Yonatan’s Death Spurs Deep Look at How L.A. Gauges Child Abuse Risk

Last month, in response to news reports about the tortured life and death of a little boy, the Los Angeles County Board of Supervisors waded into the thorny question of how to predict child abuse.

The board’s first substantive action, in the wake of 11-year-old Yonatan Aguilar’s death, was to pass a motion questioning whether the county’s long-used system for measuring the risk of child abuse was working.

“Who was there to catch that failure in the system, to protect that young child, save that life?” asked one of the motion’s authors, Supervisor Mike Antonovich, during a September 20 board meeting. “Should that child should have been removed from the family sooner?”

In August, police found Yonatan’s 34-pound body, wrapped in a blanket, in the closet of his mother’s apartment in Echo Park.

Just last week, The Los Angeles Times published new details about Yonatan’s case, again noting that Aguilar’s family was known to the county’s child protection agency, the Department of Children and Family Services (DCFS).

Using a risk-assessment protocol called Structured Decision Making (SDM), child abuse investigators deemed the family at high risk for subsequent abuse four times from 2009 to 2012.

But Times reporters Richard Winton and Hailey Branson-Potts neglected to compare those “risk” scores to also important “safety assessments.”

Case files show that the four safety assessments conducted alongside the “risk assessments” all deemed that “no safety threats” were present. DCFS maintains that its workers cannot remove a child if there is no threat to his or her safety.

During the September 20 board meeting, supervisors gave the county’s Office of Child Protection and DCFS 30 days to complete a report diving into those issues. That deadline has come and passed, and the report’s timing remains unclear.

Ultimately, blame will be hard to ascribe in Yonatan’s case. It may be an instance where tragedy escapes the reach of a system unable to prevent it.

It will, however, be a chance for the county to take a hard look at the “front door” of child protection — that murky space between a caller reporting child abuse and the moment a social worker either removes the child, or walks out of that child’s life.

The implications are significant. More than half the states in the country use SDM, making what happens here an issue of national importance.

What is Structured Decision Making?

Structured Decision Making is “a suite of assessment instruments that promote safety and well-being for those most at risk— from children in the foster care system to vulnerable adults,” according to its developer, the non-profit National Council on Crime and Delinquency (NCCD).

When it comes to child protection, that “suite of instruments” is really a set of six different questionnaires that help social workers make decisions about what to do with referrals of child abuse like those involving Yonatan Aguilar. The system is very similar to the “actuarial” questionnaires that insurer’s use to determine rates.

At every step of the case ­– from the moment the call comes into the child abuse hotline to the reunification with parents after children have been removed from their family homes – NCCD’s suite of child protection tools help social workers decide what action to take.

For years, SDM has enjoyed primacy in the risk-assessment market.

Evaluations, many of which were commissioned by NCCD, or conducted by former contractors, indicate that SDM is a better tool for stratifying risk than a worker’s gut instincts or the consensus of a worker and his or her peers and supervisors.

In a 2012 report submitted to England’s Department of Education, which reviewed a wide range of risk assessment tools, researchers concluded that SDM is essentially better than anything else out there, but still far from perfect.

“Our review found that although there is evidence favouring the validity, reliability and impact of one actuarial SDM risk assessment tool (California Family Risk Assessment tool), evaluation of its implementation in other contexts highlighted a range of significant problems,” Jane Barlow and her colleagues wrote.

What the British research team was saying is that there is significant variability in SDM’s accuracy depending on where it is deployed, and who is using it.

Here in Los Angeles, SDM featured prominently in a scathing report submitted to county officials in 2012. Conducted by the county’s Children’s Special Investigative Unit, the report looked at 14 child fatalities and one critical injury that were caused by severe abuse. In 11 of these cases, a social worker either failed to use SDM, or misused it.

This type of user error was central to the explanation given by NCCD CEO Kathy Park for Yonatan’s death.

“The Board of Supervisors needs to find out why the high risk level was repeatedly not acted upon,” Park said during public comment at the September 20 board meeting. “It needs to understand whether this is happening in other cases; children in Los Angeles deserve this. However, the most crucial issues go beyond Structured Decision Making to the organizational and systemic. The Board of Supervisors needs to ask: is the Department of Children and Family Services’ leadership supportive of using research in child protection?”

