became known to the horrified public through press coverage of their deaths in February and April of 2020. Each of them died from head trauma inflicted by a parent or stepparent. Makenzie suffered from multiple contusions to the face and head, skull fractures, and other injuries, and her mother pleaded guilty to manslaughter, receiving a ten-year prison term with seven years suspended on the condition that she obtain mental health treatment and have no unsupervised contact with children. Gabriel’s autopsy found abrasions and contusions to the head, face and torso; contusions to the heart and thymus gland; liver and kidney laceration; new and healing fractured ribs; and a brain hematoma. His stepfather was sentenced to 12 years and eight months in prison and his mother, who did not seek medical help for Gabriel or his critically-injured three-year-old brother, was sentenced to four years of probation and three years of supervised release.

But there was a third homicide by blunt force trauma. A three-year-old girl died of trauma to the abdomen in the home of an aunt where she was placed by CFSA after being removed from her drug-addicted mother. Her injuries included contusions to the forehead and abdomen, a lacerated liver, and blood in the abdominal cavity. No charges were filed against either the aunt or her boyfriend, and the case received almost no public attention.

Neglect deaths: Opioid Poisoning and other causes

Three children (a three-year-old girl, a three-year-old boy, and a three-month-old girl) died of synthetic opioid toxicity, with fentanyl implicated in all three deaths. (One of the children had also ingested a controlled substance called eutylone.) There is no information about how the children might have ingested the drugs, but all lived with parents who were known or alleged to abuse substances. These deaths never became known to the public, which is not surprising since it appears that none of the parents were arrested or charged.

A 17-month-old boy died of “complications of thermal and scald injuries,” and his mother told the investigator that she had no idea how it happened or how he ended up face-down in the bathtub several hours later. A seven-year-old died of injuries from a car accident. His mother was a long-time substance abuser and was arrested for Driving Under the Influence (DUI) in the accident. She was driving from Florida to Washington and her children were not sitting in car seats or belted in. A five-month-old boy died of asphyxia by drowning after being left alone in the bathtub with a one-year-old sibling while their mother searched for her car keys.

Deaths for Which the Manner was Undetermined

Two deaths has known causes but the manner – whether abuse or neglect or something else – was not determined. A twelve-year-old girl with asthma died of an untreated bacterial infection and pneumonia but also had enough bruising from two separate beatings in the previous two days to support a CFSA substantiation of the mother for physical abuse. It is unclear why this was not considered a medical neglect homicide. A ten-month-old girl died of asphyxia but the manner of death was undetermined. Her mother had left her in the care of her father and returned to find her unresponsive.

The cause as well as the manner of death was unknown or undetermined in five cases. These included an 18-month-old boy with a subdural hematoma, which could have been caused by abuse or a fall, an 11-month-old girl whose mother reported leaving her unsupervised on her stomach with a bottle in her mouth for about 40 minutes, a nine-month-old boy put to bed with a bottle and found face-down on a pillow; a two-month-old girl who died while sleeping with her mother, and a three-month-old girl found unresponsive by her parents one morning. Unsafe sleep practices may have contributed to some of these deaths, but other unsafe sleep fatalities were categorized as accidents, for which case summaries were not provided.

Demographics

A quarter of the children who died were younger than six months old and half of them were one-year-old or younger. Another quarter were two or three. This is not surprising as young children are more vulnerable and similar results are found nationally. But older children were not invulnerable to abuse or neglect, including the seven-year-old who died in a car accident and the 12-year-old who died of an untreated bacterial infection and pneumonia.

Fifteen of the decedents were African American and one was classified as “African-biracial.” According to the latest data from Kids Count, 54 percent of children in the District of Columbia are Black. So Black children were overrepresented among the children who died of maltreatment or possible maltreatment. The overrepresentation of Black children among children who died points to Black children’s particular need for protection. And it suggests that current emphasis in the District and around the country on reducing the involvement of Black families in child welfare may cause more suffering and more deaths among Black children.  

The prevalence of large families among those that lost a child due to abuse or neglect is striking. More than two thirds of the mothers of children who died by maltreatment had four or more children. The average mother in the group had 4.6 children, often with more than one father.

