Effects of Moral Outrage on Child Welfare Reform

(Originally published March 2011)

The aftermath of recent abuse related child deaths in Florida and New York City provide a reminder of a cycle in which public child welfare agencies in the U.S. and England seem stuck: abuse or neglect related child deaths following several CPS referrals, often from a single concerned person or organization; media exposure of inadequate or unskilled CPS response leading to public outrage; high profile case reviews by child welfare managers, blue ribbon review panels and/ or grand juries; the firing of caseworkers or supervisors for violations of agency policies and, in some instances, falsification of records; an insistence from child advocates and editorial writers that there be an in - depth review of system failures and organizational deficiencies contributing to failures of child protection; public "mea culpas" by top managers and elected officials vowing to do better on behalf of vulnerable children.


Within a few weeks or months, public child welfare agencies in these jurisdictions will likely announce wide ranging reform initiatives that may increase the number of CPS investigators, tighten up procedural requirements recommended by a blue ribbon fatality review committee, possibly revise or alter safety assessment/ safety planning tools, train staff in new practices and procedures, perhaps enter into new agreements with other community agencies or add liaison positions whose job it is to facilitate improved inter - agency communication and collaboration. Editorial boards and child advocates will register their approval of these ambitious reforms; public interest in the state or county child welfare system will diminish; implementation of announced reforms will proceed with an energy proportionate to the continued commitment of top managers and elected officials to the reform agenda, and other child welfare concerns pushed to the side during the political crisis will come to the fore.

There are, however, new variations to this common story. In recent years, there have been prosecutions for negligence and/or falsification of records of both public and private agency staff; and, in fact, a caseworker and supervisor face criminal charges in the recent New York City case. If  found guilty, they could receive prison terms of 4 -7 years.  


Energetic and persistent reporters may continue to uncover new cases that seem to reflect failures of child protection, or there may be attacks on agency policies and practices that go well beyond the events of a single case or handful of cases. For example, an ongoing media controversy over reunification practices and the counting and reporting of child deaths was almost certainly a factor leading to the resignation of the child welfare director in Los Angeles County in 2010. 

 In some states and large cities in this country, this cycle has been repeated once or twice a decade, and is likely in my view to continue indefinitely despite lack of evidence that it has made children reported to CPS safer or improved child welfare practice. In fact, there is good reason to believe that a recurring cycle of child welfare reform driven by public outrage has unintended consequences that often undermine reform efforts.


 Consider the following elements that are common features of a cycle fueled by moral outrage: 

  • Fatality review committees typically focus on the events that led to a single child death, instead of looking for patterns in much larger numbers of child death cases. Recommendations for procedural changes, and sometimes even changes in law, tend to be based on the idiosyncratic fact pattern of a single case, changes that may have little or no impact on other types of cases more representative of abuse / neglect related child fatalities.   

  • Management teams under intense persistent media attack sometimes yield to public pressure to fire or demote caseworkers, supervisors or managers who have made errors of judgment in order to satisfy the public demand that someone be held accountable for a child's death. There are instances when caseworkers' or supervisors' failure to conscientiously perform their duties warrant termination of employment; but it is a serious lack of understanding of child protection to assume that practitioners or managers are always to blame when children on open or recently open cases die due to abuse or neglect. In addition, firing child welfare staff because they made mistaken judgments in specific cases undermines the capacity for organizational learning. Who will acknowledge error when the consequence may be loss of employment? Firing caseworkers, supervisors or managers in an attempt to calm a media firestorm is likely to lead to a risk aversive organizational culture in which avoidance of blame becomes a primary goal. One can only imagine the chilling effects of criminal indictments of a caseworker and supervisor in New York City on other practitioners' motivation to remain working in child protection.

  • Even enlightened efforts to better understand the multiple causes of errors in CPS decision such as Root Cause Analysis (see Rzepnicki and Johnson, 2005) or systems analysis (Munro, 2005) lead away from dispassionate consideration of approaches to preventing child deaths that are likely to be more successful than CPS reform. Most children who die from abuse or neglect have not been reported to CPS; to greatly reduce the incidence of child deaths, preventive services must be provided to high risk children and families before babies and other young children are referred to CPS and assessed to be "unsafe" by child welfare agency standards.


 In these circumstances, it is not surprising that neither state agencies nor the federal Administration for Children and Families (ACF) collect and report child abuse/ neglect fatality statistics in a way that allow trends in abuse/ neglect related deaths to be used as a performance measure. There has been a steady increase in maltreatment related child fatalities in NCANDS data since 2001, but about a fifth of child deaths reported in NCANDs are based on information provided by organizations other than states’ public child welfare agencies; and some of the children included in NCANDS annual reports may not have been referred to CPS prior to death. The 2009 NCANDS report comments on the increase in maltreatment related fatalities that  “Several states that did report an increase in the number of child fatalities from FY 2008 to FY 2009 explained in their State commentary … that the increase was the result of new legislation, new procedures and better reporting.” Without additional information, it is impossible to know whether the increase in maltreatment related fatalities in NCANDS data is the result of improvements in states’ identification and reporting of child fatalities, or reflects real increases in incidence of abuse/neglect related deaths. There is no excuse, however, for a large degree of uncertainty regarding the meaning of the reported increase in maltreatment related fatalities to continue for several years. ACF should take responsibility for resolving this important issue.


There are no national guidelines for categorizing child deaths as caused by or related to abuse or neglect. For many years, Washington State’s Children’s Administration (CA) was reluctant to categorize child deaths as abuse or neglect related unless a medical examiner or coroner officially found abuse or neglect to be a cause of death (a rare event in neglect cases in which children died in accidents such as house fires, drowning, or ‘roll over’ deaths resulting from suffocation of a baby sleeping with a parent), or unless a parent was criminally charged for actions contributing to a child’s death. As a result, there were years in which CA reported very few neglect related child deaths; but agency statistics were more a product of rules for counting child deaths than due to outstanding performance in protecting children from fatal maltreatment.  

There are good reasons for not utilizing a measure of a low base rate phenomenon like abuse/ neglect related fatalities as a standalone performance indicator. Small yearly fluctuations in numbers of reported maltreatment related fatalities can easily appear to represent significant changes when that may not be the case. However, numbers of properly counted child abuse/ neglect related deaths could be combined with numbers of serious injuries resulting from abuse and neglect and numbers of sexually abused children on open/ recently open cases to arrive at a cogent and defensible performance measure. Arguably, such a measure would add credibility to child welfare agencies’ claims regarding their track record in protecting children from severe harm resulting from child maltreatment.   


Public child welfare managers have been understandably reluctant to develop a severity measure of child safety that includes annual counts of child deaths, along with serious injuries resulting from abuse or neglect and sexual abuse on open or recently open cases because of the view that neither elected officials or concerned citizens would tolerate the reality that a small (but predictable) percentage of children investigated by CPS will die each year in abuse/ neglect related incidents. The rancorous public debate in Los Angeles County in 2010 was an unusual anomaly in that both critics and supporters of public agency managers used analyses of aggregate child death statistics to support their position.


Usually, public agency managers, media critics or child advocates have little or nothing to say about trends in maltreatment related fatalities in local jurisdictions or the state as a whole. Public agency managers know better than to acknowledge that some children reported to CPS die year in year out, and critics of the agency often have difficulty understanding child fatality statistics organized and presented in confusing ways. Public agencies may report maltreatment related fatalities in combination with all child deaths on open cases resulting from other causes such as illnesses or traffic accidents. Abuse/ neglect related child deaths may be included in a category labeled “preventable deaths” that include deaths from multiple causes. Even if an agency report provides a distinct category for maltreatment related deaths, it is likely that some of these cases were referred subsequent to a child’s death due to the need to protect surviving siblings in the home. For this reason, annual numbers of abuse/ neglect related deaths reported by public agencies cannot be easily used to track agency performance unless agencies also provide explicit detailed information regarding rules for counting and the number of maltreatment related child deaths on open/ recently open cases. In addition, as a general rule, child welfare agency counts of child deaths become more credible when they are arrived at in collaboration with public health departments and other organizations with a stake in child abuse/ neglect prevention.


There is another reason that reform agendas fueled by moral outrage often have little, if any, effect in reducing abuse/ neglect related deaths. Public agency managers and elected officials need to be viewed as proactive in correcting agency flaws and dealing with inadequate performance; admission of ignorance or uncertainty regarding how to eliminate child deaths on open or recently open cases is unlikely (to say the least) in these circumstances. It is a far better managerial survival strategy to aggressively pursue multiple reforms viewed by well informed persons as addressing needed agency improvements than study the issue at length or limit changes to agency practices, training programs or accountability mechanisms in a highly targeted way. As a result, child fatality reviews typically result in additions to agency policies and procedures that add to the regulatory burden caseworkers have to accommodate, and increase the likelihood that subsequent post- fatality reviews will find caseworkers out of compliance with some agency policies.


Abe Bergman, a Seattle pediatrician known for his outspoken views, has maintained for years that CPS actions have little or no impact on child homicide rates. The apparent futility of the cycle of high profile child deaths followed by a media firestorm and public outrage leading to a fatality review by a blue ribbon panel charged with developing multiple recommendations for child welfare reform suggests gaps in knowledge and understanding that need to be addressed by research studies or more discerning use of existing studies. Tina Rzepnicki and Eileen Munro are outstanding child welfare scholars who have made important contributions to understanding complex patterns of causation in child abuse/ neglect related deaths. Their recommendations for analyzing the multiple factors contributing to specific child deaths in fatality reviews should receive careful consideration.


Nevertheless, something is missing in the scholarship and in the use of the excellent studies on child abuse/ neglect related fatalities that have already been done. Four fifths of children who die in abuse/ neglect related incidents are 0-3, and they are repeatedly found to have lived in homes with the same list of common risk factors present in non – fatal high risk cases: substance abuse, mental health problems, domestic violence and poverty. These factors are not a basis for coercive CPS action in and of themselves (nor should they be), but waiting to intervene until a CPS investigation assesses a child as ‘unsafe” is a poor guideline for practice in cases involving infants and other young children. Babies and toddlers are too physically and emotionally vulnerable to wait for events or conditions that clearly indicate the presence of danger before taking action. Interventions (such as relapse planning, daily child care) must occur earlier to effectively protect young children.


In addition, some of the best studies of maltreatment related fatalities have found that emotionally disconnected parents and caregivers who have weak emotional connections to young children often represent a risk to children, depending on their histories or temperaments. One of the best longitudinal studies of the development of physical abuse ever conducted (Altemeier, et al, 1982) found that mothers with a history of rejection during adolescence in their birth families were at elevated risk of becoming abusive parents.  Some risk assessment tools and processes do not include these factors that are critical for safety decisions and safety planning in high risk cases. Risk assessment guidelines should reintroduce some concepts from clinical assessment protocols to strengthen the targeting of high risk cases.


However, the single most important step needed to reduce maltreatment related child deaths is for the public sector as a whole to adopt an epidemiological perspective on child fatalities, and offer voluntary services to some high risk families as early as possible. Emily Putnam – Hornstein and Barbara Needell at the Center for Social Services Research at the University of California at Berkeley have recently demonstrated that 50% of children in a birth cohort in California referred to CPS before age 5 could be identified by a small number of risk factors present at a child’s birth. Fifty per cent of the children in the 2002 birth cohort referred to CPS by age 5 came from just 15% of the population. Putnam–Hornstein and Needell comment that “A risk assessment tool that could be used on the day of birth to identify those children at greatest risk of maltreatment holds great value.” They add, “Needless to say, a standardized assessment tool that relies on a demographic profile can never replace more comprehensive assessments of an individual family’s strengths and risks. But against an invariable backdrop of limited resources, the ability to provide preventive and intervention services to a highly targeted swath of at – risk families has the potential for cost savings to be realized, while also improving child well – being.”


 Along these same lines, Washington State’s DSHS Research and Data Analysis (RDA) has disseminated studies indicating that approximately half of infants born to mothers receiving publicly funded substance abuse treatment services are referred to CPS by their first birthday. Any parent of a baby, 0-2, receiving publicly funded substance abuse or mental health treatment should be offered home visitation services by a public health nurse and free daily child care. The guideline for public policy should be: the higher the risk to children, the earlier help is offered to troubled parents. Waiting for CPS intervention, or worse, waiting for children to be assessed as ‘unsafe’ by CPS caseworkers before intervening is a formula for failure in initiatives designed to reduce child deaths.


 Despite the negative effects of moral outrage as a driver of child welfare reform discussed above, moral outrage has an undeniable power to disrupt entrenched bureaucracies and make sweeping public policy changes possible. Horrible cases of child cruelty led to the creation of child protection as a community institution in the late 19th century and to the development of the nation’s modern child protective services system in the late 1960s and 1970s. When the citizens of a state or community are truly upset by the plight of vulnerable children, it becomes possible to create major improvements in children’s lives when leaders have an agenda that can be easily explained to the public. In the case of maltreatment related fatalities, the easily understood ideas that should be advanced in the midst of a political crisis are (1) waiting for babies and toddlers in vulnerable families to be in danger before taking action is doomed to fail on some occasions due to human error and for other reasons and (2) if states and communities want a more effective child welfare system, then there has to be a major investment in the child welfare work force. Child welfare workloads are often a serious concern, but it is also important to raise caseworkers’ salaries to a decent level, create incentives for professional development and think carefully before adding to regulatory frameworks that make the jobs of caseworkers and supervisors intolerable and undermine professionalism.


When child welfare leaders are able to convince concerned citizens and child advocates, not just Governors and legislatures, to take these ideas seriously, there will be a decline in maltreatment related child deaths rather than a steady increase.  




Altemeier, William A., O’Connor, Susan, Vietze, Paul M., Sandler, Howard M., Sherrod, Kathyrn B., “Antecedents of child abuse,” The Journal of Pediatrics, Vol. 100, No. 5, May 1982.

Baumann, D., Gober, K., Graham, J.C. & Kern, H. , The Texas Child Fatality Study: A Comparison of Fatality and Non-Fatality Cases, Texas Department of Protective and Regulatory Services, 1998.


Boone, Ruschell, Child Welfare Workers Decry Homicide Charges Against Former ACS Employees, NY 1, March 25, 2011.


CFP "News Bulletin."


Child Maltreatment 2009, Administration for Children and Families, Administration on Children, Youth and Families, Washington D.C., 2010.


Child Welfare Information Gateway bulletin "Child Welfare in the News

Graham, J. Christopher, Stepura, Kelly, Baumann, Donald J., and Kern, Homer, “Predicting child fatalities among less – severe CPS investigations,”, Children and Youth Services Review , 32, 2010.


Jagannathan, Radha and Camasso, Michael J., “The crucial role played by social outrage in efforts to reform child protective services,” Children and Youth Services Review, xxx, 2011.



Kajese, Tanyaradzwa M., Nguyen, Linh T., Pham, Giao Q., Pham, Van K., Melhorn, Katherine, Kallail, James K., “Characteristics of child abuse homicides in the state of Kansas from 1994 -2007,” Children and Youth Services Review , 35, 2011.


Munro, Eileen, “Improving practice: child protection as a systems problem,” Children and Youth Services Review, 27, 2005.


Putnam – Hornstein, Emily and Needell, Barbara, “Predictors of Child Protective Service Contact between Birth and Age Five: An Examination of California’s 2002 Birth Cohort,” accepted for publication, Children and Youth Services Review , 2011.  


Rzepnicki, Tina L. and Johnson, Penny R., “Examining decision errors in child protection: a new application of root cause analysis,” Children and Youth Services Review, 27, 2005.




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