Relisha Rudd: new podcast misses crucial questions about her disappearance

WAMU’s new podcast series, Through the Cracks, has just completed its first season, which focused on the disappearance of eight-year-old Relisha Rudd from the DC General family shelter in 2014. The podcast presents a compelling picture of how multiple generations of untreated trauma, combined with an inadequate social safety net, makes such tragedies possible. However, the podcast falls short in its effort to document the systemic failures leading to Relisha’s disappearance. Specifically, it draws an incomplete picture of the failure of DC’s Child and Family Services Agency (CFSA) to keep Relisha safe despite an open case on the family.

In Through the Cracks, host Jonquelyn Hill retells the story of Relisha Rudd’s 2014 disappearance, which many readers will remember well. By the time Relisha was declared missing, it had been 18 days since she was last seen at Payne Elementary School or the DC General shelter where her family resided, according to the podcast. After Relisha had accumulated 14 absences from school,[1] Payne’s social worker, LaBoné Workman, suspected anything was wrong with the excuse notes Relisha’s mother had been submitting, which were signed by a Doctor Tatum. When Workman arrived at the shelter to investigate, he quickly learned that no such Dr. Tatum existed. Instead there was a janitor with the same name. And not just an ordinary janitor. Investigators learned that Tatum had a criminal record that should have prevented his being hired to work at the shelter. Moreover, he had befriended many children and teens and given them gifts. Some parents had turned down the gifts and terminated the relationships, but not so Relisha’s mother, Shameka Young. The social worker’s visit touched off a citywide hunt for Relisha. On March 20, Kahlil Tatum’s wife was found dead of a gunshot wound to the head. On April 1, Kahlil Tatum was found dead from a self-inflicted gunshot wound. Despite extensive searching by police and volunteers, Relisha Rudd has never been found.

Through the Cracks explains how multiple systems set up to protect Relisha failed. Her mother and stepfather themselves survived instability, abuse, and trauma, which left them with issues that impaired their ability to parent her. Tenant protections failed to prevent the eviction of this family from their home. An abandoned hospital that treated homeless families like prison inmates became the family’s home. A predator named Tatum was hired at this shelter despite his criminal record.

But when it comes to the agency tasked with responding to abuse and neglect in the District of Columbia, the podcast missed the mark. In the penultimate episode, Hill finally mentioned that Relisha’s family was known to CFSA when she disappeared. In fact, she reported that Relisha’s mother Shameka Young was reported three times to the child abuse hotline–in 2007, 2010, and 2013. Hill noted that in none of those cases did the agency elect to remove any of her children, and she devoted some time to discussing that fact. She spoke with a CFSA official, and with Judith Sandalow of the Children’s Law Center, about the policies surrounding the decision whether or not to remove a child. Based on these conversations, Hill finally concluded that “…. because Relisha wasn’t taken away, I can infer that social workers didn’t find enough evidence of abuse or neglect, or I can infer that they believed they could solve whatever the issues were by offering solutions like affordable child care or parenting classes. And if that’s the case, I’m not sure what kind of follow-up there would have been.”

However, the Washington Post‘s extensive coverage of the case has already eliminated the need for some inferences. The Post reported that the abuse or neglect complaints mentioned above were all “sustained” or “verified” by the agency and provided further details. In July 2007, social workers reported finding “inadequate food and supervision for Relisha and her newborn brother and that Relisha had an injury that could have been caused by abuse.” In April 2010, workers investigating a complaint that Shameka failed to bring her son for a follow-up medical appointment after surgery found a home full of cigarette butts and trash and small children being allowed to bathe themselves “without supervision.” In the investigation of the 2013 call, a social worker noted that one of the children had been thrown to the ground, cutting open his lip, and slapped in the face. Young was stated to be “verbally abusive on a regular basis and would leave [the children] alone often.” The Post also explained that these three were the only reports to be sustained by the agency, but others may have been received as well.

Hill and her team could also have consulted CFSA about their options when abuse or neglect is found to have occurred. When CFSA finds abuse or neglect, it can take one of three actions: remove the child or children if they are deemed in imminent danger, open a case for in-home services if the risks are high for future harm to the child, or refer the family to a community-based agency for help if the children are not deemed at high risk. In the case of the 2013 call about Relisha’s family, we know what they did. They opened a case for in-home services.

Several pieces of evidence attest to the existence of an open case on Relisha’s family. Unnamed “sources” told NBC News that “D.C. Child and Family Services Agency (CFSA) had an active case working when Relisha went missing, along with three prior cases dating back to 2007.” (A reporter can actually be heard reporting this story in the background of the podcast.) The same information was implied by CFSA Director Brenda Donald in a Letter to the Editor stating that “the fact that CFSA does not remove a child as a result of a substantiated abuse or neglect allegation does not mean we do not provide any services.” The City’s heavily redacted report on Relisha Rudd also makes clear to anyone who knows child welfare that her family had an open case.[2]

The fact that a case was opened means that Hill reached some faulty conclusions. First, as explained above, the opening of a case means that the investigator did find abuse or neglect, contrary to Hill’s suggesting that was only a possibility. Second and more important, if Hill was indeed “not sure what kind of follow-up there would have been,” she only had to ask CFSA or the Children’s Law Center. A case for in-home services means there would be follow-up, including twice-monthly visits to make sure the children were all right and to assess the family’s compliance with their case plan. If things were not going well, the social worker had the option of removing the children or seeking court involvement to hold the parents accountable for changing their ways within a given period of time to avoid removal of the children.

Perhaps Hill and her co-producers fell victim to the common misconception that the primary function of child welfare agencies is removing children and placing them in foster care. In fact, as of December 31, 2014, CFSA was serving 2,812 D.C. children, of whom 62 percent were being served in their homes and only 38 percent in foster care. “In-home services” were the main vehicle for serving abused and neglected children in the District of Columbia. (The in-home percentage was slightly higher as of December 2020–about 65 percent). Then, as now, families with in-home services had a case plan outlining the steps they had to take (like receiving therapy or drug treatment) before the case could be closed. The social worker assigned to their case would have been required to visit them at least twice per month to monitor compliance with the case plan and to check on the safety of the children. That social worker would have been required to see each child on each of these visits.

The timeline provided by Through the Cracks indicates that Relisha was last seen on March 1, 2014 at a Days Inn with Tatum on video. (Police told the Post that she had been with him since February 26.) The school social worker’s visit to the shelter on March 19 touched off the citywide search for Relisha. If they had realized the significance of the in-home case, the producers of Through the Cracks might have wondered if the CFSA social worker visited the family late in February or between March 1 and March 18. If so, they might have wanted to know whether the social worker simply accepted Shameka’s claim that Relisha was safe in another location without seeing her, and if the social worker truthfully indicated that fact in her notes. Moreover, the Washington Post reported that Payne Elementary called the CFSA hotline on March 13, after she accumulated ten unexcused absences. A “person familiar with the case” told the Post that CFSA did not treat this as a high-priority call because Relisha’s brothers continued to show up at school. But this report should have been forwarded to the family’s in-home social worker and at least triggered a call or visit to the family by that worker. If they had read the article, the podcast producers should have wondered about that too.

Of course, it is clear that CFSA would not have answered any of these questions. NBC and the Washington Post cited leaked information from unnamed sources for their reports. CFSA refused to comment on Relisha’s case because it would violate the family’s privacy–the same response they give when asked about any individual case. But at least the podcast staff could have done a bit of digging, searching for someone who has left the agency since 2014 and might be willing to talk. They might have asked their police sources if the social worker had been interviewed. In any case, they could have discussed CFSA’s confidentiality protections and whether they truly protect families or serve primarily to serve the agency. And they could have at least raised the issue of CFSA’s how in-home services are supposed to work to address abuse and neglect while keeping children safe at home, and what changes might need to me made to make them more effective.

Why is it important to know how Relisha was able to fall through the cracks of CFSA? It matters because CFSA was Relisha’s last safety net. After tenant protections, the shelter, and the school failed, the only system left to save Relisha was CFSA. And CFSA continues leaving children in homes where they have been abused or neglected under the assumption that they will be safe with monitoring and services. If a child could disappear from a family that had such a case, then there was obviously a need for change. And indeed, the District recognized this. In the heavily redacted report on Relisha’s case that was released by the District government, many of the findings and recommendations concern CFSA (even though that must often be inferred in the findings, where the agency’s name is often redacted[2]), suggesting the agency should have done a better job of recognizing the family’s problems, sharing information with other involved agencies, and perhaps intervening more intensively by seeking court involvement or removing the children. Available information incidentally casts doubt on whether the recommended changes were actually made or retained, but that is beyond the scope of this post.

One hopes the failure to investigate CFSA’s failure in Relisha’s case was not a reflection of ideology on the part of Hill or the Through the Cracks team in general. In the podcast, Hill states that “Black mothers are so often gleefully blamed when things go wrong for their children.” It may not be an accident that she never specifies the details of the three founded reports against Shameka Young. Hill and her team did not mention the details of these findings, such as Shameka cursing her kids, splitting her son’s lip, and letting small children bathe alone. Were these details excluded so as not to make Shameka look bad? Did did the podcast team fear that saying CFSA should have assumed a more interventionist posture would go against the current child welfare climate and the growing movement urging child welfare agencies to stop policing black families, regardless of whether their children need protection?

The unifying theme of Through the Cracks‘ first season is the question of whether Relisha’s disappearance could have been prevented. The producers point out the irony of the District’s statement that the abuse could not have been prevented, while recommending a long list of changes to the policies and practices of all the agencies that interacted with the family. They rightly question the logic of exonerating DC agencies while telling them to change their practices. It is unfortunate that they missed the opportunity to explore the ways in the city’s child welfare agency failed to fulfill its duty to protect Relisha.

[1] According to the Washington Post, on March 13, Relisha had 10 absences and the school called CFSA. On March 19, Relisha had (by deduction) 14 absences and the school social worker went to the shelter.

[2] On page 4, “child welfare” was obviously redacted from Finding #1 and on page 5, “CFSA” is obviously whited out in Finding #2.

Testimony before the DC Council, CFSA Oversight Hearing, February 25, 2021

Good afternoon! Thank you for the opportunity to testify before the Committee today. My name is Marie Cohen, and I write the blog, Child Welfare Monitor DC, as well as Child Welfare Monitor, which focuses on national issues. I am also a former social worker in CFSA’s foster care system. My testimony is based on the data that CFSA has been sharing on its new data dashboard, as well as their performance oversight responses and published reports. The most recent dashboard data were uploaded last week and pertain to the quarter that ended in December. I’ll also be making some remarks about CFSA’s efforts around in-home services and prevention, leaving my friends at FAPAC and Children’s Law Center to talk about foster care..

My testimony makes a few major points.

There was a drastic drop in calls to the CFSA hotline starting last March following the closure of schools and the imposition of a stay-at-home order by the Mayor. Total calls were 25 percent lower in March through December 2020 than in the same months of 2019. The number of calls gradually returned to almost normal by December, after CFSA provided training to schools in how to detect abuse and neglect in a virtual environment. The number of investigations, and the number of findings of abuse or neglect, followed the pattern of hotline calls.
CFSA does not currently have valid data on the number of in-home cases opened each month so we cannot tell if that has been affected by the pandemic. But point-in-time data shows the number of children being served in their homes dropped about six percent from 1,333 on December 31, 2019 to 1,250 on that date in 2020.
Foster care entries displayed a surprising trend during 2020. There was a big decrease in foster care entries before the pandemic, and since then quarterly entries have bounced up and down.
Foster care exits declined by 24 percent between March and December, perhaps reflecting court and service delays due to the pandemic, but the gap seems to be closing, with exits actually eclipsing the previous year in October and December.
The total number of children in foster care declined from 771 on December 31, 2019 to 662 on December 31, 2020, for a decrease of 14 percent. The fiscal year decrease of 13 percent is larger than for any other year since FY 2014. We do not know the extent to which this accelerated decline in the foster care rolls reflects policy and practice changes, demographic changes in the city, or other factors, but it does not appear to reflect the loss of hotline reports due to COVID-19. Such a big decrease in foster care caseloads raises concerns about whether children’s safety is being compromised.
The total number of children served in foster care and in their homes declined by nine percent between December 2019 and December 2020. This is a decrease of almost 10 percent in one year in the total number of children served by CFSA.
About 65 percent of children served by CFSA are being served in their homes rather than in foster care, but we know too little about the services they and their parents are receiving. The oversight responses show a large dropoff between referral and receipt of services, and nothing about completion. Moreover, CFSA does not report on how many parents receive basic psychiatric, therapy, drug treatment and domestic violence services provided by DBH and other agencies. We know that quality and availability are both issues for these services.
CFSA has invested in Family Success Centers as its strategy for the prevention of child abuse and neglect before they occur. These centers seem to be off to a good start and are offering a large menu of services geared at strengthening families. But these centers make no special effort to engage those who need them most, who are traditionally hardest to engage.
Several policy recommendations are suggested by these findings. These include: training alternative reporters for child maltreatment; collecting and sharing data on children diverted to kinship care and their outcomes over time; reviewing CFSA policies and practices to make sure they are not compromising child safety; recognizing the critical role of DBH services for CFSA clients, including parents and those with in-home cases; adding a prevention program that is targeted to the children most at risk of being maltreated, and ensuring speedy implementation of the Children’s Ombudsperson Act.

My observations are discussed in more detail below.

