A Fatal Collision: The Opioid Epidemic and the Dismantling of Child Protection Services in Washington State

by Marie Cohen

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

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

How did DCYF reduce foster care by nearly 50 percent?

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

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

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

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

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

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

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

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

The cost of foster care reductions

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

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

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

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

Has DCYF given up on protecting children?

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

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

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

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

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

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

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

Conclusions and Recommendations

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

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

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

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

Notes

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

Reducing Congregate Care Placements: not so easy, not always good for kids

Most child welfare experts and policymakers at all levels seem to agree that our nation needs to reduce the use of group homes and other non-family placements (often called “congregate care”) for foster youth. Yet signs from around the country suggest that the drive to move foster youth quickly out of congregate care is facing some obstacles–and may be resulting in more damage to foster youth.

The child welfare establishment–including the federal Administration for Children and Families, agency leaders at the state and local level, prominent think-tanks, scholars, and foundations–is in agreement that “every kid needs a family.” These leaders acknowledge that some foster youth need a group placement to address behavioral issues that may prevent success in foster care, but such youth should be moved out of the group setting as soon as these issues are addressed.

In 2015, the California Legislature took the lead in implementing this new focus by enacting the Continuum Care Reform (CCR), which required all foster youth to be placed in families except those requiring intensive supervision and treatment for a temporary period. Such youth must be placed in Short-Term Residential Treatment Programs (SRTP’s), which must be accredited and meet rigorous standards.

Congress followed in 2018 by adopting the Family First Prevention Services Act (FFPSA, (Title VII of the Bipartisan Budget Act of 2018), which imposed similar changes on the federal level, with a temporary congregate therapeutic option called Quality Residential Treatment Programs (QRTP’s) instead of SRTP’s. To receive reimbursement for a QRTP placement, a “qualified professional” must determines within 30 days of the placement that the child needs to be placed in such a setting rather than a relative or foster family home. The decision must be approved by a court within 60 days and reviewed at subsequent hearings (usually every three to six months). Moreover, a child cannot remain in a QRTP for more than 12 consecutive months (or 6 months for a child under 13) without written approval from the head of the agency.

California, where CCR took effect in 2017, has been widely viewed as a harbinger of what might happen after FFPSA takes effect next October. But Golden State policymakers have been “shocked shocked” to learn that children have not been moving out of congregate care settings as fast as anticipated. The reform was expected to pay for itself due to savings from moving children from pricier congregate care settings to cheaper family homes. However, this has not happened. The Office of the Legislative Analyst has found higher than projected state spending for one main reason: instead of moving from group homes into family foster homes, children are moving into “STRTPS,” the new congregate option offered by CCR.

Although the Legislative Analyst did not speculate about reasons for the slow transition, one does not have to look far for clues. A report from San Joaquin County indicates that the county is unable to find homes for the teens with the greatest needs, who remain in group homes. Efforts to recruit foster parents willing to take on these challenging youths have so far failed.

Another jurisdiction that started eliminating group homes long before the Family First Act was New York City. The city’s Administration for Children and Families (ACF) is reeling from an alarming report about the intake center where children are taken after being removed from their families. Workers described an atmosphere of chaos, violence, weapons in plain sight, feces-smeared walls, overcrowding and “a dangerous mix of babies and young children with special needs living alongside troubled teens and even adults straight out of jail.” This intake center was was meant as a place for children to wait for a few hours until a placement could be arranged. But staff report young people with behavioral problems or medical needs living in the shelter for months because foster families cannot be found for them. One disabled teenager lived there for a year. The president of the union representing ACF workers blamed these long stays on management decisions made years ago to close group homes, based on the belief that family homes were better for children. Unfortunately, the agency has not been able to find families to take in many children with behavioral problems, mental disabilities, and histories of trauma and abuse.

In Georgia, there are more children in foster care than ever before and not enough homes for them. Wanting to address this problem, long-time foster and adoptive parents John and Kelly DeGarmo started the Never Too Late (NTL) foster home for boys. But when they applied for a license to accept youth from the foster care system, they found it was too late. Due to the Family First Act, Georgia was not going to license any new residential group homes. State administrators instead asked NTL to serve as a Transitional Living Program, (TLP), for youth ages 16-21 as the boys transition from foster care to independent living. These programs are also needed, but one can’t help but wonder about Georgia’s plan for meeting the needs of the many children who cannot find foster homes and could have thrived in atmosphere of loving care at Never Too Late.

In my own jurisdiction, the District of Columbia, the Child and Family Services Agency is proud of the low percentage of foster youth that are in group homes, attributing it to “the agency’s success in supporting children and youth with higher needs in traditional foster homes.” Yet, advocates are declaring a foster care placement crisis. There is a lack of appropriate foster homes for many children, particularly older teens and those with behavioral problems. As a result, according to the Children’s Law Center, foster youth experience multiple placement disruptions, with devastating consequences to their mental health. CLC also blames the placement crisis for delayed removals of children from unsafe homes, youths remaining in poorly matched placement, and youths leaving their official placements for unofficial community settings. Yet, there is no voice advocating for more therapeutic group homes, the most appropriate setting for many such youths.

The state of Washington has about 100 youths in out-of-state facilities due to a lack of in-state beds. A scathing report recently described abusive restraint practices and other problems at an Iowa facility where Washington was sending some of its foster youth. In a letter to the legislature, Ross Hunter, director of the Department of Children Youth and Families, acknowledged that the agency has an insufficient array of therapeutic group homes and residential facilities for children with severe behavioral problems that make it impossible to maintain them in foster homes. Among the consequences of this shortage, Hunter cites the following: (1) children being repeatedly placed in homes that can’t handle them, resulting in damage to the children and loss of foster parents to the system; (2) over 2000 office and hotel stays for children last year; and (3) use of expensive one-night placements “at extraordinary cost and detriment to the child,” in addition to the out-of-state placements. Hunter proposes to bring all of Washington’s children home and eliminate office and hotel stays by expanding the number of therapeutic group home beds, as well as increasing the quality of existing congregate placements.

Oregon is also reeling from reports of abusive out-of-state placements. After being sued for housing foster kids in hotels, it stopped that practice but sent more high-needs children out of state. Reports of a nine-year-old being injected with Benadryl to control her behavior have led to a public outcry that over 80 Oregon foster kids are in out-of-state facilities, many of them troubled for-profits, because the state lacks residential programs to provide the treatment they need.

Washington and Oregon are among the states with the highest proportions of foster children placed in families, according to federal data cited in a recent report from the Annie E. Casey Foundation that drew extensive press coverage. The report provided state-by-state numbers, generating media coverage (but not in Washington and Oregon) that praised those jurisdictions with lower group home percentages and chastising those with higher rates. But nowhere did the authors mention the fact that eliminating too many congregate placements may lead to foster youth staying in offices, hotels, emergency placements, and abusive out-of-state facilities.

We are not taking this opportunity to argue that many group homes (especially those using the house parent model) are more family-like than many foster homes–which we have argued elsewhere. Even if we accept the premise that no young person should be in a group home one minute longer than necessary once ready to function well in a foster home, there are several problems with implementing this premise in the real world.

We don’t have a diagnostic instrument capable of determining in advance who “needs” a congregate placement and who does not. As of now, it is a subjective determination, making it difficult to project a specific decline in congregate care placement. There is concern that the FFA may make it too difficult for children to gain access to the therapeutic placements they need.
Whether a child is “ready” for family life depends upon the families available. Some very gifted, well trained and dedicated foster parents can nurture high-needs youth who would not thrive in the average foster home. But when such a parent is not available, a child might be better off in a high-quality therapeutic group placement.
Often a family simply cannot be found that is willing to accept a teen with troubling behaviors or a history of residential treatment or delinquency. The most ridiculous sentence in FFPSA is this one: “A shortage or lack of foster family homes shall not be an acceptable reason for determining that the needs of the child cannot be met in a foster family home. ” What should be done then with a child that has no place to go?
A year (or six months for a preteen) may not be enough time for a troubled child to become “family-ready.”. Many children and teens in foster care have suffered years of trauma in their homes, and perhaps multiple placements in foster care. The time required is more likely measured in years than in months.
It may be difficult for smaller, high quality group homes to meet the criteria for QRTP’s.

There is no doubt that many congregate care facilities are of poor quality–witness the horrors suffered by Washington and Oregon youths who were shipped out of state. The framers of FFPSA were right in wanting to ensure that these facilities entrusted with our most fragile youth are up to the task, although they adopted a blunt instrument for doing this. Let’s hope that other states follow Washington’s plan and respond to FFPSA by ensuring that therapeutic group homes are adequate in quality and quantity rather than eliminating them.