Investigation into the Death of Emily H.
released March 12, 2001
conducted by the Child Fatality Review Panel

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Key elements of the report: 

Executive Summary
Findings and Recommendations

This independent panel finds that Emily died because someone with no regard for her young life, raped her and fatally injured her.

At the next level, her own mother, through commission or omission, did not prevent the abuse of Emily.

Finally, there was a failure of professionals who knew this family to recognize the risk factors which increase the likelihood of fatal child abuse. This failure involved not only child protective  services, but also medical. legal, and law enforcement services as well.

In the case of Emily's family, only the school system shows a dedicated and consistent understanding of the risks faced by the children in this family.

Emily died on March 13, 1995 at the age of nine months. Emily was born into a family where domestic violence; child medical neglect, physical neglect, and physical abuse; adult drug abuse; and gang related threats and fears were facts of life. Emily was born into a family known to the community: the courts, the police, medical professionals, the school system, parent support programs, drug addiction services, and neighbors. Emily was the youngest in a family known to the Department of Children and Families for over three years. Emily suffered a broken leg, with no reasonable explanation only three weeks before the injuries which led to her death.

On March 14, 1995, the day following Emily's death, Governor Rowland called for an independent review of the case to answer the question, "Why did Emily die?". A panel of experts was charged by Governor Rowland and Commissioner Rossi with conducting this review and issuing a report. Betty Spivack, M.D., head of Hartford Hospital’s Pediatric Intensive Care Unit and a recognized expert in the area of child abuse diagnosis, was appointed Chairwoman of the panel to review the Emily case.

The committee began its work on March 17, 1995 with the support and resources of the Attorney General's Office and with full access to DCF, Juvenile Court and police arrest records. Additionally, the Commissioner of DCF made available the services of nationally recognized child welfare consultant Loretta Kowal, LICSW, of Kowal and Luong, Boston, MA. Ms. Kowal was contracted by the DCF to complete an in-depth, internal review of Emily's family's case record and carefully evaluate the services provided to this family through the DCF.

While Ms. Kowal conducted the case file research and conducted interviews of DCF staff who had provided services to this family with a focus on the child protection services provided by the Department, the panel considered the many questions surrounding Emily's death from a more global perspective. Emily's tragic death is unfortunately not unique to Connecticut; nationally, 40% of the children who die from fatal child abuse have active cases in their state child protective service. Was her death a case of "we did everything we could and it didn't work" or was there more to it?

The panel reviewed records and heard from individual professionals who had knowledge of the case. The records were at times confusing and lacked important information. Professionals gave information which was never recorded or shared during the three and a half years this case was open with DCF. The panel sought to distinguish issues involving individual caseworkers and supervisors from systemic problems inherent in the way in which the Department of Children and Families functions internally, and in its interactions with the many other public and private agencies responsible for the care and protection of children.

The panel also considered the roles and responsibilities of these other agencies in the protection of children. In order to separate out these systemic problems, which are the more dangerous, since they ultimately may affect many children, the committee also looked briefly at four separate cases where children known to DCF were critically or fatally abused.

According to the information learned during the panel's review of the Emily case, there were several points at which the extreme danger to children in this family might have been recognized, and disaster averted.

First, the multiple injuries to a sibling during the sibling's first year's of life were never recognized as suggestive of abuse by medical staff at a local hospital during sporadic clinic appointments. When severe medical neglect of another child was reported to DCYS, the serious consequences of that neglect were not sufficiently understood by DCYS, medical information concerning the siblings was not sought (which would have revealed a pattern of possible of abuse) and the DCYS case was closed.

In October 1991, the police arrested the mother for Risk of Injury. The arrest record states that the officers found two children hanging out of an open, third-story window. There were no adults in the unheated apartment (52 degrees F), there was animal excrement on beds, and no food was available. An appropriate protective response would have been immediate notification of DCYS by the police, DCYS assessment of risk to the children, and then a background check on any home where the children might be placed. However, the responding police officers placed the children with a relative, arrested the mother, and did not call DCYS until the next day (a call which was not recorded in the DCYS records, the only note of this is in the arrest record, there is no written report to DCYS by the police). Two days later, DCYS is notified of the mother's arrest by the Family Division of Superior Court.

The case then continues its long journey through multiple DCYS/DCF workers and numerous community-based service providers with minimal focus on the factors which created a high risk environment for these children.

