Currently, I’m involved in the review of a child fatality case. Earlier in my career I participated in a number of these. As I became more focused on family support and primary prevention, I stepped back from these, in part because it seemed like there was a dissonance between fatality reviews and my efforts to encourage colleagues to move services farther upstream.
But there is no denying that there is a very real and practical connection between prevention programming and fatalities, with child safety on the top of the family support pyramid.
There are many types of child fatalities, so let me clarify. I’m talking about the grim, senseless killing of a child, often over an extended period, by an adult entrusted with their care — both of whom are known to a child welfare agency. In this scenario, we come face to face with an event we suspect might be happening, but whose reality we deny and whose consequences we fail to imagine.
These cases are especially egregious and heartbreaking. The burns, deprivation of food or medical care, the shaking of children whose families deserved closer attention and scrutiny, left unchecked. The system in place to remediate these fragile situations continues to struggle with its own frailty, resulting in a persistent and unacceptably high rate of fatalities: In 2020, federal data shows 1,750 children died as a result of maltreatment. Historical trends show that about half of those kids had come to the attention of child protection agencies — theoretically, the organizations designed to achieve the best goals possible.
Our check-and-balance process for preventing such tragedies — supervision most often — has become a shadow of its former self. It is now a weak underbelly of a process more concerned with compliance than clinical competency that makes any knowledge of a family a long-distance exercise.
We underestimate the complex reality of situations. We fail to account fully for the confluence of parental stress, mental health issues, social isolation, substance use and in some cases, the probability that certain human beings will do evil things to those who are unable to protect themselves. Concurrently, many of our caseworkers and our systems are inadequately prepared to integrate the density of factors leading to the death of a child.
Our system’s shallow well of capacity, memory and critical thinking is not sufficient to interpret all that it sees through the distractions of the situation. Every review team on which I have served came to the same conclusions: The failure of an under-supported social worker, supervisor and an entire system to factor in the historical and current-day stressors for a family. There was poor communication among professionals about the confluence of substances or severe mental illness, the impact of social isolation, or the total lack of a caregiver’s conscience or moral compass. As a result of our individual and systemic dereliction, a child suffered in the most unspeakable way, and then became a data point for an annual state report or a research study.
In addition, we maintain cumbersome processes for sharing information among systems, and we treat every case that comes through child welfare’s door in the same way. We fail to incorporate how supports like food and rent for families can help to buy time for a child, and to stabilize a situation. Delivering those types of services can also be a way to break down the walls of isolation a family is experiencing so that we provide alternative eyes and ears for family safety and stability.
Of course, hindsight is always the clearest perspective. My colleague Dee Wilson, a senior child welfare practitioner and academic, likens the look back on fatality cases to Daniel Kahneman’s work, “Thinking, Fast and Slow,” where the author explains how the brain of one person can routinely be bamboozled, creating decision-making misfires. Indeed, we see those misfires on the look back.
But what also becomes clear is the insufficiency of our decades old model — deploying one caseworker in these higher-risk cases. In my experience, Kahneman’s findings support the value of teamwork on difficult cases. The road to reducing child fatalities lies in a collaborative approach examining specific cases, as well as systemic causes.
Community-based, multidisciplinary collaboratives have taught us the effectiveness of partnerships with families, neighborhood stakeholders and professionals, especially for the most vulnerable. When a community’s primary orientation turns toward the well-being of its members, everyone takes the safety of children more seriously. It’s an approach that encourages collective action.
These models frequently prioritize the health and safety of young children. Adding coordinated supports for families with little ones allows us to dramatically reconfigure the use of medical and mental health professionals into our work. Collaborations also open the door to the use of family helpers with lived experiences.
All our theories about what works to reduce child welfare fatalities highlight the sly contrast between what sounds smart and what is truly wise. We need to move from the brightest of conversations in our hygienic bubbles to the saddest of possibilities in a child’s home. Something might resemble a smart idea until it actually sees the light of day, when it’s digested by front-line staff. Since they are frequently way downstream with families, we can only hope that fewer children will be lost.
