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This is the fourth story in a series produced under a , which focuses on the stories of vulnerable communities. The first story explored how COVID-19 has affected young adults "aging out" of the foster care system; the second focused on grandparents raising kin; and the third was on how the pandemic impacted parents and reunification efforts.

The pandemic, its associated isolation, and economic challenges prompted child welfare to sound the alarm: COVID-19 will likely result in a spike in child abuse.

But whether such a trend is certain fact or educated intuition is still open to question. Complete data won't be available until mid-2021, at the earliest.

Some experts fear that at-risk children won't be seen because stay-at-home orders are keeping them away from the watchful gaze of mandated reporters, especially teachers, who report one in five cases of suspected abuse and neglect to hotlines and responsible agencies.

Others worry this lack of visibility could trigger an over-reaction from child welfare investigators or exacerbate historical biases. At the same time, experts expressed concern that economic stressors and a lack of social supports may overwhelm parents leading them to poor parenting decisions.

Experts interviewed by MedPage Today all agreed the consequences of abuse and neglect occurring behind closed doors are dire, but many also cautioned against an overly aggressive approach to family investigations and child removals in the era of COVID-19.

In the absence of national data on rates of violent deaths and child removals in 2020, child welfare agencies are continuing to transition toward measures that support families and prevent them from getting involved with child protective services (CPS) in the first place.

Lindsey Bullinger, PhD, a child abuse researcher at Georgia Tech in Atlanta, said fewer in-person interactions with CPS in the pandemic can be good for families, especially those at low-risk, because CPS has therapeutic responsibilities to help parents get back on track, as well as punitive ones.

"On that hand, this is good for those families -- they are no longer having to go through that process," Bullinger told MedPage Today. "On the other hand, we could be missing out on some very tragic cases."

Shift Began Before Pandemic

The concern over a possible increase in child abuse and neglect in 2020 because of the pandemic occurs against a backdrop of a change in philosophy and best practices for child welfare agencies. Modern approaches call for more prevention and supports and less removal from homes and entry into foster care or group homes. A 2018 law, aims to push funding in that direction.

In October 2019, states were given the option to use certain federal child welfare dollars to pay for a portion of the evidence-based prevention services and programs they plan to engage. States can't just implement any program; the federal government established a of approved services states can draw from to develop and submit a Family First or Title IV-E Prevention Plan, which also must be approved by the federal government.

In addition, the Family First Act placed new restrictions on foster care maintenance payments, in an effort to steer children away from low-quality, non-family settings.

To date, 8 states have submitted plans and another 8 and the District of Columbia have seen their plans approved, according to the , an office of the Administration for Children & Families at the Department of Health and Human Services (HHS).

However, states can opt to delay the , including these limitations on reimbursements for non-family settings, until Oct. 1, 2021, and more than half have not yet submitted their plans.

"I think what we've seen study after study, time after time, has been kids want to be with their families. And if there is an intergenerational pattern or a cycle of poverty or something like that where we can actually address it as a system ... instead of being punitive and removing that kid, why aren't we just helping treat that family?" asked Maral Karaccusian, MSW, Children and Human Services Deputy for Supervisor Janice Hahn of the Los Angeles County Board of Supervisors.

"That's my hope for things as we move forward."

More Stressors, More Abuse?

Preliminary evidence seems to support the notion that child abuse has increased in 2020 compared to years prior. Within the 12 weeks following mandated "shelter-in-place" orders, . In one study from Brigham and Women's Hospital in Boston, the incidence of during the COVID-19 pandemic compared to prior years.

The concerns around vulnerable children during lockdown are clear-cut, said Michael Meit, MPH, MA, director of research at the Center for Rural Health Research at East Tennessee State University, and a senior fellow for the Public Health Research department at NORC at the University of Chicago.

"If you're not in a safe home environment, being quarantined with your family is not a good thing," Meit told MedPage Today. "It's as simple as that."

But other data are less clear. In a of emergency department visits related to suspected or confirmed child abuse and neglect in early 2020, visits declined by 53% compared to 2019, although overall ED visits also fell by roughly 70% among children during this period. The number of visits resulting in hospitalization, indicating more severe abuse, remained stable from 2019 to 2020.

Mandated reporters such as teachers have had fewer eyes on students with stay-at-home orders and the switch to virtual learning.

That has in part led to fewer reports, and subsequently fewer investigations into homes. Relative to 2018-2019, child maltreatment allegations in Georgia, for example, following the emergency declaration.

In November, the Children's Bureau within HHS allowed flexible funding for Title IV-E agencies to when such programs would be unavailable to families otherwise.

Ted Dallas is president and CEO of Merakey, a national nonprofit that provides developmental, behavioral health, and education services and has 6 years of experience managing the Pennsylvania and Maryland Department of Human Resources agencies.