The last opportunity to avert tragedy came in February and March of 1995, when Emily presented at a local hospital emergency room with a spiral fracture of her leg. This injury was reported by the hospital to the Department six days after the child was initially treated by an emergency care physician and an orthopedist. This DCF referral was handled by a social worker who believed the inconsistent explanation of an "accidental injury" given by the mother. Emily remained in the home and was fatally abused at the age of nine months.

The panel found evidence of inadequate investigation and casework, compounded by inadequate documentation and inadequate evidence of supervision. This appears to have contributed to an inadequate representation in court of the dangerous aspects of this family's pattern of behavior. There is also evidence of inadequate recognition of signs of abuse and neglect by physicians, as well as an inadequate knowledge of their responsibilities a mandated reporters of abuse and neglect. In addition, the court system and statutes of Connecticut appear, in some respects, to be inadequate to protect certain groups of seriously abused or neglected children.

Our review found that these defects occurred consistently over the period of several years, and involved many individuals. Although these individuals are responsible for their own actions, nevertheless, we conclude that these persistent problems are indicative of system flaws both inside and outside of DCF.

The panel presents the following recommendations to address many of these issues. Additionally, the Department of Children and Families is urged to act upon the recommendations submitted by Loretta Kowal as part of her expert child welfare assessment of the Emily case. The panel has read, discussed and accepted her report and feels that implementation of her recommendations in conjunction with those presented by panel will improve children's protective services in Connecticut.
Findings and Recommendations

1.  Mission of DCF

In the past decade it has become increasingly clear that an organization must clearly express its mission and goals in order for those goals to be pursued by its employees. In the case of DCF, it must be clearly stated that protection of children is its principal goal and mission. Protection of children comes in many forms; in some families, protection is best achieved by introducing services into a family, educating parents, and supplying support of various kinds. However, it must be recognized by every DCF employee, that in some extreme situations, children cannot be protected without removal from the family home. It must also be clear that protection implies the need of a child for a sense of permanence and stability, and that this may require that, in some cases, parental rights must be terminated.

In implementation of this mission, DCF must interact with many individuals and agencies. Any time that there are multiple individuals involved in a case, there may be differing perceptions of the importance of certain facts. During our investigation, we have noted the high frustration of many dedicated service providers, who have felt that their concerns had not been adequately addressed. The creation of a departmental ombudsman, who has direct access to the Commissioner, could improve the interagency communication which is so vital to the smooth functioning of DCF.

Recommendations:

• DCF must as an agency develop a mission statement that reflects that child protection is the primary goal of the agency. This statement should express clear principles to guide workers in determining when family preservation or reunification is not possible. It should also clearly state that DCF should remain the responsible case manager, no matter what other services have been utilized as a portion of case management.
• A departmental ombudsman should be established, answerable directly to the Commissioner, to facilitate communication of concerns expressed by people or agencies relative to the actions taken in a case.

In order to function effectively as a working document, the case record needs to contain information about problems in the family, about the nature, goals and results of attempted treatment for those problems, and who (name, title, address, phone) are the providers of services. The notes need to be entered in a timely fashion, both to facilitate the use of the file as a working document, and to ensure the reliability of the information if it is needed in court. Supervisors should periodically review the case file, and indicate their agreement or disagreement with the conclusions. It is felt by the panel to be important that the case record be a single document, and that it should reflect supervisory notes as well as case worker documentation. Evaluative material concerning caseworker performance, of course, belongs elsewhere.

Recommendations:

• A summary section at the front of the file should list all workers and supervisors with dates of responsibility for the case. Providers of all services should be listed, with complete name, address, and phone number, type of service and dates of service. A problem list should be maintained and kept current. Members of the household should be listed with relationship and dates of residence identified.
• All entries in the narrative section of the case file should be identified by date and signature.
• Narrative entries should be timely, with dictation no more than two weeks subsequent to the contact described. Dictation should reflect the worker’s assessment of the data collected during any contact, and the impact of that data on any plans for treatment or court action.
• Supervisory approval and knowledge of the case should be evident from examination of the case file. Any time a case is discussed in the weekly supervisory meetings, the content of that meeting should be documented by both the worker and the supervisor. All case notes by the supervisor should be entered in a unified case file.
• All medical, legal and school records necessary for full delivery of service need to be in the appropriate sections, and referenced in the chronologically appropriate place in the narrative section. This will facilitate timely transfer of information if any of the children requires placement out of the home, as well as simplifying the updating of treatment plans.
• These recommendations should be incorporated into the planning of the unified central computer database (SACWISS).   

