DEE WILSON CONSULTING
Commission to Eliminate Child Abuse and Neglect Fatalities:
Final Report
(Originally published March 2016)
Congress created the Commission to Eliminate Child Abuse and Neglect Fatalities (CECANF) in 2013. Twelve commissioners appointed by Congress and the President were given a little more than two years to develop a national strategy to end child maltreatment fatalities, an ambitious goal given the lack of even a modest reduction in the number of these fatalities reported in National Child Abuse and Neglect Data Systems (NCANDS) during recent years. The Commission was chaired by David Sanders, Executive Vice President for Casey Family Programs. Other commissioners included Michael Petit, one of the leaders of the National Coalition to End Child Abuse Deaths which lobbied for passage of the Protect Our Kids Act that created the Commission; David Rubin, a pediatrician and child welfare researcher at the University of Pennsylvania; Theresa Covington, Director of the National Center for the Review and Prevention of Child Deaths; Wade Horn, former head of the Administration for Children and Families; Judge Patricia Martin from Cook County, Illinois; Susan Dreyfus, a former director of umbrella human services agencies in Wisconsin and Washington; Marilyn Zimmerman, Director of the National Native Trauma Center; Cassie Statuto Bevan, a Child Welfare Fellow at the Center for Children's Policy, Practice and Research at the University of Pennsylvania; Jennifer Rodriquez, Executive Director of the Youth Law Center; Robert “Bud” Cramer, a former Congressman from Alabama; and Amy Ayoub, President of The Zen Speaker. The Commission held public meetings in 11 locations around the country in 2014-15 and heard from a wide range of researchers, child welfare managers and advocates, as well as parents and children who had personal experience with CPS.
The Commission's final report, Within our Reach: A National Strategy to Eliminate Child Abuse and Neglect Fatalities, estimates that 3,000 children in the United States die annually due to abuse and neglect, almost double the 1500-1600 maltreatment fatalities reported by the states/jurisdictions to The National Child Abuse and neglect Data Systems (NCANDS). The Commission concluded that child maltreatment deaths have been systematically under-counted by states and the federal government due in part to NCANDS policies and rules and is therefore a much bigger problem than described by NCANDS data. The Commission also found that “there are few promising or evidence-based solutions that have been shown to reduce child maltreatment deaths,” a perspective repeated at least seven times in the report. Nevertheless, the Commission's final report expresses confidence that despite the lack of proven solutions and the lack of recent progress, child maltreatment fatalities can be eliminated. Furthermore, the Commission asserts that an immediate reduction in child fatalities can be achieved by timely implementation of the strategy it recommends. These are claims seemingly designed to raise expectations and increase the political costs of inaction. Is the Commission's confidence in its recommendations an act of faith, political chutzpah, or a well founded estimation of the likely benefits of several promising practices already sufficiently developed to be brought to scale?
The Overview
David Sanders' introductory remarks provide admirable clarity regarding the “need to dramatically redesign our approach to eliminate child abuse and neglect fatalities.” Currently, the nation's child protection systems are reactive, often intervening after children have been severely injured or killed. The Commission's report cites research indicating that about half of families of children who die due to child maltreatment (and only about a third of child victims) have been reported to CPS prior to their child's death. Furthermore, the great majority of child victims are 0-4; these young children are too vulnerable to wait until they are injured or in danger from abuse or neglect to respond with supportive services.
Sanders comments that “Members of Congress have taken the lead in proposing an emphasis on funding prevention and early intervention services in order to mitigate the need for late-end, crisis oriented, intrusive, and expensive interventions.” To this end, he asserts that “Involvement of
health care and public health agencies and professionals is vital to safety for children.” Sanders cites research in California that found a CPS referral to be the best predictor of child fatality due to inflicted or unintentional injury, and calls for changes in screening practices that would insure CPS programs follow up on all reports involving infants and toddlers and children with repeat referrals. He mentions the importance of achieving a more accurate count of child maltreatment fatalities and endorses the “continued testing, development and evaluation of strategies...” Based on this overview, readers might expect recommendations for initiatives that will develop a child welfare system with greatly enhanced capacity for prevention/early intervention, based on principles and methods utilized in public health, and which carefully tracks the outcomes of interventions designed to benefit the most children and families. Unfortunately, the Commission's final report does not come close to fulfilling these expectations.
