Beyond CPS: Developing an effective system for helping children in “neglectful” families

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Beyond CPS: Developing an effective system for helping children in “neglectful” families Michael S. Wald ∗ Stanford Law School

Policymakers have failed to address the neglect of neglect

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ver the past 25 years, reports of physical abuse and sexual abuse to child protective services (CPS) agencies have declined by 56% and 62%, respectively. Concurrently, domestic violence declined by over 60%. Unfortunately, there has been little or no decline in two other factors affecting the wellbeing of millions of children—the number of families reported to child welfare agencies

because of alleged neglect and the percent of children living in poverty. The numbers are alarming. In 2012, CPS agencies in the United States investigated allegations of child maltreatment involving over 3 million unduplicated children, nearly 5% of all children. More than 70% of these reports involved allegations of neglect, although there were overlapping allegations of physical or sexual abuse in a portion of cases. (The number of “pure” neglect

∗ Correspondence concerning this article should be addressed to Michael Wald, Stanford Law School, Crown Quadrangle, 559 Nathan Abbott Way, Stanford, CA 94305, USA. Electronic mail may be sent to [email protected]. http://dx.doi.org/10.1016/j.chiabu.2015.01.010 0145-2134/© 2015 Elsevier Ltd. All rights reserved.

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cases cannot be determined from available data.)1 Cases categorized as neglect accounted for 75% of substantiations and over 60% of all foster care placements. Especially troubling is the evidence, developed by Chris Wildeman and his colleagues, that at least 12% of all American children will have a substantiated CPS finding, usually for neglect, before they reach their 18th birthday. Like the prevalence of neglect, the proportion of children living in poverty has not declined in the past 20 years. Although there have been variations over time, about 1 in 5 children live in families with income below the poverty level. Neglect and poverty have always been closely linked. As Dee Wilson recently observed, child welfare agencies in the United States are serving a large population of families who are not just poor, many of these families are on the verge of destitution, with yearly incomes less than half of the federal poverty standard. Despite the prevalence of neglect as a basis for CPS interventions, many researchers and practitioners have asserted, for over 40 years, that there is a deep failure of policymakers to acknowledge the problems in “neglectful” families and take the steps necessary to meet the needs of their children—the “neglect of neglect.” These commentators contend that public child welfare agencies and the general public pay less attention to neglect than to

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Three million other reports were not investigated for reasons that are not clear. All of these numbers are approximations. They are drawn from the National Child Abuse and Neglect Data System (NCANDS), published by the U.S. Department of Health and Human Services and based on reports from states. Unfortunately, the inconsistency in reporting and labeling of data by the states makes the data very hard to interpret. The true incidence of any particular threat to children’s safety is not obtainable from any state or national data sets.

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physical or sexual abuse and are more tolerant of neglect even in its chronic forms, even though chronic and or severe neglect may be more detrimental to a child’s health and development than physical or sexual abuse. Commentators offer a variety of policy changes to address these perceived failures. Some experts call for a clearer definition of neglect that broadens the basis for CPS involvement. For example, Laura Proctor and Howard Dubowitz recently wrote, “We advocate defining child neglect as any situation in which a child’s basic needs are not adequately met, resulting in actual or potential harm.” Others focus on expanding formal CPS intervention in currently reported cases. For example, Elizabeth Bartholet argues that there is a need for more CPS oversight of neglectful families and more removals of neglected children from their families. Advocates also call for reorganizing CPS policies and services so that they are better designed to meet needs of the children in the multi-problem families that are currently brought to the attention of CPS agencies for neglect, especially in families evidencing chronic neglect. In contrast, other commentators have long contended that poverty is the primary cause of neglectful parenting and advocate poverty reduction as the core strategy for addressing the needs of these children and parents. I agree that the current approaches for supporting children (and their families) reported to CPS for neglect are often quite deficient. There is solid evidence that the development of a substantial percentage of these children will be significantly impaired by the inability of their parents to provide minimally adequate care, nurturance, and support during periods of their childhood, especially early childhood. Some of these children also face the threat of serious physical injury or sexual abuse because

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of their parent’s failure to provide adequate care or supervision. For most of these children, however, the major risks are to their academic, emotional, and social development, not their immediate safety. The majority of children reported to CPS as neglected have significant developmental problems, which may have begun years before CPS involvement with their families. As a group, these children are less likely to succeed in school, more likely to engage in persistent delinquent activities, and much more likely to experience physical and mental health problems throughout life than other children from families in similar economic circumstances who are not reported to CPS. Moreover, as Brett Drake and others have reported, these outcomes do not differ substantially between substantiated and unsubstantiated cases. Under current policies, many of these children and families do not receive services until they have been reported multiple times and the children’s development has been significantly compromised. When they receive services, these often are time-limited and insufficient to promote the children’s development or help their families overcome the challenges they face in providing adequate parenting. Much more needs to be done. I take issue with the proposed remedies, however. Defining the term neglect more clearly (which the Proctor and Dubowitz definition fails to do: e.g., what are basic needs, what types of harms, what does potential mean?), or expanding the scope of CPS involvement will not promote the development of most children currently reported as neglected. Neither would putting more resources into the existing CPS system to serve more children. (Resources are needed to better serve children who should be under CPS supervision.) To the contrary, CPS involvement should be reduced as a means of responding to