Dallas said certain information is more accessible when case workers physically visit the home that may be absent in child welfare visits performed virtually.

During an in-person visit when you're in the home, Dallas said, "you can look at the condition of the home. You can have a better idea about how the child's living, the food in the fridge ... Is there somebody in the home that is not somebody you knew of in the home?"

Strangers in the home, boyfriends, or people parents are dating -- who are often cited as a source of maltreatment -- can hide from a computer's lens, Dallas said.

"If you're in the home, you might see that person there. If you're sitting on a Zoom, unless the guy walks behind the camera, you might not even know he's there."

Workers may instead have to rely on data analyses and algorithms that help predict what puts children most at risk, Dallas said.

"Have there been a lot of calls about this particular child in the past, even if they're unfounded?" He said. "What is the history of this child with the child welfare system?"

Dana Weiner, PhD, a senior policy fellow at the Chapin Hall at the University of Chicago, performed one such accounting for the detection of suspected abuse observed through hotline reports, and the response to that suspected abuse, either through an investigation or an alternative response.

But confirming this suspected abuse is challenging, "because we can only see what gets reported," she said.

By comparing what's reported in a typical year to this very "atypical year," however, "we're able to also learn something about what we might not be seeing," Weiner said.

Comparing 2020 to 2019 allegations, in an area where county-level hotline call data was available, Weiner was able to identify the gaps between the number of calls received by each allegation, determine which kinds of calls might be missing, and concluded that mandated reporting can lead to a "substantial overreaction" by the child welfare system.

This raises the question of whether such reporters' role should be shifted "from surveillance to support," Weiner said.

"If they believe their only option is to call in a hotline report as opposed to having technological tools that allow them to make referrals to community supports ... for getting a family childcare or clothing or food or whatever they need, we believe that those responses would be more appropriate and responsive to what families actually need," she said.

Recognizing that factors like economic downturns and family isolation can increase children's risk of harm, stakeholders who worry about children's well-being rather than focusing on boosting supervision by mandated reporters, should instead zero in on ways to support and help stabilize families.

Impact on Inappropriate Removals

Despite fewer reports and investigations, the number of children in foster care has remained relatively stable in 2020 compared to years prior. In , the number of children in foster care fell by 1.9% from 2019 to 2020, but that followed a 2.4% decline from the year prior.

It may be that the reduction in reporting abuse and neglect is attributable to fewer low-risk reports that would not be substantiated anyway. Only 11% of reports made by teachers, for example, , according to Weiner's research.

This raises the question of whether child welfare agencies have been removing too many children from families pre-pandemic. Many parents are housing or food insecure as a result of the pandemic, and this could lead teachers, doctors, or other mandated reporters to mistake poverty for neglect.

A potential increase of inappropriate removals is a concern for Karaccusian, who wants to "narrow the door to entry" to child welfare.

"I think we have a lot of families who are in the child protection system who probably don't need to be in it right now," Karaccusian told MedPage Today.

The purpose of narrowing that door to entry is to ensure that "families don't enter the child protection agency because they're poor or because of the color of their skin," she said.

"What we've notoriously and historically done in child welfare is target people who are poor," Karaccusian said. "If patterns repeat themselves, it feels like an overwhelming thought to think about how ... our children and families are going to be impacted," particularly now, by a looming economic downturn.

Dallas agreed that implicit bias related to poverty and neglect is a major concern.

"If you're a poor black kid in Southeast Washington versus a white kid who goes to Sidwell Friends," the Quaker day school President Obama's children attended, "is the system gonna have the same reaction? Probably not. And that's a problem in the system."

If the question is whether there's a tendency to say, "'You know what, I don't know what's going on there, I'm gonna be safe and I'm gonna pull that kid out of ... the home.' It could happen. The thing that I think would balance that is the availability of placements for that child might also be down because of the pandemic."

In LA county, however, there has been a significant focus on prevention, and Karaccusian said she's hopeful that the safety net services that have been implemented will prevail.

As flawed as the child welfare system is, Karaccusian said, what she does not want is for people to ignore their instinct to call when a child is in danger.

Amy Jantz Templeman, the director of Within Our Reach at the Alliance for Strong Families and Communities, hasn't seen any data yet that would suggest child welfare systems are removing children at a higher rate or "reacting differently than they were reacting before the pandemic."

Templeman also previously served as the executive director under President Obama on the Commission to Eliminate Child Abuse And Neglect Fatalities (CECANF), established by Congress in late 2012.

She cited backing the notion that an overall drop in child abuse and neglect reports was attributable to a decrease in low-risk referrals.