Without effective investigation of allegations, the fundamental mission of DCF their mandate to protect children is thwarted.

After a thorough investigation has justified opening or re-examination of a case, a family assessment including all members of a household must be done. This must include psycho-social assessment of all residents and of non-resident caretakers. Screening tools which identify likelihood of substance abuse or domestic violence issues should target a more careful examination of these areas. This careful assessment will lead to production of a problem list and indicate appropriate treatment options.

Following a full assessment of a family constellation, a plan must be formulated with needs, goals and expectations clearly articulated. In the 10-15% of DCF cases which are serious enough to be brought to court, treatment plans take on additional importance. They are a critical vehicle for expressing to the court, the parent and others what is and is not happening with regard to specific case expectations. By stating anticipated consequences, the groundwork is laid for further DCF action. Additionally, these treatment plans are the only DCF vehicle which routinely permits the Juvenile Court and attorneys to have ongoing oversight of a case during the 18 months between disposition and the next required court action. However, in the primary case reviewed by the panel, these plans had been hastily written, copied from plans written six months earlier and were not received by the court in a timely fashion.

Administrative Case Reviews (ACRs) of treatment plans are federally mandated every six months. Unit based quality assurance must give priority attention to the completion of such treatment plans and to the timely invitation and inclusion in Administrative Case Reviews of all appropriate persons: parent(s), attorneys, foster parents, all service providers and court authorized individuals (CASA volunteers) monitoring case progress.

Once appropriate services have been put in place, every contact with any provider should result in a judgment as to whether the goals and expectations expressed in the current treatment plan are being achieved. Treatment plan review, currently held every six months just before the next mandated Administrative Case Review is not timely enough for serious cases. High risk cases, those involving substance abuse, domestic violence or children in the home under protective supervision should have the response to treatment, and changes in the nature of that treatment assessed more frequently.

Recommendations:

• Investigations should be performed by personnel specially trained in investigative techniques. This should not be the current treatment worker, as this generates a conflict in the worker-family relationship.
• Mandatory criminal record/arrest checks should be made on all household residents, as well as non-resident caretakers.
• Program directors must be made aware of all allegations of serious physical abuse (fractures, burns, head injury, organ damage) or any neglect serious enough to lead to hospitalization.
• Psycho-social evaluation should be promptly performed in all substantiated cases, by workers trained in interview and evaluation techniques related to substance abuse and domestic violence.
• Treatment plans should be based upon clear goals, clear time frames for achievement of those goals and clear consequences if the goals are not achieved.
• Treatment plan updates should be held more frequently in high risk cases; those with substance abuse, domestic violence or children at home under Protective Supervision.
• All treatment/service providers should be notified and invited in a timely fashion to treatment plan updates or Administrative Case Reviews (ACRs) and to submit reports of their interactions with the family since the time of the review.
• When services are being provided by community based organizations outside of DCF, DCF should ensure accountability as well as clarity of agreed-upon case goals and expectations via written contracts. Each contracted organization should be required to meet periodically with all other service providers, as well as individually with DCF staff.
• Supervisors should indicate their agreement with evaluation of progress in meeting expectations and goals. If goals and expectations are not progressing satisfactorily, supervisory notes should discuss options including court action.
• Bilingually and biculturally competent workers are needed to deal with families where English is not the principal family language. In such situations, service agreements and court expectations need to be expressed in a language understandable to the recipient. In Connecticut, the most common second language required for such documents will be Spanish. True linguistic and cultural competence must be effectively assessed prior to assuming that a given worker meets this standard.
• DCF policy requires that special attention be given to children designated as "high-risk infants". The definition of high-risk infant cases should be amended to include newborns whose older sibling(s) have died due to child abuse or neglect, or where there is protective supervision or out-of-home placement of older sibling(s) as a result of child abuse or neglect.
• In such a case, the department should automatically seek an amendment adding the new child to any current court Order of Protection. If the juvenile court case has not yet been adjudicated, the departments should amend its petition to include the new child in the court order. The Assistant Attorney General (AAG)/Guardian ad litem (GAL)/children's attorney should be notified of the birth of such a child.
• Safety of the DCF social worker must be insured so the practice of good child protection intervention is not avoided due to valid personal safety concerns. Domestic violence, street violence, gang involvement or known criminal history of violence cases should automatically involve coordination with the police and/or use of other security measures to insure worker safety, especially when conducting home visits.