“neglectful” parenting. CPS systems will never be able to meet the needs of most of these children and families and should not be the system responsible for so doing. A pure income approach also lacks adequacy. There is a strong association between poverty and neglect, although most poor families do not neglect their children. These parents’ poverty must be addressed. Persistent or dire poverty itself is a threat to children’s safety. (Most poor families are not chronically poor; while at least 40% of families with children experience poverty at some point, typically this is for relatively short periods of time.) However, income transfers alone will not enable most of these parents to alter the behaviors that harm their children’s development, or to escape poverty. An adequate approach must address these behaviors, while simultaneously addressing parents’ income needs. There are indications that the situation of poor children in multi-problem families has worsened over time. As I have detailed in several recent papers, as many as 20% of children in recent birth cohorts will experience seriously inadequate parenting for at least a period of time during their childhoods, almost double the number who will have a substantiated maltreatment case. Perhaps 4%-5% will suffer from chronic inadequate parenting. Recent studies have found that “neglectful” parents, to an increasing degree, experienced inadequate parenting during their childhood and live in areas of concentrated poverty, both urban and rural. A new approach is needed, one that focuses on providing a realistic system of services for engaging and helping these families, a system that will be accepted by policymakers and the public. I propose here an alternative approach, embedded in the health and education systems, that focuses on facilitating positive parenting 51

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from the time that a woman becomes pregnant, rather than the remedial and limited efforts that are inevitably associated with reliance on child welfare systems. I first examine three outcomes for children that generally are the goals of public policy regarding children: (a) that children are physically safe during childhood; (b) that children develop the cognitive and socio-emotional capacities needed to become self-sufficient adults; and (c) that children experience a “reasonable” level of mental health, in both childhood and adulthood. Each of these outcomes is influenced by the quality of parenting a child receives, although other factors, including the resources provided to both children and families, greatly influence whether children attain these outcomes. I then examine which of these outcomes is the appropriate focus for CPS programs. I argue that CPS should be utilized when there is a need to protect children’s basic safety (being safe from physical harm caused by parental actions or inactions; being safe from sexual abuse; receiving adequate medical care for physical or mental illness). Finally, I propose an alternative approach for helping all children attain the other outcomes.

Focus on Outcomes In thinking about ways to strengthen parenting, policymakers and child advocates need to start by focusing on the outcomes for children that society wants to attain through public policies and programs. When the quality of parenting appears to be a central barrier to whether a child is likely to attain a particular outcome, policymakers should consider which approaches and systems, including public health, education, and CPS, are most likely to be effective at strengthening parenting. 52

Although state policies seek to achieve a number of outcomes or goals for children, three are primary. The first is child safety; it is a goal of public policy that no child should experience parental (or non-parental) care that substantially impairs her or his current physical safety. A second outcome that underlies almost all policies regarding children is economic self-sufficiency in adulthood; a central goal of most policies regarding children is to help them acquire the academic and social/emotional skills necessary to succeed economically in adulthood. A third outcome relates to physical and emotional health. Child welfare professionals frequently propose that public policies should be designed to maximize the likelihood that children have a minimal level of physical and mental health throughout life. In the words of a committee of the National Academy of Sciences, public policy should be designed to ensure that children will be provided with the types of care and resources needed for them “to live healthy, happy, and productive lives in caring relationships with others.” This goal clearly is a more ambitious outcome than safety or self-sufficiency, and public investments designed to achieve this goal are relatively limited. The various types of parental behaviors commonly associated with “neglectful” parenting affect whether children achieve each of these outcomes. (The outcomes are interrelated.) But there are a number of ways of helping parents meet their children’s various needs. Which of these outcomes is the appropriate focus for CPS? I look next at this question.

The Role of CPS The appropriate goals for CPS in responding to various forms of inadequate parenting

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have been debated for almost 60 years. The current structure of child welfare services began to take shape in the 1960s, following the publication of “The Battered Child Syndrome,” written by Henry Kempe and his colleagues. The primary focus was initially on physical abuse and later on sexual abuse, which were the concerns discussed in Kempe’s writing. A major change occurred in 1974, when the U.S. Congress enacted the Child Abuse Prevention and Treatment Act (CAPTA). CAPTA offered states funds to deal with child abuse. A critical provision was that to receive federal support for its child protection system, the state must establish a system for investigating reports not only of physical abuse but also of neglect and serious harm to a child’s emotional or academic well-being caused by parents or primary caregivers. Thus the mandate for CPS was expanded considerably—even exponentially. In 1967, approximately 10,000 cases of child abuse or neglect were reported to child welfare agencies. By 1975, nearly 300,000 cases were reported. Over the past 40 years, the reach of the child protection system continued to expand to the current 3 million investigated reports each year. Cases involving allegations of neglect have accounted for most of this increase. From the time of CAPTA’s passage, a number of commentators, including myself, expressed concern with the broadened definition of neglect. At that time, while serving as the draftsman for the American Bar Association’s Juvenile Justice Standards Project, I argued that the primary purposes of labeling parental behavior as maltreatment should be to allow the state to require reporting of the parent’s behavior, investigate the child’s home environment, require parental participation in services, and, in some instances, terminate parental rights. Applying these criteria, I

proposed that CPS intervention should be limited only to situations involving threats to a child’s physical safety, instances of sexual abuse, or situations where a child evidences serious physical or mental health problems but the parents are not willing to provide treatment. In these situations, the harm is clear, the parental behavior causes the harm, and supervision often is needed to prevent recurrence of the parental conduct. Labeling this conduct maltreatment also sends a clear social message that this parenting behavior is not acceptable. I argued that other systems would be better able to help parents provide the types of care and interactions needed to promote the cognitive and emotional development of their children. Contrary to this recommendation, policymakers, largely by default, left the CPS system as the primary system with responsibility for dealing with all forms of inadequate parenting. Looking at developments over the past 40 years, I continue to believe that CPS intervention should be limited to the types of situations proposed in the ABA Standards. Applying these criteria, the need for CPS involvement is clear with respect to situations involving parental sexual conduct with a child and many situations currently reported as physical abuse. The same is true with respect to “neglectful” parental behavior that could lead to serious physical harm, or when a parent fails to protect a child from sexual conduct with an adult. For example, a parent may fail to feed a child, home conditions may be so unsafe that a child has suffered serious physical injury or there is a high likelihood of such injury, a young child may be left unattended or in the care of other young children for lengthy periods of time in situations that pose a significant risk of injury, or the parent may fail to provide urgently needed medical care. When a child actually suffers 53

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serious physical injury as a result of parental inattention or unsafe home conditions, or when these actions clearly create a threat of imminent serious physical injury to a child, CPS involvement (at least in terms of investigation) is justified for the same reasons as in physical abuse cases. Specifically, monitoring and supervision may be needed to protect the child from harm. Referral to CPS for a determination of risk also may be appropriate when there are indications of significant drug or alcohol use during pregnancy, because there is substantial evidence that this behavior is a strong predictor that the safety of the child is likely to be compromised. In contrast, utilization of CPS is not a desirable approach to help children where the need for state services rests primarily on helping children to achieve self-sufficiency as adults or where parent–child interactions threaten children’s long-term emotional or social development. I am not arguing that society should do nothing to address situations where the quality of parenting is clearly diminishing the likelihood that a child will develop the capacities needed for self-sufficiency and/or emotional health. It is morally unacceptable to do nothing to help the millions of children in households where the quality of parenting is likely to impair their long-term development. The policy challenge is determining the most effective way to help these parents provide basically adequate care and to support their children’s development. If our society really wants to promote the developmental needs of most of the children in families currently reported for neglect, this goal is not likely to be achieved through use of CPS systems. Proponents of broader CPS intervention acknowledge that no current CPS system has the capacity to promote the longterm development of most of the children who 54

receive services through the child welfare system, although intervention often does prevent continuation of physical or sexual abuse and other immediate safety threats. Numerous studies find that children who receive commonly available services provided or funded by child welfare agencies do not generally fare better developmentally than those who do not. These commentators contend, however, that CPS intervention can be made effective by defining neglect more clearly and broadly, providing more resources to CPS agencies, expanding some apparently effective program models for working with high-need families, and greater use of CPS as a connector to other services through alternative or differential response. Some also argue that most neglecting parents need CPS or court oversight in order to prod them into taking the actions needed to address the factors that are affecting their parenting (e.g., substance misuse, domestic violence). These claims are unpersuasive. Let us be realistic. Most CPS agencies lack the capacity to help those families and children that currently receive services, let alone provide high quality services to several million more children and families. There is no basis for believing that CPS is likely to receive substantially more resources, that a few small model programs that have been successful in working with parents in child welfare settings can be taken to scale, or that CPS will come to be seen by most parents and the community as a positive resource. The need to better address the situation of children in families that face multiple barriers to providing consistent care and attention has been a focal point of scholars, practitioners, advocates and reformers for more than 50 years. Numerous new approaches have been proposed, including three reports issued by the U.S. Advisory Board on Child Abuse and

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Neglect in the early 1990s. With the exception of some recent efforts by the Obama Administration with respect to expansion of home visiting, policymakers have not responded in any significant manner. It is not going to happen. There also is no persuasive evidence that most of these families will respond only to threats. To begin with, as Dee Wilson has written, “CPS programs were not designed for chronic neglect that does not meet a threshold for physical danger. . .. Child welfare agencies are often at a loss for what to do for children in these families who may not be in physical danger, but who experience cumulative developmental and emotional harm resulting from chronic neglect of their basic needs, including lack of nurturance.” The child welfare system is designed to investigate allegations of specific parental behaviors that threaten children’s safety and to try to prevent the recurrence of these behaviors over a relatively short period of time. This approach is not adequate to help most of the children who come to the attention of CPS through neglect allegations. The major threat to most of these children is not a specific action or inaction, such as lack of supervision. Rather, the harm comes from the stress and inconsistency in the home environment and the pervasive failure of the parents to respond consistently to the child’s physical and emotional needs. As documented by Norman Polansky and others, in these households, there may be chronic understimulation, limited caregiver responsiveness or nurturance, extreme lack of attention to children, and/or high levels of family conflict. Some of the parents (the extent is not well-documented) suffer from depression or other mental health problems and/or may be dependent on drugs or alcohol. Helping many of these parents acquire the skills necessary to meet their children’s

basic development often requires intensive, expensive high-quality services. In some percentage of families of chronically referred families, there will be a need for such services over a lengthy period of time. These families also need a regular source of adequate income. CPS agencies do not control the health, education, financial, and other community resources needed to work with multi-problem families. Even assuming that having CPS involved with a family for a long period is desirable, it is extremely unlikely that the federal government or many states are going to change the statutory mission of CPS in fundamental ways. Nor is it likely that legislators will mandate integrated approaches among multiple systems guided by CPS. The health care and education systems are far better situated to compete for the needed resources and personnel and to take a lead role in coordination of services. Even with respect to its basic mission, CPS systems throughout the United States experience great difficulty in helping the seriously endangered children who are currently in the system; the same appears to be true in other countries. Despite a variety of legislative efforts, lawsuits, and foundation investments aimed at improving systems, most states still have a long way to go in meeting children’s basic safety needs. For example, in just the past two years, the child welfare systems in Arizona, Colorado, Florida, Oklahoma, and Los Angeles have been found to be woefully deficient by political and community leaders, an old story in child welfare reforms around the country (and world). I hope that legislators can be persuaded to provide the additional funding needed by child welfare agencies if they are to protect children subjected to, or threatened with, serious physical harm or sexual abuse. In these cases, agencies also should provide services 55

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designed to meet the children’s developmental needs. There is no realistic prospect of budget increases to child protection agencies sufficient to allow them to develop high-quality programs for addressing the needs of a million more families than currently receive child welfare services. As a practical matter, CPS agencies are competing with schools, preschool and afterschool programs, and health care organizations for limited public funds targeted at supporting children. There are not enough resources to fund all of these demands, and the health and education systems are far better situated to compete for funds. The same is true for personnel. Child welfare agencies have trouble hiring and retaining qualified staff, creating adaptable organizational structures, keeping stable leadership, and maintaining political support. Recruitment and retention of child protection caseworkers has been made more challenging with the expansion of preschool and other children’s programs, because CPS must compete for personnel with these betterfunded and better paying programs. Relying primarily on CPS to promote the developmental needs of children experiencing inadequate parenting inevitably means missing many children who need help. CPS intervention is a haphazard means of helping children and parents because CPS can only respond to situations reported to the public agency. Moreover, state and locally run CPS systems vary greatly in coverage. Reporting rates range from more than 1 in 10 children each year in the District of Columbia and West Virginia to fewer than 5 per 1,000 each year in Hawaii and Minnesota; substantiation rates also vary widely. Differences in reporting and substantiation rates appear to be unrelated to differences in family characteristics in the states. States also differ in the attention paid to neglect. For example, the percentage of total substantiated 56

cases with a neglect finding ranges from 100% in New York to 20% in Kansas. Given the historical American preference for local governance, particularly with respect to family and child issues, there is little possibility that Congress will create a system with more uniform standards for intervention and services. Aside from the issues related to resources and capacity, there is the problem of framing. The CPS system does carry a moral message, and in some respects it should. Recently four authors wrote in this journal that “members of the British public have come to recognize that child maltreatment is both highly prevalent and morally reprehensible.” Although many caseworkers offer support to parents and services, blame is often in the minds of the parents, the community, and many caseworkers when a child is labeled maltreated. Although it may be desirable for the public to believe that hitting a child in a manner that can cause severe injury or using a child for sexual purposes are morally reprehensible actions, such opprobrium should not be the goal with respect to most of the parental behaviors that are labeled neglect. Most of these parents are not intentionally doing things that hurt their children, such as severe physical mistreatment or using them as sexual objects. Categorizing most of the types of inadequate parenting that now comes to the attention of CPS as morally blameworthy is conceptually wrong and often counterproductive. As detailed by the U.S. Advisory Board on Child Abuse and Neglect in its reports Creating Caring Communities and Neighbors Helping Neighbors and demonstrated by projects like Durham Connects and the Harlem Children’s Zone, community involvement must be a central ingredient in efforts to promote the long-term well-being of children in high need. Just labeling parents as neglectful may negatively influence

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communities’ willingness to invest the resources needed by the parents. Thus, CPS jurisdiction may actually decrease public support for assistance to children receiving inadequate care. In addition, CPS intervention in situations in which the parenting is not threatening the children’s basic safety—but is compromising their cognitive and emotional development—is likely to be highly arbitrary and to place a disproportionate burden on the poor. There are children in families of all income levels who experience serious emotional problems. Poor parenting in higher-income families (such as alcoholism, inattention, and high levels of family conflict) can contribute to these problems, but these families are unlikely to be reported to CPS. Fortunately, many (but by no means all) higher-income parents can afford to obtain help, which they do seek, in addressing their personal problems and their children’s difficulties. The same types of services must be made available to low-income families, but building public support for an adequate system of mental health services is not likely to happen if the parents are viewed through a maltreatment lens. Finally, I have doubts about the claim that CPS supervision and the threat of losing custody of their children is an essential element in inducing highly disorganized parents to address their needs. This claim rests in part on the assumptions that the vast majority of families reported as neglecting suffer from drug or alcohol abuse and that people who are drug-dependent will not respond to voluntary treatment. It is difficult to determine the portion of the parents reported for neglect who suffer from major drug abuse or alcoholism. It is undoubtedly very high with respect to reports involving infants because these reports often are based on substance use during pregnancy

