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Failed and Forgotten

Child deaths slip through cracks due to weak laws, oversight

By: Jill Riepenhoff, Megan Luther, and Lee Zurik

Originally Published: April 29, 2019

(InvestigateTV) – Abuse or neglect kills as many as 10 children in the United States every day.

But up to half of these children are invisible in federal data, uncounted by child protection agencies charged with tracking their deaths.

Knowing who they all are, where they lived and how they died can save other children.

But now, incomplete fatality data has left a void. A weak federal law, lax oversight and inadequate funding are largely to blame, InvestigateTV has found.

Accurately and completely accounting for these deaths is not about punishing parents or caregivers including those who did not face criminal charges.

It’s about preventing child abuse and neglect and holding accountable those with a duty to protect children – law enforcement, medical professionals, schools and child protection services agencies, Congress has said.

Nearly 1,700 children were reported to have died due to abuse or neglect between October 2016 and September 2017, the U.S. Department of Health and Human Services reported in its most recent annual child maltreatment publication.

But that report doesn’t include a single victim from Maine or Massachusetts because they chose not to disclose those cases to HHS.

It doesn’t include an Ohio toddler who drowned in his family’s unfenced and uncovered swimming pool, Arkansas siblings suffocated by their father or a Nebraska baby shaken to death by his dad, InvestigateTV found.

As many as 1,700 children could be unaccounted for in the official federal tally of maltreatment fatalities. These children are among them, according to child abuse experts, a medical examiner, child protective services agencies and/or their families. The federal government defines a maltreatment fatality as “any recent act or failure to act on the part of a parent or caretaker which results in death.” Inclusion in the count of maltreatment fatalities means that abuse or neglect played a role in their deaths and does not mean that the action or inaction of parents was a crime. InvestigateTV Illustration

The reasons why these cases weren’t counted strikes at the heart of the problems with HHS and weaknesses in a 45-year-old federal child protection law: states decide for themselves what and when to report.

“We have a law that’s not being followed, and HHS has no regulations to guide states,” said Cassie Statuto Bevan, child welfare fellow at the Field Center for Children’s Policy, Practice and Research at the University of Pennsylvania.

The Child Abuse Prevention and Treatment Act, commonly called CAPTA, established a generic definition of abuse: “any recent act or failure to act on the part of a parent or caregiver which results in death” and neglect: “an act or failure to act which presents an imminent risk of serious harm.”

It also, among other things, directed HHS to collect case-specific information about abused and neglected children.

But the law gave states wide latitude to write their own specific definitions of abuse and neglect, creating a patchwork of state policies across the country.

While the law requires states to make details about these fatalities public, HHS hasn’t enforced it, even as Congress has said that was the intent. Many states passed laws to shroud child deaths in secrecy, making accountability almost impossible.

As a result, the data collected by HHS, which includes demographic information about each child, abuse history and death details, is incomplete and misleading because states aren’t on the same page.

That means that a child’s drowning is deemed neglect in one state and just an unfortunate accident in another.

“When we don’t have an accurate count of a problem, we can’t make the arguments to invest adequate resources to fix it,” said Amy Harfeld, the national policy director for the Children’s Advocacy Institute based at the University of San Diego School of Law.

Child advocate Amy Harfeld speaks about the tragedy of child abuse and neglect fatalities. “The ripple effects from when one child dies really extends across thousands of people and families,” Harfeld said. Photo: Timothy Knapp/Gray Television Washington News Bureau

Data helps prevent unnecessary deaths. It’s led to child car seat laws and indoor smoking bans, for example.

Yet HHS has ignored congressional directives and government watchdogs’ reports calling for better data collection and transparency.

“HHS is certainly derelict in its responsibilities,” Harfeld said.

The agency has ignored a 2010 congressional directive to force states to lift the veil of secrecy surrounding child maltreatment fatalities.

Congressman David Trone holds a copy of the 2016 report issued by the Commission to Eliminate Child Abuse and Neglect Fatalities. The Maryland Democrat was speaking at a March U.S. House subcommittee hearing on ways to improve the federal child abuse prevention law. Photo: U.S. House Committee on Education and Labor, YouTube

It has failed to implement recommendations from a 2011 report by the watchdog agency, the U.S. Government Accountability Office, to improve data collection.

It has ignored 2016 recommendations made by a congressionally-mandated commission on child abuse to, fully define abuse and neglect and force states to use that definition.

“HHS has got to do better,” said Sen. Sherrod Brown, an Ohio Democrat and member of the Senate committee that is currently reviewing CAPTA.