The Strategy
Within Our Reach: A National Strategy to Eliminate Child Abuse and neglect Fatalities highlights ten recommendations (out of more than one hundred), six of which the report asserts “will begin to save children's lives immediately.” These recommendations include:
1. The Look-back and State Plan: a requirement that states conduct a review of all child abuse and neglect fatalities from the past five years and, based on information gathered in the review, develop and implement a fatality prevention plan. Some critics refer to these recommendations as the “Surge”. Commissioners do not agree regarding the need for the “Surge” or how and to what extent to fund it, a surprisingly public difference of opinion in a report intended to convince policymakers to take legislative action. Some Commissioners want Congress to appropriate at least a billion dollars to support the review, planning and implementation process. Another group of Commissioners support additional funding to states to enable the “Surge”, but were unwilling to recommend a specific enhancement to current federal funding for child welfare. Still other Commissioners recommend the use of existing funding streams to support the initial costs of the “Surge”, but were unwilling to recommend larger federal investments in child protection “until additional evidence is developed” regarding effective approaches to preventing child fatalities. At least one Commissioner opposed making a specific request for additional funding; but “if funding is recommended it should be recommended for all for all recommendations made by this Commission,” essentially a vote of no confidence in the “Surge”.
2. A requirement that states change their screening policies to ensure that “all referrals of children under age 3 and repeat referrals receive responses,” a recommendation with the potential to greatly reduce states' screen out rates given that 20-25% of families with accepted CPS reports are re-reported within 12-18 months, and half of families are re-reported within a few years. The final report recommends that the federal government fund these new screening practices but does not indicate what the likely costs would be.
3. ACF “should spearhead a special initiative to support state and local entities engaged in protecting children, such as law enforcement and CPS, in sharing real time electronic information on children and families.”
4. The federal government should make receipt of CAPTA funds contingent on states conducting reviews of life threatening injuries similar to their child death reviews.
5. Medicaid rules should create incentives for greater investment in families at elevated risk of maltreatment. Home visitation programs should be required to serve the highest risk families.
6. The federal government should set minimum standards for states to determine which groups of professionals should be mandated reporters, and allow training of these reporters to be funded by Title IV-E.
7. The Children's Bureau should report directly to the Secretary of the U.S. Department of Health and Human Services, and the Children's Bureau should be required to make annual reports to Congress regarding implementation of the Commission's recommendations.
8. Congress should hold joint hearings on child safety in committees that oversee CAPTA, IV-E, IV-B and Medicaid to better align national policies, resources and goals pertaining to prevention of fatalities and the safety of children.
9. Congress should establish a multi-year innovation program to finance the development and evaluation of promising multidisciplinary prevention initiatives to reduce child maltreatment fatalities.
10. Congress should support flexible funding through re-authorization of IV-E waivers, and pass the Family First Bill to allow states to use IV-E funds for a statewide prevention program.
These are the recommendations the Commission's final report has chosen to emphasize. With a single exception, i.e., changes in CPS screening practices, not one of the ten highlighted recommendations would quickly lead to changes in CPS practices, the development of a more experienced well supported child welfare workforce, more and better supports to children and families or greatly enhanced prevention/early intervention services targeted at specific behaviors such as the physical punishment of infants and toddlers or safe sleep practices, or development of a more robust public health system. It's impossible to know what might come out of states' prevention initiatives, but any process that begins with two years of review and planning will not achieve quick results. Furthermore, screening in all CPS reports of infants and toddlers will not improve child safety unless investigations/ assessments lead to effective services, which currently they do not for most children and families. (see Putnam Hornstein, et al's, 2015 study of CPS reports of infants in California). Reduction in screen-out rates could have a negative effect on child safety if already overwhelmed child protection systems are required to conduct many more investigations or assessments without adequate increases in staffing levels.
The highlighted recommendations are a list for policy “wonks” and federal bureaucrats: reviews (of fatalities), development of state plans under onerous HHS guidelines, changes in reimbursement formulas, CAPTA rules or administrative structures at the federal level and joint hearings to better align federal funding streams. These are not the types of recommendations likely to have an immediate effect on the number of maltreatment fatalities or life endangering injuries to children. In addition, what must be done immediately to make steady progress eventually possible, that is, use of credible, accurate and standardized measurements of child maltreatment fatalities consistently applied, is not mentioned in the highlighted recommendations. The best use of a 5 year look-back at child maltreatment fatalities would be to establish a credible baseline by which to measure the effectiveness of states' prevention initiatives. Absent credible measures applied consistently and with integrity, it will be impossible to evaluate whether more effective practices have been identified and implemented by states and large cities.
A New Child Welfare System for the 21st Century?
Whatever one thinks of the “Surge” or proposed changes in screening practices, these and several other highlighted recommendations address the nation's child protection system as currently organized. However, recommendations that would create a new child welfare system better equipped to deliver “high quality” (in the language of the report) prevention and early intervention services to at-risk families are widely dispersed throughout the report and are not organized around one or two key proposals. There is no series of recommendations designed to create or fund a service delivery system to provide these services on an ongoing basis, and no discussion of possible costs of a better designed child welfare system. States' prevention plans, as required in the “Surge,” could develop proposals for more and better prevention/early intervention services, but a one time billion dollar enhancement – or a much larger enhancement – would not sustain an endeavor that will likely require large new expenditures not once, but every year, at least until preventive services greatly reduce CPS reports. Furthermore, the Commissioners who want to support the “Surge” with a billion dollar enhancement “believe that the first year of funding should support state efforts to implement case reviews of children known to CPS.”
The report emphasizes the importance of multidisciplinary supports for at- risk children and families and community collaboration for effective child protection, and advocates that multidisciplinary reviews and home visits occur for children and families identified as “at risk” in states' 5 year review of child fatalities. However, competent child welfare practitioners and managers have understood the critical importance of multidisciplinary support for child protection for decades; this is not a new idea. A new system designed to be proactive on behalf of child safety and well being must also have (1) greatly enhanced resources and (2) a service delivery system able to deliver or manage prevention/early intervention services. The Commission appears to believe that greatly enhanced resources can be provided by flexible use of existing federal funding streams and by Medicaid, following rule changes advocated in the report. The Commission anticipates that service delivery models can be developed through states' prevention plans and/or federally funded research and demonstration projects. However, in my experience, it is next to impossible to create new service delivery systems through time limited research and demonstration projects.
The differences of opinion among Commissioners over funding of the “Surge” has diverted attention from the most audacious idea in the report: that funding of “high quality” prevention/early intervention services potentially amounting to billions of dollars can be achieved through waivers, child welfare finance reform, and changes in Medicaid rules without
contentious political arguments over specific amounts authorized through these funding mechanisms. The hope that enhanced funding for prevention possibly amounting to billions of dollars over many years can pass “under the radar” without political controversy may explain why this recommendation is not highlighted.
Recommendations which do not describe the administrative arrangements of a new child welfare system, outline a plausible way they can be created or identify services the new system would deliver except in general terms leave undefined what “a new child welfare system for the 21st century” would be. The only prevention program the report touts is Nurse Family Partnership (NFP). A 2014 study found that participation in NFP resulted in fewer deaths from all causes to both mothers and children over a 21 year period. This study had a sample size of a few hundred children; it was not designed to ascertain the effect of NFP on child maltreatment deaths. Currently, there is not compelling evidence that NFP or other home visitation programs, if taken to scale, would reduce child maltreatment deaths.
Summary
Possibly the most important contribution of the Commission's final report is it's attempt to reorient (and reinvigorate) child protection systems toward the goal of eliminating child maltreatment fatalities. The report does not offer an explanation regarding why such a reorientation is necessary 45-50 years after the development of the modern child protection system. How can public systems developed in response to battered child syndrome fail to measure serious injuries or life endangering injuries on open/ recently open cases? Why do most states lack accurate and credible measures of child maltreatment deaths, tenaciously resist release of information following child deaths on open cases, engage in the same types of ineffective programmatic reforms year after year, ignore federal legislation that has the potential to protect children in extreme cases, and neglect the needs of vulnerable child populations such as infants and toddlers? The Commission's report does not discuss the history of child protection that explains these patterns, but this history must be taken into account to dramatically improve child protection.
The Commission's report advocates that states develop maltreatment fatality prevention plans after an in-depth review of their child maltreatment fatalities. I am skeptical that state child welfare systems can be reoriented in this way, but I hope to be proven wrong. In the meantime, there is likely to be a trade-off between improved measurement practices, which will almost certainly increase the number of child fatalities in official counts, and improved practices that hopefully will prevent some child deaths.
Please see "Hidden in Plain Sight: The Path Away From Child Maltreatment Fatalities" that offers alternative strategy for reducing child maltreatment fatalities.
References
Martin, P., The Dissenting Report of the Honorable Judge Patricia M. Martin, March 14, 2016. Available at http://nccpr.org/reports/JudgeMartinDissent.pdf
Olds, D., Kitzman, H., Knudtson, M., Anson, E., Smith, J. & Cole, R., “Effect of Home Visitation by Nurses on Maternal and Child Mortality,” JAMA Pediatrics, published online, July 7, 2014.
Putnam- Hornstein, E., Simon, J., Eastman, A., & Macgruder, J., “Risk of re-reporting among infants who remain at home following alleged child maltreatment,” Child Maltreatment, Vol. 20 (2), 2015.