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DCFS study reveals huge systemic problems

Wednesday, May 15, 2019

* AP

Illinois’ child welfare agency is so intent on keeping children with their parents even when they have strong evidence of abuse that it has sometimes left those children in grave danger, a study released Wednesday found.

Democratic Gov. J.B. Pritzker ordered the study of the Department of Children and Family Services’ Intact Family Services unit after the recent deaths of three children. That unit is responsible for overseeing households in which children are left at home after allegations of abuse or neglect.

Illinois has been lauded for having one of the lowest foster care entry rates of any state in the U.S. Yet researchers found a profound failure to communicate within the department; overburdened staffers; staffers so convinced that prosecutors wouldn’t agree with requests to remove children from homes that they didn’t bother to ask; and cases in which evidence and suspicions of abuse or neglect were brushed aside.

Keeping children with their families is “a laudable goal,” said Michael Cull, one of the study’s authors. “But over time for a variety of reasons it becomes an overriding priority that leads to decisions that (the agency) may not even know they are making.” […]

Illinois is not the only state with a child welfare system under fire. In fact, according to the study, the rate of death due to child maltreatment in Illinois in 2016 - 2.16 per 100,000 children - was actually a bit lower than the national figure of 2.36 per 100,000 children.

The study is here (fixed link) and the summary is is here.

* Tribune

Yet the organizations who provide these [intact family services] told researchers they sometimes feel like their hands are tied. They raised the concern that some of the cases they receive are “too complex, too severe or too longstanding” for them to handle but that it’s difficult to decline a case or question the appropriateness of such referrals, said Dana Weiner, a lead researcher of the six-week study. The caseworkers also reported that they didn’t believe judges, prosecutors or department investigators would support more intensive interventions if they petitioned for it.

Families are also not required to accept the services, which can range from mental health counseling to parenting classes. Supporters of intact services note that removing a child from relatives and finding a foster care placement is a traumatic experience that should be avoided when a child’s well-being is not compromised.

“The intact providers do their best to serve the families that they are assigned with the resources that they have available to them,” said Weiner of Chapin Hall, a child welfare think tank based at the University of Chicago that put out the study. “But I think that the expectation that removals will be avoided sometimes discourages them from applying critical thinking to the current safety concerns and the best course of intervention for a family.” […]

Nearly all intact family services — or about 85 percent — are provided by community-based organizations that have contracts with DCFS. The caseworkers are only supposed to have 10 open cases at a time, the report said. When possible, the department retains the highest-risk cases to address in-house.

The Chapin Hall report identified 41 child deaths due to mistreatment that were investigated by the agency’s inspector general between 2014 and 2018. In six of those cases, the fatality occurred while there was an open intact family services case.

* Sun-Times

Some of the most serious problems highlighted in the report include the lack of historical information in critical cases that prompt Intact supervisors to be “reluctant” about elevating cases to supervisory review. The report also found a lack of communication between investigators, who identified with law enforcement, and Intact supervisors, who identified as mental health and social workers.

The report also found some structural issues, such as lack of information because a case was expunged or purged. Under current law, cases are expunged after five years, so the record would only reflect an event happened. If the allegation was unfounded, there are no details on record.

[DCFS Acting Director Marc Smith] said that change could come through the legislative process, but said it would be more helpful to see a “pattern of need and support” and not just the details of an unfounded allegation.

“Assessment of a family’s safety sometimes evolves over time,” the report says. “The unavailability of so much historical information may contribute to critical case details being lost and influences child welfare staff to rely on family’s accurate self-reporting on their history.”

* NBC 5

“It’s basically a bureaucratic mess,” says Charles Golbert, the Illinois Public Guardian. “And we’ve known that for a long time.”

Golbert said private providers have no incentive to keep cases open until problems are resolved.

“They actually get paid less money if the case is still open after six months,” he said. “It makes no sense—it puts bureaucracy and artificial timelines ahead of child safety.”

* CBS 2

The study recommended nine ways to address the issues; which include refining protocol for closing cases, working with courts and state’s attorneys to refine criteria for removal, redesigning assessment and child intake processes, and giving direct attention to cases at greatest risk of severe harm.

