CFSA’s Internal Child Fatality Report for 2020: a missed opportunity to learn from mistakes and inform the public

CFSA’s Internal Child Fatality Report for 2020 was released on October 27, 2021. It provides information on 40 deaths of children and young adults whose families were known to CFSA within five years of their deaths. The report shows that most of these families had been reported to CFSA multiple times in the past five years. Many of them had experienced investigations and received CFSA services through in-home and foster care cases. Despite these interventions, these children had died within five years of CFSA’s ending its involvement. The report contains the lessons that CFSA drew from these deaths, but a careful reading suggests that the agency has not taken full advantage of this opportunity to improve future practice. Moreover, the report does not provide the information that interested readers need to make their own conclusions about agency practices and needed changes.

CFSA’s internal fatality report is different from the annual report of the citywide Child Fatality Review Team, which covers all deaths of young people up to age 18 and some deaths of those aged 19-21. The CFSA report focuses on fatalities of young people up to age 24 whose families were known to the agency within five years of their deaths. These fatalities are reviewed by the agency’s Internal Child Fatality Review (ICFR) Committee, and this report summarizes the results. As the report explains, the internal fatality review process “is one of CFSA’s strategies for examining and strengthening child protection. 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.”

The 2020 child fatality report includes only those child deaths that occurred during Calendar Year (CY) 2020 and were reviewed by the ICFR Committee during 2020 or in the first three months of CY 2021. An additional fifteen deaths that occurred in CY 2018 and CY 2019 but were reviewed in CY 2020 are summarized briefly in an appendix but are not included in the narrative and data charts provided in the body of the report. I discussed this timing issue in depth last year, when the report excluded half of the deaths reviewed during 2019. This year CFSA has improved the coverage of its report, at least in part by including cases reviewed up to March 31 of 2021: this report includes 40 (or 72 percent) of the 55 deaths reviewed between January 1, 2020 and March 31, 2021. But it is still hard to understand the purpose of leaving out more than a quarter of the deaths reviewed during the period covered by the report. All of these deaths took place in 2018 and 2019, not many years in the past. The report states that the ICFR Committee reviewed these earlier cases “as part of its internal continuous quality improvement (CQI) efforts,” but also that “[i]n line with CFSA’s CQI efforts and based on the known fatalities that occurred during CY 2020, ICFR Committee members made practice recommendations to potentially help reduce future child fatalities.” So it appears that the 15 fatalities from 2018 and 2019 were reviewed as part of CQI, but were not used to develop recommendations, which is the main purpose of CQI! Leaving out these cases accomplished nothing but giving the committee a smaller group of cases upon which to make recommendations and reducing the amount of information available to the public in the annual report.

Manner of Death

The manners of death* of the 40 children whose cases are included in the body of the report are displayed in the pie chart below. Half of these children were victims of “non-abuse homicide;” nine (or 22 percent) died of natural causes; five (or 12 percent) died in accidents; three (or seven percent) died because of abuse or neglect; and one died by suicide. The other two children’s manners of death were “undetermined” and “unknown.” While children who die from abuse and neglect after having previous contact with child welfare draw the most public concern, research shows that children who have prior contact with child welfare also tend to die more often from all causes than children with no such involvement, as I discussed in my post, Report of maltreatment: a major risk factor for child mortality.

Source: CFSA, Internal Child Fatality Report: Statistics, Observations and Recommendations: 2020, https://cfsa.dc.gov/sites/default/files/dc/sites/cfsa/publication/attachments/2020%20CFR%20Annual%20Report%20vF%20-%2010.26.21.pdf; data plotted by Child Welfare Monitor DC.

Abuse and Neglect Homicides

Abuse and neglect homicides of children known to CFSA often draw public concern because the agency’s primary role is to protect children from abuse and neglect. But they are a small proportion of the deaths to children who were involved with CFSA in the past five years. Three, or seven percent of the deaths reviewed in this report, were abuse or neglect homicides. The ICFR Committee also reviewed one abuse or neglect homicide that occurred in 2018 or 2019 and is addressed only in the appendix to the report. We know nothing about this case, not even whether the death was caused by abuse or by neglect. The two abuse homicides that occurred in 2020 were young children who died by blunt force trauma. The information provided suggests that the 11-month-old was Makenzie Anderson. Shortly after Makenzie’s death Petula Dvorak reported in the Washington Post that other residents of the Quality Inn that was then serving as a shelter for homeless families knew that Makenzie was in danger. But CFSA refused to disclose whether anyone had reported their concerns to the hotline. This report tells us that somebody, sometime, did report their concerns about Makenzie’s family, but that is all it reveals.

Given what is publicly known, the other abuse homicide discussed in the report – a two-year-old African-American male who died from multiple blunt force injuries – was probably Gabriel Eason, who died on April 1, 2020. 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. We know that Gabriel’s childcare center called the CFSA hotline on October 9, 2019, six months before he died, but we do not know what action CFSA took or if there were other calls. Unfortunately this report does not tell us anything new.

The neglect homicide included in the report involved a seven-year-old African-American boy killed in a car accident. The child and his younger siblings were passengers in a car driven by their mother in a long drive back to the District from another jurisdiction. None of the children were in car seats and the mother had alcohol in her system. The mother was charged with first-degree vehicular homicide, seatbelt violations, and driving under the influence. She was taken into custody and the remaining children were placed with relatives. The report does not tell us when and how often CFSA received reports in this family or how the agency responded.

Gun Violence

By far the most common manner of death for fatalities reviewed in this report was “non-abuse homicide,” or homicide that was not the result of child abuse or neglect. Such “non-abuse homicides” were half of all deaths reviewed, and all 20 of these deaths were caused by gun violence. Unlike in cases of abuse homicide, the media rarely asks about the history of gun violence victims with CFSA. However, the connection between child welfare history and gun violence death became obvious to me as soon as I started sitting on the citywide Child Fatality Review Committee. I learned that many of the young victims of homicide grew up in families with long histories of reports to CFSA. Reports on one family often include allegations of physical abuse, positive toxicology of a newborn, lack of supervision, and extensive unexcused school absences. Many of these reports were unsubstantiated; others were confirmed but resulted in nothing but a referral for voluntary services; others resulted in the opening of in-home cases that eventually closed; and others resulted in children placed in foster care and later returned home. But the abuse and neglect continued. Many of these families fit the pattern of chronic child neglect, which occurs “when a caregiver repeatedly fails to meet a child’s basic physical, developmental, and/or emotional needs over time, establishing a pattern of harmful conditions that can have long-term negative consequences for health and well-being.” Many of these children, with little support at home, histories of trauma, and disconnected from school, find their companionship in the streets and take up violent and illegal activities. Of the male decedents reviewed in the 2020 CFSA report, four were known to have been involved with the juvenile justice system and two were known to be involved in criminal activity when they were killed.

Of course, not all of the children included in this report who died from gun violence came from abusive or neglectful homes or were involved in violence themselves. Some of them died because they lived in a neighborhood plagued by gun violence or were in the wrong place at the wrong time. The eleven-year-old mentioned in the report might have been Davon McNeal, who was caught in the crossfire of a gunfight. And Davon was probably not the only bystander among the 20 who died. But perhaps some of the other deaths could have been prevented with more aggressive CFSA action. For example, the agency could have offered better, more intensive and long-lasting services to the parents, with court supervision to ensure they were taken up. And crucially, the agency could have refused to give second, third, and fourth chances to parents who repeatedly failed to take advantage of these services.

Natural Causes: Nine fatalities, or 22 percent of the deaths included in the report, were due to natural causes. Three of these deaths were due to prematurity and another three were due to medical conditions at birth. One might think that these deaths could not have been prevented by CFSA action, but research suggests otherwise. A population-based study using data from 3.4 million births in California found that, controlling for baseline risk factors like low birthweight and preterm births, infants with more than one CPS report were more than three times more likely to die of medical causes than those without a CPS report. The researchers also found that among infants reported for maltreatment, periods of foster care placement reduced the risk of death from medical causes by roughly half. Unfortunately, as described by child welfare expert Dee Wilson, medically fragile children are often born to the parents that are worst equipped to care for them. Thus, some of these deaths might have been prevented with more aggressive interventions, including foster care, in earlier contacts with the agency.

Accidental Deaths/Unsafe Sleep: Five of the CY 2020 fatalities, or 13 percent, were deemed accidental. Unsafe sleeping arrangements were involved in four of these deaths. (The fourth was a 20-year-old riding a moped without a helmet). In total there were five fatalities related to unsafe sleep. The other one was classified as “undetermined.” On the citywide child fatality review panel, I have seen numerous cases of children dying in unsafe sleep environments in families with long histories of child welfare involvement, often for numerous children. We tend to focus on unsafe sleeping arrangements (such as bed sharing) as the cause of death, but the reality is much more complex. Almost invariably, the parents have used marijuana, alcohol or illegal substances before lying down with the baby, and they fail to wake up when the children are struggling to breathe. With unimpaired parents, these sleeping arrangements might not result in death. That is why another study found that adjusting for risk factors at birth (including low birth weight and late or absent prenatal care), the rate of Sudden Unexplained Infant Death (SUID) was more than three times greater among infants who had been previously reported for past maltreatment than among infants who had not been reported. And that’s why more intensive interventions (including foster care placement) with families that abuse substances might have prevented some of these deaths.

Suicide: The CFR Unit reviewed one death by suicide; incredibly the decedent was an 11-year-old girl who hanged herself from the shower rod in her home. One population-based study estimated that children with any CPS history were three times as likely to end their own lives than children without such a history, and an eleven year old taking her own life suggests that something must have been amiss in her family that the agency might have been able to observe. “The family received grief services,” according to the report. That is nice to know, but it would be more important to know what type of trauma could have caused the suicide of an eleven-year-old, and what CFSA knew and should have known about this family before the child took her own life.

Undetermined and unknown: One child’s cause of death was unknown because the child died outside of the District; that child was in foster care. One fatality was classified as undetermined because the autopsy findings were inconclusive. The decedent was two months old and was found unresponsive after being swaddled for about two hours in a motorized baby swing with a blanket propping up a pacifier so that it would stay in the infant’s mouth. Unsafe sleep practices may have contributed to the infant’s death, according to the CFR Unit. This case raises the same issues as the accidental deaths discussed above. Any family that would leave a two-month-old unsupervised in a swing for two hours with a propped bottle has severe parenting deficiencies beyond their knowledge of safe sleep practices–deficiencies that required aggressive intervention in order to protect the child.

Parents’ CFSA History as Caregivers

Nine of the 40 families reviewed in the report (or about 23 percent) were involved with CFSA at the time of the fatality. Of these nine families, five had an open foster care case, two had an open investigation, one had an open in-home case and an open investigation, and one had an open permanency case and an open CPS investigation. Obviously it is concerning that these fatalities could occur while CFSA was actively involved with the family. One has to wonder whether any red flags were disregarded. But without knowing the details of CFSA’s involvement with these families, it is impossible for readers of this report to make any conclusions about agency practice.

Source: Source: CFSA, Internal Child Fatality Report: Statistics, Observations and Recommendations: 2020, https://cfsa.dc.gov/sites/default/files/dc/sites/cfsa/publication/attachments/2020%20CFR%20Annual%20Report%20vF%20-%2010.26.21.pdf.

In addition to the nine families who had an open investigation or case at the time of the fatality, four families (10 percent) had a case or investigation closed within three months of the fatality, four families had a case or investigation closed within four to nine months of the fatality, and another four families had a closure within 10 to 12 months of the fatality. It is concerning that so many families had such recent contact with CFSA; one wonders whether the case closures were premature and whether any red flags were missed. One family was not included in these calculations because it had four referrals that were screened out and no investigations or cases. It is concerning that a family with a later fatality had four reports screened out and it would be interesting to know when those referrals came in and whether the CFR unit looked at why they were rejected. There has been some concern about the accuracy of hotline decision-making. In a 2016 study, conducted by the Center for the Study of Social Policy, the court monitor in the LaShawn class action suit, reviewers agreed with the decision to screen out the referral in only 73 percent of the 223 screened-out referrals studied.

Note: One family was not included because they had no open case or investigation during the five years before the child fatality. The family did have four screened-out referrals.
Source: CFSA, Internal Child Fatality Report: Statistics, Observations and Recommendations: 2020, https://cfsa.dc.gov/sites/default/files/dc/sites/cfsa/publication/attachments/2020%20CFR%20Annual%20Report%20vF%20-%2010.26.21.pdf; data plotted by Child Welfare Monitor DC

The chart below shows the frequency of CFSA involvement for the families with fatalities. All of the families had more than one report to CPS within five years of the fatality, 31 families, or 77 percent of the families, had four or more reports. So these families were very troubled, and there were many opportunities for CFSA to intervene.

Source: CFSA, Internal Child Fatality Report: Statistics, Observations and Recommendations: 2020, https://cfsa.dc.gov/sites/default/files/dc/sites/cfsa/publication/attachments/2020%20CFR%20Annual%20Report%20vF%20-%2010.26.21.pdf; data plotted by Child Welfare Monitor DC

What happened as a result of these reports? All but two of the families had referrals that were screened out, with 40 percent having four or more such screened-out referrals. About 83 percent of the families had at least one investigation. Sixty-five of the families had between one and three family assessments, an alternative to traditional investigation that has been dropped by CFSA. Forty-three percent of the families had one or two in-home cases, and 33 percent had one or two permanency (foster care) cases. Again, this table shows that CFSA had many opportunities to assess and intervene with these families before their children died.

Source: Source: CFSA, Internal Child Fatality Report: Statistics, Observations and Recommendations: 2020, https://cfsa.dc.gov/sites/default/files/dc/sites/cfsa/publication/attachments/2020%20CFR%20Annual%20Report%20vF%20-%2010.26.21.pdf.

According to the table shown above, 33 families were the subject of investigations in the five years before the fatality. In Figure One of the report (not reproduced here) CFSA found that 19 families had at least one substantiated allegation in the five years before the fatality. That 33 of these families had investigations but only 19 (or about 58 percent) had at least one maltreatment finding suggests that many of these investigations may have failed to find existing abuse or neglect. Physical abuse was the type of allegation that had the largest number of substantiations (eight). Unfortunately, we do not know how many families received those eight substantiations; it could have been one family that received them all or several families could each have received a smaller number of substantiations. The other most frequent types of maltreatment substantiated were ‘failure to protect’ (five), and four each for inadequate supervision, substance use by parent or caregiver, unwilling/unable caregiver, positive toxicology of a newborn, educational neglect and exposure to domestic violence. It would also be valuable to see the number and subject of unsubstantiated allegations as well since a large body of literature documents the difficulty of accurately determining whether a child has been maltreated, which is why scholars often prefer to use referrals (rather than substantiations) as a metric for the rate of maltreatment.

It is no surprise that many families of children who died within five years of CFSA involvement had a long history of reports to child protective services. The known high risk level for children in a family that has multiple reports is the reason that CFSA requires a “Four-Plus staffing,” which is a special meeting for families with four or more allegations, when the last report occurred within 12 months. According to the report, these staffings “focus on gaps in practice or service delivery that may have contributed to a family returning to CFSA’s attention.” Among the 40 families included in the report, 15 met the qualifications for a Four-Plus staffing, and all of them received such a staffing. This result raises questions about the efficacy of these staffings in addressing families with multiple reports to CFSA.

CFSA’s Recommendations

Based on its fatality reviews, the ICFR Committee makes recommendations each year for CFSA and other District agencies for actions that might avert future fatalities. This year the committee made only three recommendations: provide support to child welfare professionals who experience traumatic stress; improve information sharing between DC government agencies, and encourage use of a comprehensive medical information platform among hospitals and medical providers in the District. The report explains that the last recommendation would address the problem of abusive parents who bring their children to different medical providers. It is possible that this recommendation was prompted by the case of Gabriel Eason, whose mother brought Gabriel to two different emergency rooms for his injuries, thus making it less likely that abuse would be suspected.

These are all good recommendations. But it is rather surprising that there are no recommendations to improve CFSA’s practice in conducting investigations and in-home and foster care cases. Given that nine of these decedents had an open investigation or case at the time they died, and another 12 had an open investigation or case within a year of the fatality, there is reason to wonder if anything could have been done differently in these cases. But without knowing the details of CFSA’s involvement with these families, it is impossible for reader of this report to make any conclusions about agency practice. The ICFR Committee was given the details on each case. Is it possible that they found no flaws in case practice that would lead to recommendations for the future? That is hard to imagine.

Even without being privy to case details, there are some potential recommendations that come to the mind of an educated reader. Given the fact that all 15 families that qualified for a Four-Plus staffing because of the extent of their history with CFSA actually had such a staffing, and a child died nevertheless, one might wonder if Four-Plus staffings are achieving their purpose. A reasonable recommendation might be to change these staffings or eliminate them entirely and replace them with something else. Given that among the allegations about the 40 decedents’ families by far the most allegations involved abuse, a potential recommendation might be that the agency heighten scrutiny for families that were reported for abuse. There is other evidence for such a proposal: one study found that children with a previous allegation of physical abuse sustained fatal injuries at 1.7 times the rate of children referred for neglect. Several years ago, the agency eliminated its Special Abuse Unit, which investigated allegations of physical and sexual abuse; one wonders if this was a step in the wrong direction.

Perhaps I am being too critical of CFSA’s internal child fatality report. It is difficult for an agency to criticize itself and recommend changes that may go against its ideological orientation. That is why some states give a Child Advocate, Ombudsperson or Inspector General the duty of investigating certain child fatalities in which the family was known to the child welfare agency. The City Council established the Children’s Ombudsperson in the 2020 legislative session and I advocated for that office to be given that responsibility. After putting that requirement in the original draft, the bill’s framers removed that provision. I hope the Council will consider amending the legislation to ensure that an impartial, independent party reviews some of these deaths and makes the reviews available to the public.

Reviewing the fatalities of children who were involved with CFSA in the five years preceding their deaths provides an opportunity for CFSA to suggest changes in its practices. However CFSA has not taken full advantage of this opportunity this year. First, by eliminating over a quarter of the cases it reviewed based on an arbitrary timeframe, the fatality review committee deprived itself of vital fodder for recommendations and withheld important information from the public. Second, the committee made no recommendations for changes in the agency’s investigative and case management practices that may have allowed serious red flags to be missed, leaving children vulnerable to serious maltreatment during or after their involvement with CFSA. Finally, the report represents a failure to inform the public about the performance of an agency that it pays for. Not only does CFSA’s 2020 internal fatality report fail to derive all the available lessons from CFSA’s mistakes but it does not provide the details necessary to enable members of the public to draw its own conclusions about agency performance. That’s why the City Council should give the new Children’s Ombudsperson the responsibility for investigating and reporting about such fatalities.

*”Manner of death” refers to the circumstances that caused the death, as opposed to “cause of death,” which refers to the specific disease or injury that led to the death

CFSA in the second quarter of FY 2021: rejecting more referrals, serving fewer kids

On Tuesday, Judge Thomas F. Hogan approved a settlement in the 32-year-old case now called LaShwan vs. Bowser–a suit which was filed in 1989 alleging major mismanagement in the District’s foster care system. Today, Mayor Bowser announced the end of court oversight over the Child and Family Services Agency (CFSA). Nevertheless, released by CFSA concerning its operations in the quarter ending March 31, 2021 shows there is still reasons for concern about whether CFSA is complying with its mandate of protecting DC children in a time of pandemic.

A major concern for child advocates has been the possibility that the COVID-19 pandemic would have a double effect–increasing abuse and neglect and also making it less likely to be discovered. As we have already reported, data from the District of Columbia Child and Family Services Agency (CFSA) indeed showed a drastic drop in calls to the CFSA hotline at the onset of the pandemic and associated closures. The most recent data, from the quarter ending March 31, 2021, show the beginning of a return to normal levels of hotline calls, with an uptick in calls from schools and child care providers. But just when calls are starting to return to normal, the agency seems to be focused on limiting these calls and screening out as many as possible. Moreover, a large decrease in the total child population served by CFSA (including those served both in their homes and in foster care) over the course of the pandemic is of concern as it is unlikely to reflect an equal reduction in the number of abused and neglected children.

CFSA’s Data Dashboard is updated 45 days after the end of each quarter. Child Welfare Monitor DC reported on FY 2021 Quarter One (October to December 2020) update in Testimony at the CFSA oversight hearing conducted by the DC Council’s Human Services Committee on February 25, 2021. We also reported on some preliminary data from Quarter two in a post entitled CFSA, DCPS and the Safety of children not in school buildings. This post integrates the full Dashboard data from Quarter Two (the quarter ending March 31, 2021) into an overview of trends since the onset of the pandemic.

Referrals

Figure One below shows the monthly number of calls to the CFSA hotline, known as “referrals,” from March 2020, when the pandemic emergency began, through March 2021, compared to the same dates of the previous year. (Note that March 2020 is included in both 13-month periods as the pandemic closures began in the first half of that month). DC’s sudden closure of schools for an extended spring break in March 2020 was followed by a chaotic virtual reopening, as schools and nonprofits strove to get children connected with computers and internet service. Not surprisingly, the first three months of the pandemic produced a drastic drop in hotline calls, investigations, and substantiated cases of maltreatment. Reports stayed at basically the same level from April to August, unlike a normal year, when reports drop after schools close.

Perhaps in part due to new guidance for educators produced by CFSA about how to spot abuse and neglect in a virtual environment, referrals rose In October 2020 and began to approach the previous year’s level in November and December, then dropping slightly in January in contrast to an uptick in January of 2021. But the number of referrals increased from 1,224 in January 2021 to 1,408 in February and took a staggering jump to 2,233 in March. We don’t know the extent to which this change was due to the fact that about 20 percent of the school system’s population returned to school early in February. Perhaps there was an onslaught of reports from teachers seeing students in person for the first time that school year. March was the first month where the pre-pandemic and pandemic curves crossed: the 2021 uptick contrasted with a downturn in March 2020 when pandemic closures began. In fact, there were many more calls (2,253) in March 2021 than in March 2019 (1858), when all schools were open.

Figure One

Source: Data from CFSA Dashboard and data provided by CFSA for January-March 2020.
Note: March 2020 data are shown twice in this table

The number of hotline calls per quarter is shown in Figure Two. This quarterly view shows how referrals plunged in the first full pandemic quarter (April-June 2020) and have increased in each quarter since then. The total number of referrals fell from 18,751 in the four quarters ending March 2020 to 13,172 in the four quarters ending March 31, 2021.

Figure Two

Source: CFSA Data Dashboard, https://cfsadashboard.dc.gov/page/hotline-calls-referral-type

While monthly data on reporting source are not available, annual data for FY 2020 shown in Figure Three suggest that a decline in reports from school personnel was a major factor behind the fall in referrals overall. In FY 2019, school and childcare personnel made 42.9 percent of all calls to the hotline, but this percentage went down to 35 percent in the pandemic year of 2020. But in FY 2021 to date the percentage of calls that come from teachers actually increased to 47.7 percent–which is higher than the pre-pandemic share of 42.9 percent in FY 2019. This change reflects the big increase in referrals from schools in March, after some children returned to school.

Figure Three

Source: CFSA Data Dashboard, https://cfsadashboard.dc.gov/node/1435406

Once a referral arrives, it can be accepted as an “information and referral” to be referred to another agency, accepted for investigation, linked to an existing open investigation, or screened out as not requiring any response. It is interesting to look at the numbers (Figure Four) and percentages (Figure Five) of referrals that are assigned to these four categories. Figure Four shows the large drop in the total number of referrals at the onset of the pandemic in April 2020, and the resultant rapid drop in the numbers of referrals that were screened out and accepted. But as the total number of referrals started increasing in September 2020, CFSA began screening out more of these referrals and maintaining a similar number of referrals accepted for investigation. The increase in the number of referrals in February (from 1224 to 1408) resulted in a decline in accepted referrals that month, and a near doubling of calls in March 2021 (from 1408 to 2253) resulted in a much smaller increase of accepted referrals from 307 to 379. Basically, the number of referrals accepted for investigation remained similar from September 2020 (345) to March 2021 (379) despite the big increase in referrals after November.

Figure Four

Source: CFSA Data Dashboard, https://cfsadashboard.dc.gov/page/hotline-calls-referral-type

Figure Five shows that with the rapid drop in referrals due to the pandemic, CFSA began accepting a higher percentage of those referrals starting from May to August 2020. But starting in September 2020, as CFSA began getting more calls, screeners began screening out a higher percentage and accepting a lower percentage or referrals. This trend accelerated in February and March of 2021 with the increase in calls to the hotline. This is particularly notable in March 2021, when the number of calls to the hotline jumped from to 2233 from 1408 the previous month. Confronted with this onslaught of new calls, CFSA increased the percentage screened out from 62.9 percent in January 2021 to 71.1 in February to 78.6 percent in March.

Figure Five

This decline in acceptance of referrals is not surprising because CFSA, citing an influx of referrals in the fourth quarter of previous years, made a conscious effort to reduce calls by telling educators that unnecessary calls would be screened out, as described in our previous post, CFSA, DCPS and the safety of children not in school buildings. CFSA’s increased tendency to screen out referrals is somewhat concerning, especially combined with the strong discouragement of referrals in their most recent guidance. Data provided by CFSA in response to a request from Councilmember Nadeau, shown in Figure Five, shows there is reason for concern. (Because the data provided for School Year 2020-2021 extended only through March 30, we requested data for the same period of the two previous years for comparability purposes, and these are the periods covered by the figures below). The number of educational neglect referrals fell from 3,368 in the first three quarters of the pre-pandemic school year of 2018-2019 to 2,378 during the same three quarters of School Year 2019-2020. This is rather confusing since Covid-19 did not shutter schools until March. In the current academic year through March 30, 2021, educational neglect referrals came roaring back. CFSA had already received 3,581 educational neglect referrals as of March 31–more than in the full pre-pandemic year. But the number of accepted educational neglect referrals declined from 956 in SY 2018-2019 to 443 in SY 2019-2020 to 258 in the current school year through March 31.

FIgure Five

Data Provided by CFSA

Figure Six shows the percentage of educational neglect referrals that were accepted, screened out and other. CFSA accepted 28.4 percent and screened out 71.6 percent of educational neglect referrals in the pre-pandemic academic year, 2018-2019. In the disrupted School Year (SY) 2019-2020, CFSA accepted 18.6 percent of educational neglect referrals and screened out 81.3%. And in the current academic year as of March 31, 2021, CFSA had accepted only 7.2 percent of educational neglect referrals and screened out 86.9 percent.

Figure Six

Source: Data Provided by CFSA

CFSA’s intent to keep a lid on educational neglect referrals is understandable. Administrators are presumably afraid of being overwhelmed by referrals of educational neglect. Moreover, there has been considerable pushback by activists in jurisdictions like New York City about reports of parents being investigated for educational neglect when they were not able to obtain computers or internet service. However, it is important to note that while categorized as “educational neglect,” referrals from schools about absences often serve a much broader purpose than ensuring that children are going to school. Chronic absence is often the first indicator that the child is not safe. It may even be an indicator that the child is missing. In the case of Relisha Rudd, who disappeared in 2014 and was never found, 18 days of absences did not trigger a report to CFSA because the absences were excused with the help of a bogus “doctor” who was probably Relisha’s abductor.

Investigations

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.”) It takes up to 30 days, and sometimes more, to complete an investigation, so the trends tend to reflect the previous month’s referrals. Figure Seven shows that the trend in substantiated investigations is very similar to the trend in hotline calls, but with a time lag of about a month. There was a huge decline in substantiated investigations in May, June and July 2020 compared to 2019. Substantiated investigations almost caught up to normal levels in August and September, reflecting the normal decline in hotline during any normal summer, and then fell somewhat below the previous year during the fall. Just as hotline calls approached normal in November and December, so did substantiated investigations in December, January, and February. But in March 2021 there was a big decline in substantiated investigations relative to March 2020, a month that may have been already affected by the pandemic. This may reflect that in January and February, the number of calls again lagged behind the numbers for the previous year. It will be interesting to see what happens in April, after the bulge in new referrals in March.

Figure Seven

Source: CFSA Data Dashboard, https://cfsadashboard.dc.gov/page/investigations-abuse-and-neglect

Educational neglect data provided to the office of Councilmember Nadeau and displayed in Figure Eight show that the proportion of educational neglect referrals that were substantiated increased between School Year (SY) 2018-2019 and SY 2019-2020 (when the pandemic began) and again in SY 2020-2021 as of March 31, 2021. These data may be related to the fact that proportion of referrals that was accepted for investigation has dropped so greatly. Perhaps by screening out such a high proportion of referrals, CFSA is also screening out more allegations that are not worthy of substantiation. But one wonders if there is a cost to this increased discrimination. Perhaps they are also screening out more allegations that would have been substantiated.

Figure Eight

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. 

In-Home Services

When a CFSA investigator considers children in a family to be at high risk of maltreatment, but not meet “in imminent danger of serious harm,” the policy is to open an in-home case for monitoring and servies. In-home cases have become much more common than foster care placements as CFSA has been been laser-focused on keeping children in their homes. On March 31, 2021 there were only 648 children in foster care compared with 1259 children being served in their homes, or 34 percent and 66 percent of the 1907 children being served in total, as Table One shows.

Table One: Number of Children Served in foster care and in their Homes, March 31, 2021

In HomeIn Foster Care Total
Children Served1259 (66%) 648 (34%)1907 (100%)
Source: CFSA Data Dashboard, https://cfsadashboard.dc.gov/page/total-children-and-families-served-their-homes

Based on the early data from the CFSA dashboard discussed in an earlier post, there was a drastic drop in in-home case openings after CPS investigations with the onset of the pandemic. 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 percent. However CFSA stopped publishing these data after the quarter ending June 2020 because the dashboard was not populating as expected, according to CFSA’s response to Child Welfare Monitor DC. So we do not know if that 50 percent decrease was correct nor how many cases have opened since that quarter. But we do know the number of children and families being served in their homes has dropped drastically since the start of the pandemic. The number of children served in their homes dropped by 12.6 percent from 1,441 to 1,259 between March 31, 2020 and the same date in 2021, as shown in Table Two below. This drop in children served in their homes is seriously concerning as in-home services are CFSA’s main way of monitoring the safety of children who are at risk of harm at home.

Table Two: Total Children Served in in their Homes, March 31, 2019, 2020, and 2021

DateMarch 31, 2019March 31, 2020March 31, 202
March 31, 2019136514411259
Source: CFSA Data Dashboard, cfsadashboard.dc.gov

Foster Care

Figure Nine examines foster care entries from March 2020 to March 2021, compared to the previous 13-month period. From March 2020, when the pandemic hit, through November 2020, foster care entries were always lower in the pandemic period, although the number of entries in July 2020 was almost identical to those in July 2019. But starting in December 2020 and continuing through March 2021, foster care entries each month were higher than that month in the previous year. The explanation for this trend is not obvious. Hotline calls and substantiated investigations did not eclipse prior-year levels until March 2021. But I pointed out in an earlier post the pandemic did not seem to be the main cause for changes in foster care entries earlier in the pandemic and this may continue to be the case.

Figure Nine

As shown in Figure Ten, there was a big decrease in foster care entries before the onset of the pandemic from the quarter ending March 31 2019 to the quarter ending September 30, 2019. After that quarter, foster care entries bounced up and down. Nevertheless there was some decline in foster care entries in the pandemic four quarters starting April 2020 compared to the previous four quarters. The number of entries in the four quarters before the pandemic (April 2019 to March 2020) was 269. In the four quarters beginning April 2020, the number of entries was 236. So the number of foster care entries during the pandemic period dropped by 33, or roughly 12.6 percent.

Figure Ten

Source: CFSA Data Dashboard, https://cfsadashboard.dc.gov/page/children-entering-or-re-entering-foster-care-during-fiscal-year

Foster Care Exits

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 2020 than in the same months in 2019, as Figure Eleven shows. This pattern changed after September, with monthly exits sometimes higher and sometimes lower than the previous year, perhaps as the agency and service providers adjusted to pandemic conditions and delayed reunifications began to occur.

Figure Eleven

Source: CFSA Data Dashboard, https://cfsadashboard.dc.gov/page/total-number-exits

Looking at the total number of foster care exits over time, we can see that foster care exits began to increase after the first two pandemic quarters. But exits did decrease overall during the pandemic period. The total number of foster care exits was 324 during the pandemic year from April 2020 to March 2021 compared to 400 in the previous four quarters, as shown in Figure Twelve.

Figure Twelve

During the four quarters approximately corresponding to the pandemic, there were 236 entries into foster care and 324 exits. As a result of the surplus of exits over entries, the total number of children in foster care declined from 737 in March 2020 to 648 in March 2020, which was a decline of 12 percent–similar to the 13 percent that we found occurred between September 2019 and September 2020. This is a continuation of a multiyear decrease in foster care caseloads. However, we did note in earlier testimony that the percentage drop in the number of children in foster care was greater in FY 2020 than in any other year since FY 2014. So the decline in the foster care rolls seems to be accelerating.

As shown in Table Three, the total number of children served either in-home or in foster care dropped from 2,178 on March 31, 2019 to 1,907 on March 31, 2020–a whopping 12.4 percent, which inclded a drop of 12.6 percent in children with in-home cases and 12.4 percent in children in foster care. It is important to note that this is a decrease of over 12 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. Moreover, while the drop in foster cases can be seen as continuing an earlier trend, the drop in in-home cases cannot: the number of in-home cases dropped only slightly more than two percent in the previous year.

Table Three

DateIn-Home
No. (diff. from prev. year)
Foster Care
No. (diff. from prev. year)
Total
No. (difference from previous year)
March 31, 201913658672232
March 31, 20201441 (5.6%)737 (-15.0%)2178 (-2.4%)
March 31, 20211259 (-12.6%)648 (-12.1%)1907 (-12.4%)
Source: CFSA Data Dashboard, cfsadashboard.dc.gov

To look further back, we used figures from the Center for the Study of Social Policy that date back to 2010 showing the total number of children served in foster care and in home on the last day of the fiscal year. Figure Thirteen shows that this total number served was actually increasing between FY 2017 and FY 2019 as continuing declines in the foster care population were offset by increases in the in-home population.

Figure Thirteen

Source, Center for the Study of Social Policy, LaShawn A. v. Bowser, Progress Report for the Period April – December 2019, available at https://cssp.org/wp-content/uploads/2020/06/LaShawn-A-v.-Bowser-Report-for-the-Period-of-April-1-December-31-2019.pdf, and CFSA Data Dashboard (for 2020 data), at https://cfsadashboard.dc.gov/page/total-children-and-families-served-their-homes. Note: there is an inconsistency between CFSA and CSSP in home totals for 2019–1376 (CSSP) vs. .1348 (CFSA)

So the large (12.4 percent) drop in the number of children served by CFSA was not a continuation of an earlier trend. Foster care, but not in-home, caseloads were decreasing before the pandemic. It is extremely unlikely the number of abused and neglected children dropped by 12.4 percent from March 2020 to March 2021. It appears that this big decline results from a combination of a continuing decline in foster care placement and a reduction in in-home case openings due to the COVID-19 pandemic. It is concerning that the agency is serving a significantly decreased population compared to before the pandemic.

In sum, the newest CFSA Dashboard data show some encouraging signs of a movement toward normalcy. Referrals for March 2021 are higher than they were two years before and the number of investigations that are substantiated is approaching pre-pandemic levels as well. However, CFSA has displayed a concerning tendency to screen out a large percentage of the new referrals that are coming in. It is clear that CFSA responded to COVID-19 by screening out more education neglect referrals than ever before. And large decreases in the number of children receiving either in-home services or foster care as of March 31, 2021 compared to a year before raises the question of whether CFSA is performing its duty to protect abused and neglected children in the District. As the agency exits from court oversight in the LaShawn class action suit, it is important to ensure that some oversight continues. As we will argue in upcoming testimony, the Council should authorize an Ombudsperson for CFSA to make sure that somebody is monitoring agency operations in the interests of the District’s abused and neglected children.

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

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.

The CFSA Performance Oversight Hearing: Progress and Problems

Screen Shot 2020-02-17 at 3.32.03 PMThe annual oversight hearing on the Child and Family Services Agency took place on February 12, 2020. The hearing lasted over six hours and covered a wide variety of topics and perspectives. The testimony painted a mixed picture of considerable progress along with continuing concern about major issues including the availability of placements meeting the needs of some of the more difficult-to-serve clients. Much of the testimony centered around CFSA’s responses to the committee’s oversight questions that were submitted in advance. These are a very useful resource that can be compared from year to year. Readers can watch the hearing here.

  • Widespread Praise for CFSA: The last to testify, CFSA director Brenda Donald heralded a year of accomplishment, including planning and getting approval for a five-year Title IV-E Prevention Plan under the new Family First Prevention Services Act, creating the local Families First DC program, reducing the scope of monitoring under the LaShawn class action lawsuit, settling its new arrangement for delivering foster care, fully implementing its in-house mental health unit, and gearing up for new child welfare information system. As she pointed out, CFSA is currently considered to be a national leader in child welfare. Many other witnesses also praised CFSA for these accomplishments or others.
  • Foster Care Numbers: Contrary to national trends, the number of youth in foster care continued to fall in the District since a year ago. Director Donald testified that there were only 796 children in care at the end of 2019 and 1357 were being served in their homes. Reunifications increased from 197 in 2018 to 227 in FY 2019 and the number of children aging out of care fell from 63 to 53. CFSA expects further declines because of the emphasis on front-end prevention, according to Director Donald, as well the agency’s continuing efforts to reduce the length of stay in foster care. Donald did not mention the movement of low-income families into Maryland due to rising rents in the District, which may be an even more important factor behind the continued declines at a time when the national foster care total has been rising.
  • LaShawn Exit Plan: Court Monitor Judy Meltzer of the Center for the Study of Social Policy reported that CFSA and CSSP have agreed on a revised exit plan in the 30-year-old LaShawn vs. Bowser class action lawsuit. The new plan removes 56 of the exit standards; 23 remain to be achieved. As part of the revised plan, CFSA committed to adding several types of placements and it has already satisfied most of these commitments, as described below.
  • Lack of appropriate placements: CFSA continues to struggle with a lack of placements for the young people with the most serious disabilities and behavioral problems, as described in testimony from CSSP’s Meltzer  and witnesses from the Children’s Law Center (CLC). As a result, 31 children spent a total of 60 nights at the agency between April and November 2019. The number of children staying overnight more than doubled between FY 2018 and 2019, as Aubrey Edwards-Luce of the Children’s Law Center pointed out in her valuable written testimony. The number of children staying at the Sasha Bruce emergency shelter also more than doubled. About 100, or one in every eight children, had stayed in an emergency shelter or respite home in FY 2019. Moreover, about 22% of children in care had three or more placements, the same number as the previous year, which suggests a lack of appropriate placements for some children.
  • Additions to Placement Array: CFSA has made some progress in expanding the array of placements that can accommodate children with more severe problems. The agency has contracted with Children’s Choice for 36 therapeutic foster homes for youth with intensive needs; added two “Stabilization Observation Assessment Respite (SOAR) professional foster homes, with a total of four beds, to serve high-needs children; secured six congregate care placements for children with autistic spectrum disorders, and added six additional behavioral therapeutic congregate care placements.
  • Foster Parent Retention and Supports: Judith Sandalow of the Children’s Law Center urged CFSA to focus on retention as well as recruitment of foster families by improving its support for foster parents. Margie Chalofsky of the Foster and Adoptive Parent Advocacy Center (FAPAC) suggested several improvements to foster parent supports, including on-call and timely crisis support, which has not been consistently available through the current resources; more therapy for foster youth; and a mechanism for foster parents to evaluate social workers. Interestingly, Cheryl Brissett Chapman of the National Center for Children and Families gave a dissenting position on retention, arguing that foster parents need to take a break after two therapeutic youths. She also reminded listeners that many foster homes are lost when foster parents adopt the youths in their care and that should not be considered a problem.
  • Education and Employment: Data on education and employment outcomes cited by Aubrey Edwards-Luce from CFSA’s oversight responses continues to be very concerning, although the high school graduation rate among CFSA foster youth actually increased from 67% in FY 2018 to 73% in FY 2019, based on corrected data submitted later by CFSA. The Grade Point Average (GPA)  of the 84 (out of 186) high-school aged children in care for whom this figure was available was only 1.69. Nearly 10% of high school students in CFSA care dropped out in FY 2019. And nine of the 40 foster youth who enrolled in college in FY 2019 dropped out, based on corrected data from CFSA. Moreover, less than half the young people enrolled in vocational programs completed them.
  • Youth aging out: Edwards-Luce pointed out that CFSA’s data on living arrangements of youth aging out of care are deceptive. CFSA reported that only four of the 49 youths who aged out of foster care in FY 2019 exited to unstable housing situations, which it defines being homeless, in a shelter, or incarcerated. However, CLC believes that “the agency improperly defines transitional housing, college dorms, staying with friends, and DDS placements as “stable living arrangements.” If those arrangements are considered unstable, 32 out of the 49 youths who aged out were in unstable housing.
  • Office of Youth Empowerment: CFSA touted its status as the first public agency to be awarded a three-year $10 million grant fromYouth Villages to implement the evidence-based and much-praised YV LifeSet program. But CLC’s Edwards-Bruce expressed concern about the elimination of OYE’s Career Pathways program, which served 113 youths in FY 2019, and its replacement by the LIfeSet Program, which served only 49 youths in the firsts quarter of  FY 2020. According to CFSA’s Annual Progress and Services Report, YV Lifeset requires participant buy-in, and youths who do not wish to participate will receive similar services to those provided under Career Pathways. Moreover, there is some reason for concern that the LifeSet funding may be supplanting rather than supplementing local funds, as discussed below.
  • Aftercare: In her very enlightening oral and written testimony, Marcia Huff of the Young Women’s Project described her experience running CFSA’s aftercare program in a contract that lasted from 2017 to 2019. In a nutshell, Huff found that “the vast majority of the youth we worked with were unprepared to succeed when they emancipated from care at age 21.” Among the depressing data she cited about the young people entering her program: 51% were unemployed; 9% were employed 15 hours or less; and only 20% were employed full-time; 31 out of 75 were homeless or couch surfing; 32% were in temporary housing, and only 9% were in permanent housing with a long-term voucher or rent that was sustainable based on employment; 56% had one or more children; 27% needed help managing marijuana or other drugs; 58% had unresolved mental health issues that interfered with progress in employment and housing; 17% had no GED or high school diploma; and 36% had no bank or deposit account of any kind. Lack of housing was a major obstacle to engagement with the program and progress toward goals and kept many participants in a state of crisis. Lack of child care was a huge obstacle for parenting youth. Huff’s testimony, which should be essential reading for anyone who cares about foster youth, recommended first and foremost that the agency needs to “start young and go deep” to prepare youth for life after care because “by the time they are 20 it is nearly too late and it is extremely hard to turn things around.”
  • Youth Services Reprogramming: Human Services Committee Chair Brianne Nadeau asked about the reprogramming of $449,782 allocated for teen youth services to support for the court monitor in LaShawn, which was not included in the FY 2019 budget. Donald testified that this money was saved by bringing youth aftercare in-house, without any loss of service capacity.  If true, this would point to an appalling inflation of the contract price, which seems unlikely. This writer cannot help wondering whether this money may have instead been replaced by the grant to implement YVLifeSet and hopes Chairwoman Nadeau will look into that possibility.
  • Kinship Care: Several witnesses celebrated the new Close Relative Caregiver Subsidy, including Donte Massey, whose testimony last yea sparked the creation of this program. Massey reported that the program is helping him raise his younger siblings. Stephanie McClellan of the DC Kincare Alliance asked the Council to remove the requirement that a caregiver must wait six month to receive the subsidy. This results in an actual eight-month rate which is a hardship for cash-strapped caregivers. She also asked the Council to consider emergency funding to eliminate the current waiting list. The longstanding Grandparent Caregiver Subsidy also received praise from caregiver Vernita Grimes, who credited program staff with providing emotional and moral, as well as financial, support .
  • Social Worker Support: Wayne Enoch, president of the union local representing 400 workers at CFSA, expressed his members’ concern about worker safety from attacks by clients, even in the office. The union is seeking for a “viable health and safety committee” to work with management on a long-term solution to this problem.  Worker turnover is a concern for CFSA. Social workers complain about work-life balance, support from supervisors, and micromanagement rather than pay and promotions. Despite the problems, Enoch hailed Brenda Donald for her commitment to workers’ well-being and to working with the union through the Labor Management Partnership Council.  He noted that CFSA has appointed a Wellness Coordinator to boost well-being among its workers. He said that other agencies should follow CFSA’s example of labor-management cooperation.
  • Latino Families: Isabelle Suero-Stackl of the Latin American Youth Center (LAYC) argued that CFSA is not meeting the needs of the Latin American community.  Although LAYC has a contract to deliver foster care including case management to Latino families, all of these families are initially managed by CFSA, and most are served directly by CFSA. Moreover, in-home services to all families are provided by CFSA, which may be a problem for a family that does not speak English. Instead, Suero-Stackl recommended that CFSA should assign all Latino families to LAYC as soon as they come into in-home or out-of-home care.
  • Changing nature of foster youth: Both Director Donald and Dr. Cheryl Brissett Chapman of the National Center of Children and Families (NCCF) cited changes in foster youth. They are seeing more young children with aggressive behaviors than in the past. Dr Chapman of NCCF, which manages all of the Maryland foster homes that house about half of the District’s foster youth. had some interesting observations from a long career in child welfare. Unlike the “parentified” children seen in the crack epidemic, who acted as parents to their own parents and their siblings, many of today’s children coming into care are accustomed to be treated by their parents as peers. When they come into foster care, they are not ready to treat foster parents respectfully as adults, and many older, veteran foster parents cannot cope with disrespectful behavior. Surprisingly, placement disruptions are most frequent for children aged 9 through 12, and it is this disrespect that is causing many of the disruptions.
  • CFSA Mental Health Unit: the new mental health unit to provide initial services to youth coming into care seems to have be achieving its goals of allowing CFSA to screen and evaluate children more quickly and get them into therapy sooner.  This unit works with children for six to nine months. Donald testified that CFSA has issued a contract for ongoing mental health services for some children with specialized needs and to serve some parents.
  • Child Protective Services: The number of substantiated investigations went up slightly in FY 2019, as did the number of removals, which Deputy CFSA Director Robert Matthews suggested might be due to the elimination of Family Assessment as an alternative response to investigation. He also mentioned that the quality of investigations is improving as indicated by the agency’s Quality Service reviews.  However, one representative of a charter school raised concerns about the quality of CFSA responses to reports alleging child abuse and neglect. In his written testimony, Christopher Nace of the DC International School mentioned two families that were the subject of repeated and serious reports to CFSA, none of which resulted in actions that protected the children. In the case of the first child, staff reported concerns ranging from sexualized language and behaviors, physical abuse, educational neglect and sex trafficking. none of which resulted in any change in the child’s situation. In the other case, school personnel reported concerns about a family 11 times between 2016 and 2020 on issues including domestic violence witnessed by school staff, children being left alone all night, alcohol and drug abuse in the home, children being driven to school by intoxicated parents, concerns about drug distribution, physical abuse that left bruises; and fights in which weapons were drawn and students were kicked out of the house. Nace recommended that CPS investigations should take into account past allegations as well as the present one and that CFSA should collaborate more extensively with schools and other agencies involved in the lives of children and consider adding regular “check-ins.”
  • Families First DC: The Committee heard from many of the organizations that have received grants to start Family Success Centers under Families First DC, CFSA’s new primary prevention initiative. The grantees have been chosen and given money for a year of planning. The centers are to launch early in Fiscal Year 2021.All of the grantees praised the support of CFSA and the provision of a year to plan their programs with input from community residents. Grantees expressed their excitement about this program.
  • Transparency and Responsiveness: After last year’s hearing, where representatives of several organizations lamented a decline in transparency and community involvement by CFSA, both the Children’s Law Center and the Foster and Adoptive Parent Advisory Council (FAPAC) noted that CFSA had become more open and responsive to feedback from advocates and foster parents in the last year.
  • Ombudsman Proposal: Several witnesses, including Aubrey-Luce of CLC, reiterate the need to move forward the proposal of establishing an independent Ombudsperson for CFSA in order to spur the needed improvements.

This year’s oversight testimony highlighted agency’s ability under the leadership of Brenda Donald to accomplish major initiatives. Of more doubt to this writer is how many of these initiatives actually improve children’s lives. Some of the most important testimony highlighted the major problems that still plague the District’s foster care system, especially the lack of appropriate placements for the hardest to serve children and the lack of effective approaches to enhancing education and employment outcomes for foster youth. As I have written before, CFSA’s vaunted success in getting the first Family First plan approved is of limited utility given the extreme limitations on services available for funding. However, CFSA responded in an email to this writer that “CFSA’s implementation of Family First//// is not designed to produce immediate results. ” Instead, “Family First has created the momentum for the District to look at our referral pipelines, assess the systems we have in place to ensure referral connections are made timely and, have targeted conversations to determine if we have the right services available to meet children and their families’ needs.”

The abysmal outcomes for older foster youth and those who have aged out (while consistent with those around the country) indicate that there is much room for improvement. And the transfer of $450,000 in services to older youth in order to pay for the court monitor’s oversight is particularly concerning considering the great needs of these youth. However, some of the new initiatives, such as the addition of new placements for children with greater needs, the creation of in-house mental health services, and the establishment of Family Success Centers are likely to make life better for children in CFSA care and in the community.

Director Donald’s concluded by expressing her gratitude to the Mayor for supporting CFSA in its request for funding for its new initiatives. She did not however, point out that  parents and youths involved with CFSA rely on other systems, like behavioral health and child care, in order to achieve their goals. Many parents rely on mental health and drug treatment services provided by the Department of Behavioral Health (DBH) to get their children back or keep their children at home–and these services are characterized by waiting lists, high turnover, and insufficient capacity. CFSA has attempted to compensate for DBH deficiencies by creating its own mental health unit for children in care, and is expanding that unit to serve their parents as well, but parents and children with in-home cases will still be relying on services funded by DBH. Youth who have aged out need these services as well, including help in managing their use of marijuana and other drugs, as mentioned in testimony by the Young Women’s Project. Parents with in-home and out-of-home cases, as well as parenting youth in foster care and aging out, all struggle to find and pay for child care. In order to ensure that CFSA can achieve its goals, the generosity of the Mayor must extend to other systems as well.

This post was updated on February 25, 2020 to incorporate corrections and comments from CFSA.