Child Fatalities 2016

Statistics, Observations, and Recommendations

D.C. Child and Family Services Agency 200 I Street SE, Washington, DC 20003 (202) 442-6100 www.cfsa.dc.gov http://dc.mandatedreporter.org ▪ www.adoptdckids.org ▪ www.fosterdckids.org ▪ Facebook/CFSADC Twitter@DCCFSA

Contents

Executive Summary ....................................................................................................................................... 1

Demographics: Continuing Trends ................................................................................................................ 3

Gender of Decedents ............................................................................................................................ 3

Age Groups ............................................................................................................................................ 4

Distribution by Ward ............................................................................................................................. 4

Case Status ............................................................................................................................................ 5

Manner of Death ................................................................................................................................... 5

Comparison of District Abuse Homicides to National Trends....................................................................... 7

Fatality Prevention ........................................................................................................................................ 7

Recommendations from CFSA’s Internal Child Fatality Review .................................................................. 12

Safety .................................................................................................................................................. 12

Services ............................................................................................................................................... 13

Training, Consultation, and Supervision ............................................................................................. 14

Research and Policy ............................................................................................................................ 15

System-Wide Activities ....................................................................................................................... 17

1

Executive Summary Through the Child Fatality Review and this annual report, the Child and Family Services Agency (CFSA) explores several trends related to child fatalities, particularly whether a fatality resulted from abuse or neglect or whether the child was currently involved with the child welfare system. This 12th annual Child Fatality Review (CFR) Report presents these trends alongside data analyses and practice recommendations stemming from internal child fatality reviews that CFSA conducted during the 2016 calendar year (CY). Each review meets criteria set forth in DC Official Code §4-1371.05 (a) (2) as well as the requirement of the LaShawn A. vs. Bowser Implementation and Exit Plan to review deaths of children known to CFSA within five years of their death.1 Generally, CFSA receives notification of fatalities from two sources: (1) CFSA employees or law enforcement officers who contact the District’s 24-hour Child Abuse and Neglect Hotline, and (2) media sources and notifications from the Office of the Chief Medical Examiner (OCME), which is also responsible for facilitating the District-wide Child Fatality Review Committee (CFRC). As a permanent member of the CFRC, CFSA is assured notification of all child fatalities, including maltreatment-related deaths. In CY 2016, CFSA reviewed 20 fatalities, including one from 2013, three from 2014, 10 from 2015, and six from 2016. This review of fatalities from previous years is not uncommon. A death occurring in late December might not be reviewed until the following year. Similarly, a death might not be reported to CFSA until a year or more afterwards, depending on the reporting source.2 Of the 20 fatalities reviewed for this report, only one death was the direct result of child maltreatment. The decedent was a healthy four-month-old male in 2012 before his 19-year-old birth father squeezed his ribs, shook him on multiple occasions, and accidentally dropped him in the bathtub. The father was arrested, taken into custody, and pled guilty to second degree cruelty, which included unexplained injury, broken bones, fractures, and shaking. He was placed on supervised probation for three years, and court-ordered to participate in a substance treatment program. As a result of the abuse, the child had permanent damage to 50 percent of his brain. The fatality, however, did not occur until January 2016 when the child was just shy of four years old. The medical examiner cited the manner of death as abuse homicide, the direct result of the physical abuse four years earlier. Cause of death was asphyxia associated with the non-accidental blunt head and torso trauma. The review for this case occurred in July 2016. Themes presented at the review included young parents, who had both been in the foster care system as children, as well as substance use on the part of the father, and a history of unstable housing. CFSA’s case with the family had been closed for just under two years at the time of the child’s death. The majority of the reviewed fatalities involved children under the age of 24 months (45 percent, n=9). The second largest group (35 percent, n=7) involved youth over the age of 17. Both age groups are commensurate with historical trends.

1 The LaShawn Implementation and Exit Plan was negotiated in December 2010 as the result of the American Civil Liberties

Union (later Children’s Rights, Inc.) filing the initial LaShawn A. v. Barry lawsuit in 1989 over the quality of services the District of Columbia was providing to abused and neglected children in its care. The District continues to work toward meeting all requirements of the IEP so that the local child welfare system can be released from federal court oversight. 2 An example of a delay over a year later is included in this report. A youth died in 2014 in another jurisdiction but his body was

not identified until 2016.