Hotline: There was a drastic drop in hotline calls after pandemic closures, with calls gradually approaching normal levels by December 2020

Almost as soon as the pandemic took hold and stay-at-home orders were issued, child advocates around the country began to express fears that abuse and neglect would increase due to parental stress and economic hardship. Research has suggested that family violence spikes during natural and economic disasters. At the same time, school closures raised fear that child abuse and neglect would go undetected as children stayed home away from the eyes of teachers and others who might report suspicions of abuse or neglect. And indeed, in the District as around the country, calls to the child abuse hotline dropped drastically relative to last year, especially in April and May, just after the shutdown of school and the imposition of a stay-at-home order. School closures were likely the main cause for this drop, as school and childcare personnel made 43 percent of the calls in FY 2019–and only 36 percent of calls in FY 2020. But the summer, when teachers are not seeing students anyway and reports go down, looked more like a normal year. It is as if summer started in April and did not end until August. There is usually an uptick in reports in September and especially October after children return to school and teachers get to know them. This occurred in FY 2020 but was smaller than in FY 2019. But reports began to approach their normal level in November and December. CFSA credits the guidance they developed (in the form of a webinar and a participant guide) to be used to train teachers teaching virtually about how to spot abuse and neglect in a virtual environment. In total, the number of hotline calls dropped from 15,456 between March and December 2019 to 11,579 in the same months in 2019–a difference of 25 percent.

Figure One

Some commentators around the country have wondered if the loss of some reports from teachers might be a good thing because some of these reports were trivial and should not have been made. If only the frivolous reports were being suppressed, the number of reports accepted for investigation would remain similar across the two years. This was not the case. The pattern of hotline calls accepted for investigation followed closely the pattern of all calls to the hotline.

Figure Two

The number of investigations that was substantiated followed a similar pattern to that of reports and accepted investigations. The total number of investigations that was substantiated decreased from 1,053 in March to December 2019 to 808 in March to December 2020, a decrease of 23.2 percent, similar to the percentage decrease in hotline calls.

Figure Three

We do not know how many in-home cases were opened in 2020 but we do know that the in-home caseload declined significantly between CY 2019 and CY 2020.

When child maltreatment is substantiated, CFSA can place the child in foster care (opening an out-of-home case), open an in-home case, or not open a case at all and refer the family to a collaborative. One might expect fewer cases of both types to open during the pandemic due to the decline in hotline calls. CFSA does not currently have valid data on in-home case openings, so we do not know the effects of pandemic on this indicator. (Data on in-home case openings posted earlier has been removed due to technical problems). Point-in-time data shows that the number of children served in their homes dropped about six percent from 1333 on December 31, 2019 to 1250 on that date in 2020. And the number of families served in their homes dropped about seven percent from 510 to 473.

Table One: Number of Children and Families Served In-Home

	December 31, 2019	December 31, 2020
Children	1,333	1,250
Families	510	473

Foster care entries decreased before the start of the pandemic; not so much afterwards.

It is not surprising that hotline calls, investigations, substantiations and in-home case openings all declined in the wake of the pandemic and associated closures. The big surprise is that foster care entries did not display the same pattern. Entries into foster care started out low in January, dropped in February and actually rose in March, April and May of 2020 before dropping sharply in June and a bit more in September. The total number of children placed in foster care declined from 261 in March through December of 2019 to 181 in March through December of 2020.

Figure Four

Looking at quarterly data over time shows that the big decrease in foster care entries appears to have occurred before the onset of the pandemic. It took place during the last two quarters of FY 2019. Foster care entries bounced up and down for the last five quarters, actually increasing last spring when the pandemic began. The data suggest that there was a renewed push to “narrow the front door” of foster care starting in the third quarter of Fiscal Year 2019. And indeed, CFSA’s Communications Director stated that the fall in foster care entries reflected CFSA’s “continued commitment to keep children out of foster care by supporting families in their homes.” Could an increased use of kinship diversion have contributed to these numbers? We won’t know until CFSA starts reporting data on the use of this practice.

Figure Five

It appears that there were some delays in the achievement of permanency for foster youths in the first few months after the pandemic, as evidenced by declining foster care exits, but the agency appeared to be closing the gap in the first quarter of FY 2021.

There has been widespread concern around the country that covid-19 would create delays in the achievement of permanency for foster youth. Family reunifications could be delayed by court closures, cancellation of in-person parent-child visits and increased difficulty facing parents needing to complete services in order to reunify with their children. Court delays could also hamper exits from foster care due to adoption and guardianship. And indeed fewer children did exit foster care every month from March to September, especially in May and June, than in the same months in 2019. However, the difference between the two years declined in July and August and almost disappeared by September, and the pattern reversed in October and December, so perhaps the agency and court were able to clear the backlog. The total number of children exiting foster care declined from 357 during the period from March through December 2019 to 272 in the same months of 2020.

Figure Six

A large (14 percent) decline in the number of children in foster care occurred in 2020.

The total number of children in foster care on the last day of Calendar Year 2019 was 798. It declined to 694 by December 30, 2020, for a decrease of 14 percent. This does not seem to be a consequence of the pandemic, as entries and exits decreased by a similar amount in March to December 2020 relative to 2019. The number of children in foster care on the last day of the fiscal year has declined every year since FY 2012. However, the percentage drop in the foster care rolls (13 percent) was greater than in any other year since FY 2014. Such an accelerated decline always raises questions about whether child safety is receiving adequate consideration.

Figure Seven

The total number of children served both in-home and in foster care declined from 2,104 on December 31, 2019 to 1,912 on December 31, 2020, a decrease of 9 percent. Out of these 1912 children, 662 (34.6 percent) were being served in foster care and 1,250 (65.4 percent) were being served in their homes. It is important to note that this is a decrease of almost 10 percent in one year in the total number of children served by CFSA, rather than a shift in the percentage being served from foster care to in-home. The reason for this drop is not totally clear but may reflect pre-pandemic policy and practice changes for foster care and pandemic induced reporting declines for in-home services.

Table Two: Children Served in Foster Care and In-Home

Date	Foster Care	In-Home	Total (% Difference from Previous year)
December 31, 2019	771 (36.6%)	1333 (63.4%)	2,104 (1.7%)
December 31, 2020	662 (34.6%)	1250 (65.4%)	1,912 (9.1%)

We know too little about the services received by the parents, as well as children served in their homes.

I have talked a lot about numbers but not at all about the content and quality of services, and I’ll focus on in-home services here. CFSA’s oversight responses provide a list of services provided to families with an open investigation, in-home case, and out of home case combined, not separately for each group. The responses indicated that 910 families were referred to these various services but only 544 were served in FY 2020. We have no idea how many people completed these services, but it is probably a lot less. Moreover, CFSA did not report at all on how many parents received basic psychiatric, therapeutic and drug treatment services, or domestic violence services. CFSA depends on DBH for mental health and drug treatment services and nonprofits for domestic violence services. The DBH services are often of poor quality and all of these services are often in short supply with long waits. CLC discussed the unmet behavioral health needs of children in foster care; the same applies to children in in-home care and especially their parents, who need these services in order to reunify safely with their children.

The big worry is that if the services provided to parents are not effective, cases will be closed without parents having made the changes necessary to be able to keep their children safe. Therefore, we are likely to see these families in the system again, with more harm done to their children. However, there is encouraging news from the latest Quality Service Review (QSR) Report about the In-Home Administration’s improved performance on providing supports and services to families.

CFSA seems to have made a good start in implementing the Family Success Centers but needs to do more to engage the families that are most at-risk and hardest to engage.

The Family Success Centers appear to be off to a good start in offering a diverse menu of family strengthening services close at hand for parents in Wards 7 and 8. However, it is not likely that they are going to reach the families that need them most. Families at higher risk are traditionally difficult to engage and reach with services. If CFSA really wants to make a serious effort toward prevention, it will need to target families that are identified as at high risk of child maltreatment.

One example of such a program is Hello Baby, which was pioneered in Allegheny County Pennsylvania, home of Pittsburgh and the visionary child welfare leader Marc Cherna, who has since retired. Allegheny already had Family Success Centers, and they already know that they do not reach the families that need them most. Allegheny County decided to offer a universal support program to all parents of newborns. The program has three tiers, with the least at-risk families being offered services such as a “warmline,” texting services, and website. The middle tier is connected with Allegheny’s equivalent of the Family Success Centers. And the most at-risk group receives a peer mentor and a benefits navigator or case manager who work together to ensure the family receives the services they need. To assign parents to tiers, Allegheny County uses a predictive algorithm based on a highly advanced “data warehouse” that integrates data across multiple county agencies.

Policy Suggestions

The information outlined above points to several recommendations for CFSA and the Council

Although calls to the CFSA hotline seemed to approach normal levels in December, the total hotline calls between March and December dropped by 25 percent between 2019 and 2020 . Moreover, a nearly 10 percent drop in the total number of children served by CFSA may reflect in part the loss of these reports. CFSA should consider training alternative reporters outside schools: These might include postal and delivery workers and animal control officers, because child maltreatment often coincides with maltreatment of pets. This strategy is recommended by the family violence researcher Andrew Campbell, who has spoken at more than one event under the auspices of Children’s National Medical Center.
The CFSA dashboard provides no information on kinship diversion–not surprising because CFSA has so far not collected this data. This is an omission that needs to be corrected. The new CFSA policy requires the collection of some data on each diversion and the circumstances surrounding it. These data need to be available on the CFSA dashboard, but we also urge CFSA to make it a matter of policy to track these children regularly and provide regular updates via the dashboard or a public report.
CFSA should review its policies, practices and data to make sure that it is not compromising child safety in the rush to reduce the foster care rolls through kinship diversion or changed CPS practices.
The Council must recognize that CFSA relies on DBH for some of the most important services to parents and children and must be willing to allocate funding to improve the services offered by DBH in general. They also need to inform the council about the adequacy of current Domestic Violence services to meet the need among their clients. CFSA must start collecting data on the number of clients receiving these services and the amount of services they receive.
CFSA should consider adding a more targeted prevention program that reaches out to parents at risk of abuse and neglect but are not yet known to CFSA. This would probably involve developing a predictive model based on data from CFSA as well as other agencies.
The Council is to be congratulated for authorizing the creation of an Ombudsperson office for children. The implementation of this office should not be delayed as it will be very helpful in ensuring that CFSA continues to improve its performance even in the absence of the Court Monitor after the LaShawn case is closed. Moreover, I hope that with the resources provided the Ombudsperson can do a better job than I can in analyzing the data shared by CFSA.

Thank you for the opportunity to testify. I hope this testimony is helpful in your important work.

This testimony was modified on February 26, 2021 to reflect a CFSA’s clarification to hotline data included in the agency’s oversight responses. It was modified again on June 2, 2021 to clarify the foster care caseload data.

Another baby killed in DC: another set of unanswered questions

On November 16, I wrote about Gabriel Eason, who was beaten to death around April 1, 2020 by one of the adults who was caring for him. Gabriel was not the first child to be killed by abuse in this awful year. Eleven-month-old Makenzie Anderson was brought to the hospital on February 6, 2020 already dead of physical abuse. Ten months later, her mother was charged with first degree murder in Makenzie’s death. We know even less about how Makenzie fell between the cracks than we do about Gabriel. We know that other residents of the hotel shelter where she lived were aware that the baby was in danger. But we don’t know whether they notified the Child and Family Services Agency (CFSA), which is responsible for investigating reports of child abuse and neglect, nor how the agency responded to any reports it may have received. CFSA and the Department of Human Services (DHS) refused to release any of this information based on confidentiality requirements–requirements which protect the agencies but deprive the public and its representatives of the information needed to protect children better in the future.

We learned about Makenzie’s death back in February 2020 from media reports, including a column from Petula Dvorak in the Washington Post, which discussed the stressful conditions at the Quality Inn as possible contributors to Makenzie’s death. Then there was a long silence as the pandemic descended and MPD built a case, culminating in the filing of charges against Makenzie’s mother on December 1, 2020. According to a police affidavit filed in court, Makenzie’s mother Tyra Anderson brought the baby to Children’s National Medical Center (CNMC) on February 6, claiming she had fallen off the bed on or about February 3 and began to have episodes of shaking. The baby was pronounced dead and the police were called. Anderson told police that Makenzie had fallen before, “sometimes striking her head” as the affidavit put it. Anderson stated that the day after her fall the side of Makenzie’s head was “soft like jello” and that she could no longer hold herself up or stand on her own. The day after that, the baby was gasping for breath, and a day later Anderson found her cold to the touch upon waking up in the morning. On none of these days did Anderson seek medical care for the child, telling the police that she was “scared.”

Anderson told the police that she had been diagnosed with anxiety and panic attacks and “possibly bipolar disorder, but later stated that she wasn’t sure about the bipolar diagnosis,” according to the affidavit. The officer noted that Anderson stated that she “took pills” that morning and “seemed fixated on getting her medications after [her child] was pronounced dead.” Anderson talked about Makenzie’s happy disposition and bright smile. But she also referred to Makenzie as “greedy and lazy.” When asked to explain, she stated “because that’s all she do is eat and sit around.” The police later spoke to Makenzie’s father. He stated that the 11-month-old had previous fallen from a bed on “three or four occasions” but he thought Anderson was a “good mother.”

Video footage from numerous cameras around the hotel showed Makenzie alive and alert most recently on February 1, although her mother and 20-month sibling appeared many times in the next few days. On February 3, Anderson is seen carrying Makenzie, whose head was hanging limply on her mother’s shoulder, to her father’s car along with the 20-month-old. On February 4, Anderson exited the vehicle with a limp baby on her shoulder, accompanied by the 20-month old. Later that day, a witness observed Makenzie in the hotel room sitting in a walker. She had a bump on her head and was leaning to one side, whimpering and shaking. She reported that Anderson kept pushing the baby back up, telling her to “lift her head up.” On February 5, footage shows Anderson and the 20-month-old in the cafeteria and on the way to the father’s car, but no sign of Makenzie. Later that day, images show Anderson carrying her limp body, completely covered in a pink blanket, to the father’s car before arriving at CNMC. Video from the hospital shows Anderson “calmly” walking into the main entrance of the hospital with the pink bundle. Desperate attempts to revive the baby were unsuccessful and she was pronounced dead by hospital staff.