Histories of System Involvement

All the families had been the subject of at least one report to the CFSA hotline before the fatality, or else they would not be included in this report. But many of the families that lost a child had experienced a large number of reports prior to the fatality. Among the 16 fatalities included in this report, only six occurred in families that were the subject of five reports or fewer in the last five years. Five occurred in families that had between six and 10 reports, three occurred in families with 10 to 15 reports, and one family had 24 reports. Three of the families had actually experienced a previous child fatality–a shocking statistic considering the rarity of child fatalities overall.

The families of the two children – Makenzie Anderson and Gabriel Eason – whose abuse homicides shocked the District of Columbia in February and April 2020 were both known to CFSA before the deaths, and the last report to the hotline came five months before the fatalities of both children. Makenzie Anderson’s family was reported to the hotline eight times within five years of her death. The last report alleged exposure to unsafe living conditions, inadequate supervision, and substance abuse by a parent, caregiver, or guardian. All those allegations were unfounded (not confirmed) by CFSA. Gabriel Eason’s family was the subject of 17 prior calls to the hotline since 2012, including 12 in the five years preceding Gabriel’s death. The most recent report was for unexplained physical injury in October 2019 and was also unfounded by CFSA.

Substance abuse by the parent or caregiver was the most frequent allegation CFSA received regarding the families in the five years before the deaths, with 30 substance abuse allegations collectively accumulated by the families of the 16 dead children during that period. Another  eight reports concerned positive toxicity of a newborn, a reflection of parental substance abuse. Substance abuse by the parents was observed or alleged in the families of all but four of the victims included in this report. Inadequate supervision was the second most common allegation, with 25 allegations concerning the 15 families. Almost as common was educational neglect, referring to children with excessive school absences, with 24 allegations received in the five years preceding the fatality. Ten of the 15 families had at least one report for educational neglect before the child’s death. Another major theme was exposure to domestic violence, with 17 allegations received by the families. Domestic violence was mentioned in nine of the 16 case histories as the subject of an allegation or in notes from social workers or police.

Most of these families could be described as “chronically neglectful.” According to the Child Welfare Information Gateway, “Chronic child neglect occurs when a caregiver repeatedly fails to meet a child’s basic physical, developmental, and/or emotional needs. Chronic neglect can have long-term, negative consequences for child health and well-being.” Working with chronically neglectful families is especially difficult and requires special training and skills, which many CFSA social workers may lack. Perhaps that is one reason why they struggled so hard to engage some of these families. Four of the children died while an in-home case was open. Three out of four of the in-home case narratives from CFSA portray caregivers who evaded offers of help from CFSA and other providers and refused to cooperate with efforts to monitor conditions in their homes.

System Failures

The information received suggests several areas where failures in policy and practice by CFSA and other agencies may have allowed these deaths to happen. These areas include:

  • Screened out and unsubstantiated reports: Research points to the difficulty of determining correctly whether a child has been maltreated, as well as the absence of significant differences in subsequent outcomes between children with a substantiated allegation of maltreatment and those with an unfounded allegation. Without information on how hotline and investigation decisions were made, we cannot assess the agency’s performance in these areas. But the fact that most previous reports for families with a subsequent death were screened out or unfounded is concerning.
  • Flawed management of in-home cases: Four of the deaths reviewed here happened while an in-home case was open for the family. In three of these cases, workers struggled to complete face-to-face visits with the families because parents evaded these visits. Social workers and supervisors could have filed a petition to involve the court, an option known as “community papering.” But they did not exercise this option–or they started too late, as in the case of the child who died after a meeting was finally scheduled to discuss community papering the case. The meeting was cancelled after the agency received word of the child’s death.
  • Too many chances: The mother of the seven-year-old killed in the 2020 car accident had been given numerous chances to recover from drug addiction and had relapsed many times over 18 years of involvement with CSFA. The family of the 17-month-old who died of complications of thermal and scald injuries had 24 referrals to CFSA between 2016 and 2021. Three in-home cases were opened and closed, but the children were not removed until the little boy died.
  • A fragmented health care system: In its findings on Gabriel Eason’s death, CFSA pointed out that Gabriel was taken to different medical providers for his various injuries. Because they use different information systems, the providers could not see records of the earlier injuries.

The reaction of CFSA and the criminal justice system after the fatalities obviously did not contribute to the fatalities themselves but may illustrate a pattern that contributes to future deaths. Specifically, CFSA’s tendency to place siblings informally after fatalities and the police and US District Attorney’s failure to charge parents raise concerns.