4. Problems with Quality Assurance and Supervision

Every organization needs some assurance that the goals and policies of the organization are being followed by its employees; the Department of Children and Families is no different. The structure of the department is predicated upon supervision of trainee and junior personnel by more experienced supervisors, and coordination of supervisory activity by program directors. Trainees are in special training units, with a reduced case load, which rises throughout the training period, and an increased degree of supervision during this period. However, the supervisors may not have received the same training which has been given to their subordinates in the training academy, and therefore may not be able to provide the clinical perspective necessary to reinforce the lessons learned in the classroom. It is unfortunate that at least one of the supervisors in this case had no child protective experience at all. when hired at a supervisory level based upon experience in other aspects of social work.

In order for quality assurance to be effective, it should follow a continuous quality improvement model. In this setting, evaluation proceeds from a bottom-up, unit-based perspective, with the results of evaluation leading to a sense of accomplishment generated by a perceived improvement in the unit's ability to fulfill the goals of the organization. This model is based upon the assumption that the unit's managers, in this case supervisors, program directors and regional administrator, will be able to devise appropriate monitoring tools, and make appropriate responses to the results of their on-going assessment. Each region has now set up a regional improvement team, with representation from all levels from worker to Regional administrator. Each team has developed a statement of their scope of service, and a list of indicators for their region. Nevertheless, some regions have clearly been more successful than others in adopting this model of quality improvement.

Quality assurance activities should also occur in the Central Office. Quality assurance reports should be generated through this hierarchy to a statewide committee for review of trends, successes and areas of concern.

It is also clear that the central office needs to have a systematic approach to respond to critical incidents, such as death or serious injury to a child with an open case file, or from a family whose case has been recently closed. Currently, the Quality Assurance Division only looks at cases which occur in children in placement (foster homes or residential facilities). There is a vague statement in the Policy Manual that "the (Child Fatality) Committee shall conduct periodic review of the death of any child in the legal or physical custody of the Department and of any child known to the Department." but no standardized process has been developed to assess the quality of the care and assessments made by DCF staff.

Recommendations:

• A minimum of one hour of supervision each week for trainees is insufficient. Trainees should receive a minimum of two hours a week in supervision, and the supervisor should accompany the trainee on initial home visits for the first few cases managed by the trainee. Afterward, the supervisor should accompany the trainee as needed.
• Supervisors need to demonstrate competencies before they are assigned to supervise workers. They need to be knowledgeable about policies, procedures, regulations and statutes, as well as having knowledge and experience in child protection and child welfare services.
• Supervisors should be trained in how to address poor performance in their subordinates, and should receive training in use of the performance appraisal tool.
• Program supervisors should provide regular supervision to Social Work supervisors as well as reviewing their supervisory notes monthly, as required by current policy.
• A thorough review of trainees' progress notes and case records should be performed by a supervisor on a weekly basis. The supervisor should sign off on this review, and enter it in the case record, not just in the supervisor's log. In the case of more experienced workers, a supervisor should review the case record at least on a monthly basis, and provide evidence in the chart of concurrence with the assessment and plans developed.
• Only the most experienced supervisors, with several years of direct child welfare & child protection experience should supervise training units.
• Quality Management Teams should utilize Continuous Quality Improvement principles to ensure that the goals expressed in the departmental mission statement are implemented, and that DCF policies and procedures are followed with regard to case documentation, management and supervision.
• Regional Quality Management teams should report to the Regional Administrator and the Central Office about trends in Regional Office Social Worker practice which are barriers to performance.
• Staff must have a manageable caseload based upon national, standards, in order to preserve quality of care, and to assure child safety. It is not reasonable to hold workers and supervisors accountable for the management of their cases, if they are responsible for an unmanageable caseload.
• An internal review unit must be established to systematically look at case management in the case of all deaths and critical incidents of children with open, or recently closed cases. This unit must be prepared to make recommendations for remediation or discipline if department policy and accepted practice are not followed. This internal review unit must be prepared to interface with the State or Regional Fatality Review Teams, as well as with an independent Professional Advisory Committee.
• The Professional Advisory Committee or another group should serve as a resource to the Commissioner in interpretation of Quality Management information, and review of current or proposed new policies. The already mandated State and Regional Review Councils may be adapted to serve this role.