A week later, Park submitted an op-ed to The Chronicle of Social Change and went further, writing that the board needed to ask: “Is the Department of Children and Family Services’ leadership establishing a culture that values and respects the life of every child?”

DCFS’ top official, Director Philip Browning, said that his workers followed the protocols outlined by NCCD when investigating Yonatan’s case, and suggested that Park’s comments were more about retaining SDM’s hold on the child abuse prediction market than genuine outrage.

“I think any organization that gets paid to do work is going to defend their work and try to rationalize their tool as being correct and say that someone else has misused it,” Browning said.

He added that the county is exploring alternatives to SDM.

Most notably, DCFS experimented with the use of predictive analytics to measure risk in 2014. Results from that experiment suggested that using algorithms that mine vast data sets to ascertain risk could be useful in trying to predict serious child maltreatment.

Browning also said that he is in talks with the California Department of Social Services to develop a predictive analytics system that would be applicable across all 58 counties, most of which currently use SDM.

“I think they [NCCD] know we’re interested in a predictive analytics tool, and I think they see that as competition, and they are concerned about that,” Browning said. “And I think they have a proprietary interest in continuing what they’re doing.”

According to tax filings from 2012 through 2014, NCCD’s annual revenue ranged from roughly $15.5 million to $20.5 million. Ninety-seven percent of that money was derived through government contracts, not charitable donations.

A 2012 audit showed that NCCD brought in $7.7 million in child welfare program revenues, which includes some money from SDM.

In a series of emails, NCCD Communications Director Erin Hanusa maintained that her agency is “not a commercial vendor whose goal is to sell a product.”

When asked to provide details on overall revenue from SDM, Hanusa wrote, “Compiling an estimate would require many hours, as contracts often contain multiple pieces of work, some SDM-related, some not. Given the extensive time it would require to calculate these numbers, it isn’t feasible to provide more detailed information.”

But she did point to DCFS’ payment schedule with NCCD from 2015-2017, which authorizes annual expenditures ranging from $33,570 to $55,570.

How was Structured Decision Making Used in Yonatan’s Case?

Los Angeles County uses three SDM tools when trying to determine what to do with a referral like those lodged against Yonatan’s mother, Veronica Aguilar.

First, workers at the child abuse hotline use something called the “intake assessment” to determine whether or not they should investigate a call. If they decide to go out, the tool helps them decide how fast they need to complete their investigation.

Once at the family’s home, workers conduct a “safety assessment.”

DCFS investigators conducting safety assessments in Yonatan’s case from October 2009 to March 2012 always checked “no” to prompts like the “caregiver caused serious physical harm to the child” and “caregiver describes child in predominantly negative terms.”

SDM automatically spat out this phrase every time:

“No safety threats were identified at this time. Based on currently available information, there are no children likely to be in immediate danger of serious harm.”

If a child is deemed in imminent risk of harm, the worker will either detain them on the spot or set up a “safety plan” to mitigate safety threats until they can get a warrant to remove the child or children.

The third step in SDM’s initial child protection protocol is called a risk assessment. This is what that the Times focused on.

As reported in The Times, Yonatan’s risk for subsequent abuse was rated at high risk in four investigations from 2009 to 2012.

Despite the SDM generating a recommendation that the case be “promoted” each time, the workers used the tool’s override function to close the case.


So, Was it the User or the Tool?

“Now in this particular case, from what I know about it so far, I don’t know that it is necessarily a case where the tool, the risk assessment tool, Structured Decision Making, is called into question,” said Office of Child Protection Director Michael Nash during the September 20 board meeting.

“However,” Nash continued, “I have questions about the implementation of that tool.”

While Yonatan’s is not likely the test case for the failure of DCFS’ current risk assessment system, it has served as a prompt for the county to address one of the most fundamental issues within child welfare today.

Ever since that 2012 report conducted by the Children’s Special Investigative Unit, there has been an urgent need to better understand how the child protection system responds to allegations of abuse.

Now, under these terrible circumstances, it will.

Holden Slattery contributed to this story. 

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Daniel Heimpel, Publisher, The Chronicle of Social Change
About Daniel Heimpel, Publisher, The Chronicle of Social Change 182 Articles
Daniel is the founder of Fostering Media Connections and the publisher of The Chronicle of Social Change. Reach him at dheimpel@fosteringmediaconnections.org.

1 Comment

  1. Nationwide, we have seen increasing attention paid to child maltreatment and child death as a result of maltreatment. While focusing on these issues is a good thing, it has not helped us in attaining success at ameliorating these terrible tragedies in our communities. As in this article, we see our “leaders” continuing to ask for reports and more data as well as them adding layers of bureaucracy (such as the Office of Child Protection) to address these issues, all to no productive end. We have failed to implement improvements and the required system change(s) that we can quantitatively measure so as to track our successes (and failures) toward improved outcomes for the children and families we serve. Unfortunately, our public child welfare systems have operated, more often than not, as though the process is the product. This must stop.

    The issue before us, specifically as it relates to child death at LA DCFS or any public child welfare agency, is multi-faceted with many moving parts. It is not complicated but it is complex. We need to stop talking, stop writing reports, stop analyzing the data and START problem solving by implementing obvious effective and targeted action steps that
    will proactively protect our most at-risk children and vulnerable families. And, we must infuse our system, at every level, with the philosophy of first do no harm.

    As a MSW (1981) and Licensed Clinical Social Worker (LCSW – 1985) who has
    worked in the child welfare system in several states, public and private (including with LA DCFS) for most of my career, I see several issues which we must address (nationwide) if we are to achieve improved outcomes for our most at-risk children and families. These issues are not typically addressed and evaluated by our leadership cadre or governance or stakeholders in public child welfare, which is apparent by the current and dismal outcomes we are achieving.

    In summary, the most vital issues before us which we must address if we are to achieve improved outcomes are the most basic and fundamental, as follows:

    As to which this article alludes, we tend to talk about “system failures” in the abstract because we rarely define what this concept really means. “System failure” is code for leadership failure. Leadership means having the courage to always do the next
    right thing, notwithstanding that it may not be the most popular or politically correct thing to do. It means routinely and frequently articulating and communicating our vision and
    mission – this includes our standards of service and our methods of holding
    people who work on the system and in the system, at all levels, accountable to
    compliance and the way in which they support and implement the vision and
    mission; it means engaging the workforce and community stakeholders to support the work; it means modeling and encouraging bi-directional communication (because
    those providing the services and those receiving the services are the experts with
    regard to what is needed and how to make things better); it means operating with transparency, regardless of risk of deleterious personal outcomes, in order to ensure
    accountability; it means identifying what needs to change, how change will occur, who will be affected by the change, and what happens if we do nothing and then communicating openly, honestly and routinely, at all levels, regarding these issues. This is commonly referred to as “culture change management”.

    To date, we have overwhelmingly continued in our failure to put leaders into leadership positions in public child welfare organizations. Rather, we have routinely sought out and settled for those individuals who are simply politically astute, which is an important attribute, but a one dimensional answer is not the solution. It is unfortunate that we have politicized these issues and these positions to such an extent that we are unable to tolerate professionals who have the courage to lead these systems by virtue of their credentials, practice and administrative experience in the field, and their possession of the most critical leadership core competencies (i.e., leading people, leading change, engaging important stakeholders, business acumen, and technical expertise). Until we (i.e., communities and power brokers) demand real leadership and then support these leaders once installed, nothing will change.

    2. Practice:

    Much has changed in practice since I started in the field almost 35 years ago. Some of
    the changes have been good and some have been not so good.

    One of the most significant changes, which is not a good change, is our increasing reliance on “tools” (such as the various models of Structured Decision Making) while failing to build the infrastructure to support our reliance on these “tools”.

    The Child and Family Services Reviews (CFSR) conducted by the federal Administration of Children, Family and Youth started its roll out in the early 2000’s. ACFY set out to
    evaluate each state’s public child welfare system. The CFSR process determined in every public child welfare system in every state, that supervision is our weakest link in public child welfare. This finding is both astonishing and deeply concerning given that in virtually every public child welfare agency, Child Protective Services (the most complex work we do) is always the field of practice where new and/or inexperienced hires start their career. Yet in most instances, they are not receiving adequate and/or effective supervision. In addition, as in many organizations, we tend to promote professionals to supervisory positions because they have either demonstrated competency as a case worker or because they are liked, neither of which supports such a promotion given supervision requires an entirely different skill set to case work and being everybody’s friend or teacher’s pet does not protect our children.

    An additional issue with regard to supervision and supervisors are the increased caseloads we frequently hear about as a barrier to keeping children safe. My experience
    has been that many of the “cases” on these caseloads are those that are open
    simply because they have not been closed (and many times they are not closed because
    supervisors have not approved them for closure because they don’t like to do
    paperwork). Are supervisors, management and leadership evaluating this issue? If
    not, why not? If so, what does the data tell us? What are the remedies they are implementing? What are case workers asking be done? What have supervisors/leaders done to solicit remedies from caseworkers and families? What requests for help have they (i.e., families, workers and management) proffered to correct the problem? And, if increased caseloads are a reality beyond failing to close cases timely, why are supervisors not required to carry a selective caseload or do other case work tasks to lift the burden from their subordinates so as to increase safety for children? Why are supervisors and managers not being held to account for these “increased caseloads” which we have been repeatedly told negatively impact child safety?

    Another change is the actual use of these “tools”. Tools can be helpful if implemented and then used correctly. When the decision to use “tools” is made, many times we fail to provide adequate training and then adequate oversight (see my comments re: supervision above). In addition, if we actually evaluate what happens when we use tools, we see that there is often a fidelity drift. This occurs because as workers become more
    comfortable with the tool, they frequently overlook the potential risks it identifies and/or they start to use the tool incorrectly. I have too frequently seen workers who have
    gotten so comfortable in relying solely on the tool, that they are actually looking at the form and checking off the boxes or they are looking at the computer screen and completing the fields, leaving the client to look at the top of the worker’s head as they focus on the tool. This creates a situation in which much information is missed and this then diminishes our ability to make good decisions for children and families. Bottom line: We need to ensure with all tools used that everyone understands tools are simply support for the work and that they are not effective or meaningful without adequate and insightful professional judgement.

    3. Standards and Credentialing:

    It once was true that professional social workers (i.e., BSW’s and MSW’s) were the only helping professionals employed to provide direct intervention services and supervision in
    child welfare. This was the standard of practice in hiring primarily because social work was and is the profession which “professionalized” child welfare as a distinct field of practice and because Social Work has been, and continues to be, the profession identified as uniquely qualified for this field of practice due to our focus on the most vulnerable populations and our systems perspective. These hiring and employment practices have changed.

    Today, public child welfare organizations have opened the flood gates in hiring practices for those who wish to gain employment. We see new employees with degrees in
    education, business, psychology, sociology, substance abuse, English, history,
    early education, etc. etc. etc. These hiring decisions put all vulnerable people we serve at risk as these sorts of credentials provide absolutely no training in working with vulnerable people. In addition, professional social workers are required to comply with a Code of Ethics, established by the National Association of Social Workers (NASW); non-social workers are not held to the same standards of practice. In fact, NASW has recognized our work in child welfare as so specialized that they have published a supplemental Code of Ethics for social workers providing child welfare services. The practice of hiring
    non-social workers in child welfare has resulted in minimizing the importance
    of the work to be done (which creates huge morale issues) and more significantly,
    hiring people who have absolutely no training or conceptual framework for the
    work to be done increases the risk of harm to children and families.

    There is no excuse for public child welfare systems to not hire professional social workers. For example, Los Angeles County has two accredited Schools of Social
    Work basically within a few miles of their central office; one is at UCLA and
    the other is at USC. In addition, Social Work students are offered the opportunity to have their tuition paid or forgiven through federal Title IV-E funding if they commit to work in a public child welfare agency for a limited amount of time at graduation; it is inexplicable that LA DCFS is not better advocating this incentive to social work students so as to hire the most qualified professionals in the work to be done. These students, both baccalaureate and graduate, are readily available for recruitment by LA DCFS. This is where leadership is required to engage these Schools of Social Work and the students enrolled there to ensure we are able to hire the best and most highly qualified professionals to do the important work of protecting children and serving families. In addition, if leadership were to engage in these activities, our workforce capacity would increase and our children and families would be better served.

    There are many other issues which need to be addressed and which many times are ignored, such as: implementation of a variety of Evidence-Based and Science-Based Practices, including a sustainability plan; a commitment to family engagement and family voice, implementation of trauma informed care at every level of the system; improved use of our fiscal resources (we need to stop spending money on things that don’t work or that we can’t measure), focusing on prevention and early intervention, workforce development, etc. etc. etc.

    Thanks for listening.

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