At no time in the surveillance video from the hotel between February 1 and February 6 did Anderson appear to be distressed or frightened, according to the police affidavit. Police later learned that Anderson had not allowed housekeeping staff to enter or clean her room on February 5. A social worker who worked with Anderson told police that they spoke about her housing needs on the morning of February 6, but that she did not mention that her child was hurt or needed medical help.

An autopsy revealed that Makenzie had “multiple acute contusions to the face and head,” acute skull fractures, a laceration to the [tissue behind the upper lip], a laceration inside the left ear, pulmonary edema, and hemorrhaging in the bilateral optic nerve sleeve.” The Medical Examiner ruled the cause of death to be Blunt Force to the Head and the manner of death to be Homicide. The affidavit alleges that “the DEFENDANT intentionally inflicted the decedent’s injuries and/or failed to seek immediate medical treatment which created a grave risk of harm to [Makenzie], and which ultimately led to the decedent’s death.”

Three days after Makenzie’s death, her paternal grandmother went to court to request custody of her two siblings. At an emergency hearing, she testified that she had cared for the older child for her entire life and for the younger child for most of hers. She reported that Anderson was incarcerated in Alexandria, Virginia from April to November 2019, when she reclaimed her younger two children. So it appears that Anderson cared for Makenzie for only a fraction of her very short life. The judge granted sole legal custody to the paternal grandmother on the grounds that “the children are in danger from their mother who killed their 11-month old sibling on February 6, 2020.”

When a child dies of abuse or neglect, child advocates want to know whether the death was preventable. Were there opportunities for agencies to intervene? Only with this knowledge can one determine if and how the system failed and how to fix it. We know of one government agency that was involved with Makenzie’s family, and that was DHS. The family was staying at the Quality Inn, which at the time was serving as an “overflow shelter” for families for whom there was no room at the main family shelter at DC General–now closed as well. If DHS staff had been required to lay eyes on Makenzie daily, she might have been saved. But instead, as reported by Dvorak, the staff did “bed checks” at 10pm daily when Makenzie was quietly lying in her bed–dead or alive. Ironically, these bed checks were instituted to prevent future cases like that of Relisha Rudd, whose disappearance from the DC General shelter in the company of a janitor raised no alarms and who has never been found.

One question that needs an answer is whether the hotel shelter staff complied with their responsibility to report any suspicion that Anderson was abusing or neglecting her children. All staff members were mandatory reporters of child abuse and neglect and were trained at least once a year in that requirement, according to DHS. There were 25 staff members serving the 110 families who were living at the shelter as of January 15, according to DHS. This included licensed mental health professionals, case managers, and supervisors. Each family had a case manager that was required to meet with the family weekly.

It is hard to imagine that none of these staff members knew that Makenzie and her sister were in peril. In a December article, Petula Dvorak reported that other residents of the Quality Inn knew that Makenzie was in danger. Family members contacted MPD during its investigation with reports of the mother and father taking drugs like Ecstasy, PCP and Percocet together. We know that Makenzie’s father had been barred from the Quality Inn after a domestic incident with Anderson on January 15, 2020. This was not the first incidence of domestic violence between them. Court documents show that Tyra Anderson went to court three times in 2015 and 2016 to seek protection orders from Makenzie’s father, saying that he punched, kicked and tried to strangle her and also kicked in her front door and damaged her apartment. He also filed for protection against her once in 2015. Court documents also show that Anderson’s mother was raising an older son of hers, who was born in 2009. At the time Tyler was born, Anderson was a teenager and asked her mother to raise him. The grandmother testified in court that the father had been incarcerated during most of the child’s life and Anderson had been intermittently incarcerated and rarely visited her son. As mentioned above, Anderson was incarcerated again soon after Makenzie’s birth, with the three children going to their paternal grandmother this time, only to be reclaimed by their mother only two to three months before Makenzie’s death.

All of these facts suggest a troubled family, and one that definitely came to the attention of shelter staff due to the domestic violence that occurred only two to three weeks before Makenzie’s death. A DHS official told this writer that she was not allowed to disclose whether any staff made reports to the CFSA hotline about this family. Nor do we know if any family members or friends may have reported concerns about the family, since CFSA refused to comment as well. Without knowing if CFSA received any reports, we cannot know if the agency fulfilled its obligations to investigate and make accurate findings.

This is not acceptable. In Florida, an immediate investigation by a Critical Incident Rapid Response Team is required for any child death reported to the Department of Children and Families (DCF) if any child in the family was “the subject of a verified report of suspected abuse or neglect” during the previous year. The investigation must be initiated no longer than two days after the case is reported and a preliminary report must be submitted within a month. The team must undertake “a root-cause analysis that …attributes responsibility for both direct and latent causes for the death or other incident, including ….specific acts or omissions resulting from either error or a violation of procedures.” The team’s report must be made available on DCF’s website, with confidential information redacted. A similar law exists in the State of Washington, where the Children’s Administration (CA) conducts a review when the death or near-fatality of a child was suspected to be caused by child abuse or neglect, and the child had any history with CA in the year prior to death. These reports must be completed within 180 days of the fatality and must be posted on the Department’s website with confidential information redacted.

Ironically, this writer is one of the few people who will eventually find out whether DHS staff reported Makenzie’s mother to CFSA and how CFSA responded. That is because I serve on the District’s Infant Mortality Review Committee, which will be responsible for reviewing the case after Anderson’s trial is over. Unfortunately, I will not be allowed to share what I learn with anybody, even members of the legislature, without risking a $1,000 fine and expulsion from the committee, as I discussed in my post about the death of Gabriel Eason. So the public will never know the answer to these questions, unless the Council takes action to allow the disclosure of this type of information.

With our limited knowledge of how the system failed little Makenzie, there is only one recommendation (No. 1 below) that we can make about how to protect future Makenzies. Two other recommendations would ensure the release of sufficient information about child maltreatment fatalities to enable a fuller set of recommendations to be made. Here is what we recommend:

Homeless shelter staff should be required to set eyes on each resident child daily, or in the case of a child said to be staying temporarily with a friend or relative, verify that the child is alive and well.
When a child dies of abuse or neglect, any history with any government agency that should have been concerned with the safety of the child (such as the child welfare agency, the homeless services agency, and the youth services agency) should be made available to the public.
The DC Council should change the broad prohibition on sharing any information from a meeting to allow attendees to share any information that does not identify individuals by name.

As in the case of Gabriel, there is not one picture of 11-month-old Makenzie to be found online. Did she ever know a moment of love? Was her life full of fear and pain, or was she a victim of an adult’s sudden snap? Why did nobody help her before it was too late? The DC Council should pass legislation requiring that the public be notified about what the government knew and what it did about children like Makenzie and Gabriel. We owe it to them and to all the children who could be saved by such knowledge.

Hotline calls, investigations, substantiations, and services still gravely suppressed by pandemic

In August, I wrote about the drastic decline in reports to CFSA’s hotline, investigations, and substantiated abuse and neglect allegations in the wake of the Covid-19 emergency, which closed schools and resulted in increased social isolation for children. CFSA has released data from June through October 2020, and the same trends are continuing. Reports, investigations, substantiations, and in-home case openings are down drastically. Foster care entries have decreased as well, but that drop seems to have occurred mainly before the pandemic. With plans for reopening schools up in the air, it is long past time to worry about the children who are not being seen in school or child care and to find alternative ways to reach them until schools and childcare centers are fully open. Moreover, these frightening data lend support to those calling for schools to reopen soon–especially for children of elementary-school age or younger, who are incapable or less capable of seeking help.

In the District, Mayor Muriel Bowser declared a public health emergency on March 11, 2020 and schools closed for in-person classes on March 13. After a two-week spring break, online learning began on March 24 and the stay-at-home order went into effect on April 1. Online learning ended on May 29, nearly a month early, and the same day that the District entered Phase One of reopening. Schools started on a virtual basis again on August 31. In its public-facing Dashboard, CFSA posts data for each quarter 45 days after the quarter ended. The data for the July through September quarter were posted on November 13, 2020. Using this data, we compared the numbers of reports, investigations, dispositions, in-home case openings and foster care placements since the pandemic with the numbers during the same months of 2019.

Reports to the Hotline

Hotline calls are generally a family’s first contact with CFSA and thus the earliest indicator of the effects of the pandemic. Figure 1 shows the number of hotline reports per month in FY 2019 and 2020. In FY 2019, the number of reports increased every month until May, dropped to a much lower level in July and August when schools were closed, and then bounced up in September with the opening of schools. The pandemic year of 2020 looked very different. The number of calls fell from February to March with the closure of schools, followed by a much larger drop in April, with the number of calls staying fairly flat until a modest rise in September with the opening of school. It’s as if summer vacation started in March, with a slight increase of reports when school started again.

Comparing the months across years shows that in January and February 2020, before the pandemic shutdown began, there were actually more hotline calls than there were in the same months of 2019, suggesting that the year would have seen increased reports if not for the pandemic. But in every month of the pandemic, the number of hotline calls in 2020 was considerably less than its counterpart in 2019. (The actual numbers are provided in Table 2 at the bottom of this post.) The biggest year-to-year differences were in April and May 2020, after the pandemic emergency began, when calls were down by 64 percent and 67 percent respectively over the same months in the previous year. In July and August, the differences between 2019 and 2020 were less drastic, which is to be expected because schools are normally closed during the summer months. But still reports were down by nearly a quarter in both July and August 2020 from the previous year. The total number of hotline calls received between March and September (roughly the period affected by covid-19) fell from 14,245 in 2019 to 9,780 in FY 2020, a decrease of 31 percent.

It is likely that the school closures were a major reason for the drop in hotline reports. Many schools, especially in the poorest areas, struggled to engage many of their students in distance learning last spring; some students were missing for the entire quarter. In addition, signs of maltreatment may be harder for teachers to observe online, although a virtual platform does allow them to observe incidents in the home that might otherwise go unreported. Moreover, DCPS closed several weeks early, offering not even virtual education in June. The lower level of reports even in the summer months may be due to families being more isolated due to the pandemic, spending less time with friends, neighbors, and extended family members who might report suspected abuse or neglect, as well as putting off visits to doctors, another common reporting source.

While monthly data on reporting source are not available, annual data shown in Table 1 support the hypothesis that a decline in reports from school personnel was a major factor behind the fall in reports overall. In 2019, presumably a fairly “normal” year, school and childcare personnel made 42.9 percent of all reports to the hotline. This is larger than the national percentage of 21 percent for these groups in FY 2018, probably because the District requires schools to report to the hotline all students who have more than 10 unexcused absences during a school year. These data show that these groups made a smaller share of reports in the recently completed Fiscal Year 2020 (in which more than half of the school year was virtual) than in FY 2019. In FY 2019, childcare and school personnel made 7,704 reports, which was 43 percent of all reports to the hotline. But in 2020 they made only 5,006 reports, which was only 36 percent of all reports. Counselors, therapists and social workers also made fewer reports in FY 2020, probably reflecting services that were suspended and or transitioned to a virtual platform. Their reports dropped from 2,342 to 1,702, or 13 percent of reports, which was not a large percentage change. On the other hand, law enforcement and medical personnel made an increased number and share of reports. Law enforcement personnel made 1,938 reports in 2020, a slight increase over the 1,891 reports they made in FY 2019. Their share of total reports increased from about 11 percent to 14 percent of all reports. Medical personnel made 965 reports in FY 2020, a big increase from the 866 reports they made the previous year, and their share of reports increased from five to seven percent. Friends and neighbors made fewer reports, but these reports were a slightly higher fraction–about 14 percent) of those received. Clearly no group could make up for the missing reports from teachers, so the total number of reports for the year was 14,046, down from 17,960 in 2019. The increasing number and share of reports due to law enforcement and medical personnel reflects their status as essential workers who have continued to see District residents in person. There have been anecdotal reports from many areas that maltreatment cases that do come to the attention of child welfare tend to be more severe; this may reflect the increased role of these reporters, who are more likely to see children who are seriously injured, and the reduced role of teachers, who are often said to report concerns that do not rise to the level of abuse or neglect.

Table 1: Hotline Reports by Source, 2019 and 2020

Reports accepted for investigation

A hotline call can be screened out as not meeting the requirements for an investigation, referred to another agency, or accepted for investigation. The number and percentage of reports accepted for investigation is shown below in Table 2. The percentage of hotline calls accepted was higher each month during the pandemic period (especially in May and June) than in that same month of the previous year. This pattern suggests that the reports made during the lockdown tended to be more serious, with the less serious reports less likely to be made. Such a trend has been observed in other jurisdictions where data have been analyzed in more depth, as reported in my national blog, Child Welfare Monitor. As mentioned above, some commentators have suggested that teachers in particular make many reports that do not merit investigation. Virtual schooling may have screened out some of this “noise.” CFSA data provide evidence for a small winnowing effect but one that was far from enough to make up for the drastic drop in the number of reports.

Table 2: Hotline Calls Accepted for Investigation

Completed and Substantiated Investigations

In addition to the number of calls accepted for investigation each month, CFSA also reports on the number of investigations completed each month. This is a different number because investigations can take a month or sometimes even longer to complete. So we can expect a time lag in observing the effects of the pandemic on the number of investigations completed. Also there is a small number of investigations that are not completed, as explained on the dashboard. These of course are included as part of total, but not completed, investigations.

Figure 2 shows a similar pattern of differences in completed investigations as shown in Figure 1 for reports, with the time lag delaying the effect by a month. In 2019, completed investigations mostly increased from January through June and then fell through September. In the pandemic year of 2020, the number of completed investigations fell precipitously in April and May, with the onset of the pandemic, drifted slightly upward through August, and fell slightly in September.