…Adding… From the governor and DCFS

DCFS Immediate Actions

Action: Review of Open Investigations. DCFS is prioritizing the highest risk cases by taking a close look at investigations where young children are involved and certain allegations of abuse and neglect are present. This urgent review by some of DCFS’ most senior staff will cover more than 1,100 open investigations and focuses on reviewing compliance with key safety measures. Investigations found to be out of compliance will be rectified immediately and receive an additional qualitative review. DCFS expects to have findings from this internal investigation in coming weeks. These findings will help determine the scope of future reviews of investigation work.

Action: Crisis Intervention Team. In the tragic event of a child death, this 8-member team will initiate an immediate review when the death occurs during an open investigation or involves a child with an extensive history of contact with DCFS. The team will examine the family’s full history of involvement with DCFS and all relevant investigations and casework, including other current and previous cases that staff involved are handling. Their scope includes both human and systemic failures that may exist. The Crisis Intervention Team is tasked with quickly developing recommendations following their investigation and when appropriate, implementing changes in training or protocols that will rapidly lead to improving our work of protecting children.

Action: Expanding Training Programs and Retraining Caseworkers. Starting in June, veteran investigations staff will have access to the department’s newest and most advanced simulated (SIM) lab training facility in Englewood. This initiative will give key veteran front-line workers access to the latest tools and techniques being used in training. DCFS is also introducing a re-training program for all child welfare workers across the state. All staff licensed with DCFS, whether they work for the department or for a private agency, will be required to participate in ongoing training. The first re-training will be launched this summer and will focus on safety training, including identifying risks and warning signs.

DCFS Responses to Chapin Hall’s Recommendations

1) Recommendation: Develop and refine protocol for closing Intact cases. When caseworkers are properly supported and they have the right tools, they make good decisions. DCFS will address this problem immediately and develop new standard protocols for closing Intact cases in the next 60 days.

2) Recommendation: Clarify goals and expectations across staff roles. DCFS will clearly articulate expectations for every actor and agency involved in the work of promoting child safety. Defining roles for DCFS investigators, supervisors, Intact providers and staff will be addressed over the next 60 days through training, changes in policy and through communications with staff.

3) Recommendation: Utilize evidence-based approaches to preventive case work. DCFS will examine models that have been piloted and tested in Illinois and other states. We will work closely with Chapin Hall to address this recommendation over the next six months.

4) Recommendation: Improve the quality of supervision. DCFS will develop a new structure for supervision within the agency that provides more clear lines of authority and accountability. DCFS will also work with supervisors to ensure that their teams are openly communicating. Following this report, we will prioritize Intact teams to receive training on the new practice model within the next 30 days.

5) Recommendation: Adjust the preventive service array to meet the needs of the population. We will continue to work with Chapin Hall to identify the services to best support the populations Intact is serving. This process will take 12 months to implement.

6) Recommendation: Restructure preventive services (generally) and Intact (specifically). DCFS has convened a working group to develop a restructuring plan so that there is better collaboration between Intact services (which provides services) and the Investigations division (which is responsible for case investigations). DCFS will develop this plan over the next 30 days, followed by a 30-day rollout across the department.

7) Recommendation: Work with courts and State’s Attorneys to refine the criteria for child removal in complex and chronic family cases. DCFS will work to build consensus among courts and State’s attorneys concerning removal of children who have experienced multiple incidents of abuse. The department will work with partners like Casey Foundation and Chapin Hall to help us implement this system change over the next 12 months.

8) Recommendation: Redesign the assessment and intake process based on systemic review to: a) reduce redundant information collection and data input; b) support decision making with youth and families; and c) improve effective communication across child serving systems. DCFS has introduced several recent changes that eliminate some redundancy in information collection and data input. Over the next 60 days, the department is putting into place a re-training of staff to improve the efficiency, reliability, and accuracy of assessments across screening, intake, service planning, and care transitions.

9) Recommendation: Direct attention to cases at greatest risk for severe harm. DCFS, in consultation with Chapin Hall, will revisit predictive models for help identifying cases with a high risk for maltreatment. Chapin Hall has identified that other child welfare systems are increasingly making use of administrative data to speed the detection of cases that may require additional attention or intervention. This process will take 12 months to complete.