or at the time of the baby’s birth. The percentage of parents who abuse substances has not been reliably measured in cases involving older children. However, there is no evidence supporting the common claim that substance abuse is involved in 80% of these families (the best available evidence would put the number at 20%–30%). In addition, although there is evidence that multi-problem families often do not follow through with services, several studies have found that they are initially willing to enroll in programs like home visiting and parent training. These families face many challenges surviving on a day-to-day basis. Some suffer from depression, which undermines their capacity to take action on their own behalf. But it is not clear that these parents are more responsive to services ordered by a court or overseen by CPS than they are to well-designed and competently administered voluntary services.

Is Safety a Major Issue in Reports of Suspected Neglect? I have been arguing that CPS involvement is appropriate when there is an indication that a child’s immediate safety (as defined above) is threatened, but not when the basic concern is with longer-term developmental issues. I would try to strengthen the parenting in the latter group of families through the new system that I am proposing. In order to focus CPS on the “right” cases, I would revise mandatory reporting laws by greatly narrowing the definition of reportable harms; two possible definitions are included in the appendix. Some commentators argue that most current reports of neglect, especially substantiated reports, involve threats of serious physical 57

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injury or sexual abuse, in addition to threats to the children’s long-term involvement. These commentators conclude, therefore, that neglect cases do require some form of mandatory intervention. Unfortunately, this claim cannot be clearly answered from the data drawn from the “neglect” cases now investigated or substantiated by CPS. States use varying, often vague, terminology in defining neglect. Therefore, summary statistics, such as those published annually in NCANDS, provide only a limited understanding of what is happening in these families. (The inability to establish a reliable system of data collection in the 40 years since the establishment of the National Center on Child Abuse and Neglect is another indicator of limited capacity to implement a competent and coherent child protection system.) Proponents of CPS involvement in more neglect cases often cite the fact that more children die from neglect than physical abuse as evidence that neglect allegations generally entail the threat of serious physical harm to children. Approximately 1,600 children die as a result of parental abuse or neglect each year, with perhaps 900 of these from causes related to neglect. This number, however, constitutes less than 0.1% of the 2 million children named in investigated reports of alleged neglect. It makes no sense from a resource or targeting perspective to expand CPS involvement in millions of more families as a way of trying to prevent some of these deaths. This point is especially true for the 60% of neglect cases involving children older than 5. The use and improvement of risk assessment tools is a better way of increasing the likelihood that children at real risk of serious harm will be identified. Of course, an additional portion of reported cases involve parental behaviors that could lead to substantial physical harm from abandonment, seriously inadequate supervision, failure 58

to provide medical care, or other forms of gross inattention. Although it is not possible to determine what percentage of reports fall in this category, several factors, including discussions with highly knowledgeable observers of the CPS systems, lead me to conclude that the figure is no more than 20%. First, even with respect to the approximately 600,000 substantiated neglect reports, about half of the families do not receive formal services. For whatever reason, the child welfare agency determined that there was not a sufficient threat of future harm to the child to require substantial CPS involvement. Fewer than 200,000 families (fewer than 10% of reported families) are placed under court supervision, an indication that extensive monitoring is believed necessary to assure a child’s safety. It appears that court involvement is primarily invoked in situations where the CPS agency is requesting legal authorization for removal of children from the parents’ homes. The risk of serious harm is likely to be even smaller in the approximately 2 million investigated neglect cases that are deemed unsubstantiated. I recognize, as Brett Drake and others have pointed out, that the fact that a report is not substantiated does not necessarily mean that there was no problematic parental behavior. The problem may relate to the inability of the agency to document the behavior. In addition, as Emily Putnam-Hornstein and others have shown, re-reports occur in as many as half of all unsubstantiated reports. The parenting in these families often is dysfunctional in many ways that threaten the development of their children. However, it is far from clear that there is a serious threat to the child’s immediate safety. The majority of re-reports are not substantiated and, when substantiated, generally do not lead to removal of the child. The child welfare system is unable and unwilling

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to place most of these children into foster care. Moreover, foster care is not a good option for most of the children. (It might be a needed response with respect to families who persistently fail to utilize the services I propose below.) Again, I believe that society has a moral obligation to help all children reach the outcomes I have identified. These children and their parents need an adequately funded, coordinated set of services, designed to help the parents develop the capacities that they need both to support themselves and to further the basic development of their children. However, this help should be provided outside CPS.