2

Eleven of the reviewed cases were closed at the time of the child’s death. Two families had active investigations, and one family had open Family Assessment case.3 Of the two active investigations, there was a history of 15 Hotline calls for one family over a period of 15 years. Eleven of the calls were allegations that did not rise to the level of abuse or neglect and were subsequently documented as Information and Referrals (I&R). Three of the calls alleged neglect (substantiated), and the fourth call was related to the fatality. The decedent was 20 years old and died from a gunshot wound. The second family had a history of six reports over the course of three years. Two calls were screened out as I&Rs. One allegation was substantiated for positive toxicity of a newborn (not the decedent). An allegation of neglect was unfounded, and another allegation occurred out of the District’s jurisdiction. In addition to the annual report, CFSA presents internal findings to the CFRC in support of their mission to develop District-wide recommendations and strategies to reduce risk factors known to play a role in child deaths from a broad system perspective. CFSA also compiles agency-specific recommendations based on feedback received during the internal child fatality review (CFR) meetings. CFSA’s Agency Performance, which conducts the meetings, distributes internal recommendations to CFSA senior managers for follow-up actions. In CY 2016, Agency Performance organized recommendations under the following topic areas:

Safety - One recommendation in CY 2016 called for expansion of CFSA’s domestic violence services.

Services - Two recommendations were related to service needs of birth fathers and children diagnosed as medically fragile.

Training, Consultation, and Supervision - Four recommendations suggested updates on siblings under age 18 during reviews, increased training emphasis on information gathering for validating substantiated reports, increased training emphasis on critical thinking, and a need for CFSA to clearly define “parentified child.”

Research and Policy - CFSA received five recommendations related to research and policy. One called for a workgroup to study agency policy and practice around parental substance use. Another requested a review of CFSA’s protocol around administration of psychotropic medications. Two policy-specific recommendations addressed child supervision and referrals to the nurse care manager program. The fifth recommendation suggested a protocol to support staff well-being.

System-Wide Activities - Of the three recommendations related to systemic issues, one called for an inter-agency promotion of safe sleeping standards. Another called for enhanced data-sharing between CFSA and the Department of Health’s Vital Records Division. The third requested increased partnering between CFSA and the District’s Metropolitan Police Department (MPD) to improve social worker safety in the community.

3When CFSA’s Child Protective Services (CPS) administration determines that a child’s immediate safety is at risk of harm, a

formal investigation occurs (CPS-I). Families with certain neglect allegations and no immediate safety concerns may be referred for a Family Assessment (CPS-FA). The Family Assessment (FA) social worker utilizes clinical skills to partner with the family to voluntarily develop a service plan to meet their needs. CPS does not assign a substantiated disposition for FA participants.

3

Demographics: Continuing Trends Table 1 provides an overview of demographics regarding child decedents who were the subject of fatalities CFSA reviewed in 2016.

Table 1: Demographics According to Manner of Death

Natural Causes

Homicide Abuse

Homicide Accident Suicide Undetermined Pending Total

Age

< 24 months 3 2 4 9

2 – 6 years 1 1 2

7 – 12 years 1 1

13 – 16 years 1 1

17+ years 5 1 1 7

Total 4 6 1 1 1 2 5 20

Gender

Male 2 6 1 1 3 13

Female 3 1 1 1 1 7

Total 5 7 1 1 1 1 4 20

Placement Status

No placement 2 7 1 1 2 3 16

In-Home 1 1 2

Out-of-Home 2 2

Total 3 9 1 1 1 2 3 20

Gender of Decedents The majority of deaths involve males. This trend reflects similar statistics across the United States. According to the 2014 National Vital Statistics Reports (published June, 2016), 65 percent of deaths of youth ages 1-19 were male. The corresponding 35 percent of deaths were female in the same age bracket.4 As Table 2 shows, CFSA’s data for children from birth to 20 years reflects similar percentages.

Table 2: Five-Year Percentages of Gender of Decedents

Year 2012 2013 2014 2015 2016

% Male 58 67 68 63 65

% Female 42 33 32 37 35

4 Retrieved May 12, 2017: https://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_05.pdf

35% (n=7) 65% (n=13)

Gender of Decedent

Female Male

4

Age Groups The oldest children (ages 17+) and the very young (under 24 months) are most vulnerable. Table 3 shows the continuation of this trend.

Table 3: Five-Year Percentages for Age Group at Time of

Death

Year 2012 2013 2014 2015 2016

% 0-2 years 46 33 26 33 45

% 2-6 years 8 17 16 10 10

% 7-12 years 4 13 0 10 0

% 13-16 years 29 12 5 0 5

% 17+ years 13 25 53 47 40

Distribution by Ward Table 5 provides an overview of children under age 18 living in the District.5 The disproportionate distribution of the child population throughout the eight wards of the District remains steady from previous years. Children in Wards 7 and 8 make up approximately 39 percent of all District children—and about 80 percent of the CFSA caseload. Thus, it is not surprising that of the fatalities CFSA reviewed in 2016, 50 percent of the child decedents came from Wards 7 and 8.