…Adding… Illinois Collaboration on Youth Chief Executive Officer Andrea Durbin…

We appreciate the thorough and thoughtful analysis by Chapin Hall focused on Intact Family Services and agree with many of its findings and recommendations. Supporting and strengthening the Intact system is a goal we all share. It is important to remember that taking children from their families can have lasting negative effects and is a very serious step that should be considered when a child’s safety is paramount. We should also remember that while Intact is an important piece of the child welfare system, it is not the only piece. The system needs focused attention across all levels of care in order to achieve long term stability. We look forward to continuing this critically important discussion and finding solutions to stabilize Illinois’ child welfare system in the days ahead.

- Posted by Rich Miller        

27 Comments
  1. - wordslinger - Wednesday, May 15, 19 @ 9:39 am:

    –“They actually get paid less money if the case is still open after six months,” he said.–

    Obviously, that artificial incentive needs to end. It serves no purpose.

    But I think people need to wrap their heads around the removal situation. The policy now is to err on the side of keeping families intact. To change that, to err on the side of removal for child safety, would be a significant increase in the exercise of state powers.

    In other words, don’t cry crocodile tears over an in-home tragedy, and then rail about the state abusing its powers and taking children from their parents later.

    They’re tough calls; personally, I go with erring on the side of child safety. With that choice, reunification is possible and should be the goal.

    The ultimate downside, as we’ve seen, to erring on the side of keeping families intact is death of a child.


  2. - wordslinger - Wednesday, May 15, 19 @ 9:42 am:

    –Nearly all intact family services — or about 85 percent — are provided by community-based organizations that have contracts with DCFS.–

    Is it possible to have any sort of consistent application of policy and law with at-risk cases when virtually the entire program is farmed out? How is sufficient training and oversight handled?


  3. - supplied_demand - Wednesday, May 15, 19 @ 9:50 am:

    Maybe some of that Restoring Our Communities Program grant money in the marijuana bill (25% of total revenue) should be earmarked specifically for DCFS?


  4. - LINK - Wednesday, May 15, 19 @ 9:50 am:

    wordslinger et Al,

    Maybe just me but this detail screamed out at me: “The Chapin Hall report identified 41 child deaths due to mistreatment that were investigated by the agency’s inspector general between 2014 and 2018. In six of those cases, the fatality occurred while there was an open intact family services case.”

    That seems to me to be pretty high and scary. Sad too.


  5. - Juvenal - Wednesday, May 15, 19 @ 9:52 am:

    The big nugget here is that the regional directors were not reviewing Intact Cases under their authority that were being closed to ensure they should be closed. Cases were kept open for six months whether they needed to be open for nine months or only three.

    But the report is most notable not for what it says, but for what it does not say.

    Open Intact cases account for only 15% of child deaths where the agency has had prior involvement.

    An average of one child death per year over the last five years.

    This study only looked at and made recommendations regarding open Intact deaths.

    We are about to devote a bunch of time and energy over the next 90 days to addressing a slim number of cases at the expense of the vast majority of child deaths. After that we will pat ourselves on the back for accomplishing the check list, but we’ll be no closer really to keeping kids safer.


  6. - Truthteller - Wednesday, May 15, 19 @ 9:59 am:

    From the Tribune article:
    After privatization, the department saw a surge of deaths in homes that were receiving intact family services from the contract agencies, many of which are nonprofits, the Tribune reported in 2017. The Tribune found that 15 children had died between 2012 and 2016 as their families were given intact services compared with only one such child death under the program from 2007 through 2011.

    So the number of deaths increased from 1 to 15 after services were privatized. I hope the Tribune editors, who think every service should be privatized have time to read the paper today and take time to reflect on this fact


  7. - DuPage Saint - Wednesday, May 15, 19 @ 9:59 am:

    The system needs well run orphanages/child placement centers. Each facility should have parenting classes women’s shelters, drug and alcohol counseling. Goal to monitor and enforce treatment plans and parent child visits. If parent does not comply termination procedures should start and child placed for adoption.


  8. - Cassandra - Wednesday, May 15, 19 @ 10:06 am:

    I hope we are not heading for another foster care panic. After the tragic death of Joseph Wallace in 1993 there was a big spike in removals. Children were removed, a disproportionate number of them minorities, who likely could have stayed with their families with services. Foster care panics are bad for kids.