Data on removals that child welfare agencies submit to the federal government won't be available until about June 2021, however. If the percentage of calls that result in the removal of a child is higher in 2020 compared to years prior, that would not necessarily mean that those removals are inappropriate.

"It still might not tell us that they're being more reactive," Templeman said of child welfare decision-makers, usually the investigators. "It might still be that they're removing appropriately, it's just that they're dealing with a lot more serious cases than they usually do."

Those removal ratios will need to be calibrated alongside data on risk levels and the types of allegations received -- physical or sexual abuse, neglect, educational neglect, or some other concern -- before drawing conclusions about the system's reactivity.

It will still be several months, she said, "before we really see what's happened this year."

Weiner does not anticipate a "tsunami of reports" when in-person schooling resumes that would indicate a surge of abuse that has been happening behind closed doors. However she noted that unemployment rates and child abuse rates do track together. A 1% increase in monthly unemployment rates is associated with an increase of 61 screened-in reports for abuse and neglect allegations of maltreatment.

It's likely that child maltreatment, which is linked to poverty and unemployment, has indeed risen in the pandemic, but "the concern around that narrative may be misdirected," Weiner said.

"It's not that we don't think we should be concerned about families, it's that we think we should formulate responses that are attuned to the issues that families are actually struggling with," Weiner told MedPage Today.

Families need community based supports to address those significant concrete economic needs, her report noted.

Focus on Prevention

Pre-pandemic, there was a movement to reduce the number of children involved in child welfare overall. With the passage of the FFPSA in 2018, policymakers aimed to bring new attention to family preservation and prioritize family or "kin" placements over licensed foster homes and congregate settings.

The law allows states to redirect some Title IV-E entitlement funds, most of which are traditionally spent on foster care maintenance and adoption payments, to pay for services to support parents with the tools they need to keep the family together -- parenting classes, substance abuse treatment, or mental health counseling.

State child welfare agencies spent roughly $30 billion on child welfare services in fiscal year 2016, according to Child Trends, with 56% of those dollars coming from state and local governments and nearly 27% stemming from federal programs, mostly through Title IV-E and Title IV-B of the Social Security Act (SSA) and the Child Abuse Prevention and Treatment Act (CAPTA), according to the .

An additional 17% of funding comes from federal programs associated with child welfare but that aren't primarily focused on it, such as the Social Services Block Grant (SSBG) and Temporary Assistance for Needy Families (TANF).

Templeman calls the Family First Act a good "first step."

In the CECANF report Templeman oversaw under President Obama, the commission concluded that child abuse is in fact preventable, that new evidence has shown what measures are needed to enable prevention; and that child welfare agencies alone cannot fix the problem.

A growing body of research has shown that the answer to preventing child abuse relies on establishing several core protective factors: enhanced social connection; quality child care; access to health insurance; engagement with services that reduce stress; and stable employment that provides for basic needs, Templeman said.

But the Child Protective Services system isn't designed to help improve protective factors at all, Templeman said.

"CPS is designed to intervene when there's a case of abuse or neglect to serve as a protective function, to investigate, and then to treat any type of abuse or neglect that has occurred for a child and hopefully help the family move forward," she said.

"It really does take more of a public health approach from within the community and other agencies to take responsibility for the role that everybody can play to ensure child and family wellbeing," Templeman said.

The next "logical step" to the FFPSA should be to increase investment in The Child Abuse Prevention and Treatment Act, a federal program that funds community-based child abuse prevention programs that invest in families, Templeman argued.

CAPTA was enacted in 1974, both to recognize the problem of child maltreatment and to provide federal funding and a policy approach to respond to the issue.

"So you're not only preventing foster care, but you're preventing any of those triggering events that might cause somebody to call CPS about a concern with a family," Templeman said.

CAPTA funding for preventing cases on the "front end" of the child protection spectrum is small relative to federal funding for foster care and permanency on the "back end," . In fiscal year 2016, CAPTA funds accounted for less than 3% of the federal government's $13.5 million allocated for child welfare.

CAPTA funding, which includes state grants for improving CPS and Community-Based Child Abuse Prevention Grants, .

Teresa Rafael, MSW, executive director of the Children's Trust Fund Alliance (CTFA) said part of the problem with prevention work -- that is, improving family resources to prevent CPS involvement in the first place -- is that it's not housed under one umbrella like "child welfare" or "public health" and thus sometimes gets lost in the public perception.

"It's seriously under-resourced around the country, but the payoff in society is huge," Rafael told MedPage Today.

Child maltreatment prevention and intervention programs can lead to as much as , according to the Casey Family Programs.

The CTFA leads a national network of state children's trust funds and distributes more than a quarter of a billion dollars every year in support of community-based family strengthening and child abuse prevention programs.