Table 6: Distribution of Fatalities by Ward

Ward 1 Ward 2 Ward 3 Ward 4 Ward 5 Ward 6 Ward 7 Ward 8 Other Jurisdiction Total

0 0 0 3 2 1 2 8 4 20

5 Kids Count Data Center 2015

45%

10% 5%

40%

Age Group at Time of Death - 2016

0-2 2-6 7-12 13-16 17+

Table 5: Number of Children under 18 by Ward, 2015

Ward 1 Ward 2 Ward 3 Ward 4 Ward 5 Ward 6 Ward 7 Ward 8

10,523 4,348 12,722 15,616 14,604 10,873 16,731 26,112

5

Case Status Children are less likely to die during CFSA involvement. Of the 20 fatalities reviewed during 2016, only three (15 percent) of the children had an open case with CFSA at the time of the fatality. One of these cases involved a youth who absconded in September 2014 after a weekend visit with a family member. Despite engaging local law enforcement and the National Center for Missing and Exploited Children (NCMEC) for assistance, CFSA could not locate the youth for over a year. Finally, in late 2015, CFSA learned that in September 2014, officials in the state of Pennsylvania had recovered his body from the Allegheny River but were unable to identify the remains until CFSA circulated dental records. CFSA closed the case in January 2016. Table 4 below breaks down case status for all of the fatalities reviewed.

Table 4: Case Status for CY 2016 Reviews

At the time of the fatality, CFSA was involved with a quarter of the families.

Closed case 11 (55 %)

Active case 2 (10 %)

Open Case 1 (5 %)

No case 6 (30 %)

Total 20 (100 %)

Manner of Death Infant deaths continue to be impacted by unsafe sleeping arrangements. Despite District-wide efforts to educate parents on safe sleeping habits, sleeping-related elements continue to be noted during reviews of infant fatalities. Educational efforts have included a safe-sleeping campaign that clarifies terminology. There is a distinct difference between bed-sharing (i.e., infant and any other individual in the same bed) and co-sleeping (i.e., infant and other individuals in the same room). For the CY 2016 reviews, four of the nine infant fatalities had unsafe sleeping components associated with the infant’s death. Although one death was ultimately attributed to pneumonia, an unsafe sleeping element was

55%

10%

5%

30%

Case Status - 2016

Closed - Known

Active

Open

No Case - NotKnown

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noted as potentially impacting the infant’s fatality. One infant was discovered caught between two beds. Another infant’s death was undetermined but the family confirmed a history of bed-sharing. The cause of the fourth infant fatality was also undetermined but a blanket was observed covering the infant’s face when the fatality was discovered.

Table 7: Five-Year Trends for Manner of Death

Year 2012 2013 2014 2015 2016

# Deaths of

Known Children 25 24 22 30 20

# Non-Homicide 21 13 14 17 13

# Non-Abuse

Homicide 3 9 7 13 6

# Abuse

Homicide 1 2 1 0 1

Non-abuse homicides of older youth (age 13+) continue to be the leading cause of death for children known to CFSA, followed by natural causes. These deaths reflect larger societal issues, including the common theme of children and youth repeatedly exposed to gun violence in their neighborhoods. In one non-abuse homicide, the decedent was a 19-year-old male whose family history with CFSA included more than one in-home case over seven years. In the decedent’s history were details of four separate gun-related incidents, including his sibling being shot in the hand when he examined a gun at school, two separate family members being shot in the foot within a year, and a drive-by shooting directed at the home of the maternal grandmother. The cause of death for the decedent was listed as “gunshot wounds to the torso”. Abuse homicides continue to be low. Of the 20 fatalities CFSA reviewed in 2016, only one (5 percent) was due to abuse, details of which are noted in the Executive Summary of this report.