Turning to the numbers, in the pre–pandemic months of January and February 2020, the number of investigations was 24 percent and 36 percent higher than it was in January and February 2019. (Table 2 below the text shows the numbers and percentage changes.) It appears that the agency was on track to have more reports and investigations in 2020 than in 2019, if not for the pandemic. Completed investigations fell in April but it is not until May that the number of investigations completed in FY 2020 dropped below that of FY 2019. Once the number of investigations began to fall, however, it dropped like a stone. In May, only 230 investigations were completed compared to 565 in 2019–a drop of 59 percent. There were 56 percent fewer investigations completed in June 2020 than in June 2019. The gap between FY 2019 and FY 2020 lessened in July but was still large at 39 percent, reflecting the fact that many of these investigations would have begun in the first half of June, when school was still in session in 2019 but not 2020. It was only in August and September that the year-to-year difference declined to 21 percent and 18 percent respectively, reflecting the time lag between reports and completed investigations. It is worth noting that the year-to-year difference was still significant even in those months. This presumably reflects the continuing suppression of hotline reports during the summer of the pandemic. The total number of investigations completed between April and September (roughly the period affected by covid-19) fell from 2,716 in 2019 to 1,787 in FY 2020. That was a decrease of 25 percent–somewhat less than the difference in reports, reflecting the fact that a higher fraction of reports was investigated in 2020.

An investigation can have several possible results. It can result in a finding of “inconclusive,” meaning the evidence is insufficient to prove maltreatment despite some indications it occurred; “unfounded,” which means “there was not sufficient evidence to conclude or suspect child maltreatment has occurred,” or “substantiated,” indicating that the evidence supports the allegation of maltreatment. (See the CFSA Data Dashboard for the full definitions of these terms as well as of “incomplete investigations.”) As shown in Figure 3, the monthly trends and yearly differences were very similar to those for investigations in general. The total number of substantiated investigations for April through September dropped from 643 in FY 2019 to 420 in FY 2020, a decrease of 35 percent. The percentage of investigations that was substantiated during that period stayed almost exactly the same from year to year at approximately 24 percent.

In-home cases opened

When an abuse or neglect allegation is substantiated, several things may happen, depending on the perceived level of risk to the child or children in the home. The agency may take no action, refer the family to a community-based collaborative, open an in-home case, or place the child or children in foster care. As Figure 4 shows, there was a drastic drop in in-home cases opened between March and April, coinciding with the closing of schools and the pandemic emergency. Case openings dropped 48 percent in April, 54 percent in May and 74 percent in June compared with the previous fiscal year.[2] Data were not available for the quarter ending September 30, 2020. Presumably the trend in new case openings reflects in large part the trend in substantiated allegations; the patterns appear similar but not identical in the two measures. The total number of in-home cases opened in the pandemic months of March to June dropped from 533 in March-June 2019 to 267 in the same months of 2020–a decrease of 50.0 percent.

Source: CFSA Data Dashboard, available at https://cfsa.dc.gov/service/cfsa-data-dashboard
Note: In-Home Data not available for July-September 2020

Foster Care Entries

It is not surprising that hotline calls, investigations, and substantiations all declined in the wake of the pandemic and associated closures. The big surprise is that foster care entries do not display the same pattern. There was a big drop in foster care entries in February 2020–before the pandemic closures hit. Foster care entries actually rose in March, April and May of 2020 before dropping sharply in June and a bit more in September. True, monthly entries into foster care were always lower in 2020 than in 2019, though only by one child during the month of July. The total number of children placed in foster care declined from 193 in March through September of 2019 to 119 in March through September of 2020.

But the big decrease in foster care entries appears to have occurred before the onset of the pandemic, as Figure 6 shows. The number of entries into foster care was falling throughout FY 2019, aside from slight rises in May and August. There was actually somewhat of a rebound in the spring pandemic quarter, while the summer quarter entries fell back to the January-March levels.

The downward trend in foster care placements that began before the pandemic may have been due to policy or practice changes. As we mentioned in an earlier post, the data suggest that there was a renewed push to “narrow the front door” of foster care starting in the third quarter of Fiscal Year 2019. As we reported then, CFSA’s Communications Director indicated that the fall in foster care entries reflected CFSA’s “continued commitment to keep children out of foster care by supporting families in their homes.” Of course, we do not know if placements would have been higher in the absence of the pandemic; perhaps the school closures and pandemic orders did suppress foster care entries somewhat. But clearly, the pandemic has had a more obvious effect on the opening of in-home cases, resulting in a big decrease in in-home case openings. This makes sense if we assume that CFSA had become more likely before the pandemic to open in-home cases in lieu of foster care cases.

Exits from Foster Care

Commentators around the country have expressed concern that covid-19 would create delays in the achievement of permanency for foster youth. Family reunifications could be delayed by court closures, cancellation of in-person parent-child visits and increased difficulty facing parents needing to complete services in order to reunify with their children. Court delays could also hamper exits from foster care due to adoption and guardianship. The monthly data in Figure 7 show that fewer children did exit foster care every month from March to September, especially in May and June, than in the same months in 2019. The difference between years declined in July and August and almost disappeared by September, so perhaps the agency and court were able to clear the backlog. The total number of children exiting foster care declined from 261 during the period from March through September 2019 to 178 in the same months of 2020, a difference of 83 children or 32 percent. A small part of the reduction is due to the City Council’s decision to allow older youth to stay in foster care instead of aging out during pandemic. There were 27 exits by emancipation in the third and fourth quarters of FY 2019 and only 10 in the second half of FY 2020. But this difference does not account for most of the drop in foster care exits during the pandemic period.

Figure 8 shows the trends in total foster care caseload over time, which reflects both entries and exits. The total number of children in foster care on the last day of Fiscal Year 2020 was 695, compared to 798 on September 30, 2019, for a decrease of 13 percent. This reflects a total of 217 entries and 321 exits during the year. [1] (The percentage declines are listed in Table 7 at the bottom of this post). Combining Dashboard data with previously published data shows that the number of children in foster care on the last day of the fiscal year has declined every year since FY 2012. However, the 13 percent fall during 2020 was greater than in any other year since FY 2014. It appears that this decline happened mostly before the pandemic. Comparing data from March to September of 2019 and 2020 shows that 74 fewer children entered foster care and 68 fewer children exited it, suggesting that the pandemic had little effect on the total foster care caseload.

Conclusion

The release of fourth-quarter FY 2020 data on CFSA’s data dashboard shows a continuation of the trends that were displayed in the second-quarter data released in August. The pandemic and its associated closures had the expected downward effect on calls to the child abuse hotline, investigations, substantiated maltreatment reports, and in-home case openings. What was not expected was that although foster care entries fell in FY 2020, most of that fall occurred before the pandemic and appeared to be due to other factors, such as policy and practice changes. It appears that by suppressing reports and investigations, the pandemic probably suppressed the opening of in-home cases more than it reduced removals into foster care. But in any case, it resulted in a loss of protective services for children. Child Welfare Monitor DC has long been urging CFSA to do more to reach the children who may be suffering behind closed doors through means like working with schools to track down no-shows, launching a public awareness campaign about child abuse and neglect, educating non traditional reporters to spot signs of abuse and neglect, and reaching out to at-risk families known to the system. These ideas are discussed in my national blog, Child Welfare Monitor. With no clear plan for reopening schools, it is hoped that CFSA will now make this their top priority. Moreover, the data are sobering enough to support a return to school soon for children of elementary school age or younger as soon as possible because school is such a crucial safety net for abused and neglected children.

[1] The total is 694 rather than 695, which presumably reflects a small inconsistency in counting of entries and exits.

[2] There was an anomaly in the in-home case data that casts some doubt on the accuracy of the case opening numbers. We are awaiting clarification from CFSA.

Additional Tables

Table 2: CFSA Hotline Reports by Month, FY 2019 and FY 2020

Table 3: Investigations by Month, FY 2019 and FY 2020

Table 4: In-Home Cases Opened by Month

Note: Data not available for July-September 2020

Table 5: Foster Care Entries by Month

Table 6: Foster Care Exits by Month, FY 2019 and FY 2020

Figure 7: Children in Foster Care on Last Day of Fiscal Year

Another child, known to police and CPS, dead of abuse in DC

His name was Gabriel Eason. His story is achingly familiar. A young child dead at the hands of those who should have been caring for him in the District of Columbia. A family that was investigated by both police and child protective services, who were apparently unable to confirm the multiple incidences of past abuse. An agency more concerned about parents’ rights than children’s safety and hiding behind confidentiality laws to protect itself.

On October 9, 2019, an unnamed childcare center called the Child and Family Services Agency (CFSA) child abuse hotline to report that two-year-old Gabriel Easton had an unexplained injury, according an affidavit provided to DC Superior Court by the Metropolitan Police Department (MPD) and summarized in a Washington Post article. On October 16, 2019 CFSA and Metropolitan Police Department (MPD) investigators went to the home of Ta’Jeanna Eason and Antonio Turner in Northeast Washington to initiate an investigation. By March 2020, detectives had determined that there was not enough evidence to prove or disprove the allegation of abuse and closed the case. Two weeks later, police called to the home found EMT’s unsuccessfully trying to revive two-year-old Gabriel.

An autopsy showed old and new injuries to Gabriel’s body, including swelling of the head and brain, abrasions and contusions to the head and torso; lacerations of the kidney and liver; injuries to the. heart and vena cava; cuts on the face and neck; blunt trauma to the genitals; and 36 rib fractures, six of which were healing and believed to have happened in an earlier incident. The medical examiner reported that Gabriel appeared to have been punched, kicked, slapped, or hit with an object on his right flank and punched or hit in the chest. She concluded that the main cause of death was significant head and abdominal trauma.

Both of Gabriel’s siblings had experienced physical trauma. The three-year-old was admitted to the Intensive Care Unit with life-threatening injuries including a fractured rib and a lacerated liver. There was evidence of old and new injuries. A child abuse pediatrician determined the injuries were due to blunt force trauma equivalent to being involved in a multiple-vehicle accident or falling from a twenty-story building. The liver lacerations were inflicted within two days of the child’s presentation at the hospital. The 11-year-old was found with a healing black eye and older injuries. Both surviving boys have been placed in foster care.

Gabriel’s older brother, age 11, told police that he was required to clean the house, do the laundry, and change his siblings’ diapers at night while the adults slept. If a diaper was wet in the morning he would be beaten. He disclosed that Turner had previously hit him in the eye, on the chest, and with a belt. He reported that his mother hit him with her hands, her fists, and a belt. The 11-year-old stated his mother did not recognize that “the marks and bruising rampage” started when Turner arrived, and that Turner would beat his younger brothers when his mother was not around or not in a position to hear the abuse. When she noticed the injuries, she blamed her oldest son instead.

Turner admitted to police he routinely used physical force to punish his partner’s children. He reported punching the 11-year-old in the face to “teach him a lesson.” He also admitted that he beat the boy up once, giving him a “teenager whooping.” He reported that he “went to his body, like my father did me” during that incident. Turner also said that he hit the 11-year-old in the head and kicked him in the body when he found the boys playing with one of his metal weights the day before Gabriel’s death.

Eason, the boys’ mother, repeatedly blamed the 11-year-old for the injuries to Gabriel, telling the police on the murder scene that he was evil. Eason later told police that she started to notice bruises on Gabriel after she met Turner, but later concluded they were inflicted by the 11-year-old. But the child abuse pediatrician who examined and treated the three-year-old stated that neither his injuries nor Gabriel’s could have been caused by a child weighing 80 pounds.

The police concluded that Eason and Turner “collectively and chronically inflicted injury upon the three children who lived with them, including two-year-old [Gabriel], who died at their hands. They did this this both by abusing the children and failing to obtain medical attention for the injuries.” Police charged both defendants with First Degree Cruelty to Children and Felony Murder.

There is a system to protect children like Gabriel and his brothers. It starts with the requirement that professionals who work with children report all suspected abuse to CFSA’s hotline. It appears that the staff of Gabriel’s day care center did not fulfill their mandatory reporting duties as established by District law, failing to report four suspicious injuries to Gabriel. On May 22, 2019, a teacher saw Gabriel with a black eye. When asked the cause of the injury, Eason told the teacher a brother hit him with a boxing glove. The same teacher found injuries on Gabriel’s back in June. The mother said she did not know what caused the marks. In August 2019, Gabriel showed up with another black eye. The center director told police she did not report the August incident because Eason had an explanation for the injury (Gabriel had fallen and hit his eye on a toy) and produced a doctor’s note indicating Gabriel had been cleared to return to day care. (Receiving medical clearance from a doctor to return to day care should not be a reason not to report suspected abuse.) A staff member saw bruises on Gabriel’s face and ears on October 7, 2019. Eason wrote and signed a note saying the injuries came from playing roughly with siblings. On October 9, Gabriel had bruises on his ears, which his mother could not explain. That is when the center finally called the CFSA hotline. It should not have taken five suspicious injuries before a report was made. It is not clear whether the staff were sufficiently trained in mandatory reporting, especially the principle that all suspected abuse must be reported.