HHS declined requests for an interview and only would only provide limited answers to InvestigateTV’s questions through email.

HHS “has long supported the development and continuance of fatality review teams at state and local levels to address the most tragic consequences of maltreatment,” spokesman Patrick Fisher wrote.

Congress has started examining CAPTA again because the law is due for its periodic renewal. Advocates say this is a golden opportunity for Congress to implement necessary changes.

“It’s very sad because we know the solutions,” said Marketa Garner Walters, secretary of the Louisiana Department of Children and Family Services. “I fear for our youngest children in our society.”

Deaths remain hidden

Abuse or neglect contributed to the deaths of 34 Ohio children in 2017 that coroners ruled were homicides, according to death records.

Ohio officials confirmed to InvestigateTV that five of the 34 children are not included in the state’s maltreatment tally. They said state law prevented them from disclosing any other information. The state shrouds these deaths in secrecy.

All 50 states receive federal funds through CAPTA’s annual $26 million in grants in part to make information about child fatalities publicly available. But there are no penalties if they don’t.

“We have a weak law that’s underfunded and unenforced,” Harfeld said.

In 2010, the last time that Congress renewed CAPTA, a Senate committee knew states were underreporting deaths. Members were so alarmed by the secrecy surrounding serious maltreatment cases that the panel directed HHS to develop policies that would force transparency.

“Public disclosure of information about a case of child abuse or neglect which has resulted in a child fatality or near fatality ensures improved accountability of protective services and can drive appropriate and effective systemic reform,” the Senate Committee on Health, Education, Labor and Pensions wrote at the time.

Rather than create that policy, HHS rescinded every CAPTA regulation it had, largely leaving states to decide for themselves how to carry out the law.

“It was a pretty bold move,” Harfeld said. “HHS doesn’t really have the discretion to ignore Congressional instruction, but they did it anyway.”

The HHS spokesman did not explain why HHS has not followed the Senate directive. He did write in an email that the regulations were rescinded because the policies were “outdated” and did note that states can receive advice through a Q&A on the website.

Public disclosure of these cases helps hold accountable those who are supposed to protect children – parents, politicians, law enforcement, teachers, doctors, other mandatory reporters and CPS.

Wisconsin is among about 10 states that independently releases maltreatment case details on its own website. It reviews the investigation, looking for system breakdowns that could have prevented the deaths.

For example, the state found that a CPS caseworker lost track of a family under its watch. The parents, who had a history of sharing their bed with their infant, moved to another county without telling the caseworker. The child eventually died while sleeping with them in their bed.

Tennessee provides online reports of every suspected maltreatment fatality – even those in which investigators eventually determined that child abuse or neglect claims were unfounded.

The child abuse commission created by Congress concluded in its report that public disclosure of these cases is critical.

“Without access to clear and accurate information,” the commission wrote, “the public and other key stakeholders are unable to make informed decisions about what is needed to reduce child abuse and neglect fatalities and hold agencies and systems accountable.”

Three years later, that recommendation has yet to be implemented.

Where a child dies matters

The commission also called for a definition of abuse and neglect that would be followed by all states.

Right now, the definitions vary greatly from one state to the next.

Kansas, for example, considers lack of supervision to be a form of neglect.

Ten states don’t address medical neglect, when an ill child isn’t given the treatment he or she needs.

“The definitions should not rely on agency-specific definitions of child abuse and neglect and should be developed for the purpose of counting and preventing fatalities,” the commission wrote.

It also said that those definitions should be broad enough to include fatalities that don’t meet criminal standards for prosecution.

The inconsistencies now play out daily.

In 2017, New Jersey CPS found an aunt neglectful for the drowning death of her 7-year-old nephew. He and other children were swimming without supervision at a hotel pool birthday party.

That same year, a 5-year-old girl, who didn’t know how to swim, drowned at a Florida church pool party attended by more than 15 adults and other children. Her death wasn’t included as a maltreatment death because the state deemed it didn’t fall under the definition of “inadequate supervision.”

In 2016, a Mississippi police officer left her 3-year-old daughter in the patrol car on a hot day while she visited another officer at his house. Four hours later, the girl was dead.

Her death counted, and her mother was sentenced to 20 years in prison for manslaughter.

But in Arizona, when an uncle and his girlfriend forgot about the baby in their care that was in the car, that case wasn’t counted. They pleaded guilty to child abuse and were placed on probation.