30%

10%

25%

5%

15%

10%

5%

Manner of Death - 2016

Homicide

Accidental

Natural

Abuse homicide

Undetermined

Pending

Suicide

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Comparison of District Abuse Homicides to National Trends There are several causes of abuse homicides, including (but not limited to) abusive head trauma, punches or kicks to the abdomen (leading to internal bleeding), drowning, scalding, and smothering. Abuses most frequently occur as a result of a caregiver’s lack of patience for common child behavior (e.g., crying, bedwetting, and disobedience).6 Abuse homicides include both chronic (i.e., long-term) and singular incidents. Under both circumstances, the abuse is considered specific to an action of the caregiver. On the other hand, neglect-related homicides are more likely connected to a failure of action but may also involve chronic neglect (e.g., starvation or dehydration) as well as singular incidents of neglect (e.g., lack of supervision resulting in death). According to the most recent national data available, there were an estimated 1,670 children who died from abuse or neglect in fiscal year (FY) 2015.7 This number roughly translates to a rate of 2.25 children per 100,000. Three-quarters (74.8 percent) of these child fatalities included children who were younger than 3 years old. Children younger than 1 year accounted for 49.4 percent of all fatalities while youth ages 15-17 years accounted for only 1.4 percent, and .2 percent for older youth ages 18-21, inclusive of unborn infants or ages unknown. Though any number for abuse homicides is too large, CFSA emphasizes that the District’s trend for abuse homicides has been consistently low for the past five years (see Table 7 above). Overall, the data is consistent with the national trends.

Fatality Prevention CFSA and the District are using a number of strategies that the U.S. Department of Health and Human Services’ Administration for Children and Families (ACF) recommends to help prevent child fatalities.8

Child Fatality Reviews

CFSA has conducted internal child fatality reviews for over a decade. As of November 2016, CFSA has merged CFR staff with the quality service review (QSR) unit for purposes of augmenting the review process with the expertise of the QSR staff. This includes examination of family engagement, assessment and understanding of the family’s strengths and needs, and service delivery. At present, internal reviews are scheduled monthly. Review team participants come from several diverse areas of CFSA: Office of the Director, Entry Services, Community Partnerships, Permanency, Well Being, Office of General Counsel, and Office of Policy, Planning and Program Support (inclusive of training). The group also has representation from OCME and Office of the Attorney General.

6Retrieved from The National Center for Fatality Review and Prevention May 18,2017 https://www.ncfrp.org/reporting/child-

abuse-and-neglect/ 7 Retrieved May 18, 2017: Child Abuse and Neglect Fatalities 2015: Statistics and Interventions,

https://www.childwelfare.gov/pubPDFs/fatality.pdf 8 Ibid

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Public Health Approach - Citywide Child Fatality Review Committee (CFRC)

As defined by ACF, “a public health approach involves defining the problem, identifying risk and protective factors, understanding consequences, and developing prevention strategies. Additionally, a public health approach engages the entire community in preventing child maltreatment and ensuring that parents have the support and services they need before abuse or neglect occur.” The District’s public health approach is embodied in the extensive membership of Citywide Child Fatality Review Committee (CFRC):

Center for the Study of Social Policy Child and Family Services Agency Children’s National Medical Center DC Department on Behavioral Health DC Department of Health DC Department of Health Care Finance DC Fire and Emergency Medical Services DC Public Schools Howard University School of Social Work Metropolitan Police Department Mayor’s Advisory Committee on Child Abuse and Neglect Office of the Attorney General Office of the Chief Medical Examiner (committee chair) Office of the US Attorney for the District of Columbia Office of the State Superintendent for Education Residents of the District of Columbia Superior Court of the District of Columbia Superior Court of the District of Columbia Court Social Services Division

Improved Training

While CFSA does not have specific training on child fatality prevention, there has been a conscientious effort to incorporate a trauma-informed component throughout the training curricula both for direct services staff and for resource parents. In addition, there is emphasis on understanding how recognizing trauma history for birth parents can impact many aspects of child protection as part of good child welfare practice. Both pre-service and in-service training teaches social workers to identify areas of high risk for child maltreatment.

Data Collection and Analysis

In 2016, CFSA began to review additional data elements not previously provided in the annual CFR reports. For CY 2017, CFSA will incorporate these data elements, including detailed surveys on family demographics and prior history with CFSA. CFSA will also establish a database to house and track recommendations from the internal child fatality reviews. As CFSA moves toward a fully developed continual quality improvement system, these improvements will increase CFSA’s overall ability to grasp details and nuances in practice, all of which will be shared with leadership. As appropriate, outcomes learned from the internal child fatality review process will be examined for any needed changes to training, supervision, and practice.

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As an example of the value of collecting additional data elements, Agency Performance provided the following partial data sets based on existing data for the 20 fatalities reviewed in 2016: (a) history of Child Protective Services (CPS) abuse/neglect substantiations, (b) domestic violence, (c) mental illness, (d) substance use, (e) educational concerns, and (f) father involvement. For 2017, Agency Performance will include detailed data on service provision and begin to look at any correlations between these factors and a subsequent child fatality. Regarding history with CPS, the highest percentage (35 percent, n=7) of deaths had no substantiated allegations associated with the family at the time of the fatality (Graph A). The shortest length of time between the last investigation and the fatality was two months, and the longest was just over four years. The second highest percentage (30 percent, n=6) was for neglect. One of these cases included both abuse and neglect. Five of the reviewed fatalities in 2016 had a prior substantiation for abuse. Of these five, four of the cases had been closed, and one was still open. The length of time between the last investigation and the fatality ranged between three months to four years. Manner of death included two homicides (two males, ages 17 and 19); one abuse homicide (male, three years old); one natural death (male, one year old); and one manner pending (20-year-old male).

There were no reported incidents of domestic violence (DV) for 12 of the 20 cases reviewed (Graph B). For the eight cases that did report DV concerns, all involved the birth mother. Four included fathers of one or more children by the mother, and four involved paramours of the mother. All eight cases were closed at the time of the fatality. Three of the cases involved substantiated abuse allegations; two

40%

60%

Graph B. Domestic Violence in the Home

Yes No

25%

30% 5%

5%

35%

Graph A: History of CPS Substantiations Associated with Child Decedents Known to CFSA, 2016

Abuse

Neglect

Both abuse andNeglect

Positive Tox ofNewborn

None

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involved substantiations for neglect; one case was substantiated for both abuse and neglect; two cases had no substantiations at all.

As Graph C above shows, mental health issues were present for half of the 20 reviewed cases. Six of the cases included mental health concerns for the decedents, ranging in age from 12 to 21 years. All six decedents were male. There were also six cases involving mental health issues for the birth mother. Two of these cases overlapped with mental health concerns for the decedent. One involved mental health issues for the birth mother and the decedent’s siblings. In one case, a maternal grandmother had mental health issues. Seven of the 10 cases with mental health issues were also identified as having domestic violence issues.

Thirteen of the 20 cases involved a history of substance use (Graph D). Of these 13 cases, nine involved the birth mother. Four of these overlapped with a history of substance use for other family members, including siblings of a decedent, a maternal grandmother, a birth father, and a paramour of the birth mother. Two of the decedents had a history of substance use with no reports of use by other family members. Aside from the overlapping case including a birth father’s use, there was one isolated case that also included history of use by a birth father.

50% 50%

Graph C. Mental Illness

Yes No

65%

30%

5%

Graph D. Substance Use

Yes No Unknown

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35%

65%

Graph E. Education Concerns

Yes No In contrast to the 65 percent of cases with a history of substance use, there was an exact reversal for the history of educational concerns (Graph E). There were no education-related concerns associated with 65 percent of the fatalities CFSA reviewed in 2016. Of the seven cases where there were concerns, three were specific to the decedent’s truancy. One was related to the decedent being suspended four times, allegedly for selling hall passes to other students. Another was related to reported school-related “behavioral problems.” One was related to a birth mother who dropped out of her general education diploma (GED) program.

As Graph F indicates, half of the 20 cases included father involvement, although one was not a birth father but rather the mother’s paramour. In that case, the mother denied knowledge of the fathers of her children. Only one of the cases included the birth father actually living full-time in the home. He was employed and reportedly cared for and supported his children. There was also a reported history of his substance use but no reports for domestic violence or mental health issues. Half of the involved fathers were substantiated for allegations of abuse or neglect. Of these substantiations, one was dismissed after an appeal and one was arrested for the abuse homicide of his infant child. Of the cases where there were no substantiations, one birth father was also the maternal grandfather who reportedly sired three children by his daughter. There was an overlapping history of domestic violence-related incidents for that family. One father was deceased.

50%

40%

5% 5%

Graph F. Father Involved with Decedent

Yes

No

Unknown

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Recommendations from CFSA’s Internal Child Fatality Review CFSA’s internal review process seeks to identify any systemic, training, supervision, safety, or policy issues that surface during the review of these cases. As a result of the 2016 reviews, CFSA identified the following specific recommendations in hopes of reducing any factors that may relate to a fatality (despite the fact that abuse-related fatalities are statistically lower than any other type of fatality). Recommendations are categorized based on safety, services, training, consultation and supervision, research and policy, and system-wide activities.

Safety Recommendation Expand the role of the domestic violence (DV) specialist to incorporate home visits, coaching, and conversations that are mindful of available DV services. Improve marketing of DV services to staff and families.

