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The Washington Times, January 23, 2008—The recent tragic deaths of four sisters in the District of Columbia raise once again the question of why the United States, despite local outrage and national and state efforts, has not reduced child deaths from abuse and neglect. In 2005, some 1,460 children died from one or the other nationwide, virtually unchanged from 2001.
One answer could be that it is impossible to prevent the death of children at the hands of their parents. Another could be that social workers continue to make mistakes at about the same level every year, despite the best efforts of public officials responding to each tragedy in turn.
But evidence from other fields, such as the sharp reduction in deaths from plane crashes or medical errors in some hospitals, suggests a third—and more compelling—possibility: Perhaps the typical and understandable response to these tragedies, blaming and firing individual workers, is the wrong one.
To see how this last response to tragedy could backfire, consider an analogous problem in health care. In 2000, a blue-ribbon Institute of Medicine (IOM) panel analyzed the evidence on how to reduce the annual death toll from medical errors—estimated then at 44,000. In IOM's view, clamping down on individual human errors, whether through punishment or retraining, "is not an effective way to prevent recurrence." That's because reprimanding the nurse who misdials a machine leaves the underlying problem—say, a badly designed device—untouched. In contrast, collecting information on many examples of errors and near-misses helps identify and resolve the root cause of death.
A similar example is found in the airline industry. Airline tragedies often provoke public outrage and scrutiny. But to improve safety, transportation experts study not only crashes but also equipment malfunctions and near-misses.
How might this work in child welfare? First, analysts would gather comprehensive information on deaths, injuries and near-misses. This data would be viewed with a wide lens so that patterns beyond an individual social worker's actions might emerge. The patterns would prompt educated hypotheses about what is missing in today's approach to troubled families—perhaps easily available substance abuse and mental-health services for parents.
Recent advances in child-welfare information collection bode well for this approach. In particular, ways to track children's cases have improved mightily. (The District's information system is ranked near the top by the federal government.) Intensive audits of individual cases, including interviews with families, children, social workers and judges, are now used by the federal government and states, including the District, to assess cases and improve service. Data from all such efforts could be tapped to analyze national patterns.
It's time to revisit our assumptions about child welfare, too. Experts on successful health care safety initiatives caution against too-easy answers that actually cause more harm. So, perhaps the conventional responses are wrong. Perhaps the best way to prevent child deaths is not to place all the responsibility on the social workers who investigate abuse and neglect. Even the most skilled workers do not judge right every time—on the spot with limited information—about which parents could kill a child. Thorough and prompt investigations of abuse and neglect allegations can help children, but they may not be the best way to save lives.
Instead, let's stop waiting until the last moment, when parents snap and are reported for abuse or neglect, to offer mothers and fathers help for substance abuse or mental-health problems. Congress should expand federal funding for such currently limited services. When parents with these problems enter any part of the public system (like the homeless shelter where Banita Jacks and her family spent months) they should be steered into treatment.
Reform of child welfare agencies is crucial to children's well-being, and the District—in some ways, among the nation's stronger systems—has made substantial measurable progress in improving the lives of children in its care. But to reduce deaths from child abuse and neglect, we need to let go of the old habits that haven't worked: we need to stop scapegoating and start unearthing and treating the real problems.
Olivia Golden, a senior fellow at the Urban Institute, directed the D.C. Child and Family Services Agency from 2001 to 2004 after its return from court-ordered receivership. Contact her at email@example.com.
The views expressed are those of the authors and should not be attributed to the Urban Institute, its sponsors, staff, or trustees.
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