Ignoring the Danger Signs of Child Abuse

By Douglas J. Besharov

This article originally appeared in Newsday, April 21, 1996.

SIX-YEAR-OLD Elisa Izquierdo might be alive today if her case had not been so tragically mishandled by New York City's Child Welfare Administration (CWA), now known as the Administration for Children's Services. But focusing on the faults of that agency obscures the failure of schools, hospitals and other social service agencies to report clear signs of Elisa's possible abuse.

As documented by the recently released report of the New York City Child Fatality Review Panel, on which I serve, Elisa "was known to the Brooklyn Family Court, the Department of Probation, a legal services agency, at least three CWA-contracted purchase-preventive service programs, a noncontracted social services program, at least two drug-rehabilitation programs, one alcohol-rehabilitation program, a preschool, a public school, a school-based child and family therapy program, at least two psychiatric hospitals, several general hospitals, a private pediatrician, several relatives, an influential private individual and others."

In the 16 months before Elisa's death, there were at least 10 instances when a teacher, a doctor or a social worker saw physical injuries or "bizarre" behaviors indicative of maltreatment that were either not reported to the state child-abuse hotline or rejected when a call was made.

According to the Fatality Panel report and other published accounts, these signs included: "burns on the leg and foot"; "a bruise on the child's nose and marks around her eyes"; "head lice and a small patch of hair loss"; a "fever-like blister"; as well as repeated claims by her mother that her father, his friends, her teachers and various other adults had physically and sexually abused Elisa and "the mother's repeated references to witchcraft and voodoo, and her apparent belief that the child was possessed by the devil." Agency records also indicate that Elisa was known to be urinating and defecating throughout her home, spreading her feces on the refrigerator and drinking from the toilet.

Just as Elisa might have been saved by a more effectual child welfare agency, so might she have survived if the other agencies that saw her during her last two years of life had reported these conditions to the authorities. After all, since the early 1960s, child-serving professionals' failure to report has been punishable by law.

But what happened to Elisa is not unique to New York. A nationwide study conducted about a decade ago for the National Center on Child Abuse and Neglect provides evidence of how often professionals fail to report signs of child abuse and neglect. In 1986, about 56 percent of the apparently abused or neglected children professionals saw went unreported. That is about 500,000 children, including about 2,000 with injuries severe enough to require hospitalization.

What's going on? Although a few professionals may be callously indifferent to the plight of children like Elisa, most are not. One cannot read the records of the agencies involved in her case without observing that dozens of people were genuinely concerned. The reason we know so much about her numerous physical injuries and bizarre behaviors is that these professionals noticed them, recorded them in their files and tried to help the family. The problem is that too many professionals are not adept at spotting signs of serious physical, sexual and emotional abuse. They generally don't know what to report - and how to report it.

Widespread drug addiction among disadvantaged parents, like Elisa's, further complicates professionals' recognition of possible child abuse. Such parents may appear loving and concerned at one moment, only to turn violent and depraved when under the influence of crack and other dangerous drugs. The key to protecting their children is recognizing the circumstantial evidence of past maltreatment.

That didn't happen in Elisa's case. As the Fatality Panel noted, "There were signs of possible physical abuse and ample signs that both the child and her mother were in extreme psychological distress, that the family could no longer manage its problems and that intervention from an outside source was absolutely necessary."

In the past, many efforts to train professionals to do a better job of identifying and reporting child maltreatment have been made. But they have often been superficial (oneor two-hour training sessions are the norm) and short-lived (efforts that start with great fanfare tend to peter out as interest wanes).

Better education about reporting responsibilities would be the single most effective method of encouraging more complete and more accurate reporting. Education programs should sensitize all child-serving professionals to the occurrence of child abuse and neglect - especially within the context of chronic parental drug addiction. The programs should be comprehensive, rigorous and ongoing. (There is, after all, substantial turnover in most of the agencies that serve children.)

Moreover, the training should cover the emotional and behavioral problems that are signs of possible maltreatment - whose significance was either missed or ignored by so many professionals who encountered Elisa. As the panel noted, "In addition to recognizing physical signs of maltreatment, mandated reporters must be trained to recognize children's emotional reactions to abuse and neglect, including behavior that is abnormal, extreme and is not age-appropriate." Put simply, Elisa's behaviors were red flags signaling the need for societal intervention.

Such training will have to be planned with great care. It will not do, for example, to tell people simply to report their "gut feelings." That does not give investigators enough to go on, as we saw in Elisa's case. The more details a report contains about possible abuse, the more likely a child-abuse investigator will be able to confirm the situation.

Vague advice also increases the likelihood of inappropriate reports, a problem that is now depleting scarce agency resources. In 1993, more thanthree-quarters of the reports made to the state child-abuse hotline were closed after an initial investigation determined that they were "unfounded."

At least one of the reports about Elisa was deemed unfounded. An unfounded report does not necessarily mean that the child was not actually abused or neglected. Sometimes, the worker makes a mistake. More often, evidence of child maltreatment is hard to obtain and may not be uncovered when agencies lack the time and resources to complete a thorough investigation or when inaccurate information is given to the investigator.

But the current high rate of unfounded reporting goes far beyond anything reasonably needed by the child welfare agencies. Besides being unfair to parents, it endangers children who are really abused. It imposes an unnecessary burden on an agency already hard-pressed to investigate all the cases reported appropriately, because each report must be carefully investigated - homes must be visited; parents questioned, friends, relatives and neighbors interviewed, agency records checked and so forth. But all this takes time. When workers feel the press of new cases coming in every day, they inevitably cut corners and make mistakes.

How serious a problem is inappropriate reporting? Between 1989 and 1993, as the number of reports received by the city's child welfare agency increased by more than 30 percent (from 40,217 to 52,472), the percentage of substantiated reports fell by about 47 percent (from 45 percent to 24 percent). In fact, the number of substantiated cases - some families were reported more than once - actually fell by about 41 percent, from 14,026 to 8,326. Thus, 12,255 additional families were investigated during that time, although 5,700 fewer families received child-protective help.

As a result, children in real danger - like Elisa - get lost in the day-to-day pressures of large caseloads. For example, as of June, 1995, CWA had 712 investigative workers, but only 190 workers providing court-ordered preventive or home-monitoring services. Reducing inappropriate reporting by only 20 percent would have allowed the agency to almost double the number of caseworkers assigned to court cases.

Like nonreporting, inappropriate reporting is generally neither deliberate nor malicious. Many unfounded reports involve situations in which a well-intentioned person overreacts to a vague and often misleading possibility that the child may be maltreated. Others involve instances of poor child care that, though of legitimate concern, simply do not amount to child abuse or neglect.

The statewide child-abuse hotline could also do more to help. Right now, the hotline staff itself decides whether to reject reports from callers without reviewing the family's history of child abuse and neglect. That is a mistake.

For example, on Oct. 14, 1994, about a year before Elisa's death, the school she was attending called the hotline in Albany to report "conflicting information about an injured hand." The call was rejected, presumably because the school could not connect the injury to the mother's conduct. But this decision was made by a worker who did not have access to Elisa's record and the many previous, confirmed reports of maltreatment over the preceding five years.

If the hotline had known of this prior record, as the panel noted, "it would have been more likely to accept" the school's report. The computers at the Albany hotline should be upgraded so that records of past reports can be used - while the caller is on the line - to help decide whether to accept or reject a report of child abuse.

One hospital was so concerned about burns on Elisa's leg and foot that it asked its child-protection committee whether a report should be made. The committee eventually decided against calling the hotline, but again, if the committee had known of Elisa's maltreatment, it almost certainly would have done so. The panel called for the implementation of a long-standing state law that authorizes the hotline to provide such information to physicians.

The glare of publicity surrounding little Elisa's death may push agency officials to adopt these and other long-overdue reforms. That's a high price for her to pay, but wouldn't it be worse if she died in vain?

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