Status Within the reporting period, CFSA’s Office of Well Being (OWB) implemented the Safe and Together domestic violence (DV) model as part of a major shift towards becoming a DV-informed child welfare agency. To reinforce this shift, CFSA conducted train-the-trainer sessions on the new model. In addition, CFSA trained 15 subject matter experts (SMEs) from both in-home and foster care units within CFSA. These SMEs now serve as DV consultants to front line staff. Moreover, CFSA’s DV specialist meets monthly with the SMEs for on-going coaching and support. In FY 2018, CFSA’s Child Welfare Training Academy will continue training front line and other CFSA staff on DV-related practice standards. Training will continue to emphasize the importance of thoroughly assessing the underlying issues of the individual, DV-impacted relationship; recognizing both the unique and common patterns of the partners’ behaviors; and holding the offender responsible for all behaviors that jeopardize child safety. These components contrast sharply to past strategies that focused more heavily on “blaming” the offender versus addressing the impact of DV on children. In addition, CFSA has contracted with MSP to start a Batterer’s Intervention Program for the District for those who are not adjudicated by the court. For even more collaborative case planning, OWB has expanded its partnerships with such agencies as DC Survivors and Advocates for Empowerment, Inc. (SAFE)9 and the Court Services and Offender Supervision Agency for the District of Columbia (CSOSA).10 OWB has also worked with CFSA’s Office of Public Information (OPI) to develop and distribute a flyer to all CFSA and contracted private provider staff on DV services as well as the Batterer’s Intervention Program. The information was also shared at CFSA and contracted agency management team meetings in order for supervisors to reinforce the use of this information by social workers. OWB is also working with OPI to include DV-related services and information on CFSA’s website.

9 DC SAFE’s mission is to ensure the safety and self-determination of domestic violence survivors in Washington, DC through

emergency services, court advocacy and system reform. 10

CSOSA is a federal, executive branch agency, created by Congress in 1997 to perform the offender supervision function for DC Code offenders.

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Services

Recommendation CFSA needs to develop a better assessment of birth fathers, conduct a deeper search for birth fathers, engage them in case planning and implementation, and ensure appropriate services specific to fathers’ needs.

Status In 2017, CFSA began implementation of the “birth father cafés,” engaging biological fathers who have active involvement with CFSA and ascertaining their needs and services. Although CFSA’s goal for a total of 30 participating fathers was not reached, the 12 fathers who did gather for the 25-minute cafés all provided honest, and heartfelt comments. A table host for each café transcribed highlights and themes that emerged from pre-set questions and subsequent discussion. In general, the resulting themes represented the group’s collective thinking.

Although CFSA has not currently scheduled additional cafés, the recommendations on father engagement will be rolled up within the overall work on permanency. At present, the Agency has completed several training curricula on engagement, including one specific to fathers. Finally, the Agency is looking at birthparent engagement and will determine which strategies to incorporate for fathers during the last quarter of FY 2017 and the first quarter of FY 2018. CWTA has completed the curricular development for the following engagement-specific trainings: Best Practices in Engaging Fathers, Engaging Biological Parents, MACWS 2.0, Engagement Teaming, and Supporting Organizational Wellbeing. These trainings are not currently on the calendar for the fourth quarter of FY 2017 (July – September) but will be examined for addition to the calendar for the first quarter of FY 2018 (October- December).

Recommendation The Health Services Administration, CPS, and Community Partnerships Administration need to define “medically fragile,” and systematically ensure that children diagnosed as medically fragile, as well as all children under the age of six, are immediately identified, assessed, and provided with coordinated, timely services.

Status The Health Services Administration (within OWB) uses the following definition of “medically fragile” as drafted by the Center for Development and Disability at the University of New Mexico and published in the Family Handbook April 2008 (revised 2011):

A chronic physical condition that results in a prolonged dependency on medical care for which daily skilled nursing intervention is medically necessary and is characterized by one or more of the following:

There is a life-threatening condition characterized by a reasonably frequent period of acute exacerbation, which requires frequent medical supervision, and/or physician consultation, and which in the absence of such supervision or consultation, would require hospitalization.

The individual requires frequent time-consuming administration of specialized treatments, which are medically necessary.

The individual is dependent on medical technology and/or assistive devices such that without the device or technology, a reasonable level of health could not be maintained.

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Under CFSA’s Nurse Care Manager Program (NCMP), all children who fall under the above definition are screened for unique needs and assigned an NCM upon entry or re-entry into care. Children are discharged from the NCMP when the criteria above are no longer applicable and the child is medically determined to be stable. In the case of children receiving in-home services, medical concerns are referred to the NCM co-located at the assigned Collaborative.

Training, Consultation, and Supervision Recommendation CFR reviews should include a status update on any known siblings under the age of 18.

Status CFSA’s Agency Performance (AP) senior leadership has met individually with the child fatality reviewers to advise them that this information (whenever applicable) should be included in future child fatality case presentations. AP leadership has also sent reminders to the entire team to reinforce the importance of including sibling status updates. The QSR team reviewers, who are responsible for child fatality reports, are now including information on any minor surviving children when applicable. Recommendation CFSA’s Child Welfare Training Academy (CWTA) training needs to reinforce the importance of comprehensive information gathering (i.e., information from interviews with core and collateral contacts, history of previous reports, etc.) for validating dispositions of substantiated investigations. Disposition decisions must be based on all factors available and not isolated to partial information available at any given point in time.

Status Agency Performance and Entry Services provided refresher training in October 2016 on the Acceptable Investigations process. This training was provided for all CPS supervisors. In partnership with Entry Services, CWTA has developed a tailored “back-to-basics” curriculum for all Entry Services staff and supervisors. This refresher training is scheduled for August and September, 2017. The training will highlight the need for sufficient interview content from core and collateral contacts, in addition, to emphasizing standards for initial information-gathering steps during investigations and family assessments. It was noted in the Monitoring report that CWTA’s established pre-service curriculum includes a detailed review of the contents required for safety plans. Recommendation CWTA training for new social workers should include a detailed discussion of critical thinking as part of clinical practice, decision-making, and safety planning with families. Refresher trainings should be offered on an ongoing basis (as deemed necessary by social work supervisors, program managers, and program administrators).

Status Critical thinking is emphasized in CWTA’s pre-service training and in a number of in-service courses. However, supervision and on-the-job coaching are equally important, and this is where CFSA is placing stronger emphasis to improve the overall level of critical thinking in daily practice. The mandatory pre-service curriculum discusses assessment integration and provides detailed information regarding critical thinking, decision-making, and safety planning. This curriculum emphasizes the application of critical thinking skills for systematically organizing and examining information gathered during all initial and

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ongoing assessments. Such information supports the development of individualized family service plans (e.g., whether to recommend reunification or a goal change, or whether to recommend case closure, which prioritizes the service plan). Further reinforcement is provided during the Assessment Integration in-service training session which addresses the enhancement of safety planning practices. Lastly, CWTA is also in the process of creating a practice guidance tool to provide social workers with a step-by-step guide for the key components of a quality safety plan. CWTA provides ongoing mandatory supervisory training: Mastering the Art of Child Welfare Supervision (MACWS) 2.0. This in-service supervisory training reinforces critical thinking skills, particularly during paradigm shifts in child welfare practice (e.g., trauma-informed and DV-informed practice changes). Supervisors are guided during training to model their own critical training skills during 1:1 and group supervision. Additionally, CWTA will be launching a coaching strategy to support supervisors in enhancing these skills through 1:1 and group work. This strategy will be launched in FY 2018. CWTA also tracks attendance and informs deputies, program administrators, and program managers when members of their teams have or have not attended the mandatory MACWS 2.0 sessions. To complement these efforts, OWB provides supervisors with “learning collaboratives” that also enhance these critical thinking and supervisory skills. Recommendation CWTA needs to define “parentified child” and provide training to social workers to help them address this issue with parents and to identify age-appropriate supports for child care.

Status While there is no singular, stand-alone session that discusses children who are taking responsibility for their parents or their siblings (i.e., “parentified child”), content on the symptoms and behaviors of these children is woven throughout CWTA’s pre-service and in-service training. CWTA will develop “Practice Guidance for Supporting the Parentified Child” by the end of FY 2017.

Research and Policy Recommendation There is need for creation of a workgroup to look closely at agency practice and policy related to parental substance abuse, in particular the drug phencyclidine (PCP), safety and risk level, and appropriate safety planning.

Status In March 2017, CFSA established a workgroup, led by CFSA’s Office of General Counsel, to respond to this recommendation.. As a result, the deputies from Entry Services and OWB were assigned to review and revise the Hotline and Investigations policies regarding handling of referrals that include positive toxicology reports for infants. On June 1, 2017, workgroup participants presented their recommendations to CFSA’s internal CFR committee. The deputy for Entry Services also provided a copy of the new Hotline protocol, which was revised to address positive toxicology reports for infants. Recommendation The Health Services Administration should review its protocol for administering psychotropic medications to CFSA children and explore best practices from around the country.

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Status In March 2017, senior staff from the Health Services Administration (HSA) attended a national conference that included a presentation on appropriate use of psychotropic drugs for children and youth. The presentation also included information from other jurisdictions, such as existing protocols and tools CFSA can use to review and redesign protocol and policy. HSA staff anticipates completing the new protocol for administering psychotropic medications within the year. Recommendation CFSA’s policy unit should review the existing Supervision and Self-Care of Children policy with the specific intent to expand guidance for caregivers acting in loco parentis (i.e., acting in place of the parent).

Status The Policy Unit is currently revising the policy to apply the decision-making rubric of the Reasonable and Prudent Parent (RPP) standard, including cautionary standards.11 CFSA and private agency resource parents (i.e., traditional foster parents, kinship caregivers, and adoptive parents) have already been introduced to the RPP standard through distribution of an informational brochure. CFSA is also finalizing a resource parent handbook that will provide detailed guidance on decision-making. This information will be reinforced by cross-training for resource parents and social workers. The anticipated time frame for the training is the fourth quarter of FY 2017. Recommendation CFSA’s policy unit will review and revise the process for at-risk Family Team Meetings (FTMs) to include referrals to the Nurse Care Manager Program (NCMP) whenever needed.

Status CFSA’s Policy Unit is working directly with the FTM unit supervisors to revise the FTM policy and incorporate this recommendation. Revisions are slated for completion by autumn, 2017. Although current practice includes invitation of an NCM to an at-risk FTM when the NCM is already assigned and listed on the collateral contact list, the policy revision will address the specifics of inviting an NCM as a matter of practice in order to expedite assignment (if needed) and referrals for clients in need. The Policy Unit is also working with CFSA’s Health Services Administration to develop a policy specific to NCMs that will further formalize the recommended practice. Both the revised and new policy will include guidance for social workers and FTM staff. Recommendation CFSA’s Human Resources (HR) administration will draft a protocol to support overall employee well-being for staff dealing with a current or past child fatality case.

Status HR continues to play a critical role in the effort to roll-out organizational well-being strategies for employees at CFSA, including the identification of supportive resources for employees experiencing secondary trauma such as child fatality and near child fatalities. Under the co-direction of the Office of the Deputy Director for Administration, CFSA’s Labor Management Partnership Committee Task Force

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In 2014, the federal government passed the Preventing Sex Trafficking and Strengthening Families Act (H.R. 4980). The law is a little complicated because it addresses multiple issues at the same time. For purposes of this report, the relevant clause requires all state child welfare agencies to empower resource parents to apply a “reasonable and prudent parent standard” when making decisions for children in their care. To ensure compliance with this clause, the District also passed the Supporting Normalcy and Empowering Children in Foster Care Emergency Amendment Act of 2016 (DC Act 21-333).

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(LMPC) will continue the effort for infusing further well-being best practices and activities into the organizational culture of CFSA.

System-Wide Activities

Recommendation CFSA’s internal CFR committee recommended that CFSA’s director draft a letter to the Citywide Fatality Review Committee regarding inter-agency collaboration around a public “safe sleep” campaign.

Status The District’s Department of Health (DOH) has an existing public information campaign to educate residents and physicians on the difference between bed-sharing (infant and any other individual in the same bed) and co-sleeping (infant and other individuals in the same room). In addition, all City-Wide Child Fatality Review Committee members, including CFSA and DOH, have a robust focus on these safe sleep initiatives. Moving forward, CFSA has already initiated distribution of safe sleeping informational brochures for staff, birth parents, and resource parents. The brochures are published in English and in Spanish. CFSA is also researching safe sleeping guidelines in other jurisdictions, including research on the safety and viability of potential distribution of “baby boxes” which may provide a safe sleeping alternative for parents who want babies in the bed with them. Baby boxes are small and can be placed on a bed to allow proximity but prevent hazards such as a sleeping adult rolling over on an infant. As safe-sleeping issues have been a long-standing concern for the child welfare system, CFSA will be monitoring ongoing efforts moving forward and providing additional details and updates for the 2017 report. Recommendation CFSA should encourage partnership with MPD to improve social worker safety and well-being when entering neighborhoods that are potentially unsafe.

Status Since this recommendation, CFSA has worked collaboratively with the District’s Office of the Chief Technology Officer (OCTO) to develop and implement the RAVE panic button—a phone application designed to provide staff with an instant means of notifying MPD in case of an emergency situation. All case-carrying staff has received iPhones with the RAVE app. Recommendation CFSA’s internal CFR committee recommended that CFSA work with the District’s Department of Health’s Vital Records Division to develop and establish a mechanism for formal data sharing, i.e., notification and exchange of decedent information, especially for natural infant death cases that would not normally come before the OCME or other death investigative entities and could only be identified by a death certificate.

Status Both Agency Performance and OCME senior leadership have reached out to the Department of Health (DOH) Vital Records Division. The partners will continue their collaborative efforts toward a data-sharing process for CFSA and DOH, and assess how this information can best be used. In the meantime, CFSA and OCME have collaborated on an improved process to receive notification of infant deaths. For example, OCME staff members are now sending CFSA notification of infant fatalities that have occurred between a six-month and two-year period from the time of death.