  • Informal placements after fatalities: CFSA, and child welfare agencies around the country, have been criticized for relying on informal placements with family members, rather than formally removing the children, placing them with the relatives, and opening a case to monitor their safety and well-being. In at least four of the 16 cases reviewed here, CFSA did not officially remove the siblings of the children who died but instead relied on informal placements with fathers or other relatives to keep them safe. Nothing was done to assure that the children were not returned to the home from which they had been removed as soon as the investigations closed, or to verify that the parents or caregivers had rectified the conditions leading to the child deaths.
  • Failures by the criminal justice system: The failure to bring charges against some of the parents and caregivers described here is quite concerning, particularly in the case of the three-year-old who died of blunt-force trauma and the infant and two three-year-olds who died of opioid poisoning. There has been considerable criticism of the US Attorney’s office in the District (which handles adult criminal prosecutions) for its low rate of opting to charge people for crimes. We do not know if the problem is the Metropolitan Police Department’s failure to bring the cases to the US Attorney or the latter’s failure to pursue them.

Recommendations

Without seeing the full case studies that were available to CFSA’s internal review committee, we cannot make detailed recommendations about how to avoid child maltreatment fatalities for children known to CFSA. The minimal recommendations that CFSA’s internal review team made show the need for the City Council, advocates and the public to have access to these complete case studies: in its 2021 report the agency made no recommendations other than those dealing with the fatality review process! Therefore, our first recommendation is to the City Council, urging it to require that CFSA release comprehensive case histories on all proven or suspected child maltreatment fatalities. Our next blog post will discuss the legislative changes that are needed.

The lack of information on how screening and investigation decisions in particular were made precludes specific recommendations. Perhaps a new audit of the hotline is in order. Some changes to hotline screening policy might be advisable, especially around educational neglect. School absences should be investigated regardless of the age of the child (requiring a change in the law) and their academic performance. And perhaps investigative workers could benefit from better training in forensic interviewing techniques that might help them better evaluate parents’ and childrens’ statements for veracity and perceive more subtle signs of abuse or neglect.

The case narratives make clear that in-home social workers struggled to complete home visits to the families of the children who later died. The agency must change its policy to encourage “community papering,” making court involvement routine after a certain number of missed visits or other instances of noncooperation. CFSA might also want to consider strengthening its in-home practice, perhaps by reinstating the Chronic Neglect Units, which were eliminated barely a year after they were implemented. These units would employ specially-trained social workers with lower caseloads and longer time periods to work with families.

Despite the current ideology favoring family preservation and reunification at all costs, the agency must also recognize that sometimes it must give up on a parent and find a safe, permanent alternative for the children. Giving parents multiple chances with successive children over many years belies the true purpose of child welfare services – to protect children.

Not all needed changes fall in CFSA’s bailiwick. Reforms in the criminal justice system are also necessary to ensure that parents who killed one child cannot harm more children. Couples who refuse to cooperate with prosecutors, and parents who expose children to opioids due to their own abuse or drug dealing must also be charged. Other jurisdictions do it, and the District must do it as well.

DC Health and medical providers also have a crucial role to play in making children safer. Encouraging the adoption of a comprehensive medical information platform across the region to prevent families from using different doctors to hide abuse and neglect would be a welcome step. A campaign by DC Health to educate young women on how an early pregnancy, especially when followed quickly by others, compromises their future and that of their children, is a crucial necessity. It must be accompanied by improved access to long-acting reversible contraceptive methods.

In summary, even with the very minimal information we received, some conclusions emerge. CFSA’s extreme deference to parents and guardians emerges clearly through the redactions in these narratives. This is in direct contrast to the picture that is being painted by the foundations, advocacy groups and public agencies dominating the child welfare conversation. Their accounts portray interventionist child welfare agencies that remove children rather than giving their families the help they need and want.  We are seeing the opposite here: families who evade offers of help from the agency and providers and refuse to cooperate with efforts to monitor conditions in the home. The goal of such parents often appears to be to avoid surveillance by outsiders rather than to improve their ability to care for their children. And CFSA workers often seem unwilling or unable to intervene in a way that will protect these children.

‘The tragic deaths of children whose families are known to CFSA are the tip of a much larger iceberg. For every child who dies of abuse or neglect, an unknown number of others are living in fear or pain from abuse, suffering chronic neglect that will cause lifelong intellectual an emotional damage, or lacking the loving attention necessary for optimal mental, emotional and physical development. Sadly, it is only the children who die whose cases can be used to learn lessons to prevent similar tragedies in the future. This information must be public, so that the public can push for a system that protects all children who are not receiving the parental care they need to survive and thrive.