Doctors are also mandatory reporters of child abuse and neglect. We know that Gabriel received a doctor’s note clearing him to return to school after his black eye in August, 2019. MPD found that Eason had taken Gabriel to Prince George’s County Hospital on August 30. He was diagnosed with a black eye and eye abrasions. According to notes from the medical record, Eason claimed she was on her computer while the “father” was watching the kids. At some point Gabriel was playing in the closet and Turner said he had to get Gabriel out because the doors were off the track. Gabriel fell asleep on the couch and woke up crying but Eason did not see an injury. Nevertheless, she gave him Benadryl because she thought he might be having an allergy attack. She claimed she did not see child abuse by the “father,” suggesting she was asked that question. She also declined a CT-scan because she did not want Gabriel sedated or exposed to radiation. Eason’s explanation of the injury seems incoherent and self-contradictory, and a mother’s response that she did not suspect abuse by her partner should be expected and not necessarily credited. Eason’s refusal of a CT scan might be unremarkable if the doctor did not recommend it–but we don’t have that information. If there were any concerns about Eason’s explanation or behavior, the hospital should have made a report to the CFSA hotline just to be safe, but we do not know if this happened.

The next known contact with medical personnel occurred on January 28, 2020, when Turner called 911 and Gabriel was taken to Children’s National Medical Center (CNMC) with a severe laceration to his forehead. Turner claimed Gabriel fell off the bed while the 11-year-old was watching him, at Turner’s request. Doctors diagnosed Gabriel with a “complex” seven-centimeter laceration with concern for facial nerve laceration, as well as a concussion. To a layperson like this author, such a laceration sounds quite unusual from falling off a bed unless Gabriel somehow fell onto a sharp object, which would raise serious concerns about the home’s safety. Moreover, Turner’s statement that he had asked an 11-year-old to “watch” a two-year-old should have been concerning. We do not know if the emergency room doctor had good reason to call the hotline or if in fact a call was made. We can only speculate about whether a call could have saved Gabriel.

MPD also has a role in protecting children, but its duty is primarily to investigate crimes, arrest offenders, and charge them in court. There is no point in charging people when the charges will not hold up in court. Therefore, it is not clear that MPD made any errors in investigating the October report from the day care center. It is understandable that MPD did not find evidence of abuse that could support a criminal charge. The injury that was actually investigated did not appear serious and did not require medical attention. Eason lied about her own use of corporal punishment and the 11-year-old, undoubtedly terrified to tell the truth, reported that his mother did not use physical discipline. More importantly, there is nothing about Turner in the summary of MPD’s first investigation; it is not clear whether whether MPD or the child care staff knew of Turner’s existence. Whether MPD should have uncovered his presence is a question we cannot answer at the moment.

The responsibility to assess the validity of an abuse allegation and ensure safety for the child is with CFSA, not MPD. Rather than investigating allegations to determine whether charges should be presented in court, CFSA decides whether or not to confirm, or “substantiate” allegations. Investigators must substantiate an allegation when it is “supported by credible evidence and is not against the weight of the evidence.” Therefore, CFSA may substantiate an abuse allegation when MPD does not find evidence to make criminal charges. The call from Gabriel’s childcare went to CFSA and it is not clear how MPD got involved. Perhaps CFSA asked MPD to accompany the investigator on the initial visit to the home, but we have no information what CFSA itself did. The only mention of CFSA action in the MPD complaint is that “On October 18, 2019, CFSA filed a report with MPD about the October 9, 2019 incident.” CFSA’s Communications Director told the Post she could not comment on CFSA’s interactions with the family, citing local and national confidentiality laws. So we don’t know if CFSA delegated the entire investigation to MPD, which would be unusual, or if CFSA conducted its own investigation. If CFSA did investigate, we do not know the quality, results, or findings of the investigation, or any further actions by the agency.

Not knowing these facts is unacceptable when a child is dead of abuse. The taxpayers pay the cost of maintaining an agency to investigate complaints of child maltreatment and make arrangements to ensure that the children are safe. We have a right to know if it did its job. If the problems are systemic, we need to fix them. If one or more individuals made errors, they need to be held accountable.

CFSA’s conduct in this case will be reviewed in by at least two bodies, but the results will not be available to the public. An internal CFSA fatality review committee will review the agency’s conduct to determine whether there were opportunities to save Gabriel. It will make a public report, but that report will not include details about the agency’s response to individual cases. The District’s Child Fatality Review Committee will review the case as well. I have served on this committee for over three years. Unfortunately, the committee will not have the opportunity to review Gabriel’s case until Eason and Turner have been sentenced or acquitted. When that day comes, we might have less than an hour to review the case, unless a longer time is allotted as it was on one occasion during my tenure when a high-profile case was being discussed. The document we read will not include the names of Gabriel and his family members, referring to him as “the decedent.” Undoubtedly, I’ll be able to identify Gabriel’s case from the description. But if I call him by his name instead of “the decedent,” as I have done in the past, I will be chastised and possibly punished for violating confidentiality. I will be able to read summaries of the family’s interaction with MPD, CFSA, and other agencies with which they had contact. Although I won’t see the full case files, I may get at least partial answers to my questions about how the case was handled. But I won’t be able to share what I learn with anybody outside the meeting even without including any names. If I do, I will be subject to a fine of up to $1,000. The panel may make recommendations, which will be shared in its annual report. But there will be no case study included in the report. Information about individual cases in these reports is statistical only.

This is not an acceptable state of affairs. As a first step, the law regarding the Child Fatality Review Committee should be changed to allow members to share information about how District agencies respond to reports of abuse and neglect. Secondly, the D.C. Council must require that all deaths from abuse or neglect, and all deaths of any child whose family has been the subject of an earlier child abuse report, be reviewed by experts. This review should be made public with names (such as those of the surviving brothers) redacted when necessary. This review could be done by a special multidisciplinary team staffed by the child welfare agency as in Washington State or by a neutral agency like Illinois’ Office of the Inspector General for DCFS or the Office of the Child Advocate in Rhode Island. I prefer the neutral agency so that the agency that failed the child is not involved in the review. That is why I support including child fatality review in the bailiwick of the proposed child protection ombudsperson under legislation that is currently being marked up.

In the absence of any information about CFSA’s response to the initial call from Gabriel’s child care center, we cannot know why Gabriel’s suffering was not discovered in time to save him. But I cannot help placing some responsibility on a mindset that values parents’ rights above child safety. This orientation is becoming even stronger, with a growing chorus of groups arguing that child welfare as we know it should be abolished. According to some of these organizations, like a new movement called upEND, removing a child from home is always traumatic and never recommended. (See my recent post for discussion of this movement.) I wonder what the folks at upEND would make of what the 11-year-old told the interviewers at the Child Advocacy Center after he was finally liberated from his hellish home. He told them that he felt safe in his foster home. In contrast, he said his own home felt like a “death trap.” Would they say he was traumatized by his removal and not by his home life? Would they say that Gabriel is better off dead than in foster care?

Gabriel’s case also supports the importance of childcare and school in protecting children. The police affidavit states that Gabriel and his three-year-old brother did not attend childcare for most of February and all of March. Ironically, this was not related to the closure of the childcare center in March due to the coronavirus pandemic. Instead, Turner told police that Eason was not able to get the children to the center because she was pregnant with his child–a baby that died shortly after birth. It is reasonable to wonder if Gabriel might have been saved had he been attending childcare in the days before his death. Perhaps another report would have been made and this time this house of horrors would have been seen for what it was. There has been much talk about how school closings due to Covid-19 mean that children are no longer seen by adults who might spot and report signs of abuse or neglect. While the pandemic did not apparently contribute to Gabriel’s death, the circumstances show the importance of of keeping childcare centers and schools open, especially for children at risk of maltreatment.

I searched the internet in vain for a photo of little Gabriel Eason. Perhaps nobody loved him enough to take a photo. There have been no vigils or demonstrations about his death. But for those who care about children, forgetting Gabriel is not possible. Let us remember him by holding accountable those who let him die, and learning why the system failed him so badly, so that such failure can be prevented in the future.

CFSA’s Internal Child Fatality Report leaves out more than half of dead children known to system

On September 10, 2020, the Child and Family Services Agency (CFSA) released its internal child fatality review report for 2019. This report raises many issues and concerns. Some relate to the scope and coverage of the report. Others concern the cause and manner of death, the existence of families with repeated CFSA involvement that nevertheless have a child death, the predominance of large families as a correlate of child deaths, and the suggestion that unrelated adults in the home may have perpetrated a child fatality.

Child fatality review is an important way for an agency to assess the quality of its work. CFSA states in the report that “the fatality review process is one of CFSA’s strategies for examining and strengthening child protective performance. It provides the Agency with specific information that helps to address areas in need of improvement and to identify any systemic factors that require citywide attention–all with the goal of reducing preventable child deaths.” But the goal of child fatality review should be broader than reducing child deaths. Child fatalities should be seen as the tip of the child welfare iceberg. For every child who dies, there may be many others who are left in abusive or neglectful homes with no monitoring or support.

There are two child fatality review reports issued in the District. The District of Columbia’s Child Fatality Review Committee (CFRC) is located in the Office of the Chief Medical Examiner. CFRC reviews all deaths regardless of cause of all District residents from birth through 18 years, as well as the deaths of youths aged 19 to 21 who were known to child welfare within four years of the fatal event or those known to intellectual and disability services or juvenile justice programs within two years of the fatal event. Each year CFRC reports on all the fatalities reviewed in that year, but these fatalities could have occurred in any previous year. In the most recent report, on 104 cases reviewed in 2018, the deaths reviewed were from 2014 through 2018.

CFSA’s internal child fatality review reports are based on information gathered by the CFSA’s Child Fatality Review (CFR) unit and recommendations developed by the agency’s Internal Child Fatality Committee (ICFR). These reports focus on a smaller subset of child fatalities–all known fatalities of children whose families were known to CFSA within five years of the child’s death. In the past, the report included all fatalities reviewed in each calendar year. As stated in last year’s internal fatality review report, which has been removed from the CFSA website: “Historically, every CFR annual report has also included review data outside of the calendar year, depending on when the CFR Unit received notification of a child’s death. For [Calendar Year] 2018, reviews included fatalities from years 2015 to 2018.” However, the new report, includes only those fatalities that occurred during 2019. This is only 13 of the 33 fatalities the Committee reviewed during 2019, as the agency explains in a footnote. The other 20 fatalities reviewed occurred in previous years and will therefore never be included in a CFSA child fatality report unless the previous practice of including deaths from previous years is reinstated.

Cause and Manner of Death

Of the 12 fatalities for which cause and manner were known, the causes were equally divided between maltreatment, natural causes, non-abuse homicides, and accidents.

The cause of death was abuse or neglect by a caregiver for three of the children who died in 2019, 25 percent of the 12 children whose cause of death was known. All of these children were under the age of three. For two of these children the cause of death was abuse by blunt force trauma. The other child died of fentanyl poisoning due to neglect.
Of the 12 children with a known cause of death, three (or 25 percent, died of natural causes. Two of these were children between one and five years old, while the third was a young adult over 18.
Non-abuse homicides accounted for 25 percent of the fatalities in CY 2019. All of the victims were males living in Ward 8. One was aged 11, another was 16, and the third was 20.
All three accidental deaths were infant fatalities and all involved unsafe sleeping arrangements.

Demographic Characteristics

The children who died disproportionately resided in Ward 8 (seven children), Ward 7 (four children), Ward 5 (one child), and Maryland (one child). All of the children who died were African-American. None of these facts are surprising since they reflect the demographics of CFSA’s clients. Most of the children were living at home at the time of the fatality, except two that were living with relatives. All of the children who died had siblings. Nine of the decedents (about 69 percent) had three or more siblings; seven (54 percent) of them had four or more siblings, and four had six or more siblings. Many of the siblings were half-siblings. Twelve of the 13 decedents had at least one-half sibling.

Source: CFSA, Child Fatalities: Statistics, Observations, and Recommendations, 2019, page 6.

CFSA History

Over three quarters of the decedent’s families (10 families) had an open case or investigation within five years of the fatality. The other three families had one or more screened-out referrals only.

Six families had four or more reports to CFSA within five years of the child fatality. Nine families had two or more reports.
Eight families had at least one CPS investigation; of these families, one had a total of 10 investigations, another had seven investigations and two had five investigations.
All of these investigated families had at least one substantiated allegation of abuse or neglect. Most substantiations were for neglect; the neglect categories with the most substantiations were inadequate supervision and caregiver incapacity. There were two substantiations for physical abuse and two for “mental abuse.”
Of the eight families that had a CPS investigation, Family Assessment, or case closed within five years of the fatality, the time between investigation or case closure and the fatality ranged from four to 13 months.

*Source: CFSA, Child Fatalities: Statistics, Observations, and Recommendations, 2019*, page 14. The frequency of CFSA involvement refers to the number of hotline reports received.

Four of the 13 decedents’ families (31 percent) were involved with CFSA at the time of the child’s death. All of these families had open Permanency (foster care) cases. According to additional information provided by the agency, one of these children, a three-year-old, was in foster care with a relative. Her death was classified as an abuse homicide due to blunt force injuries, but it was not known if the injuries were caused by the relative or another adult in the home. Another decedent, a 17-year-old male, had run away from foster care and been missing for 17 days when he was shot to death. The other two decedents were living at home at the time of their deaths: one was an accidental death (asphyxia due to unsafe sleep) and the other decedent’s manner of death was undetermined. According to additional information provided by the agency, in both of these cases the non-custodial parent lived in a different household and had an open permanency case for the decedent’s half-sibling.

CFSA’s Recommendations

CFSA’s Internal Child Fatality Review Committee (ICFR) makes recommendations based on the information it reviews; these recommendations are approved by the Agency Director. There were surprisingly few recommendations based on 2019’s child fatalities. One of them calls for the agency to “ensure that practitioners identify and evaluate all adults living (or potentially living) in the same home as a child in foster care.” CFSA’s Communications Director told Child Welfare Monitor DC that a three-year-old decedent in kinship care died of blunt force trauma that may have been inflicted by an adult that was living in the home. Based on the recommendation, we can assume that adult was not evaluated as part of the foster care licensing process. During my tenure as a social worker in foster care, foster parents (including kin caregivers) not informing their licensing agencies of adults living in the home was a common concern. Often this information is purposely kept from social workers because the adult (often a boyfriend) has a criminal or child abuse record that would prevent the home from being licensed. To address this problem, CFSA plans to have supervisors “continue to work with social workers to identify adults who live in or spend significant time in the home and ensure all adults are evaluated.”