5. Training

A.  Substance Abuse Training

DCF has developed a two day (10 hour) training on substance abuse as part of the original training received by all trainees. Voluntary training is available for previously hired workers and supervisors. Additional specialized training is available to people who have completed the basic training. Nevertheless, most caseworkers are unskilled in addressing substance abuse problems in families. Many caseworkers do not feel they have the authority to address this issue, and may also be unaware of Federal confidentiality guidelines concerning substance abuse treatment. Therefore, they are unable to establish effective communication with treatment providers. These problems are further complicated because of a statewide lack of treatment slots raising barriers to treatment.

Recommendations:

• Mandate substance abuse training for all staff.
• Integrate substance abuse into the procedures for risk assessment. This will necessitate the use of screening tools and more extensive investigation if initial screening questions indicate a high risk of substance abuse.
• Encourage and participate in development of local consortia which address the multiple needs of substance abusing families and their children.
• Encourage review of substance abuse policies and practice by a Professional Advisory Committee.
• In cases where substance abuse has been confirmed to be a problem for a family, expectation of drug treatment compliance should be clearly stated as part of the treatment plan, and incorporated into court ordered expectations. It is recognized that treatment protocols have drug testing incorporated into them.

B.  Domestic Violence

Despite recent information that indicates the high correlation between domestic violence and injury to children/child abuse, there is a high degree of ignorance at DCF about this risk factor. There is currently a one-day (5 hour) training session given to new employees. However, this is primarily didactic, without assessment of interviewing skills.

Currently, there are many cases where DCF has refused to accept reports

(a) when women have obtained a temporary restraining order or an order of protection, based upon the erroneous assumption that the woman and her children are now safe.
(b). when a child is hurt during an episode of domestic violence but there was no "intent" to hurt the child
(c). when a mother is at a shelter with her children based upon the erroneous assumption that they are now safe.
(d). when a mother is returning home, with her child to an abusive partner.

In fact, all of these assumptions are invalid and dangerous. Restraining orders, while often helpful, are only effective to the degree to which they are respected by the object of the order. By the time the assailant arrives at the home of his victim, there may not be a way for her to contact the police. Children in homes where there is domestic violence are at very high risk. In 25% of all cases of assault where a child is present, the child is injured. Older children will frequently intervene in an attempt to protect their parent. In one large study 70% of children housed with their mother in a domestic violence shelter had been physically abused. Although most commonly the abuser of the children is the same as the abuser of the mother, abused women are far more likely than non-abused women to physically abuse their children.

Recommendations:

• Integrate domestic violence into the procedures for risk assessment. This will necessitate the use of screening tools and more extensive investigation if initial screening questions indicate a high risk of domestic violence.
• Establish an expert panel to include law enforcement, domestic violence, children's protective services professionals to develop guidelines and program (with an evaluation component) for reporting and response to child abuse/domestic violence cases.
• DCF should accept and investigate reports, regardless of whether the victim has a restraining order or is housed in a shelter. Injury to a child is the highest risk, intent is not important.
• All DCF social workers and supervisors should have extensive training in the dynamics of violence, interviewing skills with regard to both the victim and the victim's partner, and on the effect of violence on children. An awareness of community resources is also very important.
• In-depth interviews and background checks should be done on all foster parents, or prospective relative placements. Children must not be placed in a home with adults who have a history of domestic violence.
• Confidentiality statutes require reworking to facilitate communication between DCF, Family Relations and Domestic Violence Programs. All Mandated Reporters should be able to share information which is relevant to the safety of children.

C.  Severe Physical Abuse, Sexual Abuse and Neglect

In the training academy curriculum, there is a single 2 1/2 hour session devoted to health related issues. Buried within information on children with special needs, health management of children in foster care, and SIDS is a short section on physical abuse, sexual abuse and neglect. In the section on physical abuse, there is no reference to the particular injuries typical of the fatally or critically abused child, although reference is made to substance abuse and domestic violence as predisposing risk factors for any sort of abuse or neