Protecting High Risk Infants
(Originally published January 2016)
Child welfare systems in this country are repeatedly confronted with child poverty, the destitution of a third to a half of families with open cases, large numbers of reports of neglect often combined with substance abuse and parents’ mental health problems (frequently co-occurring) and family violence. Any one of these factors would place children at risk of child maltreatment and a range of developmental problems; when they occur in various combinations in families with infants and other young children, some of whom have medical conditions or disabilities, the risk to children is greatly increased. Forty to fifty percent of child maltreatment related fatalities involve infants, 0-1; infants die in maltreatment related incidents at a much higher rate than even1-5 year old children, according to Child Maltreatment 2014. In addition, early severe neglect compromises infants' immune systems which may result in life endangering illness and increased rates of infant mortality.
In The Science of Neglect: The Persistent Absence of Responsive Care Disrupts the Developing Brain (2012), the Center for the Developing Child at Harvard summarizes decades of research regarding the effects of the severe lack of Serve and Return interactions, i.e., emotionally responsive care, on the developing brain and on children’s cognitive and emotional development. This important report finds that Severe Neglect in a Family Context, i.e., the lack of responsive caregiving associated with neglect of children’s basic needs often leads to lifelong problems in learning, behavior and health, including cognitive delays and reduced IQ, poor executive functioning, inability to concentrate and sustain attention, excessive activation of children’s psychological and physiological stress response systems and difficulties with both emotion regulation and peer relationships. This authoritative summary regarding the effects of early neglect on children makes it clear that young children’s needs for physical safety and responsive nurturing caregiving are interconnected, and that responsive caregiving is essential to infants’ safety, health and well-being.
The Science of Neglect sheds light on how poverty, especially annual incomes less than half the federal poverty standard, mood disorders (i.e., depression, anxiety and PTSD) , substance abuse and domestic violence combine to undermine the parenting of infants and other young children. The day in day out struggle to make ends meet (at best) or survive (at worst) depletes parents’ emotional resources needed to consistently engage in nurturing Serve and Return interactions with babies and other young children and limits the ability of parents to access other care giving resources. Mood disorders, substance abuse and family violence further exacerbate the emotional unavailability of caregivers. In worst case scenarios, parents and other caregivers may respond with hostility and aggression to the heavy child care burden of caring for infants and to infants’ inconsolable crying.
U.S. child welfare systems face an extraordinarily difficult challenge in protecting large number of infants reported to CPS. Putnam-Hornstein and her co-authors found that 5% of infants born in California from 2006-12 were the subject of CPS reports before their first birthday. Almost one-fifth of these babies (18%) were removed from the home following the initial CPS report. Sixty percent of the infants who remained in their parents’ home were re-reported within 5 years; 20% of these infants were re-reported 5 or more times during this 5 year period. Infants who were the subject of screened out reports were re-reported at the same rate as infants in screened in cases. Only 10% of infants remaining at home after the first CPS report received services other than a CPS investigation. Infants were reported for neglect in the great majority of cases, and most subsequent reports were for neglect regardless of the type of maltreatment alleged in the initial report.
In the Putnam-Hornstein, et al, study, factors which increased the risk of an initial CPS report for neglect included low birth weight, birth abnormalities, late prenatal care, low levels of maternal education, public insurance, missing paternity information and CPS reports on another child in the family. The combination of poverty, single parent families and a heavy child care burden resulting from prematurity, medical conditions or disabilities has been found in other studies of multiple CPS re-reports and recurrent maltreatment, and suggests how inadequate financial resources and heavier than usual child care responsibilities can overwhelm the capacity of parents who lack spousal support or other support for parenting. Putnam-Hornstein and her colleagues also found that almost one in ten (8.8%) initial reports alleged emotional abuse of infants, a distressing finding that points to the possibility of a pattern of harsh, non-nurturing interactions between parents and their babies prior to age 1.
Developing an Infrastructure for Protecting Young Children
Putnam- Hornstein’s study of CPS re-reports on infants in California strongly suggests that CPS programs in California in recent years lacked the staffing resources, service array and mind-set to provide early intervention services to families with high risk infants. What these agencies appeared to be doing was removing about one-fifth of infants reported to CPS in their first year of life, infants who may have been clearly in danger due mostly to neglect combined with substance abuse, and quickly closing out the remaining cases with few, if any, services. Waiting for CPS caseworkers to determine that infants and toddlers are Unsafe before intervening is a formula for CPS failure compounded in many communities by a lack of developmentally appropriate services to help children and parents. Child welfare agencies whose main interventions are crisis oriented family centered services, and foster care, lack an infrastructure for protection of babies and toddlers; and it should not be a surprise when these services prove to be “too little, too late.”
There are groups of high risk infants and toddlers, and their caregivers, who urgently need a range of support services before (if possible) CPS reports on these children are received. The children and parents include:
Children with serious medical conditions or disabilities
Pregnant women and mothers of infants with substance abuse and/or mental health conditions
Children whose parents or caregivers are engaged in recurrent family violence
Homeless parents and parents whose incomes are less than half the federal poverty standard
Public child welfare agencies currently lack the resources and (often) the expertise to provide prevention/early intervention services to an expanded group of children and families who may not have been reported to CPS. This is a role for public health departments and/or for family support centers that can offer families a wide range of services. An essential first step to strengthening the protection of infants and other young children is to build strong public health systems that can offer expert help to parents of infants and other young children who present difficult challenges to caregivers; and to develop the capacity for outreach as early as possible to parents with chronically relapsing conditions. Programs such as Kentucky's START, Oregon's OnTrack and Washington State's Parent Child Assistance program (PCAP) are examples of how to provide a combination of ongoing emotional support, concrete assistance and (often) housing for pregnant women or mothers of infants with substance abuse problems. These type of programs can be made available to substance abusing parents with or without CPS involvement.
Nevertheless, CPS programs cannot delegate responsibility for the protection of infants on open cases to other community agencies. This is a difficult challenge that requires changes in CPS practices and practice models, as well as new resources. Infants are too vulnerable to be effectively protected only after they are assessed to be in danger, i.e., unsafe. Furthermore, minor inflicted injuries to infants should never be ignored or minimized; one recent study found that about one fourth of babies and other young children with abusive head trauma had experienced minor inflicted injuries prior to being seriously harmed. In addition, severe lack of nurturance during infancy greatly increases the risk of life endangering illnesses by compromising babies' immune systems. CPS caseworkers need training and tools for assessing the nurturing environment in which infants are parented. Severe deprivation of responsive care of an infant requires an immediate CPS response; delay can be fatal or result in serious long lasting emotional harm to a baby.
CPS programs need new practice models for families with combinations of substance abuse, chronic mental health conditions, family violence and severe poverty. A model developed in Oregon more than 15 years ago used small case management teams consisting of a CPS caseworker, substance abuse treatment professional, parent advocate and mental health specialist to serve 20-25 families at any one time. This model evolved into the Intensive Addiction Recovery Services Teams (IARST) which have served substance abusing parents and their children in some Oregon communities. A child development specialist can be added to these case management teams which could be housed in a single office and bring greatly enhanced resources and expertise to multi-problem families. CPS agencies should also experiment with models that assign two caseworkers to families, one of whom works intensively with parents to support their entry into and completion of treatment programs and the other who concentrates on infants and other young children in the family. Concretely, CPS programs need to bring more expertise and more hands on deck to work with parents and children who which have such extensive needs. A single child welfare caseworker who must organize several busy professionals to meet regularly to develop a case plan for families with multiple challenges is likely to be overwhelmed by the many challenges these families present. In addition, CPS programs need new resources such as day nurseries, respite care on demand and high quality child care to support families with high risk infants. Oregon's Relief Nurseries is a model program that can be widely replicated to serve infants and other young children.
A Relief Nursery manager provided the following description of Oregon's 26 Relief Nurseries:
“Relief Nurseries serve the most vulnerable families with children, 0-6. We offer a therapeutic classroom coupled with home visits by the teacher of the classroom. Some families are served simply with home visitation – if this is what best meets their needs. We also offer parenting education, respite care, resource referral and emergency basic needs help … Many of the Nurseries offer support groups for recovery from alcohol and drug addiction; others offer mental health counseling for children and adults; some offer help with basic medical needs, such as immunizations, eye and dental exams, etc. We have strong cooperative relationships with Department of Human Services; some Nurseries have staff co-located in DHS offices. Many of the Nurseries have contracts to provide Healthy Families programs and three of the nurseries have affiliated Head Start programs in their buildings.”
Some families are referred to a Relief Nursery by DHS, some parents self refer and others are referred by community agencies. The Nurseries receive both public and private funding. I was informed by the Director that “Our outcomes are stellar. A recent evaluation by Portland State University found that after six months, more than 95% of families had no further involvement with the child welfare system.”
There are other promising programs for serving high risk infants and their families around the country, including Safe Baby Courts, Family Treatment Drug Courts, Pregnant and Parenting Women residential treatment programs that allow mothers to retain physical custody of their infants, and many others. These programs are costly, but foster care, adoption and adoption support are also costly; and these costs which often extend to age 18 are rarely questioned.
There was a lengthy period in child welfare when foster care, termination of parental rights and adoption were considered by many practitioners, judges and policymakers to be optimal strategies and outcomes for young children of substance abusing parents and for many other maltreated children as well. Parent advocates and attorneys and some scholars have periodically questioned these views because of the severe emotional harm suffered by
parents who lose their children in dependency and termination actions and because of abuses of power and unnecessary removals which sometimes occur when CPS caseworkers view foster care as the default solution to children's need for safety.
However, some research studies in the past decade have raised troubling questions about the quality of foster care for infants and the effects of foster care on infant development. Bada, et al,(2008) found that infants exposed in utero to opiates and/or cocaine did no better developmentally in foster care than when parented by their mothers, and that every move from one home to another caused developmental harm to infants. Research based on the National Study of Child and Adolescent Well Being (NSCAW) has found that infants are often placed in foster homes with other babies and young children, arrangements that may limit the amount of responsive care giving an infant receives. Furthermore, many child welfare agencies have acute and chronic shortages of foster homes which ensure that some homes will be overcrowded. Child welfare agencies may move infants and other children from home to home, sometimes for administrative reasons.
Foster care is an essential resource for some children, and many babies and young children receive wonderful care. Nevertheless, the quality of foster care is erratic and uncertain, and has not been found to confer dramatic improvements in child development for maltreated children, especially for infants.
Finally, it is one thing to depend solely on foster care (kin or non-kin) when there is no other reasonable way to protect children from serious child maltreatment; it is something else to fail to provide safe alternatives to foster care when effective model programs exist, and can allow children to remain in the care and custody of birth parents. It has become feasible to fund other ways of protecting infants and other young children, but not on the cheap and not with most CPS practice models currently in widespread use.
Bada, H., Lagasse, J., Twotney, J., Bursi, C., Shankaran, S., Lster, B., Higgins, R. & Maza, P., “Importance of Stability of Early Living Arrangements on Behavioral Outcomes of Children With and without Prenatal Drug Exposure,” Journal of Developmental and Behavioral Pediatrics, Volume 29, No. 3, June 2008.
Putnam-Hornstein, E., Simon, J., Eastman, A.& Macgruder, J., “Risk of re-reporting among infants who remain at home folllowing alleged maltreatment,” Child Maltreatment, Volume 20 (2), 2015.
The Science of Neglect: The Persistent Absence of Responsive Care Disrupts the Developing Brain, Center for the developing Child, Harvard University, 2012.