In the pandemic, the alliance has worked with family resource centers to provide diapers and other supplies through "porch drop-offs" to low-income families in West Virginia; worked with the Alabama Department of Child Abuse & Neglect Prevention to develop a "warm line" to direct families in need to resources; and improved the reach of family visitation programs in various regions.

Rewarding families with resources when they ask for help, rather than having a pejorative view, can prevent a case from getting more serious, Rafael said.

"Some of the things we've heard from families is that when I ask for help, it comes with a price, meaning someone is now involved in my daily life second-guessing my decision, and that is a barrier to accepting the help and reaching out for what's needed," Rafael said.

Other regions have also tried to get ahead of a potential increase in child maltreatment by expanding outreach to at-risk families.

In Michigan, 600 staff members were trained in late April to complete outreach with roughly 14,000 families vulnerable to going into care within the next year in an attempt to increase preventative services, said Danielle Martin, of the Michigan Department of Health and Human Services.

"Our numbers were indicative of the need for families to connect," Martin told MedPage Today. "We saw families reaching out more for substance abuse and domestic violence services, or housing services."

One "promising" intervention Templeman highlighted is embedding family resource centers physically in schools, which has been done in and . When a teacher has a concern, especially related to neglect, "rather than call CPS for that concern, sometimes there's the ability to just walk with the student to the family resource center and make a referral ... so that the child, and potentially the whole family could receive the support they need."

The Los Angeles Prevention & Aftercare community network has also established "Moving families from the Hotline to a Helpline" pilot program, where callers are routed to one of 10 community-based organizations and linked to services, which tripled the number of families linked to prevention services in 2019 versus 2017.

Karaccusian recalled a mother who wasn't able to get to work because of a problem with her car. As a result, she was depressed, worried about losing her job and her home, and her children weren't in school.

When a concerned adult reported that the children were playing in the street instead of being in school, rather than bringing those children into the child welfare system, the family was diverted to a community-based organization through the local Prevention & Aftercare network, which had the flexible funding to fix the woman's car.

Los Angeles County has also been tapped as one of four jurisdictions to be part of the three-year pilot program, which is a partnership between the Annie E. Casey Foundation, Casey Family Programs, Prevent Child Abuse America, and the Children's Bureau.

Karaccusian characterizes the initiative as "a silo-busting effort for our county agencies for everything from prevention that our mental health department provides to substance abuse that our department of public health provides ... to domestic violence to individual counseling to family therapy."

And she shares many advocates' vision for radically transforming child welfare.

"What we need to do as a system is to take a step back and really treat families holistically and that includes access to decent paying jobs, having school systems that provide equitable education, having access to food ... Those are things that we as a system have to look at holistically and I think that by the time a child enters DCFS [the Department of Children and Family Services] it really is too late for our families."

"And I think we have to really figure out a way to really work with families and children who shouldn't be part of our child welfare system but just needed a little help," Karaccusian said.

"If we can do more of that, that is how we solve child welfare," she added

Some child welfare experts see the pandemic as an opportunity to move forward with the principles behind FFPSA with a new vengeance.

COVID-19 may make it even more clear that incidents of child abuse and neglect "don't occur in isolation," said Paul DiLorenzo, interim executive director of the Philadelphia Children's Alliance.

Rather, they "happen within a set of circumstances that could sometimes be years or generations in the making," DiLorenzo told MedPage Today.

Parents with child welfare involvement who underwent a CPS investigation themselves are than the general population, in part due to mental health problems persisting after the alumni's involvement and a lack of social support.

Family preservation has been linked to better outcomes for youth and families, whereas removals or CPS interactions have been shown to .

Allison Green, JD, Legal Director of the National Association of Council for Children, agreed COVID-19 has reinforced the philosophy behind the FFPSA.

Although the "jury is still out" on how rates of child abuse and neglect have been impacted by the pandemic, "what we do know is that financial stress is extremely hard on families," Green said.

"So let's as public health systems do what we know can help," Green told MedPage Today. "Let's provide support -- financial support, social support -- work on protective factors and well being."

Dallas said the goal of the child welfare system is to make investments upfront, reducing child abuse and neglect cases to nonexistence and reducing the amount of time families who do have their cases substantiated are in the system.

Altogether, it aims "to put itself out of business," he said.

Congregate and institutional settings he sees as the "deep end" of child welfare, whereas preventive, community based services are on the opposite side of the spectrum.

"Where you want to be is on that end of addressing the family proactively, addressing the social and economic determinants of health, providing that intervention early on, and you want to get as many kids out of what I used to call ... 'the deep end' of the system as possible," Dallas said.

"If there's a silver lining to COVID, it's that it only reinforces this is where the system needs to go."

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