Analysis

This report raises many issues and concerns. These include the exclusion of 20 cases from years prior to 2019, the many children who died of causes that might have been prevented by CFSA, the deaths of children in families with long histories of CFSA involvement, the large size of many decedents’ families, and the possible role of an uncleared adults in the home in a child fatality.

Scope and Coverage of Report: While the ICFR Committee reviewed 33 fatalities during 2019, the report covers only those 13 fatalities that actually occurred in 2019; all of the other 20 occurred in prior years, mostly 2017 and 2018. Unless CFSA returns to its earlier practice of including all fatalities reviewed in a calendar year in that year’s report, these 20 fatalities will never be covered in a future report. This is the first year the ICFR left out all deaths that did not occur in the same year as they were reviewed. Like the citywide Child Fatality Review Committee, until this year the ICFR reported on all of the fatalities it reviewed in a calendar year–not just the ones that occurred in the same year they were reviewed. Leaving out more than half of the fatalities of children known to CFSA in its annual fatality report every year deprives the public, policymakers and stakeholders of crucial information that, if acted upon, could help prevent fatalities and harm to children in the future.

Lack of Case Detail: The lack of detail on the individual cases is a major problem in making sense out of the information provided in this report. Statistical data on such a small number of cases is of limited utility, but knowing the history of CFSA involvement in each case would enable readers to pinpoint the opportunities that may have been missed to prevent the fatality and lessons for the future. The public should know such details, as long as personal information redacted. Some states, like Texas, Florida, and Washington are required to post fatality reviews for children who died of abuse or neglect following involvement with the child welfare agency, as described by Child Welfare Monitor. Detailed fatality case studies on child deaths with agency involvement (without identifying information) are provided in other jurisdictions by independent agencies like the Office of the Child Advocate in Rhode Island and Connecticut and the Inspector General for the child welfare agency. Legislation to establish an independent Ombudsperson for CFSA was introduced in 2019 by Councilmember Brianne Nadeau. Such fatality reports were not included in her original legislation, which was never put to a vote, but could be added to the next version.

Cause of death and preventability: The cause and manner of death were known in 12 of the 13 cases and were distributed evenly between four categories–natural causes, accidents, abuse homicides, and non-abuse homicides. The deaths from natural causes were very likely not preventable by CFSA action. Deaths in the other three categories, however, could possibly been prevented if CFSA had responded differently to these families when they came to the agency’s attention. Clearly the fatalities from abuse or neglect raise the question of whether CFSA terminated its involvement without ensuring that the maltreatment that led to the initial allegation had ended. Accidental deaths can reflect neglect. For example, all of the accidental deaths in this report reflected unsafe sleep practices..

Preventability of non-abuse homicides: We don’t know the details on the tragic deaths of an 11-year-old, a 16-year-old and a 20-year-old of non-abuse homicide. Was the youngest victim (most likely an innocent bystander and possibly the case that appeared in media reports in June 2019) exposed to violence because of the lifestyles of the adults who were caring for him? Were the two older youth themselves involved in violence and criminal activities, as is the case for many young victims of violence? Three of the families were involved with the Department of Youth Rehabilitation Services (DYRS), suggesting that one child (perhaps not the decedent) in those families was involved in illegal activities. I spent five years working as a social worker in foster care and almost four years serving on the citywide Child Fatality Review Committee. In this work I have seen numerous examples of young people who became involved in crime and violence after growing up in families that were repeatedly involved in child welfare due to drug activity, domestic violence, mental illness, and abusive or neglectful parenting. Cases were opened and closed, and children were in and out of foster care, but none of these interventions resulted in any substantial change in parental behavior. Perhaps some of these tragic deaths could have been prevented if better, more intensive and long-lasting services had been provided to the parents, or if the children had been removed from these homes after their parents failed to take advantage of offered services.

Families with Repeated CFSA Involvement: It is clear from the extensive history of some of these families with CFSA that the agency is failing to identify some children who are in danger in their homes. Some investigations may fail to identify the family’s most severe problems; some cases may be opened for foster care or in-home services but may close before the parents succeed in changing their behaviors. CFSA requires a “4+ staffing” for all families that have four or more allegations with the last report occurring within the past 12 months. There was concern in previous years that families with child fatalities had more than four allegations but there was no documentation of a 4+ staffing. As a result, ICFR in 2018 recommended that the agency “make 4+ staffings more consistent,” a recommendation that was reported as “complete” in this year’s report. CFSA reports that five of the families with a child fatality in 2019 were eligible for a 4+ staffing. Of these families, four were documented as receiving such a staffing, but there was no explanatory documentation for the family that did not receive one. If the agency is indeed more consistently holding these meetings, it may be time to evaluate their effectiveness.

Unknown adults in a kinship home: Information provided by CFSA indicates that one of the abuse homicides was perpetrated in a kinship home and that it is not clear whether the perpetrator was the relative or another adult in the home. Evidence suggests that many abuse homicides are perpetrated by other adults living in the home, particularly nonparent partners, as described in Within Our Reach, the report of the Commission to Eliminate Child Abuse and Neglect Fatalities.

Large families: There is considerable evidence that the deceased children tended to come from larger families. Not only did 70 percent of the decedents have three or more siblings but more than half of the decedents had four or more siblings. The average number of children in a family is only 1.9 in the United States. Large numbers as well as close spacing of children are correlated with more abuse and neglect. Many of these mothers started having children as teenagers. Often, the medical providers used by low-income women lack access to the more modern, effective modes of contraception such as Long Acting Reversible Contraceptives (LARC’s) at all, or require a second visit to obtain these methods.

Recommendations

Cover all fatalities reviewed: CFSA should return to its previous practice of covering all deaths of children known to CFSA within five years–not just those that took place in the year of review. This would probably at least double the number of cases included, providing a much larger basis for making conclusions.
Provide detailed case studies by a neutral party: The public needs to have access to a detailed case study of each fatality in a family with which CFSA had recent involvement. Such a case study would include a chronology of agency involvement and a description of touchpoints where the agency could have done something different and perhaps averted the death. This is particularly important for legislators, who might want to take action to avert future deaths, and for members of the media, who are often the ones that make the public aware of gaping holes in our child safety net. Ideally, such an analysis would be performed by a neutral party, such as the child welfare ombudsman’s office that was proposed last year.
Pay attention to those with repeated CFSA reports: CFSA should assess the nature of the 4+ staffings to determine whether they are having any impact on families with multiple allegations, whether the current guidance for such meetings needs to be changed, and whether other measures should be implemented to ensure that families with repeated allegations get more attention.
Evaluate all adults in the home: The IFRC suggested that the agency “ensure that practitioners identify and evaluate all adults living (or potentially living) in the same home as a child in foster care.” To implement this recommendation, the report states that CFSA plans to have supervisors “continue to work with social workers to identify adults who live in or spend significant time in the home and ensure all adults are evaluated.” More specific guidance may be needed for supervisors and workers as to how to identify such adults.
Increase access to effective birth control methods: The large size of many decedents’ families highlights the need for policies to increase access to modern, effective and long-acting birth control options for all women in the District. Some of the saddest moments in my life as a foster care social worker came from hearing that a mother struggling to get her existing children back from foster care was pregnant again. Clearly expanding access to family planning is in the bailiwick of the Department of Health (DOH) rather than CFSA. However, even in the absence of DOH initiatives, CFSA could collaborate with DOH to ensure that the parents involved in cases have access to effective contraception as soon as their cases are opened and are educated about the deleterious effects of close child spacing and large families, and that family planning is included in case plans.

Studying fatalities among children known to a child welfare agency is an important way to find out how well an agency does its job of protecting children and to suggest changes to protect children better in the future. CFSA’s review of a limited number of child fatalities (probably less than half) among children known to CFSA in FY 2019 suggest that the agency could have done more to identify and protect some children in danger. And for every dead child, several more may be suffering from abuse and neglect that will poison their future. Leaving out over half of the children whose deaths were reviewed in 2019 just because they died in previous years is an unnecessary loss of information that could be crucial in saving lives in the future. And without a detailed study of each case, it is impossible for legislators and members of the public to evaluate whether CFSA did all that it could to prevent these deaths and protect the many other children in these homes.

This post was modified on October 15, 2020 to incorporate new information provided by CFSA on the families of decedents who had open permanency cases as well as to modify a statement regarding the scope and coverage of the report.

30-year old class action case wrapping up in DC

On August 7, 2020, the parties in a 31-year-old class action suit against the District of Columbia’s child welfare system, currently known as LaShawn vs. Bowser, agreed to a settlement in the longstanding case. The parties agreed that the agency had made sufficient progress to recommend a process and time schedule for closing the case. Judge Thomas Hogan preliminarily approved the settlement and set a hearing for June 1, 2021 to determine whether to grant final approval after receiving information regarding the agency’s compliance with its provisions.

In 1989, the American Civil Liberties Union filed the lawsuit then called LaShawn A. vs. Barry, on behalf of the District’s abused and neglected children. The suit challenged nearly every aspect of the District’s child welfare system and sought comprehensive reform of the city’s child welfare agency, the Child and Family Services Agency (CFSA). After a trial in 1993, Judge Thomas Hogan concluded that the District’s child welfare system was “a shambles.” In 1994, he approved an extensive order requiring reform in every part of the child welfare system and appointing a court monitor, the Center for Law and Social Policy (CSSP) to oversee the agency’s remediation efforts.

In the years that followed, the original order was succeeded in turn by three different plans agreed upon by the parties to the suit and and setting forth the outcomes to be achieved by CFSA in order to exit the lawsuit. The most recent agreement, the Exit and Sustainability Plan (ESP), was approved by the court on October 31, 2019. It recognized that the agency had made progress in fixing the problems identified the lawsuit and removed 56 of the exit standards the agency had achieved, setting forth a reduced list of 24 outcomes to be achieved. The latest LaShawn progress report from CSSP, published in June 2020, described continued progress on some outcomes but indicated that others had not yet been achieved.

The Settlement Agreement contains a list of actions to be taken by the agency in order to exit the LaShawn lawsuit. These actions, which target the outcomes not yet achieved, include:

CFSA will contract with a provider to develop a psychiatric residential treatment facility for children in foster care between the ages of eight to twelve.
CFSA will license enough foster homes by December 31, 2020 “to have a 10 percent built-in surplus of foster care beds, thereby creating more matching choices and prompt and appropriate placement for all children in care.”
CFSA will “ensure accessibility for clinical and therapeutic services” by maintaining four in-house behavioral therapists, a behavioral health clinical supervisor, and a psychiatric nurse practitioner; maintaining a contract with a Core Services Agency that will provide for the ability to serve “150 children and families” each year with “support and specialized therapeutic and crisis stabilization services.”
CFSA will maintain its ongoing commitments outlined in the ESP regarding self-regulation and public reporting, including policy development and publication, continuous quality improvement, quality service reviews, and publishing an Annual Needs Assessment and Resource Development Plan.
CFSA will maintain caseload standards embodied in the ESP.

The agreement also lays out the schedule and parameters for continuing monitoring, enforcement, and potential exit from the lawsuit. CSSP will provide a report on CFSA’s performance during calendar Year 2020 by March 31, 2021. A hearing will be scheduled for June 1, 2021 and the case will be dismissed in the event that there are no compliance concerns. The agreement will remain enforceable as a contract between the District and the plaintiffs for a period to be defined, with CSSP acting as an “Independent Verification Agent (IVA).” CFSA will prepare two semiannual public performance reports covering Calendar Year 2021 with the second report due by March 31, 2021. These reports will be “validated” by CSSP. The plaintiffs will have an opportunity to file an action for breach of the Settlement Agreement based on the public performance reports. In such a case, the parties will attempt to resolve the concerns through mediation by IVA and the agency will have up to 60 days to fix the problems before plaintiffs may file an enforcement action. In the absence of such an action, the Settlement Agreement will expire on the 181st day following CFSA’s final public performance report.

Analysis

CFSA’s performance in protecting children from abuse or neglect, caring for children in its custody, and helping families address the problems that put their children at risk still leaves much room for improvement. However, the egregious problems that led to the lawsuit and court supervision have been addressed to the satisfaction of the plaintiffs, as the new agreement indicates. The case could be kept open forever, with new benchmarks replacing those already achieved. But court oversight is an expensive way for dealing with systemic problems, using funds that could have been used for services to children to pay attorneys and evaluators instead. Moreover, it is a blunt instrument that relies on benchmarks that are measurable but not necessarily meaningful.

As a social worker in the District of Columbia’s child welfare system between 2010 and 2015, this writer found several of the provisions of the exit plan in force at the time to be more harmful than helpful to children in the system and the social workers trying to help them. I described some of these in a blog post in 2015 when these aggravations were fresh in my memory. One example was the standard requiring that 83 percent of youth in care must have two or fewer placements. Because of this standard, I was told that I could not move one of my clients whose foster parent provided no support and left him alone most of the time. At other times I was forced to waste precious time on unnecessary activities such as performing the required four visits to a child new foster home even when the “new placement” was actually just a change in placement status and the child had not actually moved, or making sure a “Youth Transition Plan was on the books every six months even if the client refused to participate in the required meeting. Actions taken for compliance purposes take time that overwhelmed social workers need for work that actually improves the lives and futures of clients.

Not all of the outcomes outlined in the ESP have been achieved, and specific provisions of the Settlement Agreement address these continuing issues. These provisions are discussed in more detail below.

Contract with a provider to develop a psychiatric residential treatment facility for children in foster care between the ages of eight to twelve. CFSA has reported that it is seeing more young children with aggressive behaviors than in the past. It is often difficult to find a residential facility for these children, and they end up disproportionately staying at the agency overnight after being sent back by foster parents who cannot deal with them. According to the latest LaShawn progress report, over half of the children experiencing overnight stays in the CFSA building between April and December 2019 were between the ages of eight and 13. Therefore, establishing a facility to care for these children makes sense.
License enough foster homes by December 31, 2020 “to have a 10 percent built-in surplus of foster care beds. The agency must establish a recruitment plan, which will focus on traditional family-based homes as well as specialized placement types to meet special needs. This is a somewhat surprising recommendation in light of data provided to the DC Council as part of its oversight process showing that there were 327 vacant beds available in the District and Maryland out of a total of 941 beds–a vacancy rate of way over 10 percent, making it unnecessary to license more homes to achieve such a surplus. This large number of vacancies at the same time as children were spending the night at the agency indicates that the problem is not the overall number of foster homes. The issue that has been of concern in this case is the lack of placement options (therapeutic foster homes, group homes, or residential treatment centers) for young people who have more serious problems, which has resulted in children moving from placement to placement and even staying overnight at the agency. Another issue is the poor quality of care provided in many of the existing homes–a problem that has not been addressed at all in the LaShawn case.
Maintaining in-house behavioral therapists and contract with core services agency: CFSA added three in-house behavioral therapists in 2018 because many children entering foster care were waiting months to be evaluated and matched with mental health providers by a Core Services Agency. It was part of a new strategy to move from a model of dependence on the Department of Behavioral Health (DBH) to a model with therapists on staff at CFSA to provide time- limited services for children newly arrived in foster care or those experiencing placement instability. To further expand services CFSA also entered into a contract with MBI Health Services, a DBH “Core Services Agency,” running from October 1, 2019 until September 30, 2020. The settlement agreement aims to institutionalize these innovations. However, contracting with a Core Services Agency does not address the the inconsistent quality of behavioral health services provided by these agencies. During my time as a foster care social worker, both CFSA and private agencies contracted with private providers in order to obtain higher-quality therapeutic services for clients with more complex needs.The District needs to overhaul and enhance its behavioral health services because it is not just CFSA clients who are in desperate need of timely, high-quality therapeutic services.
Maintain CFSA commitments regarding self-regulation and public reporting. The maintenance of these commitments is important; however they do not substitute for review by an external monitor, as discussed below.
Maintain caseload standards. The closure of the court case is most worrying as it relates to this outcome. Thanks to the case, CFSA has reduced its caseloads to meet the standards imposed by LaShawn, which are considered acceptable and are lower than actual caseloads in many jurisdictions. However, even these low caseloads are too high to do the myriad of duties expected of social workers, at least in some jobs. During my service as a foster care social worker between 2010 and 2015, I found that a caseload of 15 children was almost unmanageable and made it hard to focus on anything beyond crisis management, even when working more than 50 hours per week. A caseload of ten mostly older and harder-to-serve clients was equally unmanageable. This was mostly because foster care social workers in the District (at least during the years of my tenure) performed many of the tasks that foster parents were supposed to do–like taking their children to doctors and therapists and dealing with their schools. If caseloads are allowed to get higher, investigative social workers will be forced to cut corners and ongoing services social workers will be unable to do much other than respond to crises. Children and families will pay the price. That is one reason continued oversight is needed, as described below.

A Need for Continuing Oversight

While court supervision may no longer be the appropriate way to ensure acceptable performance by CFSA, the end of CSSP’s role as court monitor leaves the District without an independent agency to report to the public on problems with the agency. With its critical responsibilities that can mean life or death for children in or out of the system, and with the need for privacy that allows the agency to refuse to share information about its failures, we need an independent agency to monitor CFSA’s performance. Legislation to establish an independent Ombudsperson for CFSA was introduced in 2019 by Councilmember Brianne Nadeau. The Ombudsperson would respond to complaints, monitor agency policies and practices, and report annually on its findings. As the Children’s Law Center outlined in its testimony on behalf of legislation, there is no other agency that can perform this role because the only other institution that have the authority to do it—the DC Council and the Citizen Review Panel–lack the resources and the capability to do this important work. At least 15 states have established independent child welfare ombudspersons that perform such a role. Councilmember Nadeau’s Ombudsperson bill was not brought up for a vote in 2019; the Councilmember was planning to make adjustments in the legislation based on the testimony received, before the pandemic intervened. The legislation should be passed as soon as possible to avoid a large gap between the closing of the court case and the opening of the office.

It is time for LaShawn vs. Bowser to close. However, we cannot leave maltreated District children in unprotected both in and out of foster care. In order to protect the children of the District, we need an independent ombudsperson to ensure that CFSA is fulfilling its mandate to protect the children or the District of Columbia and ensure their wellbeing and transition to permanent homes.

CFSA hotline calls, investigations and substantiated maltreatment reports plummeted under Covid-19 shutdown

Report Child Abuse—It's the Law | Attorney General Karl A. Racine

Last spring, reports poured in from around the country about drastic drops in calls to child abuse hotlines after the closure of schools due to Covid-19 and the loss of reporting from teachers and other school personnel. The District of Columbia was no exception, and Child Welfare Monitor DC shared early data from the Child and Family Services Agency (CFSA) that documented a dramatic decrease in the number of hotline calls in the first month of the lockdown compared to the same period of the previous year. CFSA has finally uploaded data for the entire third quarter–April through June 2020–to its online Data Dashboard. This newly available data confirms the drastic decline in reports, investigations, and substantiations under the Covid-19 emergency.

The loss of reports from schools was the primary explanation for the drops in reports of child maltreatment around the country last spring. And indeed the shift to online education delivered a double blow to child protection efforts. For children who did attend virtually, it was harder for teachers to see signs of trouble, like bruises or hunger, than it would be in person. But many children were absent from digital classrooms much or all of the time. DCPS did not collect data on school participation last spring. But 57 percent of the 2,000 teachers who responded to a survey by the Washington Teachers’ Union, said that less than half their students were participating in virtual education. A child’s failure to participate may reflect the lack of a dedicated computer or internet access, difficulties in accessing platforms, a child too busy watching siblings or even working, or lack of engagement in virtual education. Whatever the explanation for their absence, these children were not being seen by teachers, counselors or other school staff, often the ones who notice red flags. Other potential reporters, like doctors and extended family members, were also less likely to see children under the Covid-19 stay-at-home orders.

In the District, schools closed for in-person classes on March 13, 2020. After a two-week spring break, online learning began on March 24 and ended on May 29, nearly a month early. So any effect on hotline calls should be observed starting in mid-March and ending in late June, when schools would normally close. To assess the effect of the school closure and health emergency, we compared the numbers of reports, investigations, dispositions, and foster care placements in the third quarter of 2020 (or April through June 2020) with the numbers during the same period of 2019.

The difference between the third quarter of 2020 and the same period of 2019 was staggering, as shown in Figure I. There were only 2,231 calls to the CFSA hotline between April and June 2020, compared with 6,058 during April to June 2019. That is a decrease of 63 percent. Unfortunately, CFSA does not provide quarterly data on the reporting source, so it is not possible to see which reports declined most. But if it the District is like other jurisdictions, school personnel probably accounted for a large fraction of the drop. The District’s drop in hotline calls may be even more pronounced than the national trend due to the District’s emphasis on school reporting of student absences before the pandemic, according to Judy Meltzer, President of the Center for the Study of Social Policy, who has followed CFSA for many years as the Court Monitor in its longstanding class action suit.

Calls to the hotline can be screened out as inappropriate, treated as “information and referral,” or result in investigations. The number of investigations dropped from 1773 in the third quarter of FY 2019 to 842 in the third quarter of FY 2020– a decrease of 52 percent–as shown in Figure 1. The fact that investigations decreased by a lesser percentage than hotline calls reflects the fact that hotline calls were more likely to result in investigations in 2020 than in 2019. The percentage of hotline calls resulting in investigations increased from 29 percent to 38 percent between the third quarter of 2019 and that same quarter of FY 2020. This suggests a trend that has appeared in other jurisdictions where data on referrals has been analyzed in detail. These analyses reveal that the reports made during the lockdown tended to be more serious, with the less serious reports more likely not to be made, as reported in our national blog, Child Welfare Monitor. This may be happening in the District, but the drastic drop in reports overall indicate that complacency is not in order. Clearly many serious referrals are being missed along with the less serious ones.

An investigation can have several possible results. It can result in a finding of “inconclusive,” meaning the evidence is insufficient to prove maltreatment despite some indications it occurred; “unfounded,” which means “there was not sufficient evidence to conclude or suspect child maltreatment has occurred;” or “substantiated,” indicating that the evidence supports the allegation of maltreatment. (See the CFSA Data Dashboard for the definitions of these terms as well as of another category called “incomplete investigations.”) There were 381 substantiated investigations between April and June, 2019, and there were only 214 substantiated investigations in the same period of 2020, representing a decrease of 44 percent. (See Figure I). Just as the number of investigations decreased by a lesser percentage than the number of reports, the number of substantiated investigations decreased by a lesser percentage than the number of investigations overall. The percentage of investigations that was substantiated increased from 21 percent to 25 percent between 2019 and 2020. Again, this may represent a tendency for the reports that come in to be more serious when school was virtual.

When an abuse or neglect allegation is substantiated, several things may happen, depending on the level of risk to the child or children in the home. The agency may take no action, refer the family to a community-based collaborative, open an in-home case, or place the child or children in foster care. Like hotline calls, investigations and substantiations, the number of children entering foster care plummeted during this quarter–from 97 in the third quarter of FY 2019 to 64 in the same period of 2020–a decrease of 34 percent. This percentage decrease, though large, is clearly smaller than the decreases in hotline calls, investigations and substantiations. Moreover, foster care entries began dropping precipitously before the pandemic hit, starting in the fourth quarter of FY 2019, as shown in Figure 2. During that period only 61 children were placed in foster care, 39 percent less than the 100 children placed in the same quarter of FY 2018. In the first quarter of FY 2019, 68 District children were placed in foster care, 40 percent less than the 114 children placed in the same quarter of the previous year. In January to March of 2020 (which saw the only the very beginning of the Covid-19 emergency), foster care placements fell by nearly two-thirds compared to the same quarter of 2019–43 compared to 115–truly the most surprising and confounding number in the graph. But in the first full quarter of the pandemic emergency, April through June 2020, 64 children were placed in foster care–almost 50 percent more than the previous quarter.

Thus, it appears that the decline in foster care placements during the pandemic emergency was actually a continuation of a trend that started earlier–and was more precipitous before the emergency than during it. When we asked CFSA about this, Communications Director Kera Tyler responded that the fall in foster care caseloads reflects CFSA’s continued commitment to keep children out of foster care by supporting families in their homes. “CFSA is committed to front-end operations to better support families with the goal of keeping them together without formal child welfare involvement whenever it’s safe to do so. In keeping with our Four Pillars strategic framework, we’ll continue to narrow the front door by linking families to community-based services that help to keep children in their homes.”

“Narrowing the front door” was the first pillar of the Four Pillars Strategic Framework instituted in 2012 by Brenda Donald in her first term at the Director of CFSA. It referred to the effort to support families so that children could remain safely at home. The number of children in foster care on the last day of the fiscal year declined every year between FY 2009 and 2019, falling from 2264 in 2008 to 798 in 2019. The decline appeared to be leveling off in Fiscal Years 2017 and 2018, but there appears to have been a renewed push to narrow the front door starting in the fourth quarter of Fiscal Year 2019. It is impossible to disentangle this trend from the effects of school closures and overall lockdowns, except to say that the downward trend in foster care placements actually moderated in the spring quarter.

The pandemic-induced reduction in calls, investigations, and substantiations remains equally alarming when we know that more of the unseen children would have been remaining at home with services rather than removed to foster homes. Because these children are invisible to the system, their families are not receiving the services they need to keep their children safe. And by the time these children are discovered (perhaps not until school buildings open again), conditions may have deteriorated to the extent that the children must be removed.

With school starting online on August 31, the need to find these unseen children is more urgent than ever. So what can be done? We have published a detailed list of suggested approaches, with examples and links, in our national blog, Child Welfare Monitor. These suggestions are listed briefly here.

Public awareness campaigns using mailings, posters, and social media to remind community members to report any suspicion of abuse or neglect. The CFSA hotline was included on a postcard that also includes hotlines for Adult Protective Services and the DC Victims hotline. CFSA could do more by developing resources that provide more detailed information about signs of child abuse and neglect.
Providing guidance to teachers and other traditional reporters on how to to spot signs of abuse and neglect in virtual settings: Many excellent materials are available and cited in the Child Welfare Monitor article. They provide some very helpful tips and warning signs for teachers to look out for, and parental behaviors to anticipate and try to prevent, like excessive punishment for children who receive a bad grade.
Reaching out to nontraditional reporters, like animal welfare workers, postal workers, garbage collectors, and home repair specialists: These workers continue to see children and should be educated about signs of child abuse and neglect. The idea of partnering with animal protection organizations is particularly interesting. Animal abuse often coexists with child abuse, and encouraging information-sharing between the two systems is a promising idea that should be explored.
Reaching out to at-risk families known to the system: Michigan and Allegheny County, Pennsylvania contacted higher-risk families with child welfare cases that recently closed to offer help with urgent needs, thus addressing stress and social isolation, which are major correlates of abuse and neglect. Many parents were very appreciative and eager to talk, and social workers reported some success in connecting them with services and benefits.
Investing in Prevention: When it is harder to identify existing abuse and neglect, it makes sense to invest in preventing it. This is already a high priority for CFSA, which is establishing neighborhood family support centers. However it is our view that a more targeted, intensive approach that can be adapted for virtual use during the pandemic is called for. CFSA should look some programs currently under development in other jurisdictions, such as Allegheny County’s Hello Baby Program, which is universal but targets more intensive services to the families most at risk, and Michigan’s new pilot program pairing at-risk families with peer counselors and benefits navigators. These programs use predictive analytics or historical data to target the families most in need of help to prevent child maltreatment.
The role of schools:: Ensuring children’s attendance in virtual education is not important only to prevent them from falling behind in school but also to fulfill the schools’ role as a protector of children. Unseen children cannot be protected. Video screens provide some opportunity for teachers to spot problems. We know that DC Public Schools were not successful last spring in getting computers and high-speed internet to all the children that needed them. The chancellor has promised to do a better job this year, but on the eve of opening day it was clear that many students still lacked a computer or an adequate internet connection. The schools must also do a better job of tracking attendance and reaching out to children who are not logging into school platforms. One Arlington County elementary school principal has directed teachers to provide the names of children who have not logged in by noon every day. Teaching assistants and other staff will reach out to these children and help resolve any problems until all students are engaged in school. DCPS and charter schools should adopt such a policy. They should also explore the possibility of adding to virtual platforms a button that children can push if they need help if there is trouble at home.

The District, like other jurisdictions, has seen a dramatic drop in calls to the child abuse hotline, resulting in a corresponding fall in investigations and substantiated allegations. These sobering statistics suggest that many abused and neglected children are currently invisible to the systems that exist to help them. CFSA and DCPS must take action quickly to identify these children; and CFSA should also develop more targeted efforts to prevent child abuse and neglect among at-risk families.

CFSA and Covid-19: Agency maintains essential operations but some concerns remain

The coronavirus pandemic, and the measures imposed to contain it, have affected almost every aspect of child welfare operations in the District of Columbia and around the country. Maintaining normal child welfare operations during this crisis was not an option. CFSA appears to have continued to meet its core responsibilities of investigations, in-home services, and providing a safe haven for children in foster care. However, some questions and concerns remain and some areas require special attention as the city moves toward normalcy.

Child welfare operations can be divided into the major categories of child protective services (or investigations), in home services, and foster care and adoption services and are discussed in that order below.

CHILD PROTECTIVE SERVICES

Investigating allegations: While other social worker visits have become virtual, CFSA has continued to send its CPS workers into the field to investigate allegations of child abuse and neglect. But there have been many fewer allegations to investigate. CFSA reports that between March 16 and April 18 of 2020, it received 897 hotline calls, compared to 2,356 hotline calls between those dates in 2020. (Child Welfare Monitor has requested updated figures from CFSA but not yet received them.) This drastic decline is not surprising because children have not been going to school or medical checkups or seeing family friends and relatives who might notice signs of maltreatment. As a result of reduced reports and resulting investigations, the number of children entering foster care has also declined. As stated in an earlier post, the agency might have done a better job at encouraging teachers to report children who were not in contact with their schools before school let out for the summer. At this point, with many summer camps canceled or scheduled to operate at reduced capacity, CFSA should be doing more to encourage awareness of child maltreatment and reporting among members of the general public and workers who see children regularly in the community.

Worker Safety: Continuing to conduct in-person investigations for child abuse or neglect means that workers are potentially being exposed to Covid-19. A recent article in City Paper painted a distressing picture of an agency that failed to provide its staff with the personal protective equipment (PPE) they needed to prevent infection. And it indeed appears that CFSA, like other agencies, was slow to obtain such protective gear. However, it is not clear that it would have been possible to obtain it any faster in light of the shortages at the beginning of the pandemic. In any case, CFSA workers have paid a high price for their important work on the front lines. As of June 21, a total of 48 CFSA employees had returned to work after recovering from Covid-19, six were currently in quarantine, and one had died. According to CFSA’s Communications Director Kera Tyler, by now all workers have provided with protective equipment and can obtain more as needed.

CPS Workforce and Caseloads: CFSA has allowed workers who are at high-risk of complications from Covid-19 to work from home, meaning that they are not able to carry out in-person investigations. City Paper reported some alarming data about declines in the CPS workforce due to at-risk workers staying home and agency vacancies, but these number were apparently inaccurate. There were 131 CPS workers in the field before the pandemic and 112 as of June 15, according to Tyler. Of the 19 employees currently staying home due to a COVID health concern, all were teleworking. In contrast to the data reported by City Paper, the current number of CPS vacancies was six on June 15. These vacancies are exempted from the hiring freeze, and the agency was actively working to fill those positions, according to Tyler. With the large decrease in hotline calls, it is not likely that CPS caseloads have risen during this time; on the contrary they have likely fallen.

Extrajudicial Placements/Hidden foster care: There has been growing concern in the District and around the country about children being placed with relatives outside of the foster care system without court involvement or agency support. This extrajudicial placement of children is often called “hidden foster care.” These concerns have escalated around the country in light of Covid-19. In the District, CFSA Director Brenda Donald stated at a budget hearing and community forum that parents who are incapacitated by COVID-19 would not be considered neglectful and that their children would be placed with kin without court involvement. This sounds like a humane policy but is actually inconsistent with DC law regarding parental illness or incapacity. Under current law, being unable to care for a child due to physical or mental incapacity is defined as neglect, regardless of the parent’s intent, as is explained in a document provided to Child Welfare Monitor by Marla Spindel of the DC Kincare Alliance. This finding of neglect by the court is required for the child to be removed and placed in foster care. By not declaring their children neglected, CFSA is treating parents affected by Covid-19 differently from parents with other incapacitating conditions. Moreover, such extrajudicial placements raise a number of concerns, including the lack of parental consent, the failure to establish a timeline, plan or services to return the child to the parents, and the child’s loss of certain rights, like the right to stay in the same school. We have no idea of the how many children have been affected by such placements due to parental incapacity from Covid-19 as CFSA has not answered our question and there is no requirement to collect this information..

IN HOME SERVICES

Over the past several years, the balance has shifted so that the majority of children served by CFSA are living at home with their families, not in foster care. In-home social workers visit families once, twice or four times a month depending on the intensity of their needs. During the pandemic, these social worker visits have shifted from face-to-face to virtual. Clearly there is a tradeoff between worker safety and child safety in this context. It is more difficult for workers to spot concerning signs of child abuse or neglect through a computer screen, especially when internet service is poor. In-home workers are an important source of CPS reports; CFSA data reported to the CRP last year indicated removals from in-home were 40% of all removals in the nine-month period ending June 30, 2019. We do not yet know whether removals from in-home cases have increased during the pandemic.

FOSTER CARE

Impact of virus and quarantine: Illness among children and foster parents has been widespread: As of June 10, 17 children in the custody of CFSA had tested positive for Covid-19. CFSA established a respite center for children who test positive for coronavirus, and a total of three children have utilized the respite facility since its inception. The remaining children remained (or been placed in) in their foster homes or group homes. There was some fear that placements might be disrupted by foster parents concerned that their foster children were failing to observe the curfew but as of June 15 CFSA reported no such disruptions. However, Judith Sandalow of the Children’s Law Center reported in her budget testimony that “placements are disrupting due to disagreements between foster parents and older youth regarding how too balance social distancing recommendations with work obligations and birth family connections.”

Visitation with parents: Parent-child visitation is a crucial part of any plan to reunite birth parents with their children. Most of these visits have gone virtual around the country in the wake of pandemic concerns. Birth parents and their advocates around the country have expressed concern that virtual visits would not be as effective as in-person visits in building parent-child bonds (especially for younger children) and that reunifications might be delayed as a result. In the District of Columbia, all visits supervised by CFSA social workers continued to be virtual as of June 15, according to Kera Tyler of CFSA. Unsupervised visits and visits that are supervised by designees, such as kinship resource parents, were being managed on a case-by-case basis. Many of these visits were taking place virtually, but some have continued in person.

Social Worker visitation: Social worker visitation to foster families, like visitation to families with in-home cases, has been virtual since the onset of the pandemic restrictions. Other jurisdictions have adopted the same policy, in accord with federal guidance waiving the requirement that these visits be in person for the duration of the emergency. As in the case of visits to families with in-home cases, it is certainly more difficult to assess the situation in a foster home online, especially if a parent is using a phone with a poor internet connection. Subtle or not so subtle cues can be missed and it can be difficult to talk privately to the children.

Reunifications and Adoptions: At the onset of the emergency, the Family Court suspended almost all operations except initial hearings for children coming into the system. Since that time, the court has slowly begun to resume operations online, as Children’s Law Center’s GAL Program Director, Jennifer Morris, reported to Child Welfare Monitor. Permanency hearings have continued to be replaced mostly by written reports and orders. We do not know whether these reduced court operations have resulted in any delays for reunifications or adoptions. Most parents with in-home or out-of-home cases require one or more services such as mental health and drug treatment to achieve reunification or case closure. These services also have been affected by the pandemic; they have presumably been either suspended or moved online with unknown impacts on accessibility and effectiveness. Brenda Donald has stated that reunifications and adoptions have continued since the coronavirus emergency but has not provided a comparison of the numbers during equivalent periods before the pandemic.

In conclusion, it appears that CFSA has been able to continue with its core operations without extreme disruption–certainly a commendable result given the widespread impact of the Covid-19 emergency. Nevertheless, the pandemic has clearly affected the agency’s capacity to identify and protect abused and neglected children and to work with their families toward reunification or case closure. In addition, there is some reason for concern that children left without a caregiver when their parents contracted Covid-19 may have been placed extrajudicially with relatives in a way that deprives them, their parents and their caregivers of significant rights and benefits. The repercussions of all of these changes are yet to be known, as is CFSA’s plan for increasing in-person visits as the city opens further.

Testimony on the Mayor’s Budget for the Child and Family Services Agency

Below is Child Welfare Monitor DC’s testimony to the Committee on Human Services of the DC Council regarding the Mayor’s revised 2021 budget for the Child and Family Services Agency (CFSA).

I write this testimony with a heavy heart. By the time it is read, the District’s public schools will have closed for the summer, and with them closes the last window of opportunity we had to identify some of the abused and neglected children who have been suffering in silence since the schools closed on March 16. It is my hope that the Committee will allocate new funding for a publicity campaign to enlist members of the public to report suspected abuse and neglect among our isolated and unprotected children..

My name is Marie Cohen, and I am an advocate for children in the District of Columbia and nationwide. I write two blogs, Child Welfare Monitor and Child Welfare Monitor DC. I am a former social worker in the District’s foster care system, a former member of the Citizen Review Panel, and a current member of the District of Columbia’s Child Fatality Review Committee.

In a recent blog post, I wrote about the increased danger facing abused and neglected children during this period of social isolation. A pandemic is likely to increase abuse and neglect through multiple pathways. Parents stressed due to job loss, fear of illness, and close quarters with children home from school are more likely to lash out in abusive ways. Parents who have to go to work, or who get sick may leave children unsupervised or in the care of abusive or unqualified caregivers. History demonstrates that child maltreatment increases during natural and economic disasters.

And indeed, data from DC’s Children’s National Medical Center (CNMC) suggest that severe child abuse is increasing in the District. As Chairperson Nadeau discussed at the budget hearing, The Washington Post reported that the number of children coming into Children’s National Medical center with abuse concerns has dropped while the percentage of severe cases has increased. From March 15 through April 20 of last year, about 50 percent of the children had injuries serious enough to be hospitalized. This year, 86 percent did. The percentage of children with head trauma, fractures, or injuries in multiple areas of the body doubled. And the percentage of children who died increased from three to ten percent.

At the same time, as Chairperson Nadeau also mentioned, reports to CFSA’s child abuse hotline have decreased dramatically. CFSA reports that between March 16 and April 18 of 2020, it received 897 hotline calls, with 30 percent coming from school personnel. During the same period last year, the agency received 2,356 hotline calls, with 52 percent coming from school personnel, according to CFSA Communications Director Kera Tyler.

In light of the dangerous situation facing so many of our children, I urged CFSA to work with DC schools in order to identify and check up on children at risk of abuse or neglect, especially those who have not had any contact with their schools, before schools closed for the summer. Sadly, the agency did not follow my recommendations. Schools will close without a concerted effort to identify the children who are being abused and neglected at home.

At the Committee on Human Services budget hearing on May 26, Chairperson Nadeau asked CFSA Director Brenda Donald how the agency was trying to get to these unreported cases of child abuse and neglect. The Director responded to this question with marginally relevant anecdote about a sharp-eyed teacher who identified a mother with symptoms of Covid-19 who needed medical attention. Seemingly unaware that schools were closing three days later, she stated that CFSA is “working with” the schools on protocols for when teachers should reach out. She appeared not to know that these protocols were published more than a month ago, and there certainly is no time to “work on” them now. Unfortunately, those protocols, as discussed in my blog, seemed to be more dedicated to limiting hotline calls than encouraging them. Director Donald had nothing else to offer other than asking those who watched the hearing to be vigilant about reporting child abuse and neglect.

Now that schools are closing, we must find another way to identify the silent victims of abuse and neglect. I hope you will consider adding money to the budget for a publicity campaign urging all community members to report suspected abuse or neglect to CFSA’s hotline. This campaign should use ads on buses, bus shelters, and Metro stations, as well as flyers to be distributed around the community. These messages could picture a child with the words, “You are his/her only hope” and information about the hotline. There should be special messaging targeted to the workers most likely to see children, including grocery and pharmacy workers. This message should also be incorporated into the Mayor’s briefings and the city’s website, coronavirus.dc.gov.

I greatly appreciate the opportunity to submit written testimony. I would be happy to work with you in developing the specifications for new budget allocations for a publicity campaign around child maltreatment reporting. Our vulnerable children deserve no less.