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99–679 2005

FAILURE TO PROTECT CHILD SAFETY 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HUMAN RESOURCES 

OF THE

COMMITTEE ON WAYS AND MEANS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED EIGHTH CONGRESS 

SECOND SESSION 

JUNE 17, 2004

Serial No. 108–61 

Printed for the use of the Committee on Ways and Means 

( 

ii 

COMMITTEE ON WAYS AND MEANS 

BILL THOMAS, California, Chairman 

PHILIP M. CRANE, Illinois 

E. CLAY SHAW, JR., Florida 

NANCY L. JOHNSON, Connecticut 

AMO HOUGHTON, New York 

WALLY HERGER, California 

JIM MCCRERY, Louisiana 

DAVE CAMP, Michigan 

JIM RAMSTAD, Minnesota 

JIM NUSSLE, Iowa 

SAM JOHNSON, Texas 

JENNIFER DUNN, Washington 

MAC COLLINS, Georgia 

ROB PORTMAN, Ohio 

PHIL ENGLISH, Pennsylvania 

J.D. HAYWORTH, Arizona 

JERRY WELLER, Illinois 

KENNY C. HULSHOF, Missouri 

SCOTT MCINNIS, Colorado 

RON LEWIS, Kentucky 

MARK FOLEY, Florida 

KEVIN BRADY, Texas 

PAUL RYAN, Wisconsin 

ERIC CANTOR, Virginia 

CHARLES B. RANGEL, New York 

FORTNEY PETE STARK, California 

ROBERT T. MATSUI, California 

SANDER M. LEVIN, Michigan 

BENJAMIN L. CARDIN, Maryland 

JIM MCDERMOTT, Washington 

GERALD D. KLECZKA, Wisconsin 

JOHN LEWIS, Georgia 

RICHARD E. NEAL, Massachusetts 

MICHAEL R. MCNULTY, New York 

WILLIAM J. JEFFERSON, Louisiana 

JOHN S. TANNER, Tennessee 

XAVIER BECERRA, California 

LLOYD DOGGETT, Texas 

EARL POMEROY, North Dakota 

MAX SANDLIN, Texas 

STEPHANIE TUBBS JONES, Ohio 

Allison H. Giles, Chief of Staff 

Janice Mays, Minority Chief Counsel 

SUBCOMMITTEE ON HUMAN RESOURCES 

WALLY HERGER, California, Chairman 

NANCY L. JOHNSON, Connecticut 

SCOTT MCINNIS, Colorado 

JIM MCCRERY, Louisiana 

DAVE CAMP, Michigan 

PHIL ENGLISH, Pennsylvania 

RON LEWIS, Kentucky 

ERIC CANTOR, Virginia 

BENJAMIN L. CARDIN, Maryland 

FORTNEY PETE STARK, California 

SANDER M. LEVIN, Michigan 

JIM MCDERMOTT, Washington 

CHARLES B. RANGEL, New York 

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records 

of the Committee on Ways and Means are also published in electronic form. The printed 

hearing record remains the official version. Because electronic submissions are used to 

prepare both printed and electronic versions of the hearing record, the process of converting 

between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process 

is further refined. 

iii 

C O N T E N T S 

Page 

Advisory of June 10, 2004, announcing the hearing ............................................. 2 

WITNESSES 

Maryland Department of Human Resources, Hon. Christopher J. McCabe ....... 7 

Baltimore City Department of Social Services, Floyd R. Blair ............................ 10 

Baltimore City Health Department, Peter Beilenson ........................................... 17 

University of Maryland, School of Social Work, Center for Families, Diane 

DePanfilis ............................................................................................................. 22 

SUBMISSIONS FOR THE RECORD 

Cook, Theresa S., Santa Clara, CA, statement ..................................................... 42 

Fight Crime: Invest in Kids, statement ................................................................. 47 

Justice for Children, Eileen King, letter ................................................................ 50 

Zero to Three: National Center for Infants, Toddlers and Families, Matthew 

E. Melmed, statement .......................................................................................... 51 

(1) 

FAILURE TO PROTECT CHILD SAFETY 

THURSDAY, JUNE 17, 2004 

U.S. HOUSE OF REPRESENTATIVES, 

COMMITTEE ON WAYS AND MEANS, 

SUBCOMMITTEE ON HUMAN RESOURCES, 

Washington, DC. 

The Subcommittee met, pursuant to notice, at 4:00 p.m., in room 

B–318, Rayburn House Office Building, Hon. Wally Herger (Chairman of the Subcommittee) presiding. 

[The advisory announcing the hearing follows:] 

2 

ADVISORY 

FROM THE COMMITTEE ON WAYS AND MEANS 

SUBCOMMITTEE ON HUMAN RESOURCES 

FOR IMMEDIATE RELEASE CONTACT: (202) 225–1025 

June 10, 2004 

Herger Announces Hearing on 

Failure to Protect Child Safety 

Congressman Wally Herger (R–CA), Chairman, Subcommittee on Human Resources of the Committee on Ways and Means, today announced that the Subcommittee will hold a hearing on a recent failure to protect child safety. The hearing will take place on Thursday, June 17, 2004, in room B-318 Rayburn 

House Office Building, beginning at 4:00 p.m. 

In view of the limited time available to hear witnesses, oral testimony at this 

hearing will be from invited witnesses only. Witnesses will include State and local 

officials and outside experts familiar with the child welfare system in Baltimore, 

Maryland. 

BACKGROUND: 

News accounts have documented events leading to the recent death of twin infant 

girls in Baltimore, Maryland. These newborns were released to their mother, a foster care runaway previously involved with child welfare authorities. The circumstances of this tragedy have prompted numerous questions that highlight broader child welfare policy concerns: How well do government officials track children in 

their care and individuals previously in contact with child welfare authorities? Are 

child abuse cases reported and investigated promptly to ensure child safety? Are 

government agencies working together effectively to protect vulnerable children? 

Federal taxpayers provided States with more than $7 billion in 2003 to promote 

safety, permanency, and well-being of children in or at risk of needing foster care. 

A significant share of these Federal funds support administrative costs, including 

systems and salaries dedicated to monitoring the well-being of children under the 

care of birth, foster, and adoptive parents. In recent months, the Subcommittee on 

Human Resources has held a series of hearings on another high-profile case involving a failure to protect children in New Jersey, as well as reporting and oversight 

issues that reflect on broader program trends and concerns in child welfare. 

In announcing the hearing, Chairman Herger stated, ‘‘This incredibly sad situation highlights once again that the current child welfare system is ill-equipped to 

protect children. Such failures to ensure the safety of children are unacceptable. 

Federal taxpayers pay billions of dollars each year for systems and salaries designed 

to prevent such tragedies from happening. This hearing will examine the circumstances of this case to better inform policymakers about steps we should consider taking to better protect children.’’ 

FOCUS OF THE HEARING: 

This hearing will focus on (1) the facts of a recent child welfare case in which twin 

infants died in Baltimore, Maryland; and (2) the implications of this case for efforts 

to improve the child welfare system. 

3 

DETAILS FOR SUBMISSION OF WRITTEN COMMENTS: 

Please Note: Any person(s) and/or organization(s) wishing to submit for the hearing record must follow the appropriate link on the hearing page of the Committee 

website and complete the informational forms. From the Committee homepage, 

http://waysandmeans.house.gov, select ‘‘108th Congress’’ from the menu entitled, ‘‘Hearing Archives’’ (http://waysandmeans.house.gov/Hearings.asp?congress=16). Select the hearing for which you would like to submit, and click on the link entitled, 

‘‘Click here to provide a submission for the record.’’ Once you have followed the online instructions, completing all informational forms and clicking ‘‘submit’’ on the 

final page, an email will be sent to the address which you supply confirming your 

interest in providing a submission for the record. You MUST REPLY to the email 

and ATTACH your submission as a Word or WordPerfect document, in compliance 

with the formatting requirements listed below, by close of business Thursday, July 

1, 2004. Finally, please note that due to the change in House mail policy, the U.S. 

Capitol Police will refuse sealed-package deliveries to all House Office Buildings. 

For questions, or if you encounter technical problems, please call (202) 225–1721. 

FORMATTING REQUIREMENTS: 

The Committee relies on electronic submissions for printing the official hearing record. As always, submissions will be included in the record according to the discretion of the Committee. 

The Committee will not alter the content of your submission, but we reserve the right to format 

it according to our guidelines. Any submission provided to the Committee by a witness, any supplementary materials submitted for the printed record, and any written comments in response 

to a request for written comments must conform to the guidelines listed below. Any submission 

or supplementary item not in compliance with these guidelines will not be printed, but will be 

maintained in the Committee files for review and use by the Committee. 

1. All submissions and supplementary materials must be provided in Word or WordPerfect 

format and MUST NOT exceed a total of 10 pages, including attachments. Witnesses and submitters are advised that the Committee relies on electronic submissions for printing the official 

hearing record. 

2. Copies of whole documents submitted as exhibit material will not be accepted for printing. 

Instead, exhibit material should be referenced and quoted or paraphrased. All exhibit material 

not meeting these specifications will be maintained in the Committee files for review and use 

by the Committee. 

3. All submissions must include a list of all clients, persons, and/or organizations on whose 

behalf the witness appears. A supplemental sheet must accompany each submission listing the 

name, company, address, telephone and fax numbers of each witness. 

Note: All Committee advisories and news releases are available on the World 

Wide Web at http://waysandmeans.house.gov. 

The Committee seeks to make its facilities accessible to persons with disabilities. 

If you are in need of special accommodations, please call 202–225–1721 or 202–226– 

3411 TTD/TTY in advance of the event (four business days notice is requested). 

Questions with regard to special accommodation needs in general (including availability of Committee materials in alternative formats) may be directed to the Committee as noted above. 

f 

Chairman HERGER. Today’s hearing focuses on a child welfare 

tragedy, the death of twin infant girls in Baltimore last month. I 

want to thank Mr. Cardin for suggesting this hearing as a continuation of our review of how child welfare systems are failing to protect children. Our purpose this afternoon is to understand what 

happened in this case so we do all we can to keep it from happening again in Baltimore and elsewhere. We welcome our guests 

from the State of Maryland and the city of Baltimore child welfare 

agencies. We also are pleased to be joined by the Baltimore City 

Commissioner of Health, who will discuss issues raised by the 

death of these 1-month-old girls. Finally, we welcome another exVerDate Aug 04 2004 05:17 Aug 19, 2005 Jkt 099679 PO 00000 Frm 00007 Fmt 6633 Sfmt 6602 E:\HR\OC\99679.XXX 99679
4 

pert and long-time observer of child welfare issues in Maryland 

who will place this case in context for us. 

This Subcommittee has held several hearings recently to investigate the Nation’s child welfare programs. We explored a disturbing case involving four adopted boys in New Jersey who were 

starved in their home, we reviewed Federal and State oversight 

measures designed to determine if local officials are doing all that 

is necessary to protect children, and we heard about Federal reviews of State child welfare programs. Unfortunately, what we 

learned was that not one State has passed their review. 

Tragedies such as this case can happen in any neighborhood. Regretfully, the evidence we have seen shows that abuse cases, such 

as the one before us today, have occurred in every State. Since November, this Subcommittee has heard testimony from more than 30 

individuals. We have received numerous e-mails, phone calls, and 

submissions for the record that highlight problems and concerns. 

What we have learned is that the current system is ill-equipped to 

protect vulnerable children. 

The case we will examine today highlights where life-and-death 

decisions are made for these children, in homes, offices, courts, and 

hospitals across the country. With one more call, one more question, or one more background check, two little girls in Baltimore 

might be alive. We owe it to them and the other children who die 

each year to understand what went wrong so we can work with 

local officials to prevent such tragedies from happening again. No 

policy is or will be perfect, but we can all agree that what is occurring today in our country’s child welfare programs is simply unacceptable and must change. Without objection, each Member will 

have the opportunity to submit a written statement and have it included in the record at this point. Mr. Cardin, would you like to 

make an opening statement? 

[The opening statement of Chairman Herger follows:] 

Opening Statement of The Honorable Wally Herger, Chairman, and a 

Representative from the State of California 

Today’s hearing focuses on a child welfare tragedy—the death of twin infant girls 

in Baltimore last month. I want to thank Mr. Cardin for suggesting this hearing 

as a continuation of our review of how child welfare systems are failing to protect 

children. 

Our purpose this afternoon is to understand what happened in this case, so we 

do all we can to keep it from happening again in Baltimore and elsewhere. 

We welcome our guests from the state of Maryland and City of Baltimore child 

welfare agencies. We also are pleased to be joined by Baltimore’s health commissioner who will discuss issues raised by the death of these one-month old girls. Finally, we welcome another expert and long-time observer of child welfare issues in 

Maryland, who will place this case in context for us. 

This subcommittee has held several hearings recently to investigate the nation’s 

child welfare programs. 

• We explored a disturbing case involving four adopted boys in New Jersey who 

were starved in their home. 

• We reviewed federal and state oversight measures designed to determine if local 

officials are doing all that is necessary to protect children. 

• And we heard about federal reviews of state child welfare programs. Unfortunately, what we learned was that not one state has passed their review. 

Tragedies such as this case can happen in any neighborhood—regretfully, the evidence we’ve seen shows that abuse cases such as the one before us today have occurred in every state. 

5 

Since November, this Subcommittee has heard testimony from more than 30 individuals. We’ve received numerous emails, phone calls, and submissions for the 

record that highlight problems and concerns. What we’ve learned is the current system is ill-equipped to protect vulnerable children. 

The case we will examine today highlights where life and death decisions are 

made for these children—in homes, offices, courts, and hospitals across the country. 

With one more phone call, one more question, or one more background check, two 

little girls in Baltimore might still be alive. 

We owe it to them and the other children who die each year to understand what 

went wrong, so we can work with local officials to prevent such tragedies from happening again. 

No policy is or will be perfect. But we can all agree that what is occurring today 

in our country’s child welfare programs is simply unacceptable, and must change. 

f 

Mr. CARDIN. Thank you, Mr. Chairman. First, let me thank you 

for calling this hearing so quickly in response to the shocking 

events that took place in Baltimore. I thank you for your continued 

commitment on this subject. As you pointed out, this is not the first 

hearing we have held in regards to the child welfare system. We 

have had several. The problems we see in Baltimore are not just 

in Baltimore, they are throughout the entire Nation. I thank you 

very much for your continued commitment and the commitment of 

this Subcommittee regarding the welfare of our children, our most 

vulnerable children that are in the child welfare system. 

This hearing is being called because of the tragic loss of the 

death of twins in Baltimore, the Swann twins, that illustrate a system that is clearly failing the very children whom it is designed to 

protect. When we talk about the twins’ case, I am not interested 

in accusations or political maneuvering. The safety of vulnerable 

children in our society is just too important, and we need to have 

answers as to what we can do to protect these children. I expect 

to hear today from our witnesses clear and concise suggestions on 

how to prevent such tragedies in the future. In short, we want results. 

Mrs. Johnson, at one of our prior hearings, expressed, I think, 

the frustration of our Subcommittee; that we want to protect these 

children, and we want to find out how we can do it. We know we 

have to change our system, and we want specific recommendations. 

Only one thing is more tragic and more horrific than a child being 

beaten to death, and that is when the deadly abuse occurs after a 

variety of warnings signs that should have told us that there was 

a problem and we should have prevented this. 

That is exactly what happened in Baltimore. On May 11, 1- 

month-old twin girls died after having their skulls and ribs fractured after being severely malnourished. The 17-year-old mother of 

these children, Sierra Swann, was a foster care runaway with a 

known drug problem who had another daughter recently removed 

from her custody because of a confirmed case of abuse and neglect, 

and yet she was still allowed to leave the hospital with twins after 

a hospital caseworker contacted the Department of Social Services 

(DSS) to inquire as to whether there was an open case or whether 

there was a concern for the mother. 

There were all types of signs that this mother had problems, and 

the hospital worker did what she thought was right in contacting 

the DSS. Social Services indicated that there was no open case 

6 

with the agency. As a result, the mother left the hospital for a vacant basement with no electricity or running water. I don’t know 

how many more signs could have been given that we had a problem 

here, and yet the children were lost because we did not respond. 

Mr. Chairman, legally the parents of a child in foster care is the 

State. We are the parents. We are the ones who have responsibility, and we failed in that responsibility. As a result of failing a 

responsibility for our child, our grandchildren died. It is unacceptable. Unfortunately, this is not an isolated incident in Baltimore. 

For example, a year and a half ago a 2-month-old baby was beaten 

to death by a mother with a psychiatric problem who was still on 

probation for abusing her first son. This tragedy occurred after 

Child Protective Services (CPS) was informed that the baby was in 

danger because its mother was failing to take her medication. 

Our past hearings, press reports from around the country, and 

Federal review of every State child welfare system suggests that 

Baltimore is not alone in failing to adequately protect their children. In fact, as you pointed out, Mr. Chairman, not one State in 

the Nation has passed all of the child well-being standards assessed by the Federal review process. Unfortunately, my own State 

of Maryland has failed in the seven measures that we use for child 

safety. That, obviously, is totally unacceptable. It is time, in fact 

it is past time, for action. We must take steps now to make sure 

that what happened in Baltimore never again happens anywhere 

in the Nation. 

We need to do more at the Federal level, and, Mr. Chairman, I 

am encouraged by our discussions as we are looking at legislation 

in order to modernize the Federal child welfare issues, and I am 

hoping that we can pass some legislation at the Federal level in 

order to help our States, and if a few foundations come up with recommendations, we are going to look at that, but regardless what 

we do at the Federal level, immediate steps must be taken by our 

States to protect our children. 

Therefore, I reiterate my request from the beginning. We want 

to know what can be done at the State level to protect our children 

today. I hope and expect the DSS will implement the necessary reforms quickly in order to protect our children. The lives of our children literally are on the line, and the cost of inaction is way too 

high. I look forward to hearing our witnesses in an effort that we 

make sure this never happens again. 

Chairman HERGER. Thank you, Mr. Cardin. Before we move to 

our testimony, I want to remind our witnesses to limit their oral 

statements to 5 minutes. However, without objection, all of the 

written testimony will be made a part of the permanent record. 

This afternoon we will be hearing from Christopher McCabe, Secretary of the Maryland Department of Human Resources (DHR); 

Floyd Blair, Interim Director of the Baltimore City DSS; Dr. Peter 

Beilenson, Baltimore City Commissioner of Health, who is also the 

son of a former Member of Congress from my home State of California, Tony Beilenson; and Dr. Diane DePanfilis, Co-Director of 

the Center For Families at the University of Maryland School of 

Social Work. Mr. McCabe to testify. 

7 

STATEMENT OF HON. CHRISTOPHER J. MCCABE, SECRETARY, 

MARYLAND DEPARTMENT OF HUMAN RESOURCES, BALTIMORE, MARYLAND 

Mr. MCCABE. Thank you, Mr. Chairman and Congressman 

Cardin, Congressman Camp, and Members and staff of the Subcommittee. Thank you for the opportunity to be with you again and 

to share perspectives on Maryland’s child welfare challenges together with this very distinguished panel. We at the State level 

rely on partners to assist us in protecting children. Indeed, our 

work often begins after a child is referred to us from schools, hospitals, churches, or law enforcement in the community. We are 

then responsible to investigate these cases and take all appropriate 

actions. 

Governor Ehrlich and I are grateful for your interest in support 

of human service issues and for the funding that is appropriated 

by Congress for these purposes. These issues are not glamorous, 

but are at times literally, as Congressman Cardin said, a matter 

of life or death. Just 1 month ago, I testified before you regarding 

the Child and Family Services Review (CFSR) process. Since then 

Maryland has received the final report from the Federal Government. The study found that Maryland was in substantial conformity with Federal standards in some areas, but did not meet 

Federal standards in others. The DHR has formed six Committees 

made up of agency employees and outside advocates to recommend 

a program improvement plan to meet Federal standards. 

While the CFSR provides our State and every State a baseline 

from which to make systemic improvements in the practice of child 

welfare, on a daily basis our local agencies still face the stress of 

critical and difficult cases that test the capability of protecting children in at-risk situations. One of those such cases occurred in Baltimore City in May of 2004, which is also the subject of this afternoon’s hearing. It has also been the subject of much angst within 

our local and central offices on what actions might have been done 

differently not just by our local agency, but a number of the partners in child protection. We do not do it alone. The Sierra Swann 

case is both sad and tragic. While limited under law regarding 

what can be said related to an ongoing criminal case, I can say that 

Sierra Swann was known by our local DSS in Baltimore City. Her 

case file alone measures 5 inches. News accounts revealed some 

but not all the pertinent history of the case. 

Sierra Swann was a teenage runaway from a Baltimore City foster family. Her status as a runaway made the challenge of keeping 

a safety net for her only more difficult. In my observations, it is 

not uncommon that teenagers who have been in foster care for 

many years run away from the system that purportedly is there to 

help them. The majority of these individuals come back to their foster homes because they learn that the alternatives that they are 

facing are not acceptable. Sierra chose not to take this course. 

When this case became known, we acted aggressively to determine what indeed had happened both internally, as far as the department’s response, and externally with the hospital and within 

the community. Very specific changes are being made as a result 

of our investigation. I will let Director Blair speak about specifics, 

but I can tell you that one of the changes we are immediately makVerDate Aug 04 2004 05:17 Aug 19, 2005 Jkt 099679 PO 00000 Frm 00011 Fmt 6633 Sfmt 6602 E:\HR\OC\99679.XXX 99679
8 

ing is in the way critical communication is received and handled. 

Not only are we providing intensive training for our internal workers on how to field these child protective calls, and when to refer 

them to experts or up the chain, we will be working with sister 

agencies and community partners, again, schools, hospitals, 

churches, to explain our processes. In addition, the department has 

delivered a package of safety-related proposals, legislative proposals, that I will be sharing with Governor Ehrlich in the weeks 

ahead for possible legislative action in the 2005 legislative session 

in the Maryland General Assembly. 

One systemic improvement that we are very aggressively trying 

to implement involves better and more timely information technology. A key component of improving information sharing is to 

bring our automated child welfare computer system, MD CHESSIE, to the desk of each child welfare worker in the city and across 

the State. You all help provide the funding for that system. Immediately after becoming Secretary of the department, I recognized 

our current child welfare computer system is minimally adequate 

and largely disjointed. Currently, among Maryland’s 24 local jurisdictions, there are several partially automated child welfare tracking systems, none of which communicate across platforms. Though 

some of these systems are adequate for local needs, the major problem is they are not standardized statewide, and our largest jurisdictions, in particular Baltimore City, struggle most with this disparity. 

Maryland’s statewide automated child welfare information system (SACWIS) is still 2 years away, but we are committed to an 

early release of the child intake module. I’ll repeat, are committed 

to the early release of the child intake module, and Baltimore City 

will be one of those jurisdictions. Other workers, their supervisors, 

and our executive staff deserve this 21st century tool to do their 

difficult jobs. The central offices and Baltimore City DSS are learning from the Sierra Swann case, as we do endeavor in each case. 

As we implement changes to fill gaps in our own system, we would 

expect our partners in child protection, hospitals, public health department, and others, to evaluate their own processes and to do the 

same. In turn, we all need to communicate with each other of our 

respective improvement plans. 

In conclusion, will the improvements I have just mentioned and 

those that Mr. Blair will outline prevent the future deaths of children in cases similar to Sierra Swann’s children? I cannot make 

that guarantee. Will it help reduce the likelihood that an incident 

like this will happen in the future? I believe so, and I am committed to doing what I can to do so. Thank you for your time and 

attention to this very serious matter, and I am prepared to answer 

your questions at the appropriate time. Thank you, Mr. Chairman. 

[The prepared statement of Mr. McCabe follows:] 

Statement of The Honorable Christopher J. McCabe, Secretary, Maryland 

Department of Human Resources, Baltimore, Maryland 

Dear Mr. Chairman and Members of the Committee: 

Just one month ago, I testified before you regarding the child and family services 

review process. Since then, Maryland has received the final report by the federal 

government. 

9 

The study found that Maryland was in substantial conformity with federal standards in training its workers, responding to the community, and licensing, recruiting 

and retaining foster and adoptive parents. 

However, our State did not meet federal standards in several other categories, including an adequate statewide information technology system for child welfare and 

the number of children in foster care reunited with their parents. 

The Department of Human Resources has formed six committees, made up of 

agency employees and outside advocates, to recommend a program improvement 

plan to meet federal standards. 

While the child and family services review provides our state—and every state— 

a baseline from which to make systemic improvements in the practice of child welfare, on a daily basis, our local agencies still face the stress of critical and difficult 

cases that test the capability of protecting children in an at risk situation. 

One of those such cases occurred in Baltimore City in May 2004, which is the subject of this afternoon’s hearing. It has also been the subject of much angst within 

our local and central offices on what actions might have been done differently, not 

just by our local agency, but a number of ‘‘partners’’ in child protection. 

The Sierra Swann case is sad and tragic. While I am limited under law regarding 

what can be said related to an ongoing criminal case, I can say that Sierra Swann 

was known by our local Department of Social Services in Baltimore City. Her case 

file alone measures five inches. 

As news accounts revealed, Sierra was a teenage runaway from a foster family, 

licensed by the Department of Social Services, which made the challenge of keeping 

a safety net for her only more difficult. 

When this case became known, we acted aggressively to determine what indeed 

had happened both internally as far as the Department’s response and externally 

with the hospital and within the community. Very specific changes will be made as 

a result of our investigation, some of which were in process, but due to this tragedy, 

were suddenly propelled to a new level of intensity. 

I will let Director Blair speak about specifics but I can tell you one of the changes 

we have made immediately is in the way incoming calls are handled. Not only are 

we training internal workers on how to take calls and when to refer them to the 

experts, but we will be working with sister agencies and community partners— 

schools, hospitals, churches—to explain our process. 

We all have to be partners, working together as effectively as possible. The job 

is tough enough already and if we are not working together, tragic things like this 

can happen, as it does in other states. 

One systemic improvement involves better and more timely communication. This 

is an ever present goal of the Administration. A key component of that improved 

communication is to bring our automated child welfare computer system, MD 

CHESSIE, to the desk of our child welfare workers. 

Immediately after becoming Secretary of the Department, I recognized our current 

child welfare computer system as inadequate and disjointed. Currently, among the 

24 local jurisdictions there are several partially automated child welfare tracking 

systems, none of which communicate across platforms. All DHR child welfare systems are predominantly paper based. Though some of these systems are adequate, 

the major problem is that they are not standardized statewide. Our larger jurisdictions struggle the most with this disparity. 

Governor Ehrlich, Lieutenant Governor Steele, and I have made demonstrable 

and substantial commitments to providing Baltimore City Department of Social 

Services with the leadership, structure, and resources to effectively and efficiently 

serve the most vulnerable citizens of Baltimore City. We do this in the context of 

a statewide human services system in need of additional staffing resources and 

training needs, to mention a few. 

In Baltimore City, we are committed that any reform we undertake will be datadriven and research-based, family—focused and strength-based, as well as based on 

interagency coordination. 

Perhaps a little history is helpful in understanding the magnitude of these commitments. 

• Soon after I was appointed Secretary, it became apparent that the Baltimore 

City Department was struggling under a great many management challenges. 

• BCDSS had been operated under a federal consent decree, lj vs. Massinga, since 

1989. 

• Sixty to sixty-five percent of our total client needs for the entire state reside 

within the boarders of Baltimore City. The sheer size of the need in Baltimore 

has a disproportional impact on Maryland’s success or failure. 

For example, the overall span of control for its director was enormous: 

10 

• The local agency employs approximately 2,400 staff members. 

• It manages 22 facilities spread across the city, touching nearly every community. 

• The agency has high caseloads in its many programs, serving families literally 

from cradle to grave. 

• Some facilities were found below par in terms of cleanliness and healthfulness. 

• Equipment needs were manifest, with communication seriously impaired from 

an aging telephone system that frequently failed at various sites and did not 

even provide many staff members with voice mail. A significant number of staff 

members were without computers and thus without e-mail or internet access to 

do their work. 

With Governor Ehrlich’s support and that of the Maryland General Assembly, the 

Department of Human Resources undertook an extensive investment of time, funds, 

personnel and other resources to bring Baltimore City Department of Social Services 

into the twenty-first century. 

• With four million dollars committed by the legislature, we are implementing a 

full upgrade of the outdated analog telephone system with a digital system, 

which on completion will provide voice mail throughout the 22 BCDSS work 

sites, as well as conferencing and transfer capability. 

• We installed one thousand computers previously ordered but never delivered to 

staff. 

• We invested significant resources in performing or negotiating with our landlords overdue repairs and renovations of facilities that were not providing a 

suitable work environment. 

• We are investing in replacement of aging and nonfunctioning basic equipment 

staff members need to do their jobs, like copiers and printers. 

• And most important, we have added fifty new state employees. Thirty-five of 

them are in child welfare to help make caseloads manageable at ninety percent 

of CWLA standards. 

In addition to these immediate steps, however, we began a careful and critical examination in the child welfare system. We determined that, while no one model in 

its entirety seemed appropriate for BaltimoreCity, we needed to transform Baltimore City Department of Social Services to provide: 

• Seamless service delivery (i.e., one-stop shops), 

• An interdisciplinary team approach, 

• Focus on Baltimore’s communities, 

• Strong interagency collaboration, and 

• Data-driven and outcomes-based service delivery. 

We are instituting a regional service delivery system co-locating services that 

serve the same clients so that they can find a variety of needed services across the 

hall rather than across town. 

Thank you again for the opportunity to provide these updates. Mr. Blair will provide additional details. 

f 

Chairman HERGER. Thank you, Secretary McCabe. Now, Director Blair to testify. 

STATEMENT OF FLOYD R. BLAIR, INTERIM DIRECTOR, BALTIMORE CITY DEPARTMENT OF SOCIAL SERVICES, BALTIMORE, MARYLAND 

Mr. BLAIR. Good afternoon, Mr. Chairman and Members of the 

Committee. I am Floyd R. Blair, Interim Director of the Baltimore 

City DSS, the largest social services agency in Maryland. I am honored and pleased to speak before you today and provide an update 

about current progress on child welfare services in Baltimore City 

and improvements to its service delivery system. Baltimore is a 

wonderful city, yet at times it is a violent place. Unfortunately, this 

is not uncommon in large urban areas. Families in urban areas frequently face a multitude of issues: violence, substance abuse, menVerDate Aug 04 2004 05:17 Aug 19, 2005 Jkt 099679 PO 00000 Frm 00014 Fmt 6633 Sfmt 6602 E:\HR\OC\99679.XXX 99679
11 

tal health issues, high unemployment, and a lack of family and 

community resources. Given this environment, children are often at 

risk, even in danger, while in the care of their own parents. It is 

a heart-wrenching for our workers to get a call to remove a child 

from a home where abuse and severe neglect compromise that 

child’s safety and security. The home the child has known as his 

or hers, that safe place, in fact, is not, and out of necessity the 

child is uprooted, the family torn apart. On the average, our workers remove about 100 children per month from their families in 

Baltimore City. 

When a child dies, it is a tragedy, and it is unacceptable. We 

have undertaken a serious, comprehensive review of the Sierra 

Swann case, reviewing not only the immediate circumstances of the 

case that eventually ended in the tragic deaths of the twins, but 

also a review of the case involving this teen mother since she first 

came to the attention of the department. Both processes are equally important to the continued improvement of our current system. 

I will explain some of the facts we have found in our investigation. Prior to public reports, there was a previous report of child 

abuse against Ms. Swann. An older child had been removed from 

her care in October 2003. Once a child is removed from a parent’s 

home and placed into foster care, that protective service case is 

considered closed, not active. It becomes an active foster care case 

and continues to be monitored by the foster care caseworker. It was 

also reported that Ms. Swann was a runaway from the State foster 

care system with an outstanding warrant for her to return to foster 

care. 

Ms. Swann, already in labor, was taken to Johns Hopkins Hospital, where she delivered twins. A Johns Hopkins social worker attending to Ms. Swann called the number normally used by internal 

DSS staff and asked the clerk if Ms. Swann had an active child 

abuse case. After checking the appropriate data screen, the clerk 

answered no, which was an accurate answer. The social worker 

from the hospital did not ask any further questions about prior 

cases regarding Sierra Swann. This call was made to a clerk, not 

a screener. A screener is trained to go beyond the question that 

was initially asked by the person from Johns Hopkins. 

When someone calls in to report suspected abuse or neglect, our 

screen unit takes the call. It is our standard operating procedure 

to do an intensive review of all such calls. Based on our review of 

the Swann case, we are implementing not only some immediate 

plans, but also systemic changes which have become part of our 

overall improvement plan, a copy of which you should have before 

you entitled, The Baltimore City DSS Systemic Improvements. 

In the Swann case, we developed an action plan, and some of 

these are the key actions: all calls reporting maltreatment are now 

routed through a central number where trained screeners can access all available information on a case. We are implementing a 

written protocol for all staff who take outside calls, detailing how 

and when to refer appropriate calls to the appropriate staff who 

can give comprehensive information to qualified verified callers. We 

are implementing a runaway risk alert feature on all screens. We 

have a priority list of cases needing response within 1 hour. Today, 

staff have initiated contact with our outside partners through writVerDate Aug 04 2004 05:17 Aug 19, 2005 Jkt 099679 PO 00000 Frm 00015 Fmt 6633 Sfmt 6602 E:\HR\OC\99679.XXX 99679
12 

ten and verbal directives detailing our processes, educating our 

partners, hospitals, schools, et cetera, on the current and future 

protocol and procedures. We plan to convene face-to-face training 

with our community partners to reinforce our processes. We have 

added staff to our screening unit to ensure calls are answered timely and properly. On July 1st, we are enhancing our 24-hour, 7-dayper-week CPS hotline. Twenty positions have been added to work 

nights, weekends, and holidays. We need all of our advocates, community resources, public officials, neighbors, experts in the health 

care system, school systems, everyone to create a positive partnership to help us ensure that services are provided through a coordinated, unified system, so that a tragedy like this never happens 

again. I want to thank you for the time. 

[The prepared statement of Mr. Blair follows:] 

Statement of Floyd Blair, Interim Director, Baltimore City Department of 

Social Services, Baltimore, Maryland 

• Good afternoon, Mr. Chairman and members of the committee. I am Floyd R. 

Blair, Interim Director of the Baltimore City Department of Social Services 

(BCDSS), the largest social services agency of the Maryland Department of 

Human Resources (DHR). I am honored and pleased to speak before you today 

to provide an update about our current progress on ensuring child safety and 

improving child welfare service delivery in Baltimore city. • When speaking to parents about children, a famous children’s television personality, Mr. Fred Rogers, said: ‘‘the roots of a child’s ability to cope and thrive, 

regardless of circumstance, lie in that child’s having at least a small, safe place 

. . . (an apartment? A room? A lap?) Where, in the companionship of a loving 

person, that child could discover that he or she is lovable and capable of loving 

in return.’’ • This quote sums up for me, the fact that the most important aspect of a child’s 

life is the security of a safe place. When children enter our care it is our priority 

to provide that safe place for those that have been abused or neglected. • Specifically, I will be briefing you on a recent child welfare case you indicate 

is of special concern. • Protecting children who are in the care of social services is one of the primary 

responsibilities of this administration. • Governor Ehrlich, Secretary McCabe and I are committed to improving services 

in Baltimore city. Baltimore is a wonderful city, yet at times it is a violent 

place. Unfortunately, this is not uncommon in large urban areas. • Families in urban areas frequently face a multitude of issues—violence, substance abuse, mental health issues, high unemployment and a lack of family 

and community resources. Given this environment, children are often at risk, 

even in danger while in the care of their own parents. • Once the local department is involved with a family, we have an opportunity 

to begin to help that family address many of these difficult issues. Our staff 

work tirelessly under very strenuous conditions with limited resources, to try 

to make a difference in the lives of these citizens. • I cannot say to you that all our workers are always giving 150%—I don’t think 

anyone in management can say that with assurance. But what I can say is that 

these exceptionally dedicated men and women save lives every day. In fact, the 

final report of the recent federal child and family services review indicates that 

on its safety outcome 1, ensuring that children are first and foremost protected 

from abuse and neglect, the outcome was determined to be substantially 

achieved in 100% of Baltimore city cases reviewed. 

• It is heart-wrenching for our workers to get a call to remove a child from a 

home where abuse and severe neglect compromise that child’s safety and security—the home that child has known as his/her ‘‘safe place’’ in fact isn’t—and 

out of necessity, the child is uprooted, the family torn apart. 

• Our staff are trained to make those tough decisions—to remove a child from his/ 

her parent’s home when it is determined to be in the child’s best interest. 

• On average, our workers remove about 100 children per month from their families in Baltimore city. 

• When a child dies it is a tragedy—and even more so when the department has 

previously intervened in an attempt to stabilize the family. 

13 

• Federal and state laws place certain restrictions on the department concerning 

case confidentiality. While this of course protects the families and children involved, it also limits what we might like to say to those who share our concern, 

particularly following a child fatality. • Given the importance of recent events, I will share as much as I can in an effort 

to assure you that BCDSS and DHR have undertaken a serious, comprehensive 

review of the Sierra Swann case, reviewing not only the immediate circumstances of the events that eventually ended in the tragic deaths of the 

twins, but also the case involving this teen mother since she first came to the 

attention of the department. Both processes are equally important to the continued improvement of our current system. • To better understand our role, the role of the hospital and others involved, we 

tracked the chronology of events in this case. It is important for us first to identify any gaps in service or procedure so that we may prescribe the proper remedies. • I will explain some of the facts we found in our investigation. • Prior to public reports, there was a previous report of child abuse against ms. 

Swann. An older child had been removed from her care in October 2003. • Once a child is removed from a parent’s home and placed into foster care, that 

protective service case is considered closed—not active. • It was also reported that ms. Swann was a runaway from the state foster care 

system with an outstanding warrant for her to return to foster care. • Ms. Swann, already in labor, was taken to Johns Hopkins hospital, where she 

delivered twins. • The Johns Hopkins social worker attending to Ms. Swann, called a number normally used by internal DSS staff, and asked a clerk if ms. Swann had an ‘‘active’’ or ‘‘open’’ child abuse case. After checking the appropriate data screen, the 

clerk answered ‘‘no’’, which was an accurate answer. As I previously stated, 

once a child is removed from the parent’s care and placed in foster care, the 

case is closed—and not active. • The social worker from Hopkins did not ask any further questions about prior 

cases regarding Sierra Swann. This call was made to a clerk, not a screener. 

A screener is trained to go beyond the question asked. • It was recently reported that sierra was charged, along with live-in boyfriend, 

Nathaniel Broadway, with the murder of their newborn twins. • I would like to describe some of the standard operating procedures we follow 

after a fatality so you will know what DHR and BCDSS have done to address 

incidents surrounding the Swann case in particular. • When someone calls in to report suspected abuse or neglect, our screening unit 

takes the call. It is our standard operating procedure to do an intensive review 

of all such calls. 

• Based on our review of the Swann/Broadway case, we are implementing not 

only some immediate plans, but also systemic changes which have become part 

of our overall improvement plan—a copy of which is attached as ‘‘document 

a:BCDSS systemic improvements.’’ 

• BCDSS has begun to initiate process improvements. I wish I could say we always do everything right. It is frustrating that change is slow even when we 

put forth our best efforts. But we are making progress. 

• In the Swann case, we completed a risk analysis and developed an action plan 

of systemic issues that we agree need to be addressed. They are: 

1. Implementation of a centralized number—all calls reporting maltreatment 

will go through a central number where trained screeners can access all 

available information on a case; 

2. Development of a written protocol—any general staff who take outside calls 

will be trained in how and when to refer calls to appropriate staff who can 

give comprehensive information to qualified/verified callers; 

3. Initiation of an alert feature—we will initiate runaway/high risk alerts on all 

screens; 

4. Revision of priority list of cases needing response within 1 hour to elevate 

the most urgent; 

5. Education of partners (hospitals/schools etc.) On protocol, procedures; and 

6. Addition of staff in screening units to ensure calls are answered timely and 

properly. 

• We need all of our advocates, community resources, public officials, neighbors, 

experts in the health care system, school systems—everyone—to create positive 

partnerships—to help us ensure that services are provided through a coordinated, unified system. 

14 

• I met recently with charlie cooper, administrator for the citizens review board 

in Maryland. We discussed the combined recommendations that the child protection panels, the city child fatality review team, and citizens review board for 

Baltimore city have made for improvements to our agency. 

• We have shared that information with internal BCDSS work groups which will 

be making recommendations for the redesign of our service delivery system. 

• We are open to an ongoing dialogue with all stakeholders as we continue this 

process. 

• We have incorporated some of the plans that a work group headed by Baltimore’s health commissioner, Dr. Peter Beilenson, recommended—some I am 

pleased to say we had already identified in our internal workgroups. Others are 

under consideration. 

• Our BCDSS mission is: 

To protect vulnerable children and adults, 

To preserve families, and 

To promote self sufficiency 

• In support of our mission, here is what we are doing now: 

1. On July 1st we will enhance our 24 hours—7 days per week child protection 

service hotline. 

2. Twenty positions will be added to work nights, weekends, and holidays. 

3. A family preservation component will be initiated in the same unit to help 

children stay in their homes and keep families together when it is safe to 

do so. 

4. We have added sixty new positions to our family investment and family services programs through the support of Governor Ehrlich and Secretary 

McCabe. 

5. Caseload ratios will significantly decrease in our family services program 

(1:20) when all positions are filled. 

6. All family services staff have been issued personal digital assistant equipment to assist our workers in the field with proper reporting and follow up. 

• We will continue to seek creative ways to work smarter and more efficiently 

with the resources that we have. It is our plan for the city’s department of social services to be more user-friendly and full-service oriented. 

• We can make a difference in the lives of Baltimore’s most vulnerable families 

and children by working in a coordinated fashion with our community partners 

and sister agencies. 

• Thank you for your commitment, involvement, and support as we move forward 

on this journey to excellence. 

DOCUMENT A: Baltimore City Department of Social Services 

Systemic Improvements 

Problem/Barrier Action Steps Persons Responsible Target Dates 

1) Multiple Contact 

Numbers 

• CPS Intake 

• Central Intake (Family Support) 

• Adult Services 

• Information and Referral 

Immediate: 

• All calls regarding 

child maltreatment 

go to 410–361–2235. 

Decisions of what 

constitutes abuse or 

neglect are the statutory responsibility 

of the Department. 

A.Towns, 

L. Williams 

July 1, 2004 

• Inform callers that 

their information is 

accepted for investigation (if screened 

in) and that they 

will receive acknowledgement letter with 

assigned worker’s 

name 

15 

Systemic Improvements—Continued 

Problem/Barrier Action Steps Persons Responsible Target Dates 

• For 3–5 days, have 

clerical staff who answer 410–361–4033, 

keep a log of calls 

for information, data 

to assist in how to 

cease the inappropriate use of that 

number 

L. Williams, 

M. Gordon 

July 15, 2004 

October 1, 2004 

Longer term: 

• Seek guidance from 

Legal to develop 

guidelines for appropriate use of the 

4033 number 

A. Towns, 

L. Williams 

October 1, 2004 

• Incorporate in design of new phone 

system to be operational 10/01/04 

• Determine feasibility 

of establishing a central ‘‘call center’’ for 

all calls 

2) Two Data Systems Immediate: 

(Client Information 

System and SADIE) 

• Continue current 

practice of clearing 

both systems on new 

referrals for investigation 

L. Williams 

and Staff 

Current 

• Information to be 

given out from either system to be determined after protocol (in 1 above) developed 

July 15, 2004 

Longer Term: 

• MD CHESSIE will 

provide complete 

data search (including CIS information) 

DHR/OTHS 2006 

3) No easily useable alert 

system for high risk situation (runaways, child 

abductions, etc) 

Immediate: 

• Determine feasibility 

of using cross-bureau (that is, all programs including 

Family Investment) 

alert procedure developed by CPI 

Team 

C. Henry, 

A. Towns, 

Holmes A. 