The similar deaths of two children in different states illustrate a key problem with the federal child abuse prevention law: states define abuse and neglect differently. States track maltreatment fatalities and report them to the federal government. In Mississippi, the death of a 3-year-old who was left in her police officer mother’s patrol car and died counted as a maltreatment death. But in Arizona, the death of a baby left in a car by an uncle and his girlfriend did not. In both cases, the caregivers were convicted. InvestigateTV Illustration

Sen. Brown is working on legislation to create a universal definition of child abuse and neglect.

Such a change, he said, “would force the federal government to come up with a definition so we then can figure out what’s going on, so we can measure it,” he said. “We have an obligation.”

The lack of a uniform definition also means there’s really no way to compare states or assess their performance in reducing child maltreatment fatalities.

Where child deaths don’t count

HHS allows each state to determine how and when it will collect data on child maltreatment fatalities.

The lack of standards means that the federal government is not accurately capturing lives that have been lost.

Katie and Jo Jo Mangan, pictured, were suffocated by their father who then killed himself. The children, ages 4 and 5, aren’t counted in Arkansas’ cases of abuse and neglect. Photo courtesy of the family

Lindsay Mangan knows that fact all too well.

Her children, Katie and Jo Jo Mangan, ages 4 and 5, were inseparable, sometimes falling asleep, snuggled together. “Neither of them remembered life without the other,” she said.

Both were buried together, in the same casket, after their father murdered them, then killed himself in 2017.

Despite worldwide media attention of their slayings, they are not among the counted child maltreatment fatalities.

“There is no trial. Where else do they get their justice?” Mangan said.

They are among eight Arkansas children who died in 2017 but are not listed in the state’s data of child maltreatment fatalities even though law enforcement agencies said their deaths were homicides, InvestigateTV found.

Citing state law, Arkansas officials said they don’t count child maltreatment fatalities until given law enforcement’s permission to prevent jeopardizing a criminal investigation.

But in four of the uncounted cases, the perpetrator has already been sentenced or is dead. Arkansas CPS officials wouldn’t confirm whether they were aware of the eight fatalities.

Alabama and Nebraska follow a similar policy. They don’t report cases until criminal prosecution has concluded, which can take years thus skewing numbers in the future.

In 2017, Nebraska reported a single child maltreatment fatality. Three other deaths found by InvestigateTV weren’t counted because criminal cases were still pending at year’s end, and per state policy, will be reported in later years.

Nine states, including Ohio, only report cases in which the family had a history with CPS or the agency investigated the death.

That too leaves many children uncounted. Experts estimate that as many as half of the victims nationally had no prior contact with CPS.

In Ohio, CPS also doesn’t investigate some cases if there are no surviving children.

A two-week-old died after she was mauled by a dog in Ohio in 2017. The police investigation found that the mother left the infant unattended with the dog after she had been warned dogs don’t like the smell of babies. The coroner ruled her death as an accident. Even though the mother was not charged, police labeled the death as a case of child abuse and/or neglect.

But Ohio doesn’t cull law enforcement records for child maltreatment cases to report to the federal government.

A two-week-old infant was attacked by a dog in the Ohio house where she lived in 2017. A sign on the house warned of a “security dog.” No criminal charges were filed in the case and the dog was euthanized. InvestigateTV illustration

Experts say many accidental deaths are caused by abuse or neglect.

To fix this issue, the child abuse commission recommended that CAPTA be amended to require states to cull records from law enforcement, vital statistics, coroners’ offices and child fatality review teams for possible maltreatment fatalities.

When researchers have conducted these deep dives in the past, they’ve found many uncounted children.

Dr. Bernard Ewigman, now a family medicine professor at the University of Chicago, was the first to conduct such a study in the 1980s. When he worked at the University of Missouri, he learned that the state had reported only six fatalities. He combed records and found 20 in a single year.

After that, he created a study to look at the state’s uncounted child fatalities over a 3-year span in the mid 1980s. He concluded that it’s necessary to review law enforcement, coroner records and vital statistics to get a complete picture of child fatalities.

“That study has stood the test of time,” he said.

Sympathy for families trumps judgment

In 2017, a young Amish boy tethered a pony to a toy wagon, climbed in and steered the makeshift vehicle onto a Pennsylvania highway.

The boy, playing without supervision, was stuck by a car and killed.

Police investigators called it a tragic accident.

The reaction was similar with an Ohio scientist whose daughter perished strapped in a car seat on an 80-degree day. The mother said that she forgot the toddler was in the car.

But to experts in child maltreatment fatalities, those tragedies are examples of neglect.

David Finkelhor has studied child maltreatment fatalities for more than three decades at the University of New Hampshire. He said there are a significant number that go uncounted “particularly among homicides in middle-class families.” Photo: Matthew Wilton for InvestigateTV

As part of her official duties on the commission, Theresa Martha Covington reviewed cases across the country in an attempt to quantify the undercount and has significant experience examining suspected cases of abuse or neglect.

“It doesn’t mean the parents [should] go to jail,” she said. “It means [there were] lapses in judgment and poor supervision.”

She and many other experts agree that biases about a family’s race or socio-economic status can color a child maltreatment investigation.

“If you have a middle class or upper-middle class family, they have a good account for what went on, that can frequently fool law enforcement or child maltreatment investigators,” said David Finkelhor, director of the Crimes Against Children Research Center at the University of New Hampshire. “They can have sympathy and accept the story that the person gives.”

This bias also contributes to the undercount.

“No one wants to think about someone injuring a child. What kind of monster would attack a small child?” said Dr. Jamie Downs, who has been a medical examiner for more than three decades and specializes in child deaths. “These people don’t look like monsters. They look like Mom. They look like Dad.”

In 2017, federal data shows, parents were responsible for more than 80% of the child maltreatment fatalities.

Consistency in investigations lacking

On Easter morning in 2017, an Ohio toddler wandered outside while his parents went upstairs to dress for the day.

Fifty minutes later, his mother found the 2 ½-year-old at the bottom of the family’s unfenced, uncovered swimming pool.

Neighbors told police the boy often played alone outside his home.

CPS never investigated so his death is not included in the state tally.

Downs said it should have been even though the parents weren’t criminally culpable.

“A pool is a hazard. It’s a death waiting to happen,” said Downs, who has investigated thousands of child deaths during his career and now serves as an expert witness involving abuse and neglect cases.

The deaths of children who drowned or were put to bed in unsafe sleeping environments are often ruled to be accidents and thus not investigated or reported as child neglect, experts said.
Spotlight on drownings and sleep-related deaths in Ohio

In 2017, more than 100 children in Ohio either drowned or died in unsafe sleeping conditions such as sharing a bed with an adult. County coroners noted the circumstances of these child fatalities in death records. All of these cases were ruled as either accidental deaths or the manner of death could not be determined. This map gives the ages and sex of these children and how their deaths occurred according to a database of death records from the Ohio Department of Health. Two children who lived in Michigan died in Ohio, making their deaths part of Ohio’s count. The location of each dot is based on the ZIP code in which they lived and does not pinpoint a precise location. In some cases, a dot may have details on more than one death.

But the lack of proper supervision or exposing children to known hazards, even though not always criminal, is a clear form of neglect, Downs and other advocates said. But each state has its own definition of neglect.

Even deaths linked to high-concern behaviors aren’t being counted.

For several years, Ohio has waged a highly public campaign to warn parents about the danger of sleeping with their babies or putting them in cribs with blankets, stuffed animals and other objects that can lead to suffocation.

Despite that, in 2017, nearly 100 children in Ohio died in unsafe sleep environments, according to an InvestigateTV analysis of death records.

Yet the state only counted 20 of them – tamping down public awareness of the urgency of the state’s warnings. It’s possible that CPS didn’t even know that many of these children existed because the agency had no prior contact with them.

Among the children who weren’t included in the state’s number is a 1-month-old who was dead when his father awakened. The baby had been in the bed with his mother, father and 3-year-old sibling.

“I would wager that wasn’t the first time they did that,” said Downs, based on his experience with these types of cases. “The problem is you’ve done it before. Your personal experience tells you it’s safe and it’s not.”

The situation is similar in Florida, where more than 160 sleep-related deaths were investigated in 2017. Only 14 were labeled as neglect cases.

The child abuse commission recommended in its report that the federal government develop national standards for how medical examiners, coroners and law enforcement investigate these and other types of suspected maltreatment fatalities.

“If we as a nation do nothing different to prevent child abuse and neglect fatalities, somewhere between 1,500 and 3,000 children will die from maltreatment” each year, the commission said.

And as many as five a day could remain uncounted.

Graphics and illustrations by Jamie Grey. Research contributions from Tyler Wann, InvestigateTV intern; Emily Thompson, Ryan Deloney, Gigi Failoni, Gina Shelton, Olivia Ellis, Jordan Blakemore, Lucas Ros, Amelia Holcomb and Lindsay Cross, University of Arkansas; Laura Jayne, Brendan Gowey, Andrew Callaghan, Anna Brunini, Rose Wagner, and Lauren LeCompte, Loyola University New Orleans; Jacqueline DeRobertis, Devon Sanders, Madeline Meyer, Maria Marsh and Bobby Crane, Louisiana State University.

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