*The case, which received media coverage, was included and easily identifiable in

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

Image: consumerhealthday.com

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The tragedy of Harmony Montgomery: Why we must strengthen the federal permanency timeline, not repeal it

Source: NBC News

I write with heartbreak and rage about a child who was removed from her drug-abusing mother at the age of two months, placed with a loving family that wanted to adopt her, ripped from this family twice more to return to her mother in a fruitless attempt at reunification, and finally placed after over four years with a father and stepmother she hardly knew without any vetting to ensure their capacity to care for her. The case of Harmony Montgomery has made national news–but only because she is now missing after that last disastrous placement. The Massachusetts Office of the Child Advocate (OCA) has released its report on the tragic case of Harmony Montgomery. The OCA report reveals the extent of the disruption to which Massachusetts subjected this young child, but unfortunately it does not draw the needed conclusions about policy and practice to ensure timely permanency for children in foster care. No child should be subject to the treatment Harmony received in the child welfare system, let alone the abuse and neglect she certainly endured after leaving it, but policy shifts being considered now would make it more likely that other children will suffer similar fates.

Harmony’s child protection case began almost as soon as she was born in June 2014 to Crystal Sorey and Adam Montgomery, who were not married and were no longer together at the time of her birth. Montgomery was incarcerated at the time of Harmony’s birth for “a shooting that involved illicit substances,” according to the report. Harmony was diagnosed at birth with a visual disability and was blind in one eye. Due to her disability, she received early intervention services until age three and then special education services from her local school district until moving to New Hampshire.

Shortly after Harmony’s birth, the Haverhill Area Office of the Massachusetts Department of Children and Families (DCF) received three reports alleging that Sorey was using illegal substances and neglecting Harmony. DCF confirmed the allegation of neglect and opened a case to provide services to the family without removing Harmony. But two more reports were made in August 2014, and DCF concluded that Sorey continued to struggle with substance abuse, putting Harmony at risk. Two-month-old Harmony was removed and placed in foster care. (A chronology at the end of this commentary provides a summary of the case history).

In January 2015, seven-month-old Harmony was returned to the care of her mother. But the following April, at the age of 10 months, Harmony was removed from Sorey again due to neglect associated with her renewed substance abuse. In July 2015, Harmony’s permanency plan was changed from reunification to adoption. In September 2015 Adam Montgomery was released from prison and moved to New Hampshire, but he did not contact DCF for a year. In February 2017, the DCF team changed Harmony’s goal back to reunification with her mother. That March, Harmony was returned to her mother for the second time. She was almost three years old and had been in foster care for a total of 28 months, including approximately 23 consecutive months since her second removal from her mother.

In January 2018, at the age of three-and-a-half, Harmony was once again removed from Sorey due to the latter’s neglect associated with renewed substance abuse, and she was placed in the same foster home where she had lived during both of her previous stays in care. In August 2018, when Harmony was four years old and after eleven months without seeing her, her father resumed supervised visits. According to OCA, in December 2018 the team began working toward “reunification”1,2 with Montgomery instead of Sorey and requested that New Hampshire conduct a home study through the Interstate Compact on the Placement of Children (ICPC).3 Nevertheless, Harmony’s goal was changed back to adoption in that same month.4

A hearing was held in February 2019 to consider both parents’ requests for immediate custody of Harmony, but Sorey was unable to attend because she was at a hearing about another of her children. New Hampshire had not yet acted on the home study request and the DCF attorney objected to the placement of Harmony with Montgomery in the absence of any information about the family. The attorneys for Montgomery, Sorey and Harmony5 all supported giving custody to Montgomery, and the judge awarded him full custody on the grounds that as a “fit parent” as defined by law, Montgomery’s right to parent his child could not be infringed by the ICPC. A week later, Montgomery brought Harmony to New Hampshire to join his household made up of his wife, Kayla Montgomery, and their two children, who were both under five years old. DCF’s involvement with Harmony was over and there was to be no agency or court oversight of the newly reunified family as there would be if Montgomery lived in Massachusetts.