July 1, 2004 

• Determine feasibility 

of using either CIS 

or SADIE for alerts 

A. Holmes July 1, 2004 

Longer Term: 

• MD CHESSIE has 

alert functionality 

DHR/OTHS 2006 

16 

Systemic Improvements—Continued 

Problem/Barrier Action Steps Persons Responsible Target Dates 

4) Priority Protocol needs 

refining to better identify cases needing immediate response 

Immediate: 

• Review and revise 

the list and definitions to appropriately identify 

those cases needing 

1 hour response 

J. Smith, 

L. Williams 

July 15, 2004 

5) Limited services provided outside of the 

‘‘normal’’ workday (that 

is, 8–5,M–F) 

Immediate: 

• Continue plans for 

implementation of 

Extended Hours 

PLUS (full service 

Intake, including 

Family Preservation 

services) 24/7 

F. Blair, 

C. Henry, 

A. Towns, 

L. Williams, 

A. Cobb 

July 1, 2004 

• Insure case data 

availability for afterhours decision-making 

A. Holmes Aug. 2004 

6) Partnerships need renewal for better collaboration 

Immediate: 

• Develop schedule to 

meet with partners 

to re-iterate commitment to collaboration 

J. Smith, 

L. Williams 

July 1, 2004 

Longer Term: 

• Plan with them for 

regular follow-up to 

keep the communication open 

L. Williams August 1, 2004 

7) Training for staff and 

educational awareness 

for stakeholders needs 

to be updated 

Immediate: 

• Develop training 

plan for all staff 

J. Smith, L. 

Williams, 

TSD 

July 15, 2004 

• Educate stakeholders in protocols 

that affect them 

L. Williams 

and Staff 

August 1–15, 2004 

Longer Term: 

• Build in regular updates L. Williams 

and Staff 

September 1, 2004 

8) Staffing is not sufficient Immediate: 

• 4 new PINS added 

to Screening 

E. Seale, 

C. Henry, 

July 1, 2004 

• Additional needs to 

be identified 

A. Towns, 

L. Williams 

June 15, 2004 

• Replacement staffing 

plan needed for 

those positions 

where the incumbents are transferring to Extended 

Hours 

C. McCabe, 

F. Blair 

July 1, 2004 

17 

Systemic Improvements—Continued 

Problem/Barrier Action Steps Persons Responsible Target Dates 

Longer Term: 

• Continue to evaluate 

needs as well as necessary staffing or 

workload shifts as 

program improvements are made 

On-going 

9) Case review process 

needs to continue 

Immediate: 

• Continue to use the 

Quick Response 

Team staffings to 

evaluate case work 

and identify gaps 

C. Henry, 

A. Towns 

Public Information 

On-going 

Longer Term: 

• Evaluate the Quality 

Assurance process 

for changes to improve effectiveness 

C. Henry, 

A. Cobb, 

A. Towns 

Oct. 2004 

f 

Chairman HERGER. Thank you, Director Blair. Dr. Beilenson to 

testify. 

STATEMENT OF PETER BEILENSON, COMMISSIONER, 

BALTIMORE CITY HEALTH DEPARTMENT 

Dr. BEILENSON. Thank you, Mr. Chairman, and fellow Californian; and Mr. Cardin, fellow Marylander; and, Mr. McDermott, 

good to see you again, sir; Mr. Camp and staff. I am the City 

Health Commissioner, and so people have been asking why am I 

involved with this, the answer to that I will get to briefly, but I 

was Chair of a Committee that made recommendations, specific 

recommendations, on how to improve the child protective system 

both in Baltimore and in the State. We got to that point because 

I am Chair of the Child Fatality Review Committee in Baltimore. 

By statute, the health officer of each county is required to Chair 

the Child Fatality Review Committee. That Committee is charged 

with reviewing cases of unexpected childhood deaths and looking 

for themes and ways that can change those sort of things. 

In Baltimore City, there are three major causes of unexpected 

childhood death: one, sudden unexplained death in infancy. A lot 

of that was due to co-sleeping cases with parents. We made public 

education and press conferences to let parents know about trying 

to avoid that. Second, were juvenile homicides. We set up a project, 

and Congressman Cardin has probably heard of it, called Operation 

Safe Kids, where we intensively case-manage the kids that are 

most at risk for shooting or being shot. The third major cause of 

unexpected childhood death are child abuse cases. There are two 

basic patterns of child abuse death cases in the city and, I would 

presume, around the country as well. Pattern number one: kid is 

neglected or abused. I will use mom, but it can be obviously mom 

or dad. Temporarily removed from the family, returned to mom, inVerDate Aug 04 2004 05:17 Aug 19, 2005 Jkt 099679 PO 00000 Frm 00021 Fmt 6633 Sfmt 6602 E:\HR\OC\99679.XXX 99679
18 

appropriately we believe. Kid is killed by mom. I will talk about 

the recommendations we made for that pattern. 

The second pattern, the one of the Swann case, is kid abused or 

neglected so severely that they are permanently removed from the 

family. As you heard from Mr. Blair, CPS closes the case; closes the 

case because there is no child to protect anymore, and those moms 

go on, almost inevitably, because they are all at reproductive age, 

to have another child within several months or a year or 2 years. 

As is the case here, it was actually a few months after the permanent removal. No one is following that mom from CPS. So, they are 

not offered contraceptive services, they are not offered mental 

health services, substance abuse services. That mom has another 

child who is at tremendous risk for neglect or abuse and is killed. 

So we, in January, made recommendations that were forwarded 

to the State and to the city DSS on concrete things that we can 

do, we think, most of which are cost-neutral. Most of these do not 

cost money. I have attached them to my testimony. I am not going 

to go through all of them. I am only to go through a few that I 

thought might have some implication on a national level, or were 

so directly related to this case that I wanted to mention them. 

First of all, improving the CPS Call Center. It has not changed. 

I am now, thanks to press coverage, getting a lot of calls from people who are reporting to me child abuse cases. I, in fact, called Baltimore County DSS, not us, a different DSS, and happened to know 

in a case that was reported to me that there had been five previous 

children removed, case closed, case closed, case closed, case closed; 

no services offered. A new kid has been born to this mom. There 

is now worry of abuse or neglect from the community. I call in and 

am only told by the person who answers the correct hotline, the 

correct hotline, because I did call the correct hotline, they did not 

tell me there had been previous cases. So, that had not changed. 

We think, in terms of the temporarily removed kids, very specific 

team approaches need to be made. Team approach decisions need 

to be made as to when to return a kid. Far too many cases, and 

Congressman Cardin didn’t mention the litany of cases that we 

have had of temporarily removed kids that are then returned to 

mom because they simply had parenting classes; because one social 

worker and, potentially, a supervisor made a decision to return the 

kid to mom, when there is all evidence to the contrary that that 

child should be returned to the mom. A team approach, multidisciplinary, should be instituted. I know it is talked about, but it is 

rarely done. 

One of the biggest problems is there is a lack of caseworkers because, and, therefore, too high caseloads, because funding is a problem. You have to streamline the process by which caseworkers go 

to court. I don’t know if the Congressman has been to juvenile 

court in Baltimore City, but it is chaotic, to say the very least. An 

immense amount of time is wasted by caseworkers just waiting 

around for cases that often just get postponed. Similarly, to keep 

judges involved and keep cases followed, just like you want to keep 

CPS involved with cases, it should be a one-judge, one-family 

setup. That has nothing to do with DSS or DHR, but it is something the court should be looking at. 

19 

Finally, as you can probably guess from my comments, it is, I 

would say, insane, it makes no sense, that when the child has been 

permanently removed from a family, that CPS case should not be 

closed. In fact, it should be stepped up, the kind of coverage for 

that family that needs to go forward. Last two points, confidentiality laws need to be revisited. I will be happy to take questions 

on that. Second, it has to be what is in the child’s best interest, 

not reunification for any reason. As Congressman Cardin knows, I 

am a dad. I have four kids. Being a father is one of the very most 

important things in my life, and preserving family is crucial. However, there are some cases where you should not reunite a family 

because it is simply not in the child’s best interest. Thank you. 

[The prepared statement of Dr. Beilenson follows:] 

Statement of Peter Beilenson, M.D., Baltimore City Commissioner of 

Health, Baltimore, Maryland 

Good afternoon, Chairman Herger and members of the Subcommittee. I am Baltimore City’s Commissioner of Health, have held this position for 12 years, and have 

been appointed by two mayors. Since our Health Department is most often associated with health service delivery, many have asked why I am involving myself in 

the reform of social service systems. It is my experience as chair of Baltimore City’s 

Child Fatality Review Team that brings me here today, and it is the pattern of child 

abuse deaths that leads me to advocate for swift systemic changes to our Child and 

Protective Services. Unfortunately, the terrible deaths of two infants at the hands 

of their parents have brought this advocacy to the forefront. 

The Child Fatality Review Team (CFR) is a multi-agency, multi-disciplinary team 

that reviews unexpected deaths (those not occurring in a hospital) of infants and 

children through age 17. The purpose of the team is to review all pertinent information on a specific case and come up with recommendations on how future deaths 

could be prevented. The team meets once per month and reviews over 100 cases per 

year. 

During recent years, as chair of the local CFR, three major causes of unexpected 

death in children have emerged. First, SIDS and SUDI (Sudden Infant Death Syndrome and Sudden Unexpected Death in Infants) occur repeatedly. In response to 

this, we held several press events to address adults co-sleeping with their babies, 

which can lead to suffocation. A second main cause is juvenile shootings, especially 

as related to the drug trade. Our Health Department has pioneered Operation Safe 

Kids, a program designed to protect our city’s youth that are most at-risk for shooting or being shot. Finally, we have reviewed countless child abuse deaths. The majority of these deaths fall in two categories. One—the Child and Protective Services 

had removed a child temporarily from a parent’s care due to abuse and neglect and 

then the child was returned to that parent and killed. Or two—after a parent had 

a child permanently removed previously from their home due abuse or neglect, the 

parent had another child, which s/he then abused and killed. 

To respond to these common patterns of child abuse deaths, with the Mayor’s encouragement, we formed an interdisciplinary task force, the Child Welfare Reform 

Committee, to examine this flawed system and to draft recommendations for improvement. Composed of eight local leaders from medical, therapeutic, advocacy, law 

enforcement, and judicial sectors, this committee represents decades of experience 

with the local child welfare system. 

Rather than the protracted processes that frequently plague longstanding commissions and committees, the Child Welfare Reform Committee held two targeted meetings. In meetings in November and December of 2003, we pointedly asked and answered, ‘‘Where are the gaps in our city’s Child and Protective Services and what 

measures will close those gaps?’’ 

In January of this year, I submitted to the Mayor the Committee’s recommendations for system reform. The briefing memomorandum included recommendations 

that impact upon a part of the process as well as recommendations that affect the 

system globally. The recommendations were then forwarded to the State Department of Human Resources, which oversees Child and Protective Services, and were 

widely covered by the press. 

Four months subsequent to the Committee’s recommendations, the horrific death 

of two infant twins at the hands of their parents shocked the entire region. Factors 

of poverty, mental health, and substance abuse played a role in the atrocity, but 

20 

what is worse—and unfortunately not at all new to the citizens of Baltimore—is the 

fact that Maryland’s safety net for victims of abuse and neglect failed these babies 

miserably. A case review shows many warning signals—namely, a runaway teenage 

mother whose previous child was permanently removed from her care because of 

abuse. Sadly, it took the Broadway twins’ case to prove the pertinence of our recommendations. 

Speaking to you today about the system’s recurring failure to protect children, I 

would like to share with you a selection of the Child Welfare Reform Committee’s 

recommendations—those that particularly relate to this case. Implementation of 

these ideas would likely have impacted the outcomes in this most recent tragedy. 

‘‘Improve effectiveness of CPS call center by increasing training and 

staffing.’’ When called, had the worker not simply commented that there was no 

open case but actually looked at the record, when Johns Hopkins Hospital called 

they would have been notified that, in fact, there was a closed case for severe abuse 

and neglect, but there was also an open foster care runaway case, which would have 

unquestionably resulted in immediate appropriate referral of the case to Child and 

Protective Services. 

‘‘Staff Johns Hopkins Hospital 24 hours per day, 7 days per week.’’ Had 

there been a worker on-site, the Hopkins social worker would have had a direct contact to the Department of Social Services. We recommend this service for this facility because it is the primary medical center for children suspected to be victims of 

child abuse. 

‘‘Equip CPS offices with adequate information technology.’’ It may not be 

fair to completely blame the telephone operator. If adequate information technology 

had been available, the intricacies of the case may have been available on his/her 

computer screen. 

Most salient of all, in January, we recommended that the system ‘‘Design measures to protect future children of a parent who has been convicted of [or 

otherwise implicated in] abusing previous children.’’ This idea is so completely logical; it almost defies explanation. We often speak of preventive care for 

high-risk populations. A new child in the care of those who have a history of abuse 

is undoubtedly at the highest risk of all, yet, incredibly, it is exactly those cases that 

are permanently closed and the abusive parent is basically free to have additional 

children without any services or follow-up to help prevent abuse of these new children—exactly as occurred in the Broadway twins’ case. 

It is unrealistic to believe that the Baltimore City Department of Social Services 

and Child Protective Services can change overnight. Undoubtedly, they have an uphill battle where fiscal and human resources limitations are consistent obstacles. 

However, a review of these recommendations shows that the vast majority of the 

suggestions are cost neutral, simply requiring a redistribution of resources or a revised mindset. 

Recently, we have begun to hear from the State’s Secretary for Human Resources 

and the Director of Baltimore City’s Department of Social Services. Frankly, I have 

been disappointed by the vague responses to our recommendations and the middling 

willingness to redress the gaps in operations, policy, and strategy of this CPS system. There is also a terrible lack of urgency in addressing these gaps. 

I fear that the State is in danger of talking about this issue ad nauseum without 

institutions actually changing. The case of Emunnea and Emonney Broadway is one 

that will never fail to stir emotion. It is my hope that as legislators and leaders our 

emotions will be stirred to mandate State involvement in any family where 

children have been previously removed. 

Thank you for your time and devotion to these issues. 

Child Welfare Reform Committee Recommendations 

Dr. Peter Beilenson, Chair 

Recommendations: The recommendations listed are concrete steps to begin reform for this agency in crisis. The Committee’s recommendations include ‘‘Process 

Recommendations’’ which include reforms for reporting, responding, decision-making, placement, and ongoing services. ‘‘Global Recommendations’’ include overall systemic and philosophical changes. 

21 

Process Recommendations 

Reporting 

• Improve effectiveness of CPS call center by increasing training and staffing. 

Committee members found wait-times for calls to report abuse or neglect to be 

over 30 minutes at times and conducted by unprofessional operators. 

Responding 

• Staff Johns Hopkins Hospital 24 hours per day, 7 days per week. These facilities are the primary medical centers for children suspected to be victims of child 

abuse. A large proportion of incidents occur on nights and weekends, and while 

the hospitals’ pediatric emergency departments are open 24 hours a day, 7 days 

a week, there is not a DSS worker to seek care for the child at these hours. 

Currently, an abused or neglected child may sit in the emergency room alone 

hours waiting for DSS attention. 

• Implement on-call system to respond to child abuse crises at other hospitals. 

Should another hospital identify an injury or condition outside of business 

hours, DSS should be able to send a worker on-call. 

Decision-Making 

• Stat-like roundtable prior to court hearing should allow more thoughtful, informed decision-making. An interdisciplinary review of case files, reminiscent of 

our KidStat process, would prepare involved parties for court day and hold DSS 

caseworkers accountable. We hope that this collaborative approach will decrease 

the likelihood of a child being returned to a dangerous home at the discretion 

of just one caseworker. 

• Triage process needed to identify cases that should be presented for roundtable 

discussion. With over 7,500 BaltimoreCity children in out-of-home placements 

it would be neither feasible nor necessary to bring every case to a roundtable 

review. Triage must assure that only cases that require discussion be considered in this formal way. 

• Streamline process of scheduling workers to be in court. Caseworkers’ time in 

court, though essential, detracts from case management and time with children. 

DSS, similar to other court-appearing agencies (i.e. Police), should thoughtfully 

schedule appearances. 

• Institute ‘‘one judge, one family’’ approach in scheduling CINA proceedings. 

Since CINA cases involve a sequence of hearings and court involvement, which 

can extend over the length of a child’s life as a minor, assigning one judge to 

all of a child’s or all of a family’s court affairs is a logical measure. More informed, consistent judicial decision-making should result if the same judge or 

master were to hear all proceedings related to a particular child or family. Furthermore, the courts would save time because the judge should already know 

the background of the case. ‘‘One judge, one family’’ should also prevent court 

decisions that may place a DSS child in harm’s way. Jurisdictions all over the 

country have instituted this measure. 

Placement 

• Increasing foster care parent recruitment. The low number of foster parents in 

comparison to the number of children needing out-of-home care, contributes to 

overcrowded and suboptimal placements. 

• Check criminal background and child abuse registry. While potential foster 

care/adoptive parents and guardians not related to the child receive extensive 

criminal background checks. However, family members who are providing kinship care do not receive background checks. All out-of-home placements should 

experience the same level investigation as foster applicants, including an application for guardianship.I 

• nclude mental health history in application for foster care and guardianship. In 

an effort to better place children, it should be required that all foster care and 

guardianship applicants include their mental health history in the application. 

The current uneven screening of guardians was a factor in recent high-profile 

deaths. 

Ongoing Services 

• Utilize a high standards approach in order to achieve 100% of required services 

for children in out-of-home care. As a response to the October 2003 legislative 

audit, which showed that DSS was not meeting bench marks for ongoing servVerDate Aug 04 2004 05:17 Aug 19, 2005 Jkt 099679 PO 00000 Frm 00025 Fmt 6633 Sfmt 6621 E:\HR\OC\99679.XXX 99679
22 

ices, the Department should be guided to assure that 100% of children in outof-home care: 

• receive recommended therapy 

• have monthly face-to-face meetings with DSS worker receive annual wellchild exam 

• receive required annual dental exams 

• are enrolled in school 

• have their caregivers contacted monthly by DSS have their homes/facilities 

subjected to annual health and safety inspections 

• Institute a case file checklist procedure to assure children’s receipt of these 

services.L Placing a checklist in caseworker’s files should allow caseworkers and 

supervisors to best keep track of these services. As the Department increasingly 

employs information technology, this type of checklist recordkeeping may be 

computerized as well. 

Global Recommendations 

• Recruit more trained social workers as opposed to current human service workers. A small proportion of caseworkers are actually trained social 

workers presumably due to the high stress and workload of the position. 

• Equip CPS offices with adequate information technology. Technological 

capacity at Baltimore City DSS can hinder productivity. 

• Change emphasis from ‘‘family preservation’’ to ‘‘child protection.’’ 

Though ‘‘child protective’’ in name, CPS has historically taken a turn toward 

keeping family intact—often in instances that do children more harm than good. 

• Revisit confidentiality laws; consider allowing the release of case files 

following child fatality. Revealing the information like the caseworker’s 

name upon a child’s fatality could be a tremendous source of accountability in 

DSS. 

• Design measures to protect future children of a parent who has been 

convicted of abusing of previous children. Currently, there are no measures in place to supervise a convicted child-abusing parent who has goes on to 

have more children. The Child Fatality Review Team has seen multiple deaths 

as a result of this abusive pattern. 

• Redefining child’s best interest. Over time, the court’s definition of a ‘‘child’s 

best interest’’ has strayed from true consideration of the health and safety of 

the child. Future legislation may be necessary to guide this philosophical 

change. 

f 

Chairman HERGER. Thank you, Dr. Beilenson. Dr. DePanfilis to 

testify. 

STATEMENT OF DIANE DEPANFILIS, CO-DIRECTOR, CENTER 

FOR FAMILIES, SCHOOL OF SOCIAL WORK, UNIVERSITY OF 

MARYLAND, BALTIMORE, MARYLAND 

Dr. DEPANFILIS. Okay. Thank you, Mr. Chairman and other 

Members of the Subcommittee. I speak to you today as a social 

worker with over 30 years of experience in child abuse and neglect 

issues, currently as a researcher and educator at the University of 

Maryland’s School of Social Work. What can we learn from this 

tragic situation which we have already heard the details about 

from our other witnesses? I offer three suggestions: first, I believe 

it is time for a paradigm shift in the way our child protection service systems are designed. Second, I emphasize the importance of 

working across disciplines and community systems, which reinforces what Dr. Beilenson just emphasized also. Third, I emphasize 

the importance of using evidence-based practices, using what we 

know has a greater chance of working to deal with this complex 

problem of child abuse and neglect. 

23 

I need to emphasize that none of these points are new ideas, and 

I think that we have known much more than we have applied over 

the years, if we sort of trace the chronology from the first enactment of the Child Abuse Prevention and Treatment Act (CAPTA) 

(P.L. 93–247). My written testimony elaborates on all these points 

in much more detail, but I am just going to highlight a couple of 

those in the oral testimony. It is my opinion that one of the principal failures to respond to protect these two infants, or any other 

children that might be classified as at risk of child abuse and neglect, is because our system is designed to respond only to the most 

serious cases. Our definition of child abuse and neglect requires 

there to be an act or omission that results in harm or serious 

threat of harm. In this case, the facts are unclear how much of that 

was actually reported, actual harm at that point in time. So, without pointing fingers, and without dwelling on that, I think we really need to take a look at whether or not that type of revolving door 

makes the most sense given where we are today. 

My research, as well as other research, have suggested that families may be reported for child maltreatment as many as 25 times 

over 5 years. That was research where I followed families over 5 

years in Baltimore City. The system continues to screen out, investigate, and serve the same families over and over again, and we 

often fail to stop this pattern that continues sometimes for generations. It is no wonder that this particular case record is 5 inches 

thick, and I think we see many, many, many other situations similarly. 

Despite the fact that research indicates that when you have a 

chance to help a family the first time they are known to some system, we tend to fail to respond to families until situations are seriously complex, perhaps fatal, and, therefore, the chance of success 

is not great. I have an analogy in my written testimony to try to 

highlight the importance here, suggesting that if you detected a 

cyst that you would worry might be cancer, it would be the same 

thing as being told you have to wait to get medical treatment until 

the possibility of cure is almost nonexistent. I think that is the picture that we have in today’s child protection system. 

In my opinion, protecting children seems to occur more by chance 

than through a system that is structured to respond differentially 

based on the safety needs of families and of children. I do think 

there has been some movement in some States to change this picture, and it is called the System of Differential Response. In the 

States that are trying a new reform of the child welfare system, 

systems are redesigned to deliver quality supportive services the 

first time there is a red flag, and instead of waiting for children 

to experience serious and sometimes fatal injuries from neglect and 

abuse, there is a triage system where community agencies can 

work together to respond differentially to those needs. The second 

point that I emphasize is the importance of interdisciplinary efforts, which you have already heard about, so I will not go forward 

on that. The third thing that I was asked to discuss is the importance of using evidence-based practices in our response to child 

abuse and neglect. Child abuse and neglect does not happen in the 

same way in all situations. It is a complex problem that really requires complex solutions, and I think we need to use the evidence 

24 

1DePanfilis, D., & Salus, M. (2003). Child Protective Services: A guide for caseworkers. Washington, D.C.: U.S. Department of Health and Human Services, Administration on Children and 

Families, Administration for Children, Youth, and Families, Children’s Bureau, Office on Child 

Abuse and Neglect. 2Dubowitz, H., & DePanfilis, D. (Eds.). (2000). Handbook for child protection practice. Thousand Oaks, CA: Sage. 

and the research that helps us understand what works best in certain situations. 

The Office on Child Abuse and Neglect presented the results of 

the Emerging Practices in the Prevention of Child Abuse and Neglect Project, which was initiated to try to identify some of these 

effective programs, and in the context of that work, our Family 

Connections Program in West Baltimore was highlighted as one of 

the programs that was deemed demonstrated effective. The results 

that we are pleased to report about in this project, which was quite 

small, reaching out to families before they were known to child 

abuse and neglect, suggested that over a short period of time, families could be helped to increase protective factors related to parenting attitudes, parent competence, social support; decrease 

known risk factors for child abuse and neglect, like depression and 

parenting stress, and life stress; and improve safety, both physical 

care, psychological care; and the prevention of child abuse and neglect known to CPS agencies. 

In summary, I think if we want to prevent future fatalities due 

to child abuse and neglect, we really need to drastically reform the 

way our community systems are structured. We need to look at this 

promising effort called differential response, or other ways to get 

responses to families before serious or fatal injuries occur. We need 

to work more effectively together using evidence-based practice 

strategies. Thank you. I would be happy to answer any questions. 

[The prepared statement of Dr. DePanfilis follows:] 

Statement of Diane DePanfilis, Ph.D., Co-Director, Center for Families, 

University of Maryland, School of Social Work, Baltimore, Maryland 

Mr. Chairman and members of the subcommittee, my name is Diane DePanfilis. 

I am an Associate Professor, Director of the Institute for Human Services Policy, 

and Co-Director of the Center for Families at the University Of Maryland School 

Of Social Work. I have more than thirty years of experience in the child protection 

field as a social worker, supervisor, administrator, national consultant, and researcher. I am the co-author of Child Protective Services: A guide for caseworkers 1

published by the Department of Health & Human Services (HHS), Children’s Bureau, co-editor of the Handbook for Child Protection Practice,2 and a former President of the Board of Directors of the American Professional Society on the Abuse 

of Children. Last year, I conducted an important study on the investigatory practices of reported child abuse and neglect in out-of-home care in the state of New 

Jersey in collaboration with Children’s Rights, Inc. I have been a consultant with 

the state of California and other states as they undertake efforts to reform their 

child protection systems and I am on an advisory committee for the University of 

Chicago’s Chapin Hall Center for Children related to a study of the impact of some 

of these reforms. I am also currently collaborating with the Institute for the Advancement of Social Work Research with support from the Annie E. Casey Foundation on a study of the effectiveness of practices to retain professionally prepared social workers in public child welfare. 

Thank you for inviting me to present my views on the safety of children following 

the tragic death of two infants in Baltimore. I commend you and the committee for 

undertaking a series of hearings on the safety of maltreated children in this country. Today, I speak to you based on my research and experience with child protection systems in Baltimore. I have studied: (1) the recurrences of child maltreatment 

in Baltimore in collaboration with the Baltimore City Department of Social Services; 

(2) screening practices regarding child abuse and neglect reporting in Baltimore and 

25 

3 U.S. Advisory Board on Child Abuse and Neglect. (1993). Neighbors helping neighbors: A new 

national strategy for the protection of children. Washington, DC: Department of Health and 

Human Services, Administration for Children and Families. 4Wells (2000). How do I decide whether ot accept a report for a child protective services investigation? In H. Dubowitz & D. DePanfilis (Eds.), Handbook for child protection practice (pp. 3– 

6), Thousand Oaks, CA: Sage. 5 U.S. DHHS, Administration for Children and Families, Administration on Children, Youth, 

and Families, Children’s Bureau, Office on Child Abuse and Neglect (2003). The Child Abuse 

Prevention and Treatment Act including Adoption Opportunities and the Abandoned Infants Assistance Act, as amended by the Keeping Children and Families Safe Act of 2003. Washington, 

DC: Author. Retrieved June 6, 2004 at http://nccanch.acf.hhs.gov/general/legal/federal/index.cfm. 6Klein, A. (2004, May 24) Officials seeking better safeguards to protect children from abuse. 

Baltimore Sun, 2b. 7DePanfilis, D. (2003). Report of the Research Committee to the State Council on Child Abuse 

and Neglect. Baltimore: Author. 8 US DHHS, Administration for Children and Families, Administration on Children, Youth, 

and Families (2004). Child maltreatment 2002: Reports from the states to the national Child 

Continued 

other jurisdictions in collaboration with the Maryland Department of Human Resources and the State Council on Child Abuse and Neglect; and (3) the efficacy of 

a promising preventive intervention in West Baltimore called Family Connections. 

My views are based on my experiences as a social worker and researcher and I do 

not formally represent any group. 

What can we learn from this tragic situation in which two young lives were lost? 

I offer three related suggestions. First I believe that it is time for a paradigm shift 

in the way our child protection systems are designed. Second, I emphasize the importance of working across disciplines and community systems. Third, I emphasize 

the importance of using evidence-based practices to respond to the complex problem 

of child abuse and neglect. These are not new ideas. 

Too Little Too Late: Time For a Paradigm Shift 

Our current laws our designed for the public child protection system to respond 

when there is a reason to believe that a child has already been harmed or is at serious risk of harm. Only a very small percentage of the children and families with 

maltreatment or risks of maltreatment actually receive help. Over ten years ago, the 

Federal Advisory Board on Child Abuse and Neglect declared that the child protection system was in a State of Emergency.3 The state of emergency continues. 

Let’s begin with the call to CPS. CPS workers are charged with screening reports 

of child abuse and neglect according to definitions in state laws.4 If the alleged concerns do not meet the state definition of child maltreatment, workers make appropriate decisions by not accepting reports for investigation. The Child Abuse Prevention and Treatment Act (CAPTA) sets the standards for a state definition of child 

abuse and neglect. The term ‘‘child abuse and neglect’’ means, at a minimum, any 

recent act or failure to act on the part of a parent or caretaker, which results in 

death, serious physical or emotional harm, sexual abuse or exploitation, or an act 

or failure to act which presents an imminent risk of serious harm.5

While I am not familiar with the ‘‘facts’’ of the Baltimore City case other than 

what I have read in the Baltimore Sun, I’m not sure that a report that alleged that 

a mother who was known to social services as a foster care runaway from whom a 

previous child had been taken away because of abuse and neglect 6 would constitute 

an imminent risk of serious harm. 

It is my opinion that the failure to respond to protect these children is not the failure of the CPS agency, but a failure of our state laws that dictate that children need 

to be harmed or at imminent risk of harm before someone in the community responds. 

What do we know about screening practices in Maryland? In 2001, a collaborative 

research team reviewed all screened out reports of child abuse and neglect in Maryland for one month. Reviewers, including University researchers and state policy analysts, determined that most (83%) of the screening decisions made that month were 

consistent with state policies.7 Of the 5,023 referrals received by 24 local CPS jurisdictions in the study month, an average of 36% of referrals was screened out. The 

proportion of referrals screened out significantly differed between jurisdictions ranging from 62.5% to 5.6%. Larger jurisdictions tended to screen out fewer referrals 

(29.8% in BaltimoreCity; 25.7% in Prince George’s County) than the state average 

(36%). These variations are consistent with screening practices nationally. Screening 

rates vary substantially between states from a low of 1.7% in Alabama to a high 

of 72.3% in Maine.8

26 

Abuse and Neglect Data System. Washington, DC: U.S. Government Printing Office. Retrieved 

June 3, 2004 at www.acf.hhs.gov/programs/cb/publications/cmreports.htm. 9DePanfilis, D., & Zuravin, S. J. (2002). The effect of services on the recurrence of child maltreatment. Child Abuse and Neglect, 26, 187–205; DePanfilis, D., & Zuravin, S. J. (2001). Assessing risk to determine the need for services. Children and Youth Services Review, 23, 3–20; 

DePanfilis, D., & Zuravin, S. J. (1999). Predicting child maltreatment recurrences during treatment. Child Abuse and Neglect, 23 (8), 729–743; DePanfilis, D., & Zuravin, S. J. (1999). Epidemiology of child maltreatment recurrences. Social Services Review, 73, 218–239; DePanfilis, D., 

& Zuravin, S. J. (1998). Rates, patterns, and frequency of child maltreatment recurrences among 

public CPS families. Child Maltreatment, 3, 27–42. 10 US DHHS (2004). 11Drake, B. (1996). Unraveling unsubstantiated. Child Maltreatment, 1 (3), 261–271; Melton, 

G. B. (2003, October). Mandated reporting: A policy without a reason. Commentary prepared for 

a virtual discussion sponsored by the International Society for Prevention of Child Abuse and 

Neglect. 12See for example, Waldfogel, J. (1998). Rethinking the paradigm for child protection. The Future of Children Protecting Children from Abuse and Neglect, 8 (1) 104–119. 

It is my opinion that assessing the safety of children occurs inconsistently between 

local and state jurisdictions. Society should not wait until a child has experienced 

a serious or fatal injury before responding to referrals of concern about children at 

risk of maltreatment. Our community systems must be available to respond to all 

families at risk for child maltreatment. 

For some families, the child protection system is like a revolving door. My research, as well as research, by others has found that families may be reported for 

child maltreatment as many as 25 times in five years.9 The system continues to 

screen out, investigate, and/or serve the same families over and over again as we 

often fail to stop a pattern that sometimes continues for generations. Despite the 

fact that research also indicates that we have a chance to alter this picture if families can be helped the first time someone recognizes a problem, our systems too 

often get involved too late. We are serving only the tip of the iceberg and waiting 

too long to offer help that has any chance of success. Imagine detecting a cyst that 

has a chance of being diagnosed as cancer but being told you can’t access medical 

care until the chances of recovery are almost nonexistent. 

It is my opinion that as a society we must develop new strategies for early detection 

and response to families at risk for child maltreatment. 

In 2002, state CPS agencies received 2.6 million referrals alleging maltreatment 

related to 4.5 million children.10 Of the referrals accepted as a report and investigated, more than half of the reports (60.4%) led to a finding of unsubstantiated 

suggesting that sufficient evidence of child abuse or neglect was not found by the 

CPS worker. In contrast, an estimated 896,000 children were determined to be victims of child abuse or neglect in 2002 based on determining that a report was substantiated or indicated. There is growing consensus that the legalistic process of reporting, investigating, and substantiating or unsubstantiating does not lead to the 

protection of children.11 While some reports that are unsubstantiated may not require a community response, it is likely that at least some of these reports represent 

children and families who could benefit from family support or other community 

services that may prevent child abuse or neglect in the future. 

In the current system, most reports of child abuse and neglect do not result in 

services to prevent the occurrence or recurrence of child maltreatment (DHHS, 

2004). Think of a funnel. Extrapolating from national reporting data, consider the 

following scenario. Out of every 100 reports of child abuse and neglect, 67.1 are 

screened in for an investigation. Of those 67 reports, 20 (30.3%) are substantiated 

or indicated. Of those, 11.8 children may receive a service response beyond an investigation of the report. The deaths of these infants in Baltimore is an example of a 

tragic situation that may have been screened out from receiving the benefit of a 

safety assessment. 

It is my opinion that protecting children seems to occur more by chance than 

through a system that is structured to respond differentially based on the safety 

needs of children and families. 

The beginnings of a paradigm shift. As others 12 have asserted, the system designed to protect children is not working. In 1990, the U.S. Advisory Committee 

made a most compelling argument that we ignored. The most serious shortcoming 

of the nation’s system of intervention on behalf of children is that it depends upon 

a reporting and response process that has punitive connotations and requires massive 

resources dedicated to the investigation of allegations. State and County child welfare programs have not been designed to get immediate help to families based on voluntary requests for assistance. As a result, it has become far easier to pick up the 

27 

13 U.S. Advisory Board on Child Abuse and Neglect (1990). Child abuse and neglect: Critical 

first steps in response to a national emergency. Washington, DC: Author. 14 U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation and Administration for Children and Families, Administration on Children, 

Youth and Families, Children’s Bureau (2003). National Study of Child Protective Services Systems and Reform Efforts Review of State CPS Policy. Washington, DC: Author. Retrieved June 

6, 2004 at http://aspe.hhs.gov/hsp/cps-status03/state-policy03/. 15 Institute of Applied Research. (1998, January). Missouri child protection services family assessment and response demonstration impact evaluation: Digest of findings and conclusions. St. 

Louis, MO: Author. 16Goldman, J. & Salus, M. (2003). A coordinated response to child abuse and neglect the foundation for practice. Washington, DC: US DHHS, ACF, ACYF, Children’s Bureau, Office on Child 

Abuse 

Institute of Applied Research. (2003, February). Minnesota alternative response evaluation 

second annual report: Executive summary. St. Louis, MO: Author; Texas Department of Protective and Regulatory Services. (1999). Flexible response evaluation. Austin, TX: Author; 

VirginiaDepartment of Social Services. (1999). Final report on the multiple response system for 

Child Protective Services in Virginia. Richmond, VA: Author. 17Wilson, C. & McGrath, P. (2004, Spring). In search of a new model for coordinated urban 

child abuse investigations. APSAC Advisor, 16 (2), 5–10. 

telephone to report one’s neighbor for child abuse than it is for that neighbor to pick 

up the telephone and receive help before the abuse happens.13

It is time to consider that there must be a better way. During the past 10 years, 

there has been a growing consensus that states and communities need to change 

the way they protect children, and many states have taken the charge to make the 

protection of children a community responsibility. One type of reform to child protection systems has been implemented: differential response. These newly designed differential response systems provide non-adversarial, flexible responses to individual 

family circumstances. Systems are redesigned to deliver quality supportive services 

the first time red flags are identified instead of waiting for children to experience 

serious and sometimes fatal injuries from neglect or abuse. Community agencies, in 

partnership with child protective services, work to triage services so that together 

the community can help families meet the basic needs of their children and keep 

them safe. A national study of child welfare reforms 14 identified twenty states that 

offer one or more alternatives to the traditional CPS investigative response. While 

it is not yet clear whether these efforts will yield better outcomes for children, some 

early evaluation results are promising.15 States have reported improvements in 

child safety and child and family well-being compared to families served through 

traditional services. Previous testimony before this subcommittee by Tom Birch on 

behalf of the National Child Abuse Coalition (2004) has already outlined information about the costs of not investing in prevention and early intervention. 

Working Together Across Systems 

Protecting children is a community responsibility. This statement has been emphasized since the enactment of CAPTA in the 70s. For example, the current edition 

of one of the federal government’s user manuals suggests that all relevant professionals must be aware of their role in child protection and the unique knowledge and 

skills they bring to their community’s prevention and intervention efforts. They must 

also understand the roles, responsibilities, and expertise of other professionals.16 All 

practitioners must also have sufficient competence and time to perform the roles 

they are assigned. Federal and state governments have invested considerable resources to require multidisciplinary teams and state coordinating bodies to collaborate in broad efforts to protect children. Unfortunately, these requirements do not 

always ensure that all professionals and organizations will work together on a daily 

basis. And there are some disagreements about how these multidisciplinary teams 

really should work.17 Child abuse and neglect is a complex problem that requires 

interdisciplinary efforts. That means we must work together, not side by side. The 

tragic case of the twins in Baltimore is an example of serious failures in multiple 

systems. Pointing fingers and blaming each other will not prevent future failures. 

Coming together and developing ways to work together on a daily basis will keep 

children safe. This is not a situation of not knowing how. It means we must have 

the will to make it happen. In Baltimore, Secretary McCabe and Director Blair, 

other witnesses here today, have already taken steps to bring groups together. We 

must tackle the serious barriers to keeping children safe as new protocols and procedures are established to prevent future avoidable tragedies. 

28 

18 National Research Council (1993). Understanding child abuse and neglect. Washington, DC: 

National Academy Press. 19 Becker, J.V., Alpert, J. L, BigFoot, D. S., Bonner, B. L., Geddie, L. F., Henggeler, S. W., 

Kaufman, K. L., & Walker, C. E. (1995). Empirical research on child abuse treatment: Report 

by the child abuse and neglect treatment working group, American Psychological Association. 

Journal of Clinical Child Psychology, 24, 23–46; Corcoran, J. (2000). Family interventions with 

child physical abuse and neglect: A critical review. Children and Youth Services Review, 22, 

563–591; DePanfilis, D. (1999). Intervening with families when children are neglected. In: H. 

Dubowitz (Ed.). Neglected children (pp. 211–236). Newbury Park, C: Sage; Kluger, M. P. Alexander, G., Curtis, P. A. (2000). What works in child welfare. Washington, DC: Child Welfare 

League of America; Oates, R. K., & Bross, D. C. (1995). What have we learned about treating 

child physical abuse? A literature review of the last decade. Child Abuse & Neglect, 19, 463– 

473; Thomlison, B. (2003). Characteristics of evidence-based child maltreatment interventions. 

Child Welfare, 82, 541–569; Wolfe, D. A. (1994). The role of intervention and treatment services 

in the prevention of child abuse and neglect. In G. B. Melton & F. D. Barry (Eds.), Protecting 

children from abuse and neglect foundations for a new national strategy (pp. 224–303). New 

York: Guilford; Wolfe, D.A., & Wekerle, C. (1993). Treatment strategies for child physical abuse 

and neglect: A critical progress report. Clinical Psychology Review, 13, 473–500. 20 U.S. Department of Health and Human Services [U.S.DHHS]. (2003). Emerging practices 

in the prevention of child abuse and neglect. Washington, D.C.: Author. 21 Bronfenbrenner, U. (1979). The ecology of human development: Experiments by design and 

nature. Cambridge, MA: Harvard University Press. 22Dunst, C.J., Trivette, C.M. and Deal, A.G. (1988). Enabling and empowering families: Principles and guidelines for practice. Cambridge, MA; Brookline Books; Kinney, J., Strand K., 

Hagerup M., & Bruner C. (1994). Beyond the buzzwords: Key principles in effective frontline 

practice. Falls Church, VA: NCSI Information Clearinghouse. 

Evidence-Based Practices 

Since child neglect and abuse are rooted in multiple and interacting intrapersonal, 

interpersonal, and environmental factors, no one intervention or treatment is expected to be effective in all situations.18 Even though research on what works to prevent and respond to child maltreatment is limited, recent reviews of intervention 

and treatment effectiveness have identified some core elements.19 As we reassess 

the field’s response to child abuse and neglect, it is incumbent that we employ methods to prevent and respond to child abuse and neglect which have some evidence 

that they are effective in reducing the risk of child maltreatment. 

In 2003, the Office on Child Abuse and Neglect (OCAN) presented the results of 

the Emerging Practices in the Prevention of Child Abuse and Neglect project, which 

was initiated to identify effective and innovative programs in child abuse and neglect prevention around the nation. In partnership with the prevention community, 

OCAN implemented this review to elevate understanding of prevention programs 

and initiatives, and to share information on emerging and promising practices with 

the field.20

In coming here today, I was asked to speak briefly about a program called Family 

Connections in West Baltimore, which was deemed ‘‘demonstrated effective’’ by the 

OCAN initiative. Family Connections received this designation because the Advisory 

Group determined that the program had undergone rigorous evaluation using an experimental design with random assignment, and the results demonstrated positive 

outcomes for participants. 

Family Connections is a multi-faceted, community-based service program that 

works with families in the context of their neighborhoods to help them meet the 

basic needs of their children and reduce the risk of child neglect. The program was 

developed by the University Of Maryland School Of Social Work in collaboration 

with the School of Medicine and the Department of Pediatrics. It was launched 

through a federal demonstration project funded in 1996 and has since been supported by a combination of federal, state, private foundation, and other sources. The 

mission of Family Connections is to enhance the safety and well-being of children 

and families by combining education of graduate social work interns, services to 

families in the West Baltimore Empowerment Zone, and research about the process 

and outcomes of the intervention. Our goal is to reach families and to prevent the 

need for a formal child protective services intervention. 

The program was designed to specifically target factors known to increase the risk 

of child neglect. The choice to focus on the prevention of neglect came out of research on the recurrence of child abuse and neglect in Baltimore. The program operates from an ecological developmental framework using Bronfenbrenner’s 21 theory 

of social ecology as the primary theoretical foundation. Child neglect is thought to 

evolve when risk factors related to the child, caregivers, family system, and environment challenge the capacity of caregivers and broader systems to meet the basic 

needs of children. Family Connections uses a home-based, family-centered model of 

practice consistent with other home-based, tailored intervention approaches.22 Nine 

29 

23DePanfilis, D., Glazer-Semmel, E., Farr, M., & Ferretto, G. (1999). Family Connections 

intervention manual. Baltimore: University of Maryland, Baltimore. Retrieved June 15, 2004 

from http://www.family.umaryland.edu. 24DePanfilis, D. (2002). Helping families prevent neglect final report. Study funded by the U.S. 

Department of Health and Human Services, Children’s Bureau 1996–2002 (Grant Number 

90CA1580). Baltimore, MD: University of MarylandSchool of Social Work. Retrieved June 15, 

2004 at http://www.family.umaryland.edu; DePanfilis, D., & Dubowitz, H. (Submitted for peer 

review, January 2004). Family Connections: Preventing child neglect—promoting well-being and 

safety. 

practice principles guide FC interventions: community outreach; individualized family assessment; tailored interventions; helping alliance; empowerment approaches; 

strengths perspective; cultural competence; developmental appropriateness; and outcome-driven service plans.23 Individualized intervention is geared to increase protective factors and decrease risk factors. 

The core components of Family Connections include: (1) emergency assistance; (2) 

home-based family intervention (family assessment, outcome driven service plans, 

individual and family counseling); (3) service coordination with referrals targeted toward risk (e.g., substance abuse treatment) and protective factors (e.g., mentoring 

program); and (4) multi-family supportive recreational activities. 

Research supported through the demonstration project illustrates positive improvements for children, caregivers, and families.24 The sample included 154 families (473 children) in a poor, urban neighborhood, who met risk criteria for child neglect, and who were randomly assigned to receive either a 3—or 9-month intervention. Self-report and CPS data were collected prior to, at the end of, and six-months 

post intervention. Observational assessments were made at the beginning and the 

end of the intervention. Data were analyzed using analyses of variance (ANOVA) 

with repeated measures. Results for the entire sample indicated: 

• enhanced protective factors (parenting attitudes, parenting competence, social 

support); 

• diminished risk factors (parental depressive symptoms, parenting stress, life 

stress); 

• improved child safety (physical and psychological care of children); and 

• strengthened child well-being (decreased externalizing and internalizing behavior). 

The nine-month intervention was more effective in certain areas compared to the 

three-month intervention (e.g., fewer caregiver depressive symptoms, fewer child behavior problems). Prior to Family Connections’ intervention, CPS had received 274 

reports of child abuse or neglect related to 87 of the 154 families (56.5%) in this 

sample. Fifty-nine (38.3%) of these reports were indicated. While Family Connections was providing intervention, twenty-four CPS reports were made related to seventeen families (11% of 154 families), and 12 of these were indicated. Six months 

following the closure of intervention, searches on 139 families found that there had 

been eleven reports made to CPS. (Fifteen families had less than six months followup time and were not included in the search). Five of the fifteen reports were for 

three-month families and six were for nine-month families. Of these 11 reports, five 

of them were indicated (four for three-month families and one for nine-month families). The low number of reports overall precluded tests of significance between 

groups. Family Connections appears to be a promising model for preventing neglect 

and enhancing children’s safety and well-being. Limitations of this original project 

are now being addressed through the replication of this program in 8 sites. The Office on Child Abuse and Neglect has funded one replication in Baltimore which is 

targeting grandparents raising grandchildren. Other projects are funded in California (2 programs); Michigan; Texas (2 programs); West Virginia; and Tennessee. 

Further information about this program may be found at the Family Connections’ 

web site at http://www.family.umaryland.edu 

A workshop on the program will also be presented at the U.S. Department of 

Health and Human Services, Administration for Children and Families, Children’s 

Bureau sponsored Biennial Child Welfare Conference: Focus on Evidence 

Based Practice being held on June 29th, 2004 at the Marriott Wardman Park 

Hotel in Washington, D.C. This national conference will provide training experiences and best practice models in child welfare as well as many opportunities for 

collaboration and partnership building. It is expected to bring together 500 participants across the spectrum of child welfare. The participants will include state child 

welfare directors, policy makers, judicial representatives, federal, state and local 

agencies, community-based organizations, faith-based organizations, advocacy 

groups, direct service providers, related associations, and other partners in the field. 

30 

25Melton, 2003, p. 9. 

Lessons Learned 

In summary, I firmly believe that if we want to prevent future fatalities due to 

child abuse and neglect, we need to drastically reform the way our communities are 

structured to respond to families who may be at risk for child abuse and neglect. 

Governments ought to facilitate the development of community environments that by 

their nature provide family support and that ensure watchfulness for children. 

Help—and, if necessary, monitoring and control—ought to be built into primary community settings in a manner that minimizes intrusions on privacy and that improves 

the everyday quality of life for children and families, whatever their vulnerability 

and needs.25 One such promising method for accomplishing this goal may be to reform child protection systems to differentially respond to children and families. We 

must also practice working together systematically on a daily basis. 

Finally, more attention needs to be paid to testing strategies to prevent and intervene so that we more efficiently use the limited resources available to dedicate to 

this major social problem. Despite gains in evaluating the effectiveness of interventions in the past ten years, we do not yet completely understand what interventions 

work with whom and under what conditions. Federal and state support for research 

on the effectiveness of child maltreatment related prevention and intervention efforts are limited. If we want to invest in programs that work to help children and 

families achieve safety and well-being, we must undertake rigorous studies on the 

efficacy and effectiveness of different program models. 

Thank you for an opportunity to express my opinions about what we may learn 

from this tragic situation in Baltimore. 

f 

Chairman HERGER. Thank you very much. The gentleman from 

Michigan, Mr. Camp to inquire. 

Mr. CAMP. Thank you, Mr. Chairman. Dr. Beilenson, it seems 

to me that the hospital had an obligation to do more than simply 

place a phone call to a clerk. You had a single parent coming in 

with twins and low birth weight. All the red flags went off that this 

person should not have been just simply sent home. Can you just 

tell me a little bit about why the hospital did not do more? 

Dr. BEILENSON. Yes. I actually know about the case. I am just 

the City Health Commissioner, I don’t work at Johns Hopkins, but 

I actually do know the case, and I have also said in the press that 

I think the Secretary and Mr. Blair have kind of taken too much 

of the heat; that not only did Johns Hopkins make that call, they 

actually knew, and the referral form that was eventually sent did 

have on it that they knew a permanent removal had occurred. So, 

I do think it was incumbent on Johns Hopkins staff to have gone 

ahead and called CPS, even though they were told by the clerk that 

there was no open case. 

Mr. CAMP. So, they had other knowledge? 

Dr. BEILENSON. They did have other knowledge. So, that is 

why it shouldn’t have happened. That is why one of the recommendations I didn’t mention, because it was very specific to the 

case, is Johns Hopkins, and you wouldn’t know this, but Johns 

Hopkins happens to see the vast majority of physical child abuse 

cases in the city. So, we recommended not a hotline extended 

hours, but 24-hour, 7-day-a-week coverage at Johns Hopkins. So, a 

CPS person could have been there and just been called upstairs. 

Mr. CAMP. From what I have seen in press reports, the circumstances of the mother coming in indicated no prenatal care. 

Dr. BEILENSON. Delivered in a sweat pant. 

31 

Mr. CAMP. I think there were other issues. I appreciate your 

comments on reunification. This clearly was not a reunification 

case. I think the Adoption and Safe Families Act (P.L. 105–89) 

really does give the authority to the judges to make the decisions 

that need to be made, but it is interesting to hear that your experience is they are not doing that. So, we may have to take a look 

at that in another issue. 

Secretary McCabe, it seems to me that this whole legislative or 

legal point that the State cannot act on a presumption that the 

same parent will abuse a child later, I know other States have different laws. For example, in Michigan, a subject can incorporate by 

reference what has happened to one child to other children later. 

It seems to me there should be a legislative change there to correct 

that. I know other States do that, and I am surprised, frankly, that 

Maryland does not have the ability to do that. 

Mr. MCCABE. We will certainly look at that. We want to learn 

from this. I think differential response that the doctor talked about 

points to that, and we will do that, Congressman. If I can also, I 

talked a little about partners in this, and I think it is important 

to also make a point that judges ultimately have the discretion and 

the authority to determine what custody is for a particular child. 

We spend a lot of time, our social workers, working with judges. 

Hence, they, in our State, very much believe in reunification, as we 

do as a department. Whenever possible we want to reunify. In fact, 

we are mandated by law to try to reunify to the extent we can. So, 

we will certainly look at that. 

Mr. CAMP. I understand, but I am really looking at the point at 

where files are closed, particularly after one child may be removed. 

If one child has been removed, and then a later child is born, there 

is a fairly high indication there may be problems again. I know 

other States account for that, and the evidence in the previous file 

can come in in a judge’s determination. The other point I wanted 

to ask you about is when you testified before us in May, you said 

that the Baltimore City DSS had been operating under a Federal 

consent decree since 1989, and the local agency is obligated to 

make systemic improvements in their programs. Obviously, there 

have been problems in the Baltimore welfare system for some time. 

I wondered if you could tell us more about why the consent decree 

was put in place, and what it means today; what improvements 

does it require; and how are these paid for? A little background on 

that, please. 

Mr. MCCABE. Sure. In 1989, the Federal courts established, in 

LJ v. Massinga, which was a class suit by plaintiffs’ attorneys, that 

the Baltimore City DSS would be operating under this Federal consent decree. Others could probably comment even more knowledgeably than I can, but I think it was because there were children in 

foster care that had been lingering there, and there did not seem 

to be any significant improvement in trying to find permanency for 

kids in foster care. 

As a result of that Federal consent decree, we are now required 

to measure our progress in a report every 6 months to plaintiffs’ 

attorneys, these are pro bono attorneys who are doing this, about 

progress against several measurable standards. I have to admit to 

you all that I think for many years it was a kind of a pro forma 

32 

exercise, where we internally recognized we had to do this report, 

but we had not been committed, as much as I think we should be, 

to making improvements so that someday we could qualify to get 

out from under this Federal consent decree. I have made a commitment with the plaintiffs’ attorneys to do everything I could to make 

changes so that we could qualify for coming out from underneath 

that. The systemic issues that they reference in that are still very 

much in play, and we are trying to do something about it. 

Mr. CAMP. There have been some comments about the technology here, and if there had been better technology. Under the 

Maryland system, even if the technology was perfect, they would 

not have told the hospital that there was a case, because it was 

closed. So, all the technology in the world wouldn’t fix that. I think 

you have a legal problem there. I noticed in your written testimony 

you mentioned 1,000 computers had been ordered but never delivered. Can you tell me about that and the reason for that delay? 

Mr. MCCABE. Sure, Congressman. Well, when I came on board, 

and I think Mr. Blair can confirm this in his shorter time at the 

helm, we recognized that the conditions in which our workers operated, particularly our frontline workers, was just unacceptable. So, 

we committed, I committed and the Governor committed, to doing 

everything we could to make sure that those tools were available 

to them. So, now every caseworker, believe it or not, has a computer on their desk. We are finally getting a phone system that you 

and I have enjoyed for years. We are finally getting our workers 

those tools, and that is a good thing. 

Specifically, I talked about MD CHESSIE, which is our SACWIS 

system. I don’t want to oversell the technology. Any technology is 

only as good as it can be if people who are using it either understand it or understand the value of it. Otherwise, it is just that, 

it is technology. So, we are very much committed to training our 

workers to use it. The more information the better. The MD CHESSIE system, when fully implemented, will have all the relevant 

case information, including placement opportunities open, where 

we can actually place a child, at the fingerpoint of the person operating the computer. That simply does not exist, and it just compounds the difficulty our caseworkers have. 

Mr. CAMP. Thank you, Mr. Chairman. 

Chairman HERGER. The gentleman’s time has expired. The gentleman from Maryland, Mr. Cardin to inquire. 

Mr. CARDIN. Thank you very much, Mr. Chairman. I want to 

ask a few questions about the Swann case to find out what happened, but also to see whether we have made changes in our system so that what happened in the Swann case will not happen 

again. 

The first point is you have a young teenager who is a runaway 

from foster care, becomes pregnant. She has a child. The child is 

taken away from this young teenager because of abuse and put in 

foster care. You have a big folder, You said, 4 or 5 inches thick. 

Why wasn’t she put into foster care or the juvenile system, or why 

wasn’t there any services provided to her after she had abused her 

child? You had to take the child away, and she is still a foster child 

herself. We have a responsibility. So, why wasn’t there any services 

provided, either through foster care or the juvenile justice system, 

33 

if need be, so she is not on her own on the streets? Question number one. Have we taken steps to make sure that doesn’t happen 

again in another case that might be looming? 

Mr. BLAIR. Congressman Cardin, yes, she was in foster care. 

She was on runaway status, meaning that she had left her foster 

care parent which is provided by the State and the services we 

would be providing for her. She had run away from us, and we 

were making strenuous attempts to find out where she was. We did 

not know she was living in an abandoned building, and we did not 

know she was pregnant. 

Once a case is closed, in a sense, the child is transferred to an 

active foster care case, where he or she will receive the supportive 

services from our agency; so she was receiving services. For whatever reason, which I don’t know and can’t comment on now, she 

ran away from us. She ran away from the foster home, and we 

were trying to find where she was. We had no idea she was living 

in an abandoned building and no idea she was pregnant. It was 

brought to our attention only after this case was brought to our attention, sir. 

Mr. CARDIN. My real question said, when she had her first child 

and the first child was taken away, why didn’t then more intense 

services, if she had a child while she was in foster care, and she 

abused that child, it seems to me that is a signal that intense 

intervention is necessary, and it is our responsibility for intense 

intervention, and just putting her back into a foster care situation 

that couldn’t supervise doesn’t seem like it is a safe alternative for 

either Ms. Swann or society, and it proved to be that way. 

Mr. MCCABE. Can I comment, just to clarify a little about our 

internal processes? The question the Johns Hopkins worker asked 

our clerical staff, which was, was there an open child abuse case 

or child abuse case, and the answer was no. When an investigation 

occurs, and then an action is taken, we may remove a child, within 

our own system we close the investigation. That, however, doesn’t 

mean that there is not an active foster care case. So, we are not 

only providing for the child, the well-being in a new foster home, 

our caseworker, the foster worker, also has a dual responsibility to 

help the foster worker. 

Mr. CARDIN. I think I understand that point, but I think Dr. 

Beilenson’s point is that this is a real big flag going up, and we 

need to provide intense services. The case should not be closed 

from the point of view of service after you take a child away from 

an abusive parent, particularly if that parent is your responsibility 

under the foster care system. 

Mr. MCCABE. We were continuing to provide services. Now, I 

agree with Dr. Beilenson, the level of service that we can provide 

a caseworker, to both a child who is in care as well as the teenage 

mom, probably they do the best they can with the tools they have 

got. 

Mr. CARDIN. I want to give Dr. Beilenson a chance at that, but 

the second point, and I want to make sure time doesn’t run out, 

is that Johns Hopkins evidently had a telephone number to call. It 

is an internal number. I don’t know who gave them the number to 

call, and I am not trying to say Johns Hopkins shouldn’t have done 

a better job in the case, but it seems to me if Johns Hopkins has 

34 

an internal number to call in the DSS, and you are calling from 

a hospital as far as children being sent home with a parent, that 

number should have connected to a person that could have given 

them the right information. Again, I am not trying to place blame 

here, but have we made the corrections now so that if a hospital 

contacts the DSS they can know for sure whether there is an open 

case with a mother before letting that child go home with that 

mother? 

Mr. BLAIR. The answer is yes, sir. For several years prior to me 

coming on board, this back-door number had existed basically 

based on workers who worked for the department who moved on 

to other employment, such as Johns Hopkins and other hospitals, 

and they utilized this number just to get simple information, not 

to actually report an issue of abuse. So, the worker was calling a 

number that she knew she would get cursory information. She did 

not suspect abuse. That is why she didn’t call the correct number, 

which is the CPS hotline. Presently that number has been shut 

down. 

Mr. CARDIN. Mr. Chairman, with your patience, a question to 

Dr. Beilenson. Do you have a comfort level today that we have in 

place in Baltimore information in the delivery rooms of our hospitals, particularly Johns Hopkins, which is the largest, you said, 

for potential child abuse cases, so that if the hospital in good faith 

is trying to get information, they can get information? Number two, 

are you confident that if you have a foster parent who delivered a 

child after they had another one taken away from them, that there 

is something in place that ensures that the foster child is going to 

get adequate services? 

Dr. BEILENSON. No. 

Mr. CARDIN. Thank you, Mr. Chairman. 

Chairman HERGER. I thank the gentleman. The gentleman 

from Louisiana, Mr. McCrery to inquire. 

Mr. MCCRERY. I have no questions at this time, Mr. Chairman. 

Chairman HERGER. The gentleman from Washington, Mr. 

McDermott to inquire. Does the gentleman from Washington have 

a question? 

Mr. MCDERMOTT. Yes, Mr. Chairman. I am interested in hearing from the witnesses whether they think the Federal Government 

has any role in this? Do you need Federal standards? Do you want 

Federal standards? Do you want us to stay out and just ship the 

money, or what is your view? We have been having hearings on 

this stuff for the last couple of years. We heard about New Jersey, 

and we have a big report here from the GAO, and we get all this 

stuff, but we never write any legislation. So, I am kind of wondering what the point is. Are you here asking or think we ought 

to do something? 

Mr. MCCABE. If I may, Congressman, I served 11 years in the 

Maryland Senate, and when an incident occurs, it, rightfully so, 

creates a lot of visibility and usually action. It should. We need to 

take urgent steps to make a fix, and we are planning to do that 

in Maryland. However, the CFSR demonstrate that we just can’t 

make a quick fix in all cases. We have got a real long-term systemic weakness in our system in Maryland, as usually most other 

States do. The Federal Government absolutely has a role, not just 

35 

by shipping money to us, and we are very grateful for that; we rely 

on it significantly. Two out of every $3 which funds Maryland’s 

DHR comes from the Federal Government. So, we absolutely need 

that partnership. 

A hearing like this, frankly, brings all of us to this table and 

really requires us to listen to each other. That is something that 

doesn’t always happen. As Dr. DePanfilis mentioned, we all work 

in our own little tunnels sometimes. I spoke with Dr. Beilenson 

about the three of us meeting next week to talk about what the 

health department does with our department and how we can better work together. So, in terms of Federal standards and legislation, I think the CFSR is that Federal role that you indicated is 

so important. We have to provide a program improvement plan 

which will incorporate this, or we risk a significant penalty. 

Mr. MCDERMOTT. Has any State ever been penalized? Have 

you ever been penalized? 

Mr. MCCABE. We just received ours, and to the best of my 

knowledge that hasn’t occurred. Our expectation, and I think the 

expectation of the Federal Government, is we will get a plan in 90 

days to them that is workable and doable. 

Mr. MCDERMOTT. So, you don’t think there is any real positive 

thing that the Congress could do in this? It is already in place, and 

it is really up to you guys at the local level? Or you folks, because 

it is men and women. 

Mr. MCCABE. Congressman McDermott, Congressman Cardin, I 

know the Committee is aware of the Pew Foundation on Foster 

Care, and one of the things we all talked about is the need for intensive services before abuse happens. Right now there is an incentive really because we get money only after we take a child out of 

care. The recommendations that will be before you indicate that 

States need more flexibility for the moneys they receive so they can 

provide some of those up front services that Dr. Beilenson and others have talked about. That is a big, long process, and that is in 

your hands; that flexibility for the use of Federal funds would be 

helpful. 

Mr. MCDERMOTT. Any of the others of you? 

Mr. BLAIR. As a local director, the Secretary is correct. We are 

receiving children who have multiple problems. Their lives are 

shattered long before they encounter a local DSS office, across the 

country, not just in Baltimore. Times have changed. Times are 

more difficult. So, clearly being able to utilize funding to create 

more preventive services to help children before they enter the 

stream. 

We are looking at a local DSS where we basically have a safety 

net out trying to catch as many as we can, but they have been 

abused or neglected long before they encounter our agency. So, any 

assistance from the Federal Government that would allow the 

State, which means local DSS, to create sort of these out-of-the-box 

type of collaboratives with the health department and others, and 

education and housing and all these other things that are important to the children before they come in contact with DSS, would 

be most appreciative, sir. 

Dr. BEILENSON. I will just be blunt. I think that by far the 

most important thing you are doing is holding these oversight hearVerDate Aug 04 2004 05:17 Aug 19, 2005 Jkt 099679 PO 00000 Frm 00039 Fmt 6633 Sfmt 6602 E:\HR\OC\99679.XXX 99679
36 

ings, because, with all due respect to the Secretary, who is a very 

decent, caring guy, who really does care about these issues, what 

has happened in the past when a bad case occurs, at least in Baltimore, is press, all these guys from Baltimore, cover it for 2 or 3 

days; DSS hunkers down, waits for the wave to crash over their 

heads, public outcry to die down, and nothing ever really changes. 

We made these recommendations to the Secretary and the head 

of DSS back in January. As Congressman Cardin knows, being the 

former Speaker of the House of Delegates, it was done to get there 

before the legislative session in case legislation had to change. I 

don’t think Federal legislation is necessary, with one exception: 

confidentiality. I can’t ever get from our own people whether it is 

State law or Federal law that affects releasing information, but I 

really believe in transparent government. This is part of transparent government. Too many times people fall back on, we can’t 

release the details of this case. Even fatal cases. I don’t understand 

the confidentiality of fatal cases actually. I have never understood 

that. We cannot discuss them. 

There is no way you are going to solve problems or change the 

system unless confidentiality, and I am all for confidentiality. I 

don’t want my medical records divulged, but that is not what we 

are really talking about here. This is to protect kids, and you keep 

falling back on confidentiality. So, if there is any one issue that the 

Federal Government, and I don’t know specifically where the confidentiality issue lays, Federal or State. That might be something 

you can be involved in. This oversight is making a difference because these recommendations are getting a lot of coverage now. 

Dr. DEPANFILIS. I would like to offer a possible alternate, but 

somewhat complementary, view, and that has to do with the way 

that our Federal and State systems are designed to respond after 

the fact. So, the guidance that the CAPTA sets up, which sets the 

standards for child abuse and neglect reporting laws at the State 

level, has a very narrow definition of child abuse and neglect. It is 

only when those omissions or acts create harm for children, or a 

serious risk of imminent harm for children, are our current systems able to respond. That, in combination with the funding issues, 

where much more support is provided after the fact, when there is 

a need to remove children, which comes out of Title IV–E funding, 

we end up with this pattern of spending all our resources to serve 

the same families at the high end, at the deep end, this revolving 

door. 

So, I think we really need to look in this country at a total new 

system and quit taking the easy road, with these small solutions, 

and really look much more deeply. Maybe the whole thinking was 

faulty to begin with, to think you could take a legalistic response 

to such a complex problem. We know that prevention works in 

many other fields of practice, if you look at medicine and others. 

We need to look at prevention with respect to child abuse and neglect. 

Mr. MCDERMOTT. It seems to me, Mr. Chairman, and I realize 

my time is up, but I think we spend $700 million on prevention 

and about $7 billion on treating the results of the problem. That 

seems like that is somewhat of an imbalance, and maybe it is 

something we really ought to look at in terms of what we do with 

37 

our money. I think it is a suggestion that this Subcommittee could 

have an impact on. 

Chairman HERGER. The time has expired, and I have been very 

generous with the time, because certainly this issue is critically important to the young people, to the children of this Nation. I again 

mention that the purpose for this hearing is to bring to light the 

challenges, the problems that we have out there. This Subcommittee is looking at coming forward with legislation. We have 

just had recently the Pew Foundation study that has come out. I 

am working with Ranking Member Cardin, along with Mrs. Johnson, Mr. Camp and others, to come up with legislation where, hopefully, we will be going out of our way to address these problems 

that we are seeing coming forth that are, again, not just unique to 

Baltimore or Maryland, but we see tragically all too often taking 

place in our other 49 States as well. Mr. McCabe, if I could ask 

you, who, if anyone, is responsible for determining whether a new 

mother, especially a teenaged mother, is fit to take a child home 

from the hospital? 

Mr. MCCABE. Ultimately, the way our process works. Oh, excuse me, in terms of who makes that determination whether a 

child should be released after birth in a hospital? 

Chairman HERGER. Yes, and do the hospitals release newborns, 

for example, to mothers who live on the streets; to mothers who 

live in homeless shelters? Maybe Director Blair, or anyone else. 

Mr. MCCABE. This is where Dr. Beilenson is saying everybody 

has to work together to determine what makes a rightful plan. Ultimately, judges in Maryland, in our juvenile system, have a role 

where we make recommendations to them on the disposition of 

children. So, if there were someone clearly at risk and there was 

history of it, I think that we do have a role to advise and recommend what the proper disposition is. As this case illustrates, in 

real time, two children were born in a hospital setting and calls 

were made. My view is that the right additional questions were not 

asked and that all parties had some role in failure here. 

Chairman HERGER. Anyone else have a comment? 

Dr. DEPANFILIS. Basically, I think what you are talking about 

is, a child is born, there is an assessment of the capacity of that 

parent to provide adequately for that child when the child leaves 

the hospital with the parent. If that person, that team in the hospital, has reason to believe that the child will be maltreated, according to the definition in State law, they may make a report of 

child abuse and neglect. In this case, it would be a risk of child 

abuse and neglect. 

So, it depends how convincing of an argument that person making the call can make to suggest that the conditions that they are 

aware of would create a significant risk of serious imminent harm 

when that child leaves the hospital. So, if the parent has been noncommunicative about the information, about their plan, if there is 

a history of substance abuse, if there is enough, if there is a good 

enough assessment done at the hospital, then you should be able 

to make a convincing case, such as in this case. It doesn’t sound 

like that happened. So, it doesn’t sound like the call was actually 

made to report the suspicion of child abuse and neglect, and that 

is why it fell, in this case, through the cracks. 

38 

Mr. CARDIN. Would you yield, just so I can clarify that? If the 

assessment is made that there is a risk here, the call is made to 

the DSS; the child, the baby, would normally be released within a 

very short period of time, 2 days. So, you are saying that the DSS 

would be contacted by the hospital, and then DSS would then come 

out and make an on-the-spot investigation? That would be the normal process that would be used? 

Mr. BLAIR. Yes, sir. As a Director, I have done that with my 

workers. I have gone to CPS and taken a call, and we followed 

through on an investigation, myself as Director, just to see what 

the process is myself, so you make decisions. You are making it in 

real time, and that is exactly what happens. 

Mr. CARDIN. So, it is your agency’s judgment, and you said 

there were 100 cases that you act on, on abuse, a month in Baltimore City? 

Mr. BLAIR. Correct. 

Mr. CARDIN. How many of these are made in this type of circumstance at the hospital? 

Mr. BLAIR. That number I can’t say. I can only say that, over 

the year of 2003, we had over 13,000 phone calls of people making 

allegations of abuse in 2003. I don’t know how many came exactly 

from the hospital, but I can get that information to you, sir. 

Mr. CARDIN. Thank you. 

Chairman HERGER. Thank you. The gentleman from California, 

Mr. Stark, to inquire. 

Mr. STARK. Thank you, Mr. Chairman. I am just trying to see 

if I can focus here, Mr. Blair, on how the system works in Baltimore City. You have a ratio of 17.5, I see here, of caseloads per 

worker. Now, is that just for this chart I am looking at, is child 

protective foster care, adoptions and whatever SFC is? Is that the 

17.5, or is this caseload for all families who would come to the attention of your department? 

Mr. BLAIR. I believe that is our foster care ratio. 

Mr. STARK. That is just foster care. 

Mr. BLAIR. I believe that is what that is. 

Mr. STARK. You have a Family Preservation Program? 

Mr. BLAIR. Yes, sir, we do. 

Mr. STARK. Give me an idea, if I were to suggest to you that 

if all Temporary Assistance for Needy Families (TANF) beneficiaries that had children, what would be, what would you guess 

the caseload to social workers would be? If you lumped all of these, 

all of your clients together, what are you operating on in your department in terms of caseload? Make a guess. 

Mr. MCCABE. We have approximately a little over 70,000 temporary cash-assistance customers in Baltimore City, excuse me, 

Statewide, and of that, a number of them single only, the child is 

a temporary cash assistance client. I don’t have that, those numbers. 

Mr. STARK. Hundreds? 

Mr. MCCABE. I am not sure if I understand the question. 

Mr. STARK. Well, how many? All of these people have to be supervised somewhere or another, minimally, if they are not in any 

immediate danger, but they have to be assigned to a professional, 

I would presume, a caseworker. I am trying to get your caseload 

39 

here, as you say, for foster care and other services is about 17.5 

cases to the social worker. I am trying to get, if you take all of your 

TANF clients and others in your DSS program, what is the overall 

caseload? 

Mr. BLAIR. The persons on TANF are receiving temporary assistance, temporary aid. So, most of them, more than likely some 

of them have active foster care cases. So, what happens? 

Mr. STARK. They do not come under Family Preservation? 

Mr. MCCABE. No. What they do, we have within our system in 

Baltimore City, as across the State, we have separate eligibility 

workers who work with those clients. They are different and distinct from the people who provide these social services to child welfare. 

Mr. STARK. Is there, do they interface a lot? 

Mr. MCCABE. They should interface a lot better. We have information. 

Mr. STARK. The idea of Family Preservation is that there is 

housing and food and poverty and transportation and child abuse, 

and foster care gets to be a very small number, but my suspicion 

is that not, it happens in Alameda County, California, is that you 

are closer to individuals supervising a hundred cases. That means 

you get to look at somebody in their surroundings to see whether 

there is a house or whether there is assistance and parenting needed once every 3 months as opposed to more often. I am just trying 

to get, in terms of the resources that we might offer, I am just trying to see how pressed you are for additional resources. 

Mr. BLAIR. As a local DSS director, we always welcome any type 

of resources. 

Mr. STARK. What do you pay a starting caseworker in the child 

protective? What does a child protective caseworker get as a starting salary? After they graduate from Dr. DePanfili’s program, what 

do you pay them? 

Dr. DEPANFILIS. First of all, I need to say that most workers 

in Maryland are not social workers. They have other training. 

Mr. STARK. Good training? 

Dr. DEPANFILIS. They have other education. 

Mr. STARK. Is there a training standard? 

Dr. DEPANFILIS. I really don’t know. I know that there is a 

training certification that occurs for all. If they have graduated 

with their masters in social work, they start at around $33,000. 

Mr. STARK. If they teach in the public school and teach in third 

grade, what do they start with? 

Mr. MCCABE. I would suspect higher than that in Baltimore 

City, without a masters degree. 

Mr. STARK. I guess what I am concerned about is that, this is 

a concern that I have across the country, that we have awfully 

minimal standards for people who are charged with observing families who probably don’t rise to the level of incipient abuse, but if 

they are not trained, they are not going to spot it. They are trained 

to add up the numbers and say, ‘‘You don’t qualify for food stamps 

any more.’’ It is not that that isn’t a job that needs to be done, but 

if we cannot somehow raise the professional level of your undergraduates and if Mr. Blair can’t demand a bachelors degree or 

some intern training of a couple of months rather than a 10-hour 

40 

indoctrination course, I think we just miss a lot of cases. That, I 

am just concerned that we are not doing that. I don’t know how, 

I know you are limited in the resources you have. I think that is 

something, Mr. Chairman, that we could do more as we do these 

programs and not only just by the money we provide, for instance, 

in TANF for the training, but we are impacting these communities 

who have to put into operation the plans that we create. I don’t 

know how we get more generous, but I think we have to be. Thank 

you. 

Chairman HERGER. I thank the gentleman from California. Dr. 

DePanfilis, could you identify for us some of the factors known to 

increase the risk of child neglect? Are child welfare systems in the 

United States currently designed to identify those factors and respond with assistance? 

Dr. DEPANFILIS. Yes. First of all, let me say that each case, 

each family situation is different. The things that have been shown 

in research to increase the likelihood that the basic needs of children are not met, which is one broad definition of neglect, substance abuse, domestic violence, mental health problems of the parents, I would say would be the primary ones. Then you have social 

isolation, having no one to turn to, lots of stress, high relationship 

between poverty and meeting the basic needs of your children, but 

it doesn’t mean, most poor people don’t support their families. In 

spite of that, they can still adequately care for their children. So, 

poverty alone usually does not result in neglect. Poverty puts you 

in neighborhoods where you have poor housing, where you have 

poor educational opportunities, lots of high rates of crime and other 

violence, which then makes the neighborhoods unsafe. 

So, I would say those are the core factors that relate to neglect 

specifically, and neglect is the primary reason that most families 

are referred to the child welfare system, and those in my own research on the recurrence of child abuse and neglect. Neglect circumstances are the most likely to come back over and over and 

over again because we failed to respond effectively the first time we 

become aware of a family who is under stress and is having challenges to meet the basic needs of their children. 

Chairman HERGER. Are there any Federal policies that you feel 

that we might come up with that might more actively encourage 

States to target these families with these factors to prevent abuse 

from happening? 

Dr. DEPANFILIS. Well, I think the whole emphasis, both within 

the CAPTA and also the way we allocate our resources under Title 

IV–E all put an emphasis on after the fact. I think, especially in 

cases around neglect, this isn’t like a one-time thing usually. It is 

not like an event occurs today and that is it. It is this chronology 

of omissions in care that sort of mount up and, in the life of a child, 

mean a great deal to their opportunities or lack of opportunities to 

succeed in any part of their life. So, I think we really need to go 

backward, I think, and look at, where are we going to put the minimal resources we have? I think we should change that ratio. 

Chairman HERGER. Well, I would like to thank you. I would 

like to thank each member of our panel. 

Mr. CARDIN. Could I make one quick comment? Appreciate that. 

Just one quick comment. First, I want to first point out, I think the 

41 

suggestion that you are now talking more among yourselves is very 

helpful. If these hearings help facilitate that then that, in and of 

itself, is important. I am glad to see that you are all trying to get 

as much expertise as possible to deal with this issue. I just would 

be bold enough to make just two suggestions that I think have 

come out of this hearing. One, it seems to me that, I understand 

Baltimore City has approximately 500 confirmed cases of abuse or 

neglect a month, of which, 100 results in the child actually being 

taken out of the family, from the information that I got from Secretary McCabe. 

That is a tough assignment. I understand that. I would just suggest that, number one, in the hospital itself we could be doing a 

better job with children who are born there. I think, I know Dr. 

Beilenson has made some recommendations here, but it seems to 

me that we should be able to assist the hospital in carrying out its 

very tough responsibility, to get DSS involved before a child is allowed to come home. It seems to me we should have better guidelines to help the hospital get the information from DSS or report 

the information to DSS in order to make the appropriate evaluation. 

The second point I would suggest is that, when we have a child 

in foster care who is a very tough assignment, such as Ms. Swann, 

we should have some type of way of putting a high priority to provide services to that individual. Again, it may not be appropriate 

within foster care. We might have to go beyond foster care. We 

should be able to put a high priority on that type of a case. We 

should be able to identify that. Once again, Mr. Chairman, I want 

to thank you very much for permitting this hearing so that we 

could try to understand what happened in Baltimore and use that 

not only to help people in our jurisdiction but to use it as a way 

to try to get national involvement to try to help our children. 

Mr. MCDERMOTT. Can I ask another question of them? 

Chairman HERGER. Very briefly. 

Mr. MCDERMOTT. My question is this: if neglect of children is 

the major reason that you pick kids up, to what extent are, or are 

you yet seeing any impact? Or do you anticipate impact from the 

lessening of the availability of Section 8 vouchers and, therefore, 

the loss of housing, so that people start living in their cars and that 

kind of thing? 

Dr. DEPANFILIS. I think, in Baltimore in particular, I think we 

are all sort of nodding our head. The housing, both the quality of 

housing and the quality of housing at an affordable price, high content of lead in the poor housing, high density of people within four 

walls, all of those things are major issues and have a big impact 

on how adequately parents can care for their children. 

Mr. MCDERMOTT. Thank you. 

Chairman HERGER. Again, I want to thank each of our panel 

members for appearing before us on this very difficult issue to discuss this tragic case. I look forward to continuing to work with all 

of you to ensure that States are doing all that is necessary to protect children from abuse and neglect. With that, the hearing stands 

adjourned. 

[Whereupon, at 5:15 p.m., the hearing was adjourned.] 

[Submissions for the record follow:] 

42 

Statement of Theresa S. Cook, Santa Clara, California 

I am a Mother who has lost a son to the Department of Children and Family 

Services not only because of a ‘‘system that is broken’’ but because ‘‘the system is 

corrupt’’. There are NO changes possible for Children in the System until you remove the problems from which they are rooted. The root to all and mainly to this 

evil is the people who currently run the programs. The Best Interest has somehow 

gotten lost and greed has taken over. These people are given bonuses for every 

adoption, tax deductions, awards, not to mention what is paid under the table and 

much more. One who denies any of this to be truth is not only lying to themselves 

but disgustingly; they also lie to the children. I know first hand because my son was 

lied to and I was lied about. The record is set up against me and it’s all-fraudulent. 

Time and time again, I continue to present my case to committees just like this one 

and time and time again I am ignored. I have the evidence to prove the lies yet; 

no one wants to take the time to see them. I am just one voice in a crowd of many 

who keep screaming out for help and are not being heard. Change is on the horizon, 

we have heard this for many years now and nothing has changed. Only the order 

of the words seems different. Before you make change, you must fix the problem. 

Get the criminals out of their positions, appoint ‘‘watchdog’’ citizen panels to review 

the cases, RETURN the children and as you witness the reunions, the looks of the 

parents who will never get their child home because of death, the scars so many 

have suffered from and the sigh of relief at a mother who holds her child after 

thinking she would never ever see him again, take those moments into consideration when deciding what changes you have to make. The answers are there as they 

have been all along. Any one of you who can’t look at the number of children being 

removed, the number of children not being returned should have some concern why 

those numbers are so high. KEEPING FAMILIES TOGETHER IS SUPPOSED TO 

BE THE GOAL HERE. Why then are so many children not going home? How many 

more children will it take to slip through the cracks before you realize the truth? 

This is Tragedy that could be so easily prevented if that were the true intensions 

at stake. 

Comments on Testimony 

Having had experience with the System and becoming an Advocate for other parents who are suffering as I am without my child, I would like to comment on the 

testimonies taken on June 17, 2004. 

A. To The Honorable Wally Herger; 

1. You stated that the purpose of this hearing was to understand what happened 

in the Baltimore case so it could prevent it from happening again. 

Your Honor, when will it be a reality to all of you that sitting down to talk about 

it will not solve the problem? You ‘‘explored’’ the case of the starving children in 

NJ; you have reviewed federal and state oversight measures, and even heard about 

each and every state FAILING the Federal Reviews. This is not the first year they 

have failed; this is one of many years it failed. And every year new changes are 

going to be made and every year, more children are taken and every year more children die and every year, this committee sits down to talk about it. The tragedy of 

a family being torn apart for ever, the death of a child who’s left in a strangers 

home to die alone, the bruises and the scars other children have and are suffering 

from tonight and the silent cries of children for their mothers and the mothers for 

their children whisper in the wind each night as the world lays down to sleep. Children are being physically dragged from their families, beaten, molested, killed all 

the while they are lied to and drugged and moved from place to place. They lose 

their identities, their rights and the very core of who they really are. 

Stopping the tragedies takes more then sitting down, it takes action and it takes 

immediate action in order to attempt to prevent the next from happening. True, no 

policy is perfect but it’s the people who have the power to implement them that are 

to blame here. They take the polices and manipulate them to their own benefit and 

that’s where change must occur. 

B. Floyd Blair; 

2. Ask any family who has been involved with the system if the Department addressed the families’ difficult issues in any other way but to use them against them 

in court? Limited resources are not the issue. The resources exist and many of them 

good ones. The problem is with the Social Worker who is under pressure of a Director who looking to make brownie points with members of the Board of Supervisors 

or someone else in position. Most social workers don’t care what the families issues 

43 

are, they are just out to get the child put somewhere and the last place they consider is to return them home. You will see in my own personal story how well the 

Social Worker helped my family. Social Workers do give 150% and that’s in making 

sure the child never returns home. 

Heart wrenching is when a parent busts their rear end to get their child back and 

a social worker recommends termination of rights because of lies. Heart wrenching 

is having a 6-year-old boy tell his mom that he will promise to come home when 

he gets big and to not move so he can find her. Heart wrenching is when the birthdays, Xmas, Mother’s Day, Father’s Day etc. roll on by each year and there’s an 

empty void because someone very special is missing. 

The statistics will show, if taken honestly and they aren’t, that most of the children who die in the homes of their parents are children who have been abused for 

years or most of their lives. They are ‘‘damaged’’ in the eyes of the Department and 

would be harder to place if they were to be removed. So, they are left behind. During a termination of rights hearing, features, ‘‘adorable-adoptable’’, always describe 

the child. Children are described at the Reunification trials as to having severe 

mental health issues that will only be aggravated more if returned home but shortly 

after while in the.26 hearing, this mental health issue will diminish and the child 

is deemed adoptable. 

We have proof in the county where I live in that paperwork is changed and altered by Officials. They even get to keep tier job when the paperwork is exposed. 

Money embezzled from someone amounts to jail time for a ‘‘citizen’’ yet, if a county 

or state employs you, you are not even held accountable. That is what happens in 

Santa Clara County and I’m sure it happens elsewhere too. 

C. To Peter Beilenson; 

3. Your recommendations are logical and unfortunately have ‘‘suppose ably’’ already been implemented but still they hold too many gaps. What about foster parents who adopt or take in several children, like the NJ case? What about the unlicensed social worker? Many of them are. What about the social workers having to 

produce evidence to prove their statements not just allow hearsay to be admitted. 

What about a Judge who gives the perpetrator of domestic violence custody even 

though classes was never completed? What about the social workers accountability 

for NOT following the mandates as they are written. 

You spoke about the three major causes of childhood deaths; SIDS (adults cosleeping with infants mentioned), Juvenile shootings and a) CPS having removed a 

child and returned it only to be killed by the parents b) one child removed and another killed later. Be realistic with your studies. California has the largest amount 

of children taken into custody by CPS. Experts here say that out of the 75,000 children taken up to 50% could have been left home. DCFS comes into contact with 

nearly 180,000 children each year. That’s five-fold and its doubled in the nation. 

More then 660 children have died since 1991 and more then 160 were homicide victims. Go onto the website ‘‘Forgotten Children’’ you’ll see the horror these children 

are suffering in the hands of CPS. There are many, too many other websites filled 

with these inexcusable and preventive deaths. 

There have been numerous lawsuits settled that involve CPS. Hundreds of parents are stepping forward and begging for help from our Government to get their 

children back because of the injustices CPS is inflicting upon us all. Yet, you refuse 

to hear the truths and continue to point fingers at the parents. That is just the easy 

way out of a very bad situation in which it appears that each and everyone of you 

A) Just don’t care B) profit from it in one way or another or C) are just too naive 

to understand about it. 

It is frustrating to try and understand why you would state that you are disappointed in the vague responses to your recommendations to the State’s Secretary 

for Human Resources and the Director of Baltimore’s DCFS. Doesn’t that non-willingness of participation ring a bell for you? What will it take to get you to see why 

you are not getting prompt responses? And what do you intend on doing about the 

lack of concern on their part? 

Before making any future recommendations, I would suggest looking at the reality 

of what is happening here and while you face it deal with it accordingly. For instance, December 2, 3003, President Bush signed the so-called ‘‘Adoption Promotion 

Act’’. This signature expanded an existing adoption bounty program. The bounty encourages states to tear children from their families-especially easy-to-adopt infants. 

Even if the adoptive parents decide to give children back, states keep their bounties 

and toss them into slipshod placements which are even more likely to fail. Fewer 

foster parents are willing to adopt then promised yet, termination of rights has increased. Between 1997–2001, 92,000 parental rights were terminated. A generation 

of ‘‘legal orphans’’. In 2002, 3000,000 were taken from their parents with termiVerDate Aug 04 2004 05:17 Aug 19, 2005 Jkt 099679 PO 00000 Frm 00047 Fmt 6633 Sfmt 6621 E:\HR\OC\99679.XXX 99679
44 

nation of rights taken. I know, my child was one of those children. Children are 

trapped in foster care each and everyday and the end results are needless. 

D. To The Honorable Christopher J. McCabe, 

The only comment needed here is that it is very strange how your explanation 

of the Departments situation and plans just so happens to be the same as every 

other Social Services Department in the country’s explanation. I am beginning to 

believe that is something one would learn in a Social Services 101 Class. 

E. To Diane DePanfilis, 

‘‘Family Connection’’ is also a program that was implemented here in Santa Clara 

County. Problem is the program hasn’t benefited any parent or child that I know 

of. The County Officials have once again formed another committee to ‘‘aid families’’ 

and no results have taken place. I can say that it is more likely then not that the 

Federal Funding was received and probably spent elsewhere as Federal money is 

easily obtainable resulting in very little progression for the safety of the children. 

Has anyone thought to recommend that any Federal money given should be only 

spent on those that produce positive results? Positive results meaning families stay 

together and family issues resolved. Positive results meaning fewer children removed and fewer children abused and killed. Positive results are having a truly 

abused child’s life saved. One who’s importance would normally slip through the 

cracks because the focus is on taking a child whose parent is willing to make 

changes and whose willing to do whatever it takes to get their child home to them. 

We already have the ‘‘Working together across systems’’ going on here in Santa 

Clara County. It consists of a team of *A Superior Court Judge and/or Commissioner, *CountyCounsel, *A Social Worker, *A District Attorney, * Juvenile Dependency Attorney, *A therapist and *a psychologist. As a team, they all work together 

to promote the negative issues of the family over a limited period of time thus resulting in the termination of parental rights for adoption of the child. 

These ‘‘known professionals’’ need only the ‘‘evidence of hearsay’’ to establish their 

case against the parents. The parents are greatly involved in each and every case 

as this team demands completion of the case plan. Parents are told after complete 

ion that it wasn’t good enough or that they didn’t learn enough or that time had 

run out. Might I add that a greater number of these ‘‘so-called professionals’’ are 

not even licensed. The ones that are were only required to take training courses 

which ran 4 to 6 hours each. 

IN RE: JOHN C. 

March 13, 2000, my son John, three years old at the time was taken into custody 

after a 911 call. I had argued with my two older boys about a relapse I had. Having 

been in treatment and diagnosis with Bi-Polar Disorder, I was suddenly caught in 

the middle of a nasty divorce, insurance cut off and no medication. The only thing 

I knew was to self-medicate. I was not happy with that decision and to prove to 

the kids I didn’t want to continue using, I dialed 911. Thinking I would end up at 

the county hospital, I soon realized I was headed to jail and John to the Shelter. 

Previously, four other children had been removed and I had never been offered any 

kind of treatment plan. Two other children went to live with their Dad but the 

Courts recommended I do drug treatment at my own expense and I had no income 

at the time. My two children were taken by their Dad out of state where he has 

held them away from me for over 11 years now. 

I was told by the first Social Worker that if I completed my case plan, my son 

would be returned home. I was put into intensive programming dealing with ‘‘dual 

Diagnosis’’ and I successfully completed each and every class I went to. I obtained 

employment and worked with other addicts, built a strong support group and continue to maintain my sobriety and contacts with my sponsor who is my best friend. 

I complied with everything. I struggled with dealing with my ex-husband and his 

family who did everything to keep me from regaining custody. There were phone 

calls made to the social worker several times, which were made out of complete vindictiveness. The social worker (SW # 4) admitted to never investigating these allegations. She merely wrote reports to the Judge and submitted the allegations as facts. 

She lied and manipulated my son away from me over a period of 21⁄2 years. I was 

accused of telling my son to lie—accused of having ‘‘diluted’’ tests’’, burning my son 

with a cigarette intentionally amongst other things. A social worker from the DA’s 

office put the icing on the cake with the cigarette burn. One burn which he had no 

doctors report on, no visits were stopped and my son was not removed at the time 

he says he saw the burn. Amazingly, on the witness stand this ‘‘so-called expert’’ 

admitted to seeing a burn and then he stated he never saw it. Out of five Judges 

45 

who sat on my case, one described me as being a MBPS Mom. Despite numerous 

letters from my doctor, the Court and the social worker made their own diagnosis 

and said that the people that were with me on a daily basis (who never witnessed 

any of the allegations I have described) were incredible. My rights were terminated 

on September 20, 2002. It had been 6 months that I had seen my son as they had 

terminated my visitation in May 2002. 

My son and I were very closely bonded. He was the sparkle of my eye and I was 

a very good mother to him. I never let him down until the Department stepped into 

our lives. Once involved, they made sure I failed my son in every way and told him 

I was the cause of the failure. He would beg for me to let him stay at my house. 

He cried when I had to take him back to his Aunt’s house and told me I didn’t’ love 

him. This result after a perfect weekend we had spent doing things together and 

with other family members. The system literally tore my son and I apart with their 

lies. I have proof to each and every lie they told and I have shown several entities, 

including this committee the documents, yet I am unheard and my son is to this 

day, somewhere out there. I have no idea if he is even alive. If he is being abused, 

if he is happy, sad, has a home, a bed . . . I have no idea and the unknowing is 

pure torture. 

Your system and the people who run it should be abolished. You people have got 

to do the right thing and bring our children home. I don’t mean to round table discuss this matter but to put it into action immediately. ‘‘Let our children go.’’ Where 

have you heard those words before? Each and every day, each and every hour, each 

and every minute that goes by with no immediate action taken on your part is a 

crime and a lack of concern to humanity on your part. Too many children are being 

taken, why can’t you understand that there is a serious violation being committed 

against the families of America and even other nations if that were to be sized properly. What is happening is not just a matter of a case or two. It’s a matter of millions of cases and it’s a greater chance that if this keeps going many, many more 

children will go unprotected as the billion-dollar industry of stealing and selling 

children is kept alive. 

There are many parents like myself who realized their mistakes and sought help. 

This has to amount for something other then the loss of our children. In today’s society, drug addicts are frowned upon and treated as if they can never make changes. 

Investigations are done and the results are ‘‘Looking into the family history and the 

social workers notes’’. We obliviously all know that cycles of family history can be 

broken and that the programs work for those who want to work them. If it is true 

that drug addicts can not change then why are so many federal tax dollars being 

‘‘wasted’’ on the programs? The truth is that the programs are working and the results are showing. So, the question now shifts to the Juvenile Dependency system. 

Unlicensed social workers are being allowed to opionate to a judge without even following state mandates. There is no room to err on the part of a parent but the social 

workers are not obligated to accountability on anything they do. The sickest part 

of the whole situation is that they know it and they will take advantage of it. 

The social worker in my case told me exactly what the Judge was going to rule 

on 6 months before the trial and she had already informed my son that he was 

never going to see his mom again. Another social worker told my son that he was 

going to be getting ‘‘proper parents’’. This is a child who was never abused, who was 

close to both parents even though my ex and I did not get along, we both were bonded to our son. This child was the focus and center of attention at all times and no 

matter what, his needs always came first. Yet, the social worker told me I was an 

‘‘unfit mother.’’ When I got upset over that remark, she informed the Judge that 

I was ‘‘maniaced and spinning out of control’’. 

When the opinion of the Sixth District Court Appeals came out, I was appalled. 

The facts of the case were incorrect. They didn’t even mention testimony and documented proof that those facts were proven wrong during the termination of rights 

trial, instead they focused on a previous trial. Termination of Reunification was a 

complete sham. Represented by a ‘‘public defender’’, my rights were certainly not 

protected in the course of the trial. They brought in statements that were not true 

and my attorney did nothing to protect my interest. She even told me after the trial 

that there was no reason to appeal because I had nothing to appeal about. I found 

out months later that the entire contents of the trial was appeal able and had I appealed I probably would have had my son returned to me today. The Justices sure 

made comment to the fact that I did not appeal the trial, but never mentioned as 

to why that occurred. 

I want my son back and I want him back now. I have patiently waited for two 

years now for people like this committee to take action and do what needs to be 

done. In LA County, they are returning children as they have admitted the wrong 

of the department. Here in my county, the Board of Supervisors continues to shuffle 

46 

the blame. Over the past two years or so, the County has been exposed in the following: 

1. Juvenile Hall Officials were busted for physically abusing the kids in custody. 

‘‘Counselors’’, better known as Police Officers were using excessive force on 

these kids resulting in bruises and broken bones. In CYA, they had cages they 

put the kids into. This abuse has been reported for years and has been ignored 

until recently. Many cases of abuse could have bee prevented had the voices 

been heard. To date, nothing has been mentioned about the reprimand of the 

officers. Child abuse is a crime and a felony at that. I wonder why it’s not 

being imposed in these cases? 

2. The Children’s Shelter investigation results were horrifying. Especially since 

my son spent a considerable amount of time there during the reporting period. 

He was 3 and 5, having been placed back into the system by my ex-sister in 

law after my visits were terminated. She didn’t raise her own son due to mental illness and had no intensions of raising mine. Her goal was to show me that 

she had the power as she put it, to stop me from getting my son back. She 

proved it all right at my son’s expense. She and the ex brother in law are now 

divorced and she has moved out of the state. The investigation of the shelter 

produced many abuses. Children were restrained and locked into a closet like 

room until they calmed down. We have discovered that the children are rugged. 

Thorizione and Adavent are given to little children to keep them calm and 

zombie like. Drugs and prostitution were exposed. Molestations. The Feds told 

the County that no child under the age of 6 is to be left at the shelter overnight. Only for the amount of processing time. It was discovered that this was 

not honored and that several children remained there for several days under 

the age of five. One six-year-old girl was molested by a thirteen yr old boy. 

This was exposed with the next that occurred in this county. 

3. Following the Shelter report, a Civil Grand Jury began investigating our complaints against the Department of Social Services. They spoke to the Ombudsman’s office. What they discovered soon made local news as the Director of that 

office was making 200, 0000.00 from the county for services and she spent the 

majority of her time in Costa Rica. She fired the two whistleblowers that exposed more of the evidence and documents against the Department’s Director 

and the Children’s Shelter. The Director-altered documents which detailed the 

molestation of the little girl. Altered documents were also submitted to the 

Board and there were other documents submitted altered. Thus, the final reports were not true. Turns out the Chairman of the Children and Family Service Committee knew about the Ombudsman’s Office and so did the Director. 

A going quay party was thrown for her when she first left. Those that attended 

were people in position in the County. End results of that scene were that the 

County fired the Director of the Ombudsman’s Office and denied knowing anything more about it. The Director who altered documents still continues in her 

position and the Board members are acting as if it never happened and that 

what happened was innocent and done for good cause and our DA is turning 

his head the other way. The local NAACP Office who opened the can of worms 

by allowing the parents to hold an open forum with County Welfare Officials 

present has announced that no civil rights were violated, (The Civil Grand 

Jury is supposed to file a report stating that there has been violations) and 

he has reneged on each and every promise made to the parents who spoke at 

that forum. Inside scoop is that the Chairman of the Committee has told the 

NAACP to ‘‘get the parents off his back’’. 

Having spoken to an FBI agent in our County about the corruption, she stated 

that they knew that there was a lot of money here being passed but that they didn’t 

know how it was ‘‘going from hand to pocket’’. She asked me if I knew anything 

and although I have been privy to some things, I told her no. That was because she 

told me that even if I had all the facts about the money, it would not change the 

status of my case as what they are doing is ‘‘legalized kidnapping’’. I would have 

to prove fraud. 

In Black Law’s Dictionary, F–R-A–U-D is defined over several pages starting with 

this; ‘‘An intentional perversion of truth for the purpose of inducing another in reliance upon to part with something valuable thing belonging to him or to surrender 

legal right. A false representation of a matter of fact, whether by words or by conduct by false or misleading allegations, or by concealment of that which should have 

been disclosed, which deceives and is intended to deceive another so that he shall 

act upon it to his legal injury/ Anything calculated to deceive, whether by a single 

act or combination, or by suppression of truth. Or suggestion of what is false, 

47 

whether it be by direct falsehood, by innuendo, by speech or silence, word of mouth, 

or look or gesture.’’ 

Fraud is what has happened in my case and in several millions of cases all across 

the USA. California is the worst. I do believe that this problem can be fixed if it’s 

truly the intent of your discussions. If you are truly concerned about the safety of 

these children then you MUST take immediate action. Return my son and other 

children who have the right to be where they belong. Stop the overflow of the foster 

care and you will then have enough fostering places for those children who clearly 

do need the help like the twins that brought you all together. 

For too many years, the system has been on the ‘‘hot seat’’ and vowing to make 

changes for the ‘‘Best Interest’’ of the children. The results prove that the System 

is failing our children. Time has come to look into other solutions. Such as doing 

the right ways by returning children, removing those who are being paid to do nothing but make more excuses every time another child dies, let the people work for 

the system and the system for them. You can figure the rest out. After all, that’s 

your job. 

My space is limited and trying to submit my evidence in 10 pages is impossible. 

I truly believe that the System knows that you people will not look into lengthy exhibits and that’s why they drag the situation out. Think about it. We are dealing 

with a highly intelligent group of people who like living in the high life and will 

do it at the expense of a child. The proof is there. The question is ‘‘How many more 

children is your Committee willing to let die before you decide to take action?’’ Tell 

the children yourself, how many of them will NOT be with their parents. Face the 

end result of the child who has been raised by the system and yet cannot get a grip 

on life and how to deal with it. There are too many wrongs here and no rights. 

Make the way clear. 

I am available for further information if you need it. Thanks for your time and 

patience. Have a good day. 

f 

Statement of Fight Crime: Invest in Kids 

Mr. Chairman and Members of the Subcommittee: 

Thank you for the opportunity to submit this written testimony. My name is Sanford Newman, and I am the President of Fight Crime: Invest in Kids, an anti-crime 

group of more than 2,000 police chiefs, sheriffs, prosecutors and victims of violence 

from across the country who have come together to take a hard-nosed look at what 

the research says works to keep kids from becoming criminals. In considering how 

to reduce child abuse and neglect tragedies, such as that of Sierra Swann’s children, 

the Subcommittee faces a formidable and very important task. I hope my testimony 

will help this Subcommittee make choices that will prevent child abuse and neglect, 

and reduce crime now and in the future. 

The members of Fight Crime: Invest in Kids, on the front lines of fighting crime, 

know that that there is no substitute for tough law enforcement. However, once a 

child has become a victim of child abuse and neglect, a jail term for the offender 

cannot replace the innocence or the life that is lost. 

On May 11, 2004, Emonney and Emunnea Broadway became yet another national 

tragedy. Both girls, only a month old, were found dead—victims of child abuse and 

neglect. The situation that led to Emonney and Emunnea’s deaths is unfortunately 

not a rare occurrence in our nation. In 2002, the latest year for which data is available, the Department of Health and Human Services reported that 896,000 children 

were victims of abuse and neglect, and 1,400 children died. Of these 1,400 children, 

41% died before reaching their first birthday. And over half of the children who die 

from abuse or neglect were previously unknown to child protective services. 

Child abuse and neglect is itself often a crime, and it also produces a cycle of violence whereby victims of child abuse and neglect grow up to become perpetrators 

of violence. Sierra Swann, a foster child, was a victim of child abuse and/or neglect 

herself. While most victimized children will not commit violent crimes later in life, 

being abused or neglected sharply increases the risk that children will emerge as 

violent criminals in their adulthood. When that happens, many thousands of additional innocent people become victims. The best available research indicates that 

each year 35,000 additional violent criminals and more than 250 murderers will 

emerge as adults who would never have become violent criminals if not for the 

abuse and neglect they suffered as children. But this fact need not become a reality 

if we invest in programs—such as in-home parent coaching—that are proven to reduce child abuse and neglect. 

48 

Research has shown that providing in-home parent coaching to at-risk moms like 

Sierra Swann can dramatically reduce child abuse and neglect. For example, rigorous research published in the Journal of the American Medical Association, shows 

that children of mothers left out of the Nurse Family Partnership program (NFP)— 

an in-home parent coaching program through which trained nurses visit single, 

poor, first-time young mothers during and after pregnancy—had five times as many 

substantiated reports of child abuse and neglect as the mothers who participated. 

A fifteen year follow up study of NFP participants showed that mothers in the 

program had only one-third as many arrests, and their children had half as many 

arrests compared to those who received no services. 


Insert offset folio 99679a.001
49 

In another study, the Healthy Start program in Hawaii (which is the basis for 

the nationwide Healthy Families in-home parent coaching program) succeeded in reducing severe abuse and neglect through in-home parent coaching. In at-risk families that received parent-coaching, only 2 in 1,000 children were hospitalized for 

child abuse and neglect compared to 13 in 1,000 children from similar at-risk families not receiving parent coaching. In other words, failing to provide high-risk families with in-home parent coaching makes the children six times more likely to be 

hospitalized for abuse and neglect. 

Currently, only 12,000 eligible mothers are being served by NFP. The Healthy 

Families program serves only 50,000 families. Other in-home coaching programs 

combined still leave at least 500,000 at-risk mothers in need of in-home parent 

coaching. Providing in-home parent coaching to all at-risk mothers, like Sierra 

Swann, means tragedies—such as the death of Emonney and Emunnea Broadway— 

are far less likely to happen. 

The Sierra Swann case highlights a nationwide problem that, if not properly addressed, can lead to more crime and even death. However, the tragedy does not end 

there. Child abuse and neglect costs America upwards of $80 billion a year. Twothirds of that is in crime costs alone. A study by RAND concluded that the Nurse 

Family Partnership program saved taxpayers four dollars for every dollar spent on 

the program and paid for itself by the time the kids were three years old. In an 

era of soaring budget deficits, we can no longer afford NOT to make the needed inVerDate Aug 04 2004 05:17 Aug 19, 2005 Jkt 099679 PO 00000 Frm 00053 Fmt 6633 Sfmt 6621 E:\HR\OC\99679.XXX 99679

Insert offset folio 99679a.002
50 

vestment to support a nationwide in-home parent coaching effort that would serve 

nearly a million at-risk mothers across the country. 

One word of caution: the President, in his Fiscal Year 2005 budget, suggested 

changing the Title IV–E foster care entitlement into a state option capped grant, 

in order to free up more funds for prevention services, such as in-home parent 

coaching. While well-intentioned, we are concerned that implementation of such a 

proposal would likely be counter-productive, and endanger children, because: (1) 

there are no guarantees that under the state option grant ‘‘flexible funding’’ plan 

proposed by the Administration, states will actually use the money on child abuse 

prevention services (and, historically, only small percentages of mixed-use funding 

pools tend to go to prevention—the vast majority tends to go to addressing the needs 

of children already in the system, also currently underfunded); and (2) there is inadequate protection for children who have been abused or neglected and need foster 

care—especially if there is a sudden upsurge in cases, as there was during the 

crack/cocaine epidemic in the late ‘80s and early ‘90s. 

In his Fiscal Year 2005 budget, the President also proposed increasing the Promoting Safe and Stable Families Program and the Child Abuse Prevention and 

Treatment Act—the two primary federal investments specifically addressing child 

abuse and neglect prevention. Congressional passage of the President’s proposed increases would be an excellent first step. However, even the President’s proposed increases would leave hundreds of thousands of America’s most vulnerable children 

without the services they need. 

Law enforcement leaders know that one of the best ways to reduce future crime 

is to invest in programs that prevent child abuse and neglect. Furthermore, studies 

have shown that in-home parent coaching is effective at preventing child abuse and 

neglect. It is time for Congress to get tough on crime by providing the resources 

needed to support in-home parent coaching for all at-risk mothers. 

f 

Justice for Children 

Washington, DC 20005 

July 1, 2004 

Chairman Wally Herger 

Subcommittee on Human Resources 

Committee on Ways and Means 

1102 LHOB 

Washington, DC 20515 

Dear Representative Herger and Members of the Subcommittee: 

We commend your initiative in calling this hearing on behalf of Maryland’s children, spurred by the tragic death of two children in Baltimore City. 

Justice For Children, a national child advocacy organization, is composed of concerned citizens who share the belief that our community must act together to protect abused and neglected children from further abuse and to defend every child’s 

right to grow up in a safe and loving environment. Justice For Children works together with Children’s Protective Services and other such agencies for the welfare 

of these children, and, when appropriate, intervenes on behalf of children in court 

or agency actions that have the potential to compound the harmful effects of the 

abuse they have already suffered. 

Since our founding in Houston, Texas in May 1987, Justice For Children’s accomplishments have been nationally recognized. Our achievements have been featured 

on ABC’s Prime Time Live, on the ABC Prime-Time documentary ‘‘Crimes Against 

Children,’’ a PBS documentary entitled ‘‘Boy Crying, Baby Crying,’’ and on Good 

Morning America, Donahue, and HBO. In our effort to expand our commitment to 

serve as an advocate for all abused children, Justice For Children now has chapters 

in Arizona and the District of Columbia. 

Our mission is to raise the consciousness of our society about the failure of our 

governmental agencies to protect victims of child abuse, to provide legal advocacy 

for abused children and to develop and implement, on a collaborative basis where 

possible, a full range of solutions that enhance the quality of life for these children. 

We accomplish this mission through intensive case advocacy, providing pro bono 

counsel for children or the protecting parent, court watch, filing friend of the court 

briefs in selected appellate cases, a community resource hotline, referrals and community presentations. Our public policy recommendations are based on hands-on expertise with abused children whose cases that have fallen through the cracks. 

51 

Since the founding of our Washington, D.C. Chapter in 2000, many cases of ‘‘system failure’’ involving abused children in Maryland have been referred to our office 

for advocacy. 

One of the first cases that came to our attention was that of little Collin Horridge. 

In 2000, when he was nearly one-and-a-half years old, Collin’s mother brought him 

and his older sister from Texas to live in St. Mary’s County, Maryland. She shared 

a house with a male friend with children of his own. 

Collin’s father, Eric Horridge, worried about Erica and especially Collin: their 

mother had been abusive to him in the past. When Mr. Horridge remembers that 

when called to speak with the children, he sometimes heard her hitting Collin on 

his head—once using the phone receiver. Another time he recalls hearing a crash 

and then the baby’s screams after Collin’s high chair was tipped over. 

Mr. Horridge has phone records documenting his futile attempts to get St. Mary’s 

Co. Department of Social Services (‘‘DSS’’) to intervene and protect Collin. After 

many calls, DSS sent a caseworker out to the house as a ‘‘courtesy’’ to what they 

obviously thought was a ‘‘disgruntled’’ ex-boyfriend. 

The caseworker gave Collin a cursory check and noted bruising around his eye 

and on his forehead. She reported that this 19-month-old baby stated: ‘‘I fell on my 

toy.’’ She never bothered to lift his shirt or remove clothing to look at his tummy, 

buttocks, back or legs. Shortly thereafter, Mr. Horridge was informed by DSS that 

they had closed Collin’s case and that he should just stop calling them. 

Two weeks later, Mr. Horridge received a telephone call: his son was dead. Collin 

had massive internal injuries as well as over forty-four old or new wounds and 

bruises on his small body, according to the medical examiner’s report. His nose was 

broken and hanging over to the side of his face. A large footprint on his abdomen 

resulted when the mother’s friend stepped on him with his full weight of 185 lbs. 

for five seconds—an attempt to ‘‘resuscitate’’ the baby as he testified at trial (he was 

tried and acquitted twice). 

St. Mary’s County released Collin’s body to his mother even though she was at 

that time charged with contributing to his death. She immediately cremated his 

body—effectively doing away with state’s evidence—and to this day she has possession of his ashes. To this date, no one has been held accountable for Collin’s brutal 

death. 

Jervis Finney, Chief Counsel for Maryland Governor Robert Erlich, confirmed in 

writing that Collin’s death has never been investigated by Maryland Fatality Review Board or by any other state agency. 

At hand of our extensive experience with cases of system failure in Maryland as 

well as in many other states, we have come to recognize the patterns and weaknesses that allow children to fall through the cracks. 

I am attaching a document created by the Arizona Chapter of Justice For Children called ‘‘Eleven Components of an Effective Child Protection System.’’ I hope 

you find them of interest as you continue to hold hearings on the failings of the 

child welfare system in America. 

Once again, we thank you for your understanding of the urgent need for systemic 

changes to protect Maryland’s children and all children in America! 

Respectfully submitted, 

Eileen King 

f 

Regional Director 

Statement of Matthew E. Melmed, Zero to Three: National Center for 

Infants, Toddlers and Families 

Mr. Chairman and Members of the Subcommittee: 

I am pleased to submit the following testimony on the safety of very young children in foster care on behalf of ZERO TO THREE. My name is Matthew Melmed. 

For the last 9 years I have been the Executive Director of ZERO TO THREE. ZERO 

TO THREE is a national non-profit organization that has worked to advance the 

healthy development of America’s babies and toddlers for over twenty-five years. I 

would like to start by thanking the Subcommittee for all of their work to ensure 

that our nation’s infants are safe. I commend you and the Committee for holding 

hearings on the safety of maltreated children in this country. 

The tragic Baltimore case on which your hearing focuses today raises concerns not 

only about the problems of adolescents growing up in the child welfare system, but 

also about the particular vulnerability of very young children and the 

intergenerational nature of abuse and neglect. I know that you have received very 

52 

1Shonkoff, J., & Phillips, D. (Eds.). (2000). From neurons to neighborhoods: The science of 

early childhood development. Washington, DC: National Academy Press. 2 Bruner, C., Goldberg, J. and Kot, V. (1999). The ABC’s of early childhood: Trends, information and evidence for use in developing an early childhood system of care and education. A joint 

publication of Iowa Kids Count and the Iowa Forum for Children and Families. 3Dicker, S., Gordon, E., Knitzer, J. (2001) Improving the odds for the healthy development of 

young children in foster care. New York: National Center for Children in Poverty. 4 Ibid. 

5Wulczyn, F., Hislop, K., & Harden, B (2002). The placement of infants in foster care. Infant 

Mental Health Journal, 23(5), 454–475; Oser, C. & Cohen, J. (2002). America’s babies: The 

ZERO TO THREE Policy Center data book. Washington, DC: ZERO OT THREE Press. 6Wulczyn, F. & Hislop,K. (2002). Babies in foster care: The numbers call for attention. ZERO 

TO THREE Journal, (22) 4, 14–15. 7 Ibid. 

8Shonkoff, J., & Phillips, D. (Eds.). (2000). From neurons to neighborhoods: The science of 

early childhood development. Washington, DC: National Academy Press. 9 National Research Council. (1993). Understanding child abuse and neglect. p. 223. 10Widom, C., & Maxfield, M. (2001). An update on the ‘‘Cycle of Violence’’, Research in Brief, 

Washington, DC: U.S. Department of Justice, Office of Justice Programs, National Institute of 

Justice. 

able testimony on the subject of older children in the system. I would like to address 

the effects of abuse and neglect on infants and toddlers and offer recommendations 

for your consideration as you look at systemic changes to the way in which states 

address child welfare. I also would like to describe a promising approach, Court 

Teams for Change, that helps improve the well-being of maltreated infants and toddlers and their families and seeks to break the intergenerational transmission of 

abuse and neglect. 

We know from the science of early childhood development that infancy and 

toddlerhood are times of intense intellectual engagement.1 A child’s first years set 

the stage for all that follows. During this time—a remarkable 36 months—the brain 

undergoes its most dramatic development, and children acquire the ability to think, 

speak, learn, and reason. In fact, by age three, roughly 85 percent of the brain’s core 

structure is formed.2 Future development in key domains—social, emotional, and 

cognitive—is based on the experiences and relationships formed during these critical 

years. 

Portrait of Very Young Children in Foster Care 

Infants are the fastest growing category of children entering foster care in the 

United States.3 They comprise the largest cohort of young children in care—accounting for 1 in 5 admissions.4 Twenty-one percent of all children in foster care were 

admitted prior to their first birthday and 45 percent of all infant placements occurred within 30 days of the child’s birth.5

Once they have been removed from their homes and placed in foster care, infants 

and toddlers are more likely than older children to be abused and neglected and to 

stay in foster care longer.6 Half of all babies who enter foster care before they are 

three months old spend 31 months or longer in placementi and they are less likely 

to be reunified with their parents. Thirty-six percent of infants who enter care between birth and three months of age are reunified with their parents compared to 

56 percent of infants who enter care at 10–12 months of age.7

Developmental Impact of Child Abuse and Neglect on Very Young Children 

The developmental impact of child abuse and neglect is greatest among the very 

young. Infants and toddlers are extremely vulnerable to the effects of maltreatment. 

Its impact on their emotional, developmental and physical health can have life-long 

implications if not properly addressed. Research shows that young children who 

have experienced physical abuse have lower social competence, show less empathy, 

have difficulty recognizing others’ emotions, are more likely to be insecurely attached to their parents, and have deficits in IQ scores, language ability, and school 

performance.8 Without intervention, by the time these children reach school age, 

they will also likely be at risk for social problems and learning deficits. 

Compounding the problem, one third of the individuals who were abused and neglected as children can be expected to abuse their own children.9

According to one longitudinal study, being abused or neglected as a child increased the likelihood of arrest as a juvenile by 59 percent, as an adult by 28 percent, and for a violent crime by 30 percent.10 Abused and neglected children are also 

more likely to have mental health concerns (suicide attempts and posttraumatic 

stress disorder); educational problems (extremely low IQ scores and reading ability); 

occupational difficulties (high rates of unemployment and employment in low-level 

53 

11 Ibid. 

service jobs); and public health and safety issues (prostitution in males and females 

and alcohol problems in females).11 However, research confirms that the early years 

present an unparalleled window of opportunity to effectively intervene with at-risk 

children. And intervening in the early years can lead to significant cost savings over 

time through reductions in child abuse and neglect, criminal behavior, welfare dependence, and substance abuse. It is critical that child well-being be the first priority in all child welfare cases. 

Promoting the Health and Well-Being of Infants and Toddlers: 

Infant-Toddler Court Teams 

I am going to briefly describe one approach that offers promise by building on the 

existing collaborative approach of the National Council of Juvenile and Family 

Court Judges Model Courts and the expertise of ZERO TO THREE: National Center 

for Infants, Toddlers and Families in translating the science of early childhood into 

resources for parents, professionals and policymakers. Multidisciplinary Court 

Teams, with a specific focus on the needs of infants and toddlers, could be a vehicle 

for implementing ZERO TO THREE’s policy recommendations, described below. By 

partnering legal expertise with the science of early childhood development, these 

Court Teams could work to raise awareness, increase knowledge and skills, and 

change practice and policy regarding the needs of infants, toddlers, and their families involved in the judicial system. 

This model envisions Court Teams co-led by a judge and in infant mental health/ 

child development expert in partnership with key community stakeholders who 

serve the very youngest children, including community leaders, Court Appointed 

Special Advocate, and guardians ad litem. By bringing together the knowledge and 

skills from the judicial system with the training and expertise of the child development field, this collaborative, coordinated model has the potential to promote child 

well-being by improving systems, services and funding. 

This Infant-Toddler Court Team model is based on the pioneering work of Judge 

Cindy Lederman and Dr. Joy Osofsky who have partnered to develop a 

groundbreaking effort to address the well-being of infants and toddlers involved in 

the Miami-Dade Juvenile Court. In this court, all infants, toddlers and mothers receive screening and assessment services. All babies are screened for developmental 

delays and referred for services. A parent-infant therapeutic intervention is available to a select number of mothers. An Early Head Start Program connected to the 

court is the nation’s first designed specifically to meet the needs of maltreated children. 

One factor that makes the Court Teams approach relevant to the Baltimore case 

is the intergenerational nature of many abuse and neglect cases. Judge Lederman 

was motivated to develop this approach after observing children who had come into 

her court as victims of abuse and return later as abusive parents. They were unable 

to be good parents because they had never been adequately parented themselves. 

A major goal of the Court Teams project is to break this cycle of abuse by giving 

these young mothers the skills they need to understand and respond to their infants 

and toddlers in a positive way. 

Research is confirming the effectiveness of the approach used in the Miami-Dade 

Juvenile Court. Three years of data in the Miami-Dade Juvenile Court show substantial gains in improving parental sensitivity, child and parent interaction, and 

behavioral and emotional parental and child responsiveness. The children showed 

significant improvements in enthusiasm, persistence, positive affect and a reduction 

of depression, anger, withdrawal and irritability. There have been no further acts 

of abuse or neglect, and 100 percent of infants were reunified with their families. 

One promising intergenerational success story that emerged from the Miami-Dade 

Juvenile Court is that of Katrina. Katrina was removed from her home for the first 

time at the age of 10 for chronic emotional neglect. She remained in care for a year 

and then returned home. Almost two years later, Katrina was removed again. She 

was found to be dirty and begging for good and her home was identified by police 

as a frequent site of drug related activities. Katrina went to live with an aunt while 

her younger siblings were placed in foster care. Katrina became a child mother. She 

was living in foster care with her own baby; however, at the age of 14 months, her 

baby was removed from her care. She did not understand why her baby couldn’t live 

with her and was unable to care for him. Because she was still under the jurisdiction of the court as a dependent child, the court would see her on a regular basis. 

The court seemed to think she had the capacity and desire to accept services and 

work with the court in order to have her baby return to her care. Six months after 

54 

12 Clyman, R., Harden, J., & Little, C. (2002). ‘‘Assessment, intervention and research with 

infants in out-of-home placement.’’ Infant Mental Health Journal, 23(5), 435–453. 13 National Research Council. (1993). Understanding child abuse and neglect. p. 223. 14Shonkoff, J., & Phillips, D. (Eds.). (2000). From neurons to neighborhoods: The science of 

early childhood development. Washington, DC: National Academy Press. 

her baby was removed, she was served with a petition for termination of parental 

rights. The court begged her to go back to school and to agree to live in a foster 

home, she agreed. She enrolled in school and in parenting classes and continued to 

have visitation with her baby. In addition, she was receiving individual counseling. 

Katrina and her son Charles (now 2 years, 11 months) appeared for an evaluation. Charles was found to be within the extremely low range of functioning. During 

the play session, there was minimal play interaction between Katrina and her son. 

Katrina appeared unable to allow Charles to explore and initiate himself. Charles’ 

day care teacher expressed frustration with Charles’ aggressive behavior. She stated 

that he is active and hits and bites other children. Charles was referred to an early 

intervention program operated by the school for a full evaluation for adequate preschool placement and services. He was also referred to the Miami Juvenile Court 

Early Head Start Program. In addition, Charles and Katrina began dyadic therapy 

initiated by the court through its IMHPP program. Katrina continues to come to 

court and is lauded for her accomplishments. She is actively involved in school, 

maintains a B average and wants to become a chef. Reunification with Charles appears to be imminent. 

ZERO TO THREE’s Policy Recommendations 

1. Prevent multiple placements for infants and toddlers in foster care. 

In the first year of life, babies need to have the opportunity to develop a close, 

trusting relationship or attachment with one special person. The ability to attach 

to a significant caretaker is one of the most important emotional milestones a baby 

needs to achieve in order to become a child who is trusting, confident, and able to 

regulate their own stress and distress. Babies form strong attachments and rely on 

their parents for security and comfort. For babies in foster care, forming this secure 

attachment is difficult. When a baby is removed from home, or never has the chance 

to ‘‘bond’’ with a parent (e.g. when a baby is placed in foster care immediately after 

birth), the baby is not able to form an attachment or an emotional connection to 

a parent/caretaker. Multiple foster care placements present a host of traumas for 

very young children. When a baby faces a change in placement, fragile new relationships with foster parents are severed reinforcing feelings of abandonment and distrust. Babies grieve when their relationships are disrupted and this sadness adversely effects their development. Children who have experienced abuse or neglect 

have an even greater need for sensitive, caring and stable relationships. In order 

to prevent placement disruption, foster parents need sufficient support and training. 

They may need assistance in how to read the infants’ emotional cues as they are 

often unclear, to understand the importance of attachment and how to develop an 

emotional connection to the child, to understand how the infants’ prior experience, 

particularly maltreatment and placement experiences, have affected them, and to 

adapt their own parenting styles to meet the unique needs of these vulnerable 

young children.12 All placement decisions should focus on promoting security and 

continuity for infants and toddlers in out-of-home care. 

2. Use evidence based models to prevent child abuse and neglect. 

Abuse and neglect during the first years can have serious consequences on later 

developmental outcomes. Research shows that young children who have experienced 

physical abuse have lower social competence, show less empathy for others, have 

difficulty recognizing others’ emotions, are more likely to be insecurely attached to 

their parents, and have elevated rates of aggression, apparent even in toddlers. 

They have been found to have deficits in IQ scores, language ability, and school performance. In addition, young children who are victims of physical abuse may experience psychosomatic disorders, anxiety, fears, sleep disruption, excessive crying, and 

school problems. By the time these children reach school age, they will be at risk 

for social problems and learning deficits. Compounding the problem, one-third of the 

individuals who were abused and neglected as children, without intervention, can 

be expected to abuse their own children.13 Research on model programs reveals that 

well-designed services with explicitly defined goals can be effective in changing parenting practices and influencing parent-child interactions.14 It is clear, therefore, 

that prevention is a critical strategy for protecting at-risk babies and their families. 

55 

15 Halfon, N.; Mendonca, A.; & Berkowitz, G. (1995) ‘‘Health status of children in foster care: 

The experience of the Center for the Vulnerable Child.’’ Archives of Pediatric and Adolescent 

Medicine, 149(4), 386–391. 16Dicker, S., Gordon, E., & Knitzer, J. (2001). Improving the odds for the healthy development 

of young children in foster care. New York: National Center for Children in Poverty. Oser, C. 

and Cohen, J. (2003). Improving early intervention: Using what we know about infants and toddlers with disabilities to reauthorize Part C of IDEA. Washington, DC: ZERO TO THREE Policy 

Center. 17 Halfon, N.; Mendonca, A.; & Berkowitz, G. (1995) ‘‘Health status of children in foster care: 

The experience of the Center for the Vulnerable Child.’’ Archives of Pediatric and Adolescent 

Medicine, 149(4), 386–391. 18Dicker, S., Gordon, E., Knitzer, J. (2001) Improving the odds for the healthy development 

of young children in foster care. New York: National Center for Children in Poverty. 19Dicker, S. & Gordon, E. (2000). Connecting healthy development and permanency: A pivotal 

role for child welfare professionals. Permanency Planning Today, 1(1) 12–15. 20Shonkoff, J., & Phillips, D. (Eds.). (2000). From neurons to neighborhoods: The science of 

early childhood development. Washington, DC: National Academy Press. 

3. Assure comprehensive, developmentally Appropriate Health Care for infants and toddlers in foster care. 

Nearly 40 percent of young children in foster care are born low birthweight, premature, or both, two factors that increase their likelihood of medical problems and 

developmental delay.15 They are more likely to have fragile health and disabilities 

and far less likely to receive services that address their needs.16 More than half of 

these children suffer from serious health problems, including elevated lead bloodlevels, and chronic diseases such as asthma.17 Sadly, a significant percentage of 

children in foster care do not receive even basic health care, such as immunizations, 

dental services, hearing and vision screening, and testing for exposure to lead and 

communicable diseases. 

4. Ensure access of infants and toddlers referred to child protective services to the Early Intervention Program (‘‘Part C’’) of the federal Individuals with Disabilities Education Act (IDEA). 

Infants and toddlers in foster care are more likely to have fragile health and disabilities and are far less likely to receive services that address their needs.18 They 

may show signs of delays in language acquisition, cognition and behavior. In fact, 

infants and toddlers in foster care have rates of developmental delay approximately 

4 to 5 times that found among children in the general population.19 Therefore, there 

must be a strong connection between the child welfare/child protection systems and 

Part C to ensure early access to services will provide significant benefits to children. 

The National Research Council/Institute of Medicine recommends that infants and 

toddlers who are referred to a protective services agency for evaluation of suspected 

abuse or neglect be automatically referred for a developmental-behavioral screening 

under Part C.20

A provision of The ‘‘Keeping Children and Families Safe Act of 2003’’ that amended the Child Abuse Prevention and Treatment Act (CAPTA) (PL 108–36) requires 

that each state develop ‘‘provisions and procedures for referral of a child under the 

age of 3 who is involved in a substantiated case of child abuse or neglect to early 

intervention services funded under Part C of the Individuals with Disabilities Education Act (IDEA) (section 106(b)(2)(A)(xxi)).’’ Although this new requirement is a 

step in the right direction, states will face new challenges in trying to ensure that 

the Part C system is able to respond to these new referrals. Impacts will vary substantially from state to state because of significant differences among states’ Part 

C systems. In some states, very large increases in workload for providers of Part 

C evaluation, assessment and intervention services are likely as a result of this legislation. In all states, a need to enhance the capacity of the Part C system to respond to social-emotional and behavioral problems (early childhood mental health) 

is likely. And in most or all states, the cost of responding to this federal mandate 

will be a problem, given very tight state budgets, unless the federal government significantly increases funding for Part C. 

5. Assure early childhood mental health assessment and access to early 

childhood mental health services for babies and toddlers in foster care. 

Early childhood mental health is the capacity of the child from birth to age 5 to 

experience, regulate and express emotions; form close and secure interpersonal relationships; and explore the environment and learn. Early childhood mental health is 

synonymous with healthy social and emotional development. Because maltreatment 

and repeated and often traumatic separation from caregivers may place infants and 

56 

21Lederman, C., Osofsky, J., & Katz, L. (2001). When the bough breaks the cradle will fall: 

Promoting the health and well being of infants and toddlers in juvenile court. Juvenile and 

Family Court Journal, (52)4, 33–37. 22Lederman, C., Osofsky, J., & Katz, L. (2001). When the bough breaks the cradle will fall: 

Promoting the health and well being of infants and toddlers in juvenile court. Juvenile and 

Family Court Journal, (52)4, 33–37. 23Dicker, S., Gordon, E., & Knitzer, J. (2001). Improving the odds for the healthy development 

of young children in foster care. New York: National Center for Children in Poverty. 

toddlers in foster care at risk for mental health disorders, mental health supports 

for babies in foster care, their birth families, and their foster care families is critical. 

Untreated mental health disorders in early childhood can have disastrous effects on 

children’s functioning and future outcomes. 

There is an enormous disconnect between what we know about very young children and their mental health, and what we do for very young children in the child 

welfare system. Over the past 20 years, much has been learned about the mental 

health of young children in foster care and how to provide early childhood mental 

health services. However, this knowledge has not reached the child welfare system. 

Early childhood mental health expertise, providers, and services for infants and toddlers in the child welfare system as well as in other systems (Part C early intervention, child care, Early Head Start) is non-existent and the need is severe! In addition to improving mental health aspects of the child welfare system, training for 

mental health and other early childhood providers is needed. It is critical that early 

childhood providers understand not only the unique needs of infants and toddlers, 

but also, the unique needs of very young children who have been victims of abuse/ 

neglect and who have been separated from their families. These early childhood 

mental health services should be integrated and delivered via early learning experiences at home, in center-based programs, or both. Federal and State policy must 

support early identification, screening and evaluation of emotional development, improving the service array for diagnosis, treatment and prevention of early mental 

health problems, and increasing mental health supports for parents and foster parents in the existing child welfare system and other systems that serve these children. 

6. Ensure that infants and toddlers in foster care have access to quality 

early care and learning experiences. 

Infancy and toddlerhood are times of intense growth and development in all areas, 

including rapid changes in motor development, cognition, and emotions.21 All babies 

and toddlers need positive early learning experiences to foster their intellectual, social and emotional development and to lay the foundation for later school success. 

Infants and toddlers who have been abused or neglected, and are at increased risk 

for adverse outcomes as a result, need additional supports to promote their healthy 

growth and development. Quality early learning experiences can provide very young 

children in foster care the opportunity to form secure attachments with teachers 

and/or child care providers who can provide consistent, positive environments. Early 

childhood training programs that promote small groups, continuity, and individualized care, such as the Program for Infant Toddler Caregivers (PITC), can help young 

children who have been abused and neglected develop these essential early relationships. These early relationships are associated with adaptive social development.22

High-quality early care and education programs can also support foster, kinship, 

and biological parents by directing them to other support systems, providing information, and connecting them with other parents that they may turn to for advice 

and support.23 Comprehensive early childhood programs, such as Early Head Start, 

that combine home visitation, comprehensive services and technical assistance, can 

provide the specialized services that very young children in the child welfare system 

need. In addition, therapeutic child care programs that address issues faced by 

abused and neglected children, such as attachment disorders and depression, can 

ensure that these young children are receiving specialized treatment and attention. 

7. Ensure developmentally appropriate visitation practices for infants and 

toddlers in foster care. 

One of the major challenges faced by young children in foster care is maintaining 

attachment relationships with their parents. In order for young children in foster 

care to maintain attachment relationships with their biological parents, parental 

visitation schedules are developed by the social worker in conjunction with the court 

and the biological parents. Foster parents are expected to cooperate with the child’s 

visitation plan to help with transportation to and from the visits. Current visitation 

practices usually consist of brief encounters that occur anywhere from once a month 

57 

24 National Conference of State Legislatures. (2002). Post-Adoption Services: Issues for Legislators. Retrieved February 26 from http://www.ncsl.org/programs/cyf/PASI.htm. 25 Casey Family Services. (2001). Strengthening Families and Communities: An Approach to 

Post-Adoption Services. Casey Family Services. 26 Ibid. 

to once or twice a week. For very young children, infrequent visits are not enough 

to establish and maintain a healthy parent-child relationship. Infants and toddlers 

build strong attachments to their biological parents through frequent and extended 

contact. One month in the life of a baby is an eternity. Visits should occur frequently, in a safe setting that is comfortable for both parent and child, and should 

last long enough for a positive relationship to develop and strengthen. For very 

young children, visits with parents can be upsetting and disruptive to their development. 

8. Assure ongoing adoption services and supports for adoptive families. 

Adoptive parents often face significant challenges in the day-to-day parenting of 

very young children. Foster children who have been adopted tend to have challenging behaviors and emotional issues as well as medical conditions that may impact their development—often due to a history of maltreatment and extended stays 

in foster care. Adoptive families facing this kind of stress are at increased risk of 

adoption failure—referred to as disruption before an adoption is legalized and as 

dissolution after an adoption has been finalized.24 Services and supports for the 

family prior to, during, and after the adoption can help to stabilize and preserve 

adoptive placements and can help in recruiting adoptive parents.25 The assurance 

of the availability of services and supports after adoption has been found to play 

a critical role in many potential adoptive parents’ decisions to move forward with 

the adoption of a child in foster care.26 These supports may also reduce the likelihood of adoption disruption and are cost-effective as they help prevent the child 

from reentering foster care. 

Conclusion 

We must ensure that infants in the child welfare system are healthy and safe. 

During the first years of life, children rapidly develop foundational capabilities—cognitive, social and emotional—on which subsequent development builds. The amazing 

growth that takes place in the first three years of life creates vulnerability and 

promise for all children. These years are even more important for maltreated infants 

and toddlers. We know from the science of early childhood development what infants and toddlers need for healthy social, emotional and cognitive development. We 

also know that infants and toddlers in the child welfare system are at great risk 

for poor outcomes. We must continue to seek support for services and programs that 

ensure that our nation’s youngest and most vulnerable children are safe and that 

promote and improve their emotional, social, cognitive and physical health and development. 

It is simply unacceptable that we wait until the safety of very young children is 

put at-risk before proper investments are made to address their needs. We cannot 

wait for an infant in the child welfare system to die before we provide states with 

adequate funds to ensure the safety, permanence and well-being of children in or 

at risk of needing foster care. Policies and funding must be directed to preventing 

harm to maltreated young children. I urge the Subcommittee to make the investment to ensure that the current ill-equipped child welfare system receives adequate 

funding to better protect our nation’s most vulnerable children. 

Thank you for your time and for your commitment to our nation’s at-risk infants 

and toddlers. 

Æ