Failures in the system meant to protect
kids are not easy to pinpoint
One-third of the
Colorado children killed by abuse from 1998 to 2000 had
contact with social services, and a tendency to downplay
past family violence was a common thread in some of
those deaths, according to a child protection report.
It would be unfair, however, to blame any one agency
or individual, cautioned Dr. Andrew Sirotnak, director
of the Kempe Child Protection Team at Children's
"You see a dead child, a child abuse fatality, hear
about a history of abuse and neglect, and you want to
assume the system failed. And that may not be the case,
because you don't know the whole story," said Sirotnak,
a member of child death review teams for Denver and the
state. "It's a lot more complicated than that."
A recent case in Brighton illustrates some of the
complexities. Kevin Henn's second-grade teacher never
saw any signs of physical or emotional abuse in the
bright, happy 8-year-old, and his family had no prior
social services contact. But after Kevin was critically
injured in his home, officers noted old injuries and
bruises all over his body.
Kevin remains on life support with a massive head
injury. His stepmother, Gail Henn, 30, has been charged
with child abuse resulting in serious bodily injury.
"We certainly have cases where the family had no
contact with social services, and a child ends up dead.
Who should have known there?" said Diana Goldberg,
executive director of Sungate, an Arapahoe County child
"Often, by the time it gets to social services, there
were lots of people who knew there was a problem," she
said. "Lots of people who could have, would have, should
have done things differently."
Colorado reported 91 child-abuse or neglect deaths
from 1998 to 2000, and at least 24 of those families, or
38 percent, had prior contact with social services,
department documents show. The national average is about
12 percent, according to the National Child Abuse and
Neglect Data System.
A draft of an internal assessment by the state
Department of Human Services obtained by the Rocky
Mountain News said the number of Colorado deaths was
too small to pinpoint the impact of child welfare
practices. But reviews of abuse deaths where child
protection services had been provided to the family
within the previous two years did reveal some recurrent
issues, the report noted.
The department's State and County Child Fatality
Review Team observed that "caseworkers often minimize
the significance of a history of family violence and
previous abuse/neglect reports when making case
decisions, including screening, assessment and
Susan Ludwig, a child protection specialist with
state Human Services, said that statement had been
removed from later versions of the report because it
could not be substantiated. The final report is not yet
Goldberg said that, in her experience, caseworkers
don't downplay family violence. But they might have
problems obtaining a family's past history when families
move from county to county or state to state.
"The caseworkers don't get access to the information,
and they don't know about it," Goldberg said. "And the
family's certainly not going to tell you."
The draft report also cited the need for improved
communication between local agencies, adding: "The
retrospective reviews have sometimes shown that one
agency knew pertinent risk or family functioning
information but failed to communicate the information
effectively to other agencies."
In 1998, the state reported 28 deaths from child
abuse, neglect or a combination. At least eight of those
families had previous social services contact for
reports of abuse or neglect, and five of them had a
caseworker assigned to the family at the time the child
was killed, Ludwig said.
In the case of one child who was killed, an earlier
report of abuse or neglect was investigated and deemed
"When you have that scenario with a previous referral
and later lethal abuse, it certainly raises concern,"
The earlier report might have been about neglect as
opposed to abuse, or the fatal abuse or neglect might
have occurred at the hands of another person, rather
than the child's main caretaker, she said.
"Had circumstances changed for the family? Was there
something that didn't come to the attention of the
department in previous involvement? Things might have
been OK at the time of intervention but went downhill
quite quickly after that," Ludwig said.
Social services removed children from the home in
just over 9 percent of substantiated abuse or neglect
reports in 1999 and again in 2000, for a total of 1,359
children, the report shows. But it also notes that
problems with the way verified abuse/neglect cases are
reported means that placements actually occur at up to
four times that rate.
In Denver, half of the child homicide victims from
1997 to 2000 were known to social services, according to
the Denver Child Fatality Review Committee report.
Child advocates say caseworkers need more support and
lighter caseloads to prevent burnout and turnover. And
they say the community needs to address the conditions
that give rise to families where kids die, such as
poverty, homelessness, unemployment, substance abuse,
lack of education and lack of affordable day care.
"For many people, it's emotionally and
philosophically easier to point fingers," Goldberg said,
"than to look at it as a communitywide problem that
we're all responsible for."