    If DCFS is largely contracting out its in-home service cases, doesn’t it have contract monitors. What is their role in this reform effort. Presumably they are expected to do more than review the bills. And while on the subject of contract workers-are their salaries and benefits equivalent to those of DCFS in-home workers and investigators. They should be.

    Finally, a word about prosecutors. If state’s attorneys are indeed a barrier to necessary removals, the governor should be having discussions with state’s attorneys around the state. As we’ve been reading in the national press lately, state’s attorneys have enormous power. Individual caseworkers, even community agencies, do not have the power needed to resolve ongoing disputes over the handling (or not) of child maltreatment petitions.


  9. - Earnest - Wednesday, May 15, 19 @ 10:23 am:

    Adequate resources is certainly part of the problem–you have to invest in either enough caseworkers or funding community providers in a timely, adequate and stable manner. The truly horrifying thing is the extent to which problems are due to poor management and supervision. I have to repeat myself there–horrifying.


  10. - Skokie Man - Wednesday, May 15, 19 @ 10:29 am:

    Your link above is to the summary of the study released by Chapin Hall. The full study is here: https://www.chapinhall.org/wp-content/uploads/Systemic-Review-Critical-Incidents.pdf


  11. - Responsa - Wednesday, May 15, 19 @ 10:31 am:

    This is as depressing as heck. It almost sounds like many people involved in children’s services and do know the system don’t give much assurance that it can be fixed any time soon. Pity the poor children currently at risk while they wait for the recommendations to bear fruit.


  12. - Stuntman Bob's Brother - Wednesday, May 15, 19 @ 10:40 am:

    It’s unfortunate that we haven’t figured out how to keep people who are likely to abuse children from having them in the first place. Maybe we need to license the procreation process (only semi /s)


  13. - illini - Wednesday, May 15, 19 @ 10:42 am:

    Those of us who are loyal followers of this blog have known for many years that there are serious problems within this agency. Hardly a week goes by that we do not see a new revelation about those who have been under served and who are not being protected.

    Underfunding, outsourcing, outdated guidelines and lack of oversight are well documented. New studies and their follow up recommendations are well researched and reasonable.

    Yet the issues remain and children are still at risk.

    Is anyone in the GA listening and willing to implement, fund and improve these programs and this agency?


  14. - Irish1 - Wednesday, May 15, 19 @ 10:45 am:

    I know that I will hear many good reasons why what I am about to say is a bad idea, but why is it that I, as an adult, can call the police if someone in my family were to seriously assault me, they would be arrested, and the criminal justice system would be involved. It wouldn’t be turned over to an agency to watch me being repeatedly assaulted or ultimately killed. Why do we allow adults to beat little children and not prosecute them until the child is dead? I understand all the systems, money, family-stay-together stuff but it seems to me that a 40 pound child should have the right to be protected from an abuser and that abuser should be immediately prosecuted.


  15. - wordslinger - Wednesday, May 15, 19 @ 10:46 am:

    –It’s unfortunate that we haven’t figured out how to keep people who are likely to abuse children from having them in the first place.–

    History is chock-fulla forced sterilizations, eugenicists and master race believers, Big Brother, if a final solution is your thing.


  16. - Truthteller - Wednesday, May 15, 19 @ 10:52 am:

    Unfortunately so much of state government in Illinois has been damaged and goes back to the Blago years, Quinn made it no better and Rauner did in what was left. Thousands of years of job knowledge and experience took early retirement or left the agencies. DCFS is just one glaring example.


  17. - RNUG - Wednesday, May 15, 19 @ 10:59 am:

    Create new rules and reorganize things a bit. Just rearranging chairs on the deck of the Titanic.

    We’ve been here before. We’ve known the intact family policy can lead to problems. We’ve known families can be non-compliant. We’ve known caseworkers are overloaded.

    And, with all this, Illinois is actually doing a bit better than average … which speaks tons about the dedication and commitment of the front line workers.

    So what could we do better? Here are my suggestions.

    First, it should be made crystal clear that non-compliance with recommended consuling and training with result in mandatory temporary removal of the kids until the families are in compliance.

    Second, require supervisory review of every open case at 15 days, then every 30 days.

    Third, require review of found but closed cases either once or twice a year for at least 2 years after the case is closed.

    And yes, I realize all that will take more staff and money than the agency has now.


  18. - RNUG - Wednesday, May 15, 19 @ 11:00 am:

    == The system needs well run orphanages/child placement centers ==

    Yes, it does.


  19. - RNUG - Wednesday, May 15, 19 @ 11:04 am:

    == Those of us who are loyal followers of this blog have known for many years that there are serious problems within this agency. ==

    As I said above, this is nothing new. I have a about 60 year old friend who calls themselves a survivor of the state’s foster care system. Their stories about their time in foster care are literally unbelievable …


  20. - Generic Drone - Wednesday, May 15, 19 @ 11:08 am:

    Cuts have conseqiences. So does privatization.


  21. - wordslinger - Wednesday, May 15, 19 @ 11:23 am:

    RNUG, those are thoughtful suggestions.

    –And yes, I realize all that will take more staff and money than the agency has now.–

    Every editorial board and columnist who routinely appropriates the tragedies of others to produce self-serving, weepy scribbles should be put to the test on this. Put up or shut up.


  22. - Falstaff - Wednesday, May 15, 19 @ 11:30 am:

    It seems the Chapin Hall report relied heavily on the Inspector General reports that have, for years, made similar recommendations, yet that is not being mentioned in the articles or comments. The recommendation of a crisis team is repeating the process of the IG. Why duplicate what is already being ignored. The annual reports, including one or redacted full reports as an appendix are worth reviewing.

    https://www2.illinois.gov/dcfs/aboutus/OIG/Pages/com_communications_inspector_prevRep.aspx


  23. - A guy - Wednesday, May 15, 19 @ 11:45 am:

    With the most recent situation that got plenty of attention and bad publicity, it’s clear that the standards for removing a child are not consistent or well practiced. Maybe there do need to be more “safer” environments to send them to. Likely so.

    But, erring on the side of the intact family is losing status with me. It’s got to be all about the child. It’s got to be.


  24. - Pave The Way - Wednesday, May 15, 19 @ 12:44 pm:

    The good thing about the Chapin Hall report is that it looked at the whole system - and recommended critical changes using safety science - that is a heck of lot more productive than throwing around utterly groundless blame. This isn’t a DCFS vs. Private agency issue at all. There were more intact cases, more difficult cases in intact, more opioid use, less community supports, and a unprecedented workforce crisis due to stagnant rates paid by Illinois to these very providers that carry out the critical work of keeping kids safe. Lets get on with making the changes to the system - including providing adequate funding to those doing the work.


  25. - AnonAurora - Wednesday, May 15, 19 @ 12:48 pm:

    This is a very difficult problem with highly variable outcomes.

    But we can see plainly the dangers of ideologically driven policy. Having “keep the family intact” as the driving policy is laudable as long as it leaves room and flexibility for counterfactual evidence and information. The one action mentions “Utilize evidence-based approaches to preventive case work. “…..perfect execution of this action WILL result in identification of the problem and realization of the best outcomes.

    In examples like this we see the limits of our capacity as humans to reliably produce sound reasoning when presented with mountainous problems. Solving these big problems is like an animal trying its best to run through a brick wall.


  26. - Marrs96 - Wednesday, May 15, 19 @ 2:15 pm:

    The problem here is that Chapin Hall (and to a lesser extent NU, UIC, & UIUC) has been an embedded, highly paid consultant for decades at DCFS. They really need new eyes on these problems.


  27. - Stuntman Bob's Brother - Wednesday, May 15, 19 @ 2:30 pm:

    ==History is chock-fulla forced sterilizations, eugenicists and master race believers, Big Brother, if a final solution is your thing==

    You’re taking more than a little liberty there, I was thinking more along the lines of free birth control, and even paying people who cannot afford to raise kids not to have any - but mostly lamenting there are no good solutions. But now that you mention it, I wouldn’t be against paying anyone who is addicted to drugs or alcohol to get snipped, and I’d start with Andy Freund’s “parents”.


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