Report
says state failing at-risk kids
Advocate tells how DYFS, others missed signs
and let a dozen die
Friday, December 10, 2004 • BY SUSAN K. LIVIO AND
JONATHAN SCHUPPE • Star-Ledger Staff
A 17-year-old boy committed suicide after three
different agencies wrongly thought the others had arranged
for his treatment when school let out for the summer.
A boy's doctor failed to let child welfare workers know
about five separate injuries that suggested abuse. The
5-year-old died from a ruptured intestine in March.
A 5-year-old boy was scalded to death after a state
caseworker bogged down by a huge workload failed to
investigate who was watching him while his mother worked the
overnight shift at a factory. The boy's baby-sitter was a
10-year-old.
Child welfare workers and other professionals missed
many opportunities to protect children who died in 2004
after they were deemed at risk of abuse or neglect, a report
released by the Child Advocate's Office yesterday concluded.
The report suggested the state is still failing to safeguard
its most vulnerable children.
"When families cannot or will not care for children, it
is up to the state to protect them," said Child Advocate
Kevin M. Ryan. "In too many of these cases, those efforts
were just not good enough for our kids."
The report points out that investigations by the
Division of Youth and Family Services often fell short
because workers were poorly trained and supervised, and had
too many cases to handle. But it also says children were
ill-protected by other professionals who should have warned
that they were in danger: teachers, doctors, local social
service agencies, and day care providers. It concludes that
children suffer when these professionals and DYFS fail to
talk to each other about potential dangers.
While stressing that "the child welfare system did not
kill any of these children," the report identified "systemic
break-downs" and said political leaders should support an
ongoing $320 million effort to reform DYFS.
The report examined 11 child abuse cases from January to
August, as well as the suicide of a 17-year-old who had
"extensive involvement with the child welfare system."
Ryan's office may release the results of probes into as many
as five more deaths still under review. The advocate
concluded there were problems in how all but one of the 12
cases were handled.
The report sharply criticized DYFS' work in the case of
Jmeir White of Asbury Park, who died from chronic
malnutrition in August, 14 months after he was born with
severe anemia. Jmeir's parents, Wesley White and Tahija
Handberry, were arrested last month for starving him.
In this case, the boy's pediatrician apparently didn't
know about his anemia because it was not included in medical
records from the hospital where he was born, Jersey Shore
Medical Center in Neptune, according to the Child
Advocate.
The pediatrician didn't sound an alarm when he saw the
boy in December 2003 and March 2004 and noted that his
weight had remained a mere 15 pounds. And the DYFS
caseworker who saw the child and noted his small size in
June said he never consulted with the nurse assigned to
assist the southern Monmouth DYFS office because "she was
frequently busy with field work," the report said.
"A caseworker with modest training ... was left to
assess the medical condition of a child at demonstrated
risk," the report said.
Ryan said this was a clear example of how a child can
fall through the cracks of the health care system.
"As you go through some of these cases, you can't help
but walk away and say we have got to build a stronger bridge
between New Jersey's child welfare system and its health
care system," Ryan said. "It's about the police, the
hospitals, schools, day care. It's about teachers. And it's
also about DYFS."
Anthony D'Urso, a psychologist who chairs the state
Child Fatality and Near Fatality Review Board, said the
report's findings mirrored what his annual reviews reveal:
that many deaths under DYFS are the result of poor
communication with medical professionals, such as doctors
and mental health clinicians. He said that still missing
from DYFS is a "culture of consultation" in which
caseworkers and supervisors aren't afraid to seek outside
help.
One dramatic example of a lack of communication between
state and local agencies is the suicide by hanging of a
17-year-old boy July 5.
The report said the boy had discovered his mother's body
after she committed suicide nearly a decade earlier, and was
under DYFS legal custody since 2001 because his father had a
drinking problem. In the months before school let out this
year, the boy's grades were high and he had gotten a job at
a grocery store. But his condition deteriorated over the
summer, when he no longer had daily treatment for behavioral
problems.
Three groups assigned to his care each thought,
incorrectly, that others had arranged his treatment through
the summer, or that he didn't need any: the ACE Program, an
alternative school for youths with learning and behavioral
problems; his DYFS caseworker; and the county-based mental
health consortium known as Case Assessment Resource
Team.
"None of these agencies ever contacted the children's
behavior health system to link (the boy) with supportive
services and care. The fragmentation of this system looms
large in these events," the report said.
DYFS workers were criticized in the case of 5-year-old
Samuel Allen, who was left with a 10-year-old baby-sitter
while his mother worked an overnight shift at a factory.
Police believe the boy was scalded to death when he could
not turn off the hot water in the bathroom. When the family
was previously investigated for an unrelated complaint about
neglectful supervision, the DYFS worker did not
independently verify the reliability of the mother's
baby-sitters.
Ryan stressed that the report was not "a verdict" on a
$320 million effort to reform New Jersey's struggling child
welfare system, saying the state's involvement in these
cases occurred before it began implementing the reforms. The
reforms are monitored by a federal judge, and are expected
to restructure and expand the state child welfare and mental
health systems.
"The report clearly makes the case for reform, and if
anything, it should burnish our political leaders' demand
for reform and continued investment in the reform plan," he
said.
State Human Services Commissioner James Davy said "the
tragedies outlined in this report underscore the need for us
to continue to work tirelessly to reform our child welfare
system..." He said he expects the reforms to solve many of
the systemic problems linked to the deaths, but
acknowledged: "Clearly, we have not yet reached that
day."
Marcia Robinson Lowry, executive director of Children's
Rights Inc., whose lawsuit prompted the reforms, said
stories of the 12 children are "illustrations of what
happens if reform doesn't take place."
"The real tragedy from a public reaction standpoint is
to think there are any quick fixes, because there are not,"
Lowry said. "We will make sure (the plan) is lived up
to."
The report stresses that reducing high caseloads is
"imperative." It suggested expediting the training and
hiring of new supervisors, and the planned creation of a
training academy for child welfare staff. Davy said the
state is in the midst of implementing many of the advocate's
recommendations.
© 2004 The Star-Ledger. Used by NJ.com with
permission.
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