A report from the Governor of New Hampshire provides a glimpse into Harmony’s troubled life after arriving in New Hampshire. On July 19, 2019, an anonymous call was made to the Department of Children, Youth and Families (DCYF) hotline stating that five-year-old Harmony was seen a week before with a black eye that Adam Montgomery admitted causing. In a visit conducted on August 7, 2019, a social worker found signs of a healing black eye, but Harmony and her father said the mark was caused by “horseplay” with a sibling. The allegation was ruled “unfounded,” but Harmony was deemed to be at high risk for future maltreatment.

On January 8, 2020, another call was made to the hotline regarding another child or children in the home. When the investigating social worker asked about Harmony, Adam Montgomery said that she had been back in Massachusetts with her mother since about Thanksgiving of 2019. Kayla Montgomery later confirmed the story, stating that Montgomery told her he was taking Harmony to Sorey on the day after Thanksgiving in 2019. On January 13 and March 16, additional calls were received regarding the household, and Montgomery again stated that Harmony was with her mother and he had not seen her in a year. In September 2021, a person known to Sorey called the DCYF hotline to say that Sorey had not seen Harmony since 2019 and had not been able to reach Montgomery to schedule a visit. DCYF learned that Harmony had never been registered for public school in Manchester.

On December 31, 2021, the Manchester police located Montgomery, but he did not have Harmony in his care and gave “contradictory and unconvincing explanations” of her whereabouts. An exhaustive police search for Harmony began, making national headlines. On January 4, 2022, Adam Montgomery was arrested on charges of second degree assault and endangering the welfare of a child. On January 6, 2022, Manchester police arrested Kayla Montgomery on a charge of welfare fraud for obtaining over $1,500 in Food Stamp benefits for Harmony after she was no longer in their household. The search for Harmony continues.

The case history shared by OCA shows that DCF, the agency charged with protecting children, instead subjected Harmony to the trauma of repeated moves during her crucial infancy and early childhood, including ripping her from a loving home where she had resided for almost two years. After being removed from her mother at two months, returned to her at seven months, removed again at ten months, and then remaining another 23 months in foster care, Harmony deserved to stay with the only family who had provided a safe and stable home for her. This family had even facilitated Harmony’s contact with family members other than her parents, who visited her in the foster home and told OCA they appreciated the care Harmony received there. But DCF sent her back to her mother, only to remove her again 10 months later. There is no better evidence of the damage done by this ill-advised action than the following quote from the OCA report:

Although placed in the same foster home after each removal, each time Harmony returned she struggled with more challenging behavior and increasing feelings of insecurity. While the foster parents provided exceptional care and were committed to Harmony, with each subsequent placement the scope and depth of her behavioral and emotional needs grew. The foster family felt that after Harmony had been removed from Ms. Sorey’s care for the last time, they were no longer able to provide for her increased needs. Several months into her third placement, Harmony’s foster parents determined that it was in Harmony’s best interest to be placed in a therapeutic foster home where she would receive the specialized and dedicated attention she needed. It is evident in the record this was an extraordinarily difficult decision for the foster parents as they consistently expressed their love for Harmony. 

Office of the Child Advocate, A Multi System Investigation Regarding Harmony Montgomery, May 2022,

The harm to children of such repeated disruptions has been well documented, as Sarah Font and Lindsey Palmer explain. Humans have a fundamental need to know where and to whom they belong. Foster care sets up a “loyalty conflict” that is familiar to every social worker who has worked in the field, and the harmful impacts of repeated movement between the two families cannot be overstated. Secondly, children need predictability, and research consistently shows that unpredictable environments harm children’s development even more than harmful environments. Every member of Harmony’s case management team should have been aware of the harm that would be caused by the repeated disruptions in her living situation, the on-and-off visitation with her father and the continued uncertainty about her future.

In subjecting Harmony to over four years of uncertainty and disruption, DCF and the court also appear to have flouted both law and policy guidelines. Massachusetts General Laws Chapter 119 Section 26 requires DCF to file a petition in court to “dispense with parental consent to adoption, custody, guardianship or other disposition” if the child has been in foster care in the custody of the state for 15 of the immediately preceding 22 months. This law is based on the Adoption and Safe Families Act of 1997 (ASFA), which requires states to observe this “15/22 rule” in order to receive Federal foster care funds. Federal and Massachusetts law provide three exceptions to the rule: if the child is being cared for by a relative, if there there is a “compelling reason” that filing such a petition would not be in the best interests of the child, and if the family has not been provided with the services that the department has deemed necessary for the child’s safe return home. DCF policy mirrors the provisions of the law by requiring that DCF review all cases of children who have been in placement 15 of the past 22 months and initiate a petition for TPR (termination of parental rights) unless one of the three exceptions described above apply.6 But there is no mention in the OCA report that such a review took place.

DCF policy includes other requirements to ensure the 15/22 rule is followed, mostly through the use of Permanency Planning Conferences (PPC’s). PPC’s are “the Department’s primary internal planning vehicle for reviewing the clinical and legal issues related to permanency decision-making.” PPC’s are required under certain circumstances, including within the first 9 months following the date of placement. At this conference, DCF policy states that:

For most families, based upon a well-reasoned prognosis about the probability of the child’s returning home given the family’s documented capacity to benefit from reunification services, the Department will decide whether to initiate a TPR action at the PPC held within 9 months after the child enters placement. In some of those cases, the Department will decide that one of the exceptions [described above] applies but will schedule another PPC for the 13th month after placement to determine whether initiating TPR is appropriate given the facts as they then exist. 

Harmony’s first PPC noted by OCA took place in July 2015, about 11 months after her placement, in apparent violation of the nine-month deadline. The result of that conference was a change of Harmony’s permanency goal to adoption, which presumably entailed “initiating a TPR action” as described by the policy. If for some reason that did not happen, another PPC should have been scheduled for the 13th month after placement. OCA does not cite another PPC until the one that took place in February 2017, which was about two-and-a-half years after placement and actually changed her goal back to reunification. So it is appears that the DCF Area Office was out of compliance with agency policy requiring it to either initiate the TPR or schedule another PPC for the 13th month after placement.

There are more safeguards in DCF policy to ensure timely permanency for children in foster care, but these did not save Harmony either. According to policy, “Any decision not to initiate [a TPR] when a child has been in placement for 15 of the previous 22 months must be the result of a Permanency Planning Conference and approved by the Director of Areas/designee.” Harmony had spent 15 of the past 22 months in care around February 2016. But there is no mention that such a PPC ever took place or that such approval was obtained. As noted above, the next PPC mentioned by OCA occurred after Harmony had been in care for two-and-a-half years.

The OCA report does not mention the 15/22 rule, even though it provides a link to the policy in which the rule is repeatedly mentioned. Presumably, the rule was not mentioned in the case records that OCA reviewed, and this may be typical. When the US Government Accountability Office (GAO) studied early state implementation of AFSA, they found that in the nine states that provided data on the use of the rule in FY 2000, “the number of children exempted from the provision greatly exceeded the number of children to whom it was applied.” This is not surprising because the exceptions can be easily interpreted so broadly as to apply to many or most cases. There is no update on the GAO survey, but available evidence suggests that application of this provision is not widespread. During child welfare monitoring visits conducted by the federal government between 2015 and 2018, practices related to timely termination of parental rights were rated as a strength in only seven of the 50 states plus the District of Columbia and were rated as an “area needing improvement” in the other 44 jurisdictions, according to a federal study. Foster parents from around the country who completed a caregiver survey disseminated by the advocacy group iFoster reported that failure to observe the AFSA timeline resulted in stalled permanency for foster youth. Certainly, the intent of the law is not being fulfilled.

Whether social workers around the country are assessing cases to determine whether the exceptions apply or simply ignoring the 15/22 rule is not clear. In Harmony’s case, no discussion is noted in the OCA report of whether she was exempt from the rule. It certainly appears that her mother received more than enough services before and after her relapses; she was reported to have received both substance abuse treatment and mental health therapy. It might have been possible to argue that Harmony’s father needed more time because he was released from prison when she had already spent ten months in foster care, but since he did not contact DCF for a year after being released, such an argument seems weak.

Respect for the 15/22 rule is if anything decreasing because of the current ideological climate in child welfare that prioritizes the rights of parents over the needs of children. Indeed, there is a new movement to repeal ASFA altogether on the grounds that it is unfair to parents. Parents’ rights advocates argue that states are not providing parents with the services they need, and it is not fair to apply the timeline when parents have not been offered the services they need in time to meet the 15-month deadline. This is a valid point. Enforcement of the timeline needs to be accompanied by prompt assessment and appropriate services for both parents. But the burden should be on the parent to make use of the services offered. An agency should not be required to beg, persuade or repeatedly urge parent to pursue visits and services. if a parent falls out of touch and cannot be reached, the child should not be penalized by delays in permanency.

Parent advocates also argue that it often takes longer than 15 months to correct deep-seated problems. In particular, it is well-known that most substance abusers (like Harmony’s mother) relapse more than once before shaking their addiction. But young children simply don’t have the time to wait for such a parent to be cured without incurring irreversible developmental damage.

In this time when parents’ rights advocates have all but monopolized the current conversation, few seem to be speaking for the rights of children. But in its recent report, Voice of the Foster Care Community, the advocacy group iFoster concluded that greater efforts are needed to support parents before their children are removed, and to help them regain their children quickly once placed in foster care. But if that quick reunification does not happen, caregivers, workers and advocates surveyed stated the need to prioritize the needs of the child over the needs of the parent to avoid delays in termination of parental rights. As one Pennsylvania foster parent put it,

….if parents are unable to work their case plan, then the 15 of 22 months rule must be followed so kids don’t languish in care for years. This is a way-too-common occurrence. Parents are given many chances to work their case plan while their children languish in care, being passed back and forth between families and living in instability.”

Advocates for children in foster care should be asking Congress to strengthen the 15/22 rule, not repeal it. Perhaps there could be different timelines for children of different ages, as has been suggested by Cassie Statuto Bevan, who helped draft ASFA. Children who come into care as teens may not want their bonds with their parents to be disrupted. But the youngest children need to achieve permanency even faster than what is prescribed by ASFA. Infants and young children placed in foster care should not spend their most crucial developmental period in limbo awaiting a parent’s eventual cure.

OCA’s central finding was that “Harmony’s individual needs, wellbeing, and safety were not prioritized or considered on an equal footing with the assertion of her parents’ rights to care for her in any aspect of the decision making by any state entity.” This finding certainly encompasses DCF’s failure to seek timely permanency for Harmony. But OCA’s specific findings and recommendations regarding time to permanency are not as well-developed as they could have been. OCA has one finding regarding permanency as it relates to DCF, but it is quite weak, stating that “the delay in achieving permanency for Harmony impacted her well-being.” OCA goes on to explain that the delay caused trauma for Harmony, which in turn resulted in the disruption of her pre-adoptive placement. In reality, If Harmony had been adopted soon after she had spent 15 months in foster care, she would have found safety and stability in a loving home. The failure to pursue adoption within 15 months of Harmony’s placement in foster care did not just damage her emotionally; it resulted in her disappearance and possible death.

Strangely, OCA made no recommendation to DCF regarding reducing the time to it takes to achieve permanency for children in foster care. There was no mention of the 15/22 rule and the failure to enforce it or follow the procedures designed to ensure its observance. It is only in the section on the legal process that OCA stated (but did not label as a “Recommendation”) that “For children whose parents will not accept services or to whom children cannot be safely returned to their home within the first two years of their removal, DCF should expeditiously move toward another permanency plan.”7

OCA had a number of other findings and recommendations. The Office rightly highlighted DCF’s exclusive focus on Sorey as a potential caregiver for Harmony throughout most of the life of the case, resulting in the failure to complete an assessment of Montgomery and his wife and develop an appropriate service plan for them. This was particularly important in light of Harmony’s disabilities, which required that a caregiver be able to provide adequate care. Clearly, DCF should have done more to engage Montgomery during the first 15 months of the case. If he and his wife had been assessed and provided with an appropriate service plan, perhaps they would have been ruled out as as caregivers long before the fateful hearing. This failure to engage Montgomery resulted in OCA’s only recommendation directed at DCF, which was that “DCF should develop a comprehensive plan to ensure both parents are adequately assessed and receive the support and access to services needed so that their child(ren) can achieve permanency.”

OCA devoted the bulk of its findings and recommendations to the legal process, and specifically to the many problems with the February 2019 hearing that resulted in Harmony’s placement with her father. Clearly, the placement of Harmony with her father in the absence of any assessment of him or his wife or any examination of their home was the immediate cause of the the tragic outcome. But that hearing, conducted over four years from Harmony’s entry into foster care, should have never taken place. OCA’s findings regarding the process are certainly worth consideration, but there should have been much more attention given to the need to ensure permanency for children much earlier.

Despite the flaws in its findings and recommendations, the OCA report is invaluable for its revelation of the problems in social work and legal practice that led to the disappearance and probable murder of Harmony Montgomery. Harmony’s story should be a cautionary tale for anyone supporting, or considering the value of, proposals to repeal the Adoption and Safe Families Act, or at least the requirement that states initiate a termination of parental rights after a child has been in foster care for 15 out of the last 22 months. Rather than eliminated, that provision needs to be strengthened by reducing the scope of the exemptions that make it toothless and perhaps by adjusting it according to the age of the child. No other child should be subjected–by a system designed to protect children– to the suffering that Harmony underwent while in the system and after leaving it.

Timeline of Harmony’s case based on the OCA report

DateMonths in Foster CareEvent/Activity
June 2014Harmony is born. DCF receives three reports of substance abuse and neglect by her mother. A case is opened
August 2014DCF receives two more reports. Harmony is removed.
January 20155Harmony meets her father for the first time, in prison, and is returned to her mother
April 2015Harmony is removed from her mother again due to substance abuse
July 20158Harmony meets her father for the second time, in prison; Harmony’s permanency plan changed to adoption
September 201510Harmony’s father is released from prison and moves to New Hampshire
February 201615Harmony has spent 15 months in foster care out of the last 22 months
September 201622Adam Montgomery contacts DCF for the first time since his release from prison a year earlier
October 201623Harmony meets Adam Montgomery for the third time.
February 201727Harmony’s permanency plan is changed back to reunification. After visiting with Harmony once a month for five months, Adam Montgomery stops responding to DCF’s efforts to schedule further supervised visits.
March 201728Harmony is returned to her mother for the third time. Over the next few months she has unsupervised weekend visits with her father.
September 201728Adam Montgomery contacts DCF after a seven-month lapse, and has one supervised visit with Harmony.
January 201828Harmony is removed from her mother for the third time due to substance abuse.
August 201835Adam Montgomery resumes supervised visits after a lapse of 11 months.
December 201839Harmony’s goal is changed back to adoption.
February 201941A Juvenile Court Judge awards custody of Harmony to Adam Montgomery. One week later, Montgomery takes her to New Hampshire and DCF involvement ends.
September 2021A person known to Crystal Sorey contacts the New Hampshire child ause hotline to report that she has not seen Harmony since April 2019.
December 2021Manchester police announce Harmony’s disappearance and their search for her. She has not yet been found.
Notes to Table: For purposes of calculating months in foster care, All dates assumed to be the first of the month

This commentary was updated on June 8, 2022 to incorporate the results of a federal study entitled Freeing Children for Adoption within the Adoption and Safe Families Act Timeline.

Notes

1. Child welfare law and policy refer to “reunification” with a parent even if the child has never lived with that parent.

2. According to OCA, “the Foster Care Review panel kept a permanency goal of reunification for Harmony but for the first time changed their focus of reuniting Harmony with Ms. Sorey to placing her with Mr. Montgomery.” But OCA explained in an earlier text box, foster care review panels make recommendations, not decisions. Therefore this statement appears to be inaccurate.

3. The ICPC is an agreement between the states that allows a state considering placement of a child in another state to request a home study of the family with whom the child will be placed.

4. This goal change raises many questions which are not addressed in the OCA report. It is not clear why the goal was changed so soon after the team reportedly agreed to continue the goal of reunification with a new focus on Adam Montgomery. This discrepancy could be related to OCA’s confusing statement that a Foster Care Review panel made the decision to continue the goal of reunification but shift the focus to Adam Montgomery. Perhaps that panel only recommended this new focus. According to OCA, the panel also recommended convening a Permanency Planning Conference (PPC), which is the body empowered to change the goal and which indeed did change the goal to adoption.

5. According to OCA, Harmony’s attorney supported custody for Montgomery because she was bound to advocate for the expressed wishes of the four-and-a-half-year old, not her best interests.

6. While federal law and DCF policy speak of initiating a TPR petition, Massachusetts law prescribes “dispensing with parental consent,” as described in the previous note. Some jurisdictions, in order to avoid creating “legal orphans” through a TPR, take this approach of dispensing with parental consent to an adoption or guardianship. The practical result would be the same, ending parental rights.

7. In its list of recommendations for the courts, OCA strangely includes a recommendation for the agency, stating that “DCF should review and determine the length of time from permanent custody to a final adjudication of adoption, guardianship or return to parent for a child in order to ensure that the case achieves a safe and expedient resolution.” In addition to being misplaced, this is a very weak statement of what needs to be done.

Opioid Crisis: New federal report shows child welfare impact

opioid crisis
Image: Youth Today

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

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

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

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

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

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