Differential Response It might be argued that the concerns that I have identified regarding CPS are being addressed by the adoption in at least 30 states of a two-tier response system, generally called differential or alternative response (DR). Differential response takes many forms. In some states, the goal is to provide a more positive approach to working with a portion of the families reported to CPS where there has been some form of maltreatment, as defined by state law, but where a full-scale investigation and/or CPS oversight is considered unnecessary to protect the children from further harm. In other jurisdictions, DR is designed to provide services to families who would otherwise not receive services because the reports are not substantiated. (There are mixed systems as well.) In many DR systems, the vast majority of families assigned to a non-investigative assessment track have been reported for suspected neglect. Proponents view DR as a way of maintaining broad reporting laws in order to identify possible risky situations while allowing a less adversarial approach to families in situations

where the child does not appear to be in immediate danger of serious harm. DR also may allow for some surveillance. DR is supported as major step towards better help for neglecting families and as a means to connect more families to services, even though the parental care has not been determined to meet the legal definition of maltreatment. However, some critics see DR as inappropriately leaving many children unprotected. Such commentators want more formal, court-enforced intervention rather than referrals for voluntary services. In addition, they claim that DR often is funded with dollars that would otherwise be used to serve children and families in substantiated cases, so that those children are put at greater risk. There is some merit to the claims of both sides. In some states, DR is providing needed services that families would otherwise not receive. It also seems likely that some children are exposed to greater risk of serious harm by the lack of a formal CPS investigation or CPS oversight, given the lack of conceptual clarity with respect to both the purposes of DR and the procedures that would be necessary to implement it in a sound manner. In addition, in some jurisdictions, DR does draw funding and other resources away from children who are appropriately under the supervision of CPS. Even if DR were implemented so that it focused solely on situations that do not pose a risk of serious harm to children and was funded with additional dollars, I doubt that the services offered through DR could adequately address the needs of the children in the families I am discussing. In order to adequately help these families, there needs to be a well-defined set of services, with a dedicated funding stream, clear mandates regarding outcomes, clear criteria regarding whom is served, a consistent theory of service provision, development of 59

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performance standards, and consistent data collection and evaluation. The funding stream should not take resources away from CPS agencies, which need more resources to protect children whose safety is at risk and who should receive services to promote their well-being once they are appropriately in the CPS system. At present, DR in virtually all jurisdictions consists of a hodgepodge of local programs (a) that vary greatly in quality, approach, and effectiveness; (b) that do not provide the types and length of services generally needed to help highly disorganized families; (c) that are not preventive; and (d) that do not address the poverty issue. It seems very unlikely that DR can be transformed into the type of system needed for impoverished neglecting families. DR programs will not be given the resources that they need, and they rely too heavily on underfunded and inadequately staffed local programs. They are not designed for accountability, and they cannot easily be transformed into programs containing the elements needed for continuous improvement. Thus, I would not try to extend the reach of CPS through DR.

A Different Approach As I have mentioned, I estimate that as many as 20% of all children will experience seriously inadequate parenting at some point during their childhood. For at least half of these children, such inadequate care will occur before they reach age 5. Child advocates should push policymakers not to rely on the haphazard involvement of CPS but instead to develop and adequately support a set of services that help all children who are at high risk of experiencing inadequate parenting. The new system should include active outreach to identify and connect with these parents, not just to provide services 60

to parents who seek help. It must be combined with, and deeply rooted in, programs to address the disabling poverty in many of these families. Because many such families are reluctant to engage in and complete services, the system may need to include some incentives for participation, conditional on the level of parental participation and behavioral changes. I outline here an approach focused on parents with young children, especially newborn and toddlers. Children younger than 5 account for nearly half of all neglect reports. A recent study by Emily Putnam-Hornstein found that 5% of all children born in California between 2006 and 2007 were reported to CPS before they reached their first birthday, in virtually all cases because of neglect or the threat of neglect. Most received no services. The period from conception to age 5, especially from birth to age 3, is particularly important from a developmental perspective and for children’s brain development. The quality of parent–child interactions plays an especially large role in children’s development during this period. In order to minimize the need to create new organizations and generate maximum political support for expanded services, the system would build on two national programs that currently serve vulnerable parents and children: the Women, Infants, and Children Program (WIC) and Early Head Start (EHS). Both of these programs have political support and a strong infrastructure. The system would also include home visiting (HV) or some other widely adopted support program for parents with newborns; HV is now available to a substantial number of families in many states and has a federal funding base. Utilizing these nationally supported programs, which are funded with health and education dollars, would facilitate the development of a more uniform set of programs

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with quality standards, technical assistance, federally-supported research and, I hope, a more reasonably secure funding base than is possible using social service dollars. WIC would be provided to all low-income pregnant women and new parents. WIC services would be expanded to offer a range of positive support programs to pregnant women at high risk of experiencing parenting problems. These women would then be connected through WIC, during pregnancy or at birth, with access to home visitors, who would provide parenting support and education directly, monitor the quality of parenting, and help parents who need additional support access other services. (HV would be made available at birth to women who did not access WIC.) Home visitors also would connect parents with education and training programs designed to work in coordination with the parenting activities. HV services also could be used for referrals by pediatricians and others who are aware of parents who seem to be providing inadequate care.2 The third component of this system would make Early Head Start available to all children in low-income families. This eligibility standard would encompass virtually all families of young children now reported to CPS as neglected. Again, there would be a need to redesign some aspects of EHS, so that the focus would be as much on the parent as the

2

There are other possible approaches to provision of parenting support that might be less expensive, easier to implement, and more successful at engaging high-risk parents than has been the case with many home visitor programs. For example, Larry Aber and his colleagues have suggested that pediatricians be at the center of the delivery system and that parents be encouraged to participate in less intensive parenting programs than is common in HV.

