New Study of New York City Child Deaths Shows Continued Problems in Child Welfare Practice Place Chi

PRESS RELEASE

Based on experts' examination of child fatalities reports, study suggests practice changes needed to prevent child deaths.

A new study on child deaths in New York City released today by Children's Rights reveals continuing concerns about the quality of child protection practices in New York City. A team of child welfare experts and pediatricians examined 194 child deaths occurring between 1999 and mid-2001 and found critical problems in child welfare practice - practices involving investigation of child maltreatment, assessment of child safety, and services to families that place all children referred to the city's Administration of Children's Services (ACS) in jeopardy. The study also provides a blueprint of actions for ACS to take to improve practice and prevent deaths.

Continuing Danger: A Report on Child Fatalities in New York City examines the exact circumstances of the 194 children who died, the characteristics of their families, and the manner of and reasons for the deaths. A Freedom of Information Act request was used to obtain child fatality review reports prepared by the New York State Office of Children and Family Services. The reports were reviewed by a team of experts, including Diana English, Ph.D., a specialist in child protective services, and three pediatricians for Doctors of the World.

The study focused on three groups of children and families: Children whose families were not known to ACS prior to the child's death; children whose families were previously known to ACS at the time of the child's death; and children in foster care who at the time of their deaths resided with relatives or non-related foster families or were placed in a group or residential care setting.

"Many of these children would not have died if the government agency charged with protecting them-ACS-was doing its job," stated Marcia Robinson Lowry, executive director of Children's Rights, a national non-profit advocacy group for children. "The serious systemic problems identified in this report have been identified in earlier reports by other children's organizations and by Children's Rights itself. The time to act on the report's recommendations is now, before more children die. ACS must be held accountable for taking those actions that are within its control. Mayor Bloomberg must equally be held accountable for taking recommended actions that are beyond the control of ACS and for ensuring that the agency has the resources to fulfill its responsibilities to children."

Lowry testified about the study at a public hearing today convened by the Office of the Public Advocate and the General Welfare Committee of the New York City Council to explore issues facing families in the child welfare system and the quality of services provided by ACS and contract agencies.

FINDINGS:
Key findings and related summaries of actual fatality reports in the study include:

For the families whose children were previously known to ACS:

*ACS conducted inadequate safety and risk assessments and interventions when the families were initially referred to ACS on allegations of child maltreatment. In a number of cases, ACS paid insufficient attention to the problems that posed serious risks to children and did not closely monitor the families, particularly when the parents failed to follow through on service plans.

In one case, a report was made in October 1999 that a 16-year old was beaten by her mother and her stepfather. Allegations of inadequate guardianship and lacerations, bruises and welts were substantiated, and it was determined that the child was "unsafe" in the home. The maternal grandmother obtained custody of the 16-year old girl, but ACS left her 9-year old half-brother in the home, without documenting the reasons for this decision. The parents were referred for mental health evaluations and anger management, among other services, but the case record did not show if the family followed through with any of the services. In March 2000, during the teenager's monthly visit with her mother, the stepfather, after drinking throughout the evening, beat the mother and step-daughter with a hammer and then took the 9-year old boy and jumped off the roof, killing them both.

For children in foster care:

Foster parents sometimes did not receive appropriate training or information to properly take care of the children they were fostering. Some foster parents did not receive training on topics such as CPR and infant sleeping positions or guidance on appropriate responses to emergency situations. Foster parents were often not told about children's serious health conditions or their need for ongoing medical attention and could not anticipate the health care services that children needed.

In one case, a 4-month old male child died because of complications of a chronic lung disease. Born 12 weeks premature, the boy was taken into custody by ACS at birth. ACS failed, however, to communicate the child's medical condition and history to the foster care agency to which ACS referred the infant. In fact, ACS informed the agency that the child was healthy and developing normally. The agency submitted a written request to the hospital for the child's medical information, but the hospital did not respond to the request until after the child died. The foster parents took the child to his well baby appointments, and he was deemed healthy. Within the last month of the child's life, the foster parents took him to the emergency room three times for various symptoms, including improper digestion, fever, and congestion. Once, the emergency room physician diagnosed him as functioning normally, and twice he was diagnosed as having a cold. Because the foster parents were not given critical information on the child's health and medical history, they could not provide the physicians with information that might have facilitated an accurate diagnosis. The child died three days after his last emergency room visit.

Several violent deaths occurred when adolescents were on AWOL status from their placements. In many cases, private foster care agencies knew that adolescents were prone to running away, yet did not put a plan in place to prevent these incidents. In other cases, agencies knew of children's whereabouts after they left facilities, but did not act to protect the children or return them to care.

In one case, a girl, age 16, was found murdered, strangled to death, two days after running away from her group home. The group home workers had not filed a missing person's report. The girl had a history of drug abuse, prostitution, and running away. She was initially placed in foster care because she ran away from her mother often, and her mother feared she could not control her. The group home, which was not a locked facility, did not implement a plan to respond to these behaviors. A few weeks before the child's death, a social worker at the group home saw the girl and suggested she be moved to a Residential Treatment Center, but no follow-up steps were taken.

For the families whose children were not previously known to ACS:

Surviving siblings seemed to be almost automatically removed from their parents' custody, as was the case for families whose children were known to ACS. In a number of cases, ACS safety assessments did not indicate an imminent risk of harm to the surviving siblings of children who died, but removed these children from their parents' custody anyway. In some cases, ACS kept parents and children separated without legal authority to do so.

In one case, ACS determined that the 3-year old sibling of an 8-day old infant who died from overlay (while sleeping with the child, the parent rolled over and suffocated the child) was "unsafe" although no risk factors were specifically identified. The toddler was placed with the grandmother. Both the grandmother and the mother were led to believe that the child had to stay with the grandmother even though ACS had no legal or protective authority to keep the child and mother separated.

RECOMMENDATIONS:
Based on Children's Rights' analysis, the report yielded recommendations for improved practice in three areas:

To improve the quality of child protective services, ACS should:

*Establish an internal quality assurance review of child protective service cases.
*Develop and/or enhance guidelines and training regarding child protective services practice, specifically for assessments and service provision in light of families' identified needs.
*Institute processes to ensure appropriate responses to families with histories of multiple referrals for child maltreatment and to patterns of high AWOL rates for adolescents in care.

To improve the health status and health care of children in foster care, ACS should:

*Assure access to health care services for all children in foster care.
*Provide foster families and other foster care providers with complete medical information on the children in their care.
*Integrate health care providers more fully as service providers for children in foster care.

To improve the quality of child fatality investigations, ACS should:

*Establish a local independent Child Fatality Review Team in New York City.
*Pay careful attention to the role of ACS in investigating child fatalities-particularly in relation to the role of law enforcement and in cases in which there is no other child in the home-and to the appropriateness of current legal requirements that investigations be completed within a specified period of time. Given the limited resources available to ACS, staff expertise and time should be targeted to safety and risk assessments as opposed to "forensic" activities and timelines should be reasonable.
Ensure greater involvement of health care professionals
*Ensure greater accountability on the part of investigative partners.

"These recommendations-which could be implemented through the collaborative efforts of ACS and the child advocacy community-would greatly strengthen the child protection system in New York City and ensure to the fullest extent possible, children do not die of preventable causes," said Madelyn Freundlich, director of policy at Children's Rights and co-author of the report.

Children's Rights works throughout the United States in partnership with national and local experts, advocates and government officials to document the needs of children in the care of child welfare systems. Children's Rights helps develop realistic solutions and, where necessary, uses the power of litigation to ensure that reform takes place.