U.S. Child Welfare System Redesign – Prevention: Data to Action

 

United States Child Welfare System Redesign

Strategic Action Plan

 

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Chapter 2. Prevention: Data to Action: Analysis and Action Steps

 

The Redesigned Child Welfare System not only improves the reactive response to reports of child abuse and neglect, but also provides proactive steps to eliminate the first instance of child abuse and neglect from occurring. This chapter provides examples of taking data already gathered and creating a new Prevention aspect to the Child Welfare System.

Several reports created by federal and state Child Welfare Systems on a monthly or annual basis provide rich sources of data which can be used to direct action to be taken to prevent child abuse and neglect before it results in a report to 911. Thus, CWS becomes both a reactive and a proactive agency at the forefront of reducing and even eliminating child abuse and neglect.

Only charts that contain data that could be used in a proactive manner are included below. The Recommendations from this section, plus the Redesigned CWS Steps from the previous chapter, are combined as the Strategic Action Plan to lay the framework for major modifications to the Child Welfare System for the benefit of all children.

United States Child Mortality 2018
United States Child Mortality 2016

United States Child Mortality 2016 Analysis

The above table represents the number of child deaths, ages 0 through 19, in the United States in 2016. For this analysis, the currency of the data is less important than the types of data demonstrated in the data. When state CPS units perform post-mortem analysis of child deaths in their states, most of them focus on Homicides which, in 2016, represented the deaths of 2,717 children, or 3.3 children out of 100,000 child population in 2016. CPS distinguishes homicides committed by family members of the child from homicides by others. Some CPS units only look at homicides of children who were in or went through their Child Welfare System.

 

Prevention: Data to Action:

By only looking at Homicides when viewing child deaths, 2,717 sounds like a lot of children and a sufficient number to meet the standards to review “Child Fatalities.” However, 2,717 children’s deaths represent only 6.24% of the total of 43,521 children’s deaths that year. If CPS is to prevent children’s deaths, other causes of deaths need to be explored as well. These additional causes of death are included in the Action Steps below, as well as a requirement that ALL homicides of children be reviewed and analyzed, not just the ones for which CWS was involved. CWS needs to understand how many children died without any CWS awareness or action by CWS.

Action Step 2.0.1: Review of Child Fatalities: Homicides: Using data gathered from a variety of sources, including state demographics, Medical Examiner reports, law enforcement records, etc., for children aged 0 through 18 (or 19, 20, 21 – the predetermined cutoff for the definition of “child”), examine EVERY child death caused by Homicide. For those children who died by Homicide for which there is no record of CPS action, determine and record/capture whether there was a report of suspected abuse that was screened-out, not assessed, assessed and determined “unfounded for abuse”, etc. Further, for those children for which there is no CWS record at all, investigate the city or county in which the child was located to determine if anyone had called in a suspected child abuse or neglect report – these children would have been among the approximately 55% of calls for which no CWS record was created. Identifying and tracking any and all attempts to help the child is important to building a prevention strategy. For example:

  • If the child died due to homicide and was under CWS auspices, then a failure within CWS needs to be addressed and remedied, to avoid future child deaths due to that CWS failure. This is not intended to be punitive, but to be used to improve processes, procedures, training, and/or services. Some examples of follow-up investigations and remedies include:

 

    • If the child was at home with a Safety Plan and In-Home services at the time of their death, then neither the Safety Plan nor the In-Home services were effective in preventing the child’s death.

 

      • Investigate how often the child and family were visited to determine if more frequent visits would be warranted.

 

        • If the child was not seen at every visit and there are no procedures stating that the child must be seen at every visit, then the procedures need to be modified to clearly state that the child (and all other children in the family) MUST be seen and talked to at ALL visits to the family. Ensure that ALL CWS staff, not just Family Services Workers in CPS are aware and understand the new requirements.

 

        • If the child was not seen at every visit but there were procedures stating that the child must be seen at every visit, then determine whether the Family Services Worker should be charged with negligence, reprimanded, fired, or simply retaught the importance of seeing the child at every visit. Ensure that ALL CWS staff, not just Family Services Workers in CPS are aware and understand the existing requirement.

 

        • If the child was seen at every visit, but the visits were less frequently than weekly and there were no procedures stating that the child and family must be visited every week, then the procedures need to be modified to clearly state that the visits to the child and family must be weekly. Ensure that ALL CWS staff, not just Family Services Workers in CPS are aware and understand the new requirements.

 

        • If the child was seen at every visit and the visits were weekly as stated in the procedures, then question whether the Family Service Worker noticed anything different in the last meeting with the child and family. It is quite possible that the perpetrator of the homicide was either (1) able to deceive the Family Service Worker during visits and/or (2) the homicide was an explosive event without warning. Ensure that ALL CWS staff, not just Family Services Workers in CPS are aware and understand the requirements about weekly visits and seeing and talking with the child at each visit.

 

      • Investigate the Safety Plan and In-Home services provided to the family of the deceased child to determine if a failure of one of those programs resulted in the child’s homicide. Talk with the family members individually. Detect whether any family member recognized the escalating violence but was afraid to say anything, or didn’t believe the child would be killed.

 

      • Take note of the specific Safety Plan and specific In-Home services being provided to the family of the deceased child to compare against other deceased children under CWS authority. Determine if a different Safety Plan or In-Home service may have prevented the child’s homicide.

 

    • If the child was in Foster Care (redesigned as Therapeutic Respite Care) at the time of the homicide, presumably Law Enforcement has taken the perpetrator into custody. Investigate the Care facility to determine if other children are at the facility and whether any of those children have been harmed or neglected. Action, with respect to the Care facility, depends on the culpability of the Care facility operator or “parent.”

 

      • If the Care facility owner/operator or “parent” killed the child, then the Care facility is immediately closed, any other children at that Care facility are moved to other Care facilities, and all staff and volunteers at the Care facility are interviewed to determine their potential to be held as an accessory to murder.

 

      • If a Care facility staff member or volunteer killed the child, then all staff and volunteers at the Care facility are interviewed to determine their potential to be held as an accessory to murder. If it is found that an owner/ operator or “parent” was aware of the potential or actual danger and/or of the killing, then the Care facility is immediately closed, any other children at that Care facility are moved to other Care facilities, and the owner/operator or “parent” is arrested as an accessory to murder.

 

      • Investigate how often the child was visited by CWS at the Care facility to determine if more frequent visits would be warranted.

 

        • If the child was not seen at every visit and there are no procedures stating that the child must be seen at every visit, then the procedures need to be modified to clearly state that the child (and all other children in the family) MUST be seen and talked to at ALL visits to the Care facility. Ensure that ALL CWS staff, not just Placement Workers in CPS are aware and understand the new requirements.

 

        • If the child was not seen at every visit but there were procedures stating that the child must be seen at every visit, then determine whether the Placement Worker should be charged with negligence, reprimanded, fired, or simply retaught the importance of seeing the child at every visit to the Care facility. Ensure that ALL CWS staff, not just Placement Workers in CPS are aware and understand the existing requirement.

 

        • If the child was seen at every visit, but the visits were less frequently than weekly and there were no procedures stating that the child and family must be visited every week, then the procedures need to be modified to clearly state that the visits to the child in the Care facility must be weekly. Ensure that ALL CWS staff, not just Placement Workers in CPS are aware and understand the new requirements.

 

        • If the child was seen at every visit and the visits were weekly as stated in the procedures, then question whether the Placement Worker noticed anything different in the last meeting with the child at the Care Facility. It is quite possible that the perpetrator of the homicide was either (1) able to deceive the Placement Worker during visits and/or (2) the homicide was an explosive event without warning. Ensure that ALL CWS staff, not just Placement Workers are aware and understand the requirements about weekly visits and seeing and talking with the child at each visit.

 

  • If the child died due to homicide and was NOT under CWS auspices, then an investigation is made into whether CWS had been notified and took no action or if CWS was never notified of the potential child abuse or neglect.

 

    • If no report of potential child abuse or neglect was reported, investigate the neighborhood and city/town where the child lived. Determine if a media campaign needs to be formulated to encourage people to report anything they suspect may be child abuse or neglect. Perhaps there is a resistance to interfere with other families, which could be addressed through a community discussion on the topic of child safety. Perhaps everyone was afraid of the perpetrator and now have guilt or remorse, which can also be addressed through a community discussion. Follow-up with the town whenever a child dies from homicide.

 

    • If a report of potential child abuse or neglect was reported, but was screened-out at Screening, then the redesign of the CWS Intake and Screening processes will ensure that the situation does not occur again. In short, all calls of potential child abuse or neglect are routed to 911, which alerts a CPS Caseworker who must respond to the call in all cases.

 

    • If a report of potential child abuse or neglect was reported, but was not assessed, or assessed as “unfounded for abuse,” or the case was determined “founded for abuse” but the victim was left at home without a Safety Plan and the case closed – all of these situations where a case could be ignored or not investigated have been eliminated in the redesigned CWS, as noted above and in the CWS Intake flow section.

 

Action Step 2.0.2: Review of Child Fatalities: Suicides: From the above Table, it is clear that the number of child deaths due to suicides is nearly as large as the number of child deaths due to homicides: 2,560 children killed themselves in the United States in 2016; this represents 3.1 children per 100,000 children or 5.88% of all children’s deaths that year. Children, especially young children, do not consider suicide unless their life is so horrendous that they can no longer live in it. Many states have campaigns against child suicides, but many CWS units do NOT consider suicides in their child fatality reviews. The redesigned Child Welfare System includes child suicides in ALL investigations into child fatalities for every state and at the federal level.

  • Using data gathered from a variety of sources, including state demographics, Medical Examiner reports, law enforcement records, etc., for children aged 0 through 18 (or 19, 20, 21 – the predetermined cutoff for the definition of “child”), examine EVERY child death caused by Suicide.

 

  • For those children who died by Suicide for which there is no record of CPS action, determine and record/capture whether there was a report of suspected abuse that was screened-out, not assessed, assessed and determined “unfounded for abuse”, etc.

 

  • Further, for those children for which there is no CWS record at all, investigate the city or county in which the child was located to determine if anyone had called in a suspected child abuse or neglect report – these children would have been among the approximately 55% of calls for which no CWS record was created.

 

  • Identifying and tracking any and all attempts to help the child is important to building a prevention strategy.

 

  • Rather than repeat the long sequence of steps, use the pattern established in 2.0.1 for child suicides as well.

 

Action Step 2.0.3: Review of Child Fatalities: Unintentional Injury: From the above Table, it is clear that the number of child deaths due to “Unintentional Injury” is over 3 times the number of child deaths due to homicides: 8,266 children died of “Unintentional Injury” in the United States in 2016; this represents 10.1 children per 100,000 children or a massive 19% of all children’s deaths that year. Obviously, some, perhaps most, of those child deaths were actually a result of “Unintentional Injury.” However, perpetrators are clever enough to disguise a homicide as an “Unintentional Injury.” The redesigned Child Welfare System includes child deaths due to “Unintentional Injury” (except motor vehicle accidents where the child was not the only victim) in ALL investigations into child fatalities for every state and at the federal level.

  • Using data gathered from a variety of sources, including state demographics, Medical Examiner reports, law enforcement records, etc., for children aged 0 through 18 (or 19, 20, 21 – the predetermined cutoff for the definition of “child”), examine EVERY child death caused by “Unintentional Injury”(except motor vehicle accidents where the child was not the only victim).

 

  • For those children who died from other “Unintentional Injury,” first match the child and the child’s family against the CWS database for any record of the child’s or the child’s family’s current or prior involvement with CWS, including determining and recording/capturing whether there was a report of suspected abuse or neglect that was screened-out, not assessed, assessed and determined “unfounded for abuse”, etc.

 

  • After that initial investigation (regardless of outcome), talk with the family of the deceased child to hear the conditions that lead up to the child’s unintentional injury which caused the child’s death.

 

  • Determine if neglect was potentially involved or if there are unusual conditions following the child’s death (e.g., husband or live-in partner suddenly leaving, or live-in partner suddenly moving in, etc.).

 

  • Bring up any CWS report data that may indicate that the child may have the specific type of unintentional injury that caused their death. For example, was a previous report determined “unfounded” and a parent excused for what was reported to be suffocating the child – and the child dies from suffocation (which has a high number of child fatalities in the table above).

 

  • Unfortunately, due to the official designation of “Unintentional Injury” as the cause of death, and in the absence of any further evidence or admission, the true cause of these children’s deaths may not be determined.

 

Action Step 2.0.4: Review of Child Fatalities: Natural: From the above Table, it is clear that the number of child deaths due to “Natural” causes is the leading cause of death in children: 29,508 children died of “Natural” causes in the United States in 2016; this represents 35.9 children per 100,000 children or a whopping 67.8% of all children’s deaths that year. Obviously, some, perhaps most, of those child deaths were actually a result of natural causes. However, perpetrators are clever enough to disguise a homicide as a natural cause. The redesigned Child Welfare System recommends including a cursory review of child deaths due to “Natural” causes in investigations into child fatalities for every state and at the federal level.

  • Using data gathered from a variety of sources, including state demographics, Medical Examiner reports, law enforcement records, etc., for children aged 0 through 18 (or 19, 20, 21 – the predetermined cutoff for the definition of “child”), for EVERY child death caused by “Natural” causes, ONLY match the child and the child’s family against the CWS database for any record of the child’s or the child’s family’s current or prior involvement with CWS, including determining and recording/capturing whether there was a report of suspected abuse that was screened-out, not assessed, assessed and determined “unfounded for abuse”, etc.

 

  • If that initial investigation discovers a match, review notes on the CWS record that may indicate that the child did have whatever “Natural” condition that “officially” caused their death.

 

  • If there is no record of the condition, write on the child’s CWS record and the child’s family CWS record the official cause of the child’s death. This information may be of use if there is a future child abuse or neglect report or another child fatality in that family.

 

 

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To submit questions or comments, please email Jo@Jo-Calk.com. I welcome all input, ideas, and suggestions. Thank you for caring for children.

Blessings,

Jo Calk