child. There are a number of successful local programs that can serve as models for the system. As Jack Shonkoff and others have elaborated, the programs provided through WIC, HV, and EHS should focus on helping parents to acquire capacities in self-regulation, planning and problem-solving, and stress management. These capacities are often inadequately developed because of the parents’ own experiences in childhood. Some parents will require more intensive services than can be provided directly through WIC, HV, and EHS. Professionals in these programs would be charged with identifying such parents and linking them with other needed services. For example, referrals might be made to evidence-based parenting programs, such as SafeStart, PCIT, Triple P, and Incredible Years, which are designed to help parents acquire and maintain specific parenting skills. Some children may need to be placed in full-day, very high quality childcare, such as Educare, so that the parent can participate in intensive services for themselves. If such a system were in place, it would not be limited to serving only those parents identified during pregnancy or at the time of a child’s birth. Pediatricians and other professionals concerned about a child could refer the parents to both HV and EHS, which could then assess the types of services needed. This approach would be more focused and reliable than the current reliance on CPS workers to make referrals. Depending on local community resources, these services might be based in a family resource or community health center. (See Fig. 1 for a diagram of the possible operation of such a system.) Some states and localities are already developing systems along these lines, often under the impetus provided by funding through The Maternal, Infant, and Early Childhood Home Visiting Program. 61

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Fig. 1. Proposed system of services.

States and localities’ capacity to develop coordinated services has been enhanced in many instances by advances in use of large, linked administrative data sets to monitor use of services and to develop risk assessment instruments to estimate the levels needed of various types of services. Such technology also can improve budgeting decisions. Two questions that must be answered to make this system work are (a) how to address the income needs of the vast majority of target families and (b) how to motivate parents to engage in needed services. These problems need to be considered together. As Robert Halpern has described in detail, coping with poverty creates major obstacles “to attentive and nurturant child-rearing.” Current approaches to reducing poverty revolve largely around connecting all parents with jobs. This approach has had some successes, but many 62

parents are not able to connect to the labor force on a consistent basis. The emphasis on work also interferes with some parents’ finding the time and energy to engage in activities relating to improved parenting. One possibility is the adoption of a children’s allowance for low-income families, made conditional on certain parental behaviors. For example, the allowance might be obtained at WIC or pediatricians’ offices or during home visits and conditioned on regular pediatric visits or involvement with the home visitor. New York City is currently experimenting in using Conditional Transfers to influence parental behavior. A less extensive approach currently being tested is combining parenting education with “hard” services to parents. For example, there are job training and parenting education programs being offered in many localities throughout the country, generally in

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coordination with childcare centers and other programs, such as EHS and HS. There are many challenges in developing a fair and effective system of implementation of contingent benefits. Nonetheless, we need new thinking to address the plight of the children living with highly disorganized and/or depressed parents who are often unresponsive to their children’s needs. In addition, these programs should be embedded in community-wide initiatives designed to engage parents, broaden the social support network available to more isolated parents, and reduce the levels of toxic stress in the community. Some, perhaps many, hardto-reach parents may respond more readily to informal services offered by neighbors than to more formal programs. Moreover, facilitating good parenting requires more than teaching parenting skills. Parenting is influenced by, and embedded in, the community in which a parent lives. In addition, community programs may be able to generate a greater level of public concern with the problems that inadequate parenting poses for children’s development. Such initiatives may also be able to generate clearer community standards for minimally acceptable parent care. Finally, community initiatives may make childrearing easier by reducing the need to cope with an unstable, violent social environment, a particularly challenging task for parents who start with poor coping skills. There are at least four promising models for increasing community engagement in support of parenting: Durham Connects, the Harlem Children’s Zone, Strong Communities for Children, and Triple P. Durham Connects and the HCZ also provide mechanisms for delivering coordinated services, a constant challenge at the local level.

The Conundrum I suspect that proponents of paying more attention to neglect within CPS would support the type of system that I am proposing; many have called for expansion of the programs I identify. However, they also would like to expand services within or connected to CPS. Some believe that the CPS system is the only one with the authority to change some parents’ behaviors, which may be true with respect to a portion of the parents, especially those with substantial drug addictions. Others may support full reliance on an alternative system, but only if the current jurisdictional standards for CPS remain in place until the new system is fully developed and implemented. Otherwise, they fear that too many children will be left unprotected. In the absence of an alternative system, constriction of reporting laws and a decrease in the number of investigations would undoubtedly leave some children (a very small percentage, I believe) at greater risk of experiencing serious physical harm. It also might mean that little to no attention is paid to some of the children living with parents who are chronically unable to provide basic nurture and attention. It is certainly true that there are people raising children who do not have the capacity to manage their lives, let alone provide the support that children need, and that these parents often fail to engage in available services. Moreover, the proposed system would require major changes in most WIC and EHS programs and some HV programs. As even expert practitioners have reported, these are not easy families to work with, even for very high quality programs with well trained staff. Many HV and EHS programs are 63

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aware of this challenge, and they are experimenting accordingly with new approaches. Full implementation of the proposed system would be expensive, because any set of new services, even if part of a coordinated system of delivery, will have limited success in producing better outcomes for children unless the services are of high quality. Given these challenges, some urge policymakers to adopt a slow, cautious approach. These commentators would wait for the results of the various research experiments now evaluating various alternatives, and they would strive to improve DR and other CPS services at the same time. Despite the risks involved in “starting at scale,” I believe that an incremental approach is not sufficient. Children’s advocates, including the U.S Advisory Board on Child Abuse and Neglect, foundation commissions, and organizations like Zero to Three, have been calling for new approaches for many years. Nonetheless, despite some progress, the services currently available are insufficient in both quantity and quality. As a result, millions of children are growing up under conditions that decrease the likelihood that they will have “decent” childhoods and that they will live reasonably adequate emotional and economic lives as adults. Reliance on prevailing reforms is likely to offer them little relief. Current policy initiatives for assistance to children emphasize increased access to preschool and improved quality of K-12 education. These services will benefit many children from low-income, loweducation homes, but they are unlikely to help the 15%-20% of young children in dysfunctional families. Instead, greater availability of preschool and improved quality of K-12 64

education are much more likely to benefit children living in families that have limited income but in which parental care is generally adequate (about 30% of all children in my estimates). Moreover, experimental research generally requires many years and often does not yield clear policy directions. There has been little progress over the past 40 years in altering the situation of the worst-off 20% of children. Waiting for more knowledge likely means little change in their wellbeing. Given the urgency and magnitude of the problem, child advocates should unite behind a set of programs. They should urge policymakers to enable adoption of some version of the system that I have outlined at scale. Then advocates and administrators should join to improve the system over time. I also would alter reporting laws so that CPS focused only on the most serious cases. CPS agencies do not have resources to handle additional cases. The savings that would accrue from elimination of CPS’s obligation to investigate millions of reports that will not lead to CPS services in any case could be used to fulfill the developmental needs of children who have experienced serious physical harm or sexual abuse. Hard choices must be made. If there is to be any real hope of improved outcomes for all children in multi-problem families, policymakers need to understand that the CPS system is not helping—and indeed cannot help—most of these children. American policymakers and the public seem to prefer parent-blaming over recognition of societal obligations to help all parents meet their children’s basic needs, the approach that is common in most other developed countries. Children in the United States have no legal

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rights to the resources needed for adequate development—no rights to a basic income, quality childcare, truly adequate education, or safety in the neighborhoods where they live. Ironically, children do not even have a legal right to CPS protection, as the Supreme Court

ruled in DeShaney v. Winnebago Department of Social Services. It is time for change! Keywords: neglect; inadequate parenting; child maltreatment; child protective services; child protection policy; system reform

Suggestions for Further Reading Dodge, K. A., Berlin, L. J., Epstein, M., Spitz-Roth, A., O’Donnell, K., & Kaufman, M. (2004). The Durham Family Initiative: A preventive system of care. Child Welfare, 83, 109–128. Halpern, R. (1999). Fragile families, fragile solutions. New York, NY: Columbia University Press. Polansky, N., Borgman, R., & DeSaix, C. (1972). The roots of futility. San Francisco, CA: Jossey Bass. Putnam-Hornstein, E., Webster, D., Needell, B., & Magruder, J. (2011). A public health approach to child maltreatment surveillance. Child Abuse Review, 20, 256–273. Shonkoff, J. (2014). A healthy start before and after birth: Applying the biology of adversity to build the capabilities of caregivers in improving the odds for America’s children. In K. McCartney, H. Yoshikawa, & L. B. Forcier (Eds.), Improving the odds for America’s children (pp. 28–39). Cambridge, MA: Harvard Education Press. Wald, M. S. (1975). State intervention on behalf of neglected children: A search for realistic standards. Stanford Law Review, 27, 985–1040. Wald, M. S. (2014). Beyond maltreatment: Developing support for children in multi-problem families. In J. Korbin, & R. Krugman (Eds.), Handbook of child maltreatment (pp. 251–280). Dordrecht, Germany: Springer. Waldfogel, J. (1998). The future of child protection. Cambridge, MA: Harvard University Press. Wilson, D. (2014). Preventing child maltreatment: How is neglect different? Sounding Board. April 2014 Retrieved from www.casey.org.

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Appendix. Possible Criteria for Authorization of CPS Involvement American Bar Association, Juvenile Justice Standards Project The child (a) has no caring adult available and willing to care for her or him; (b) has suffered physical injury causing disfigurement or impairment of bodily functioning as a result of conditions created by his parent or the failure of his parent to adequately supervise him, or where there is a substantial risk that the child imminently will suffer death, disfigurement, or impairment of bodily functions as a result of conditions created by his parent or the failure of his parent to adequately supervise him; (d) is suffering serious emotional damage, evidenced by severe anxiety, depression, or withdrawal

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or untoward aggressive behavior or hostility toward others, and his parents are not willing to provide treatment for him; (f) is in need of medical treatment to cure, alleviate or prevent his suffering serious physical or emotional damage, and his parents are unwilling to provide the medical treatment.

Department of Health, United Kingdom The persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development. It may involve a parent or carer failing to provide adequate food, shelter and clothing, failing to protect a child from physical harm or danger, or the failure to ensure access to appropriate medical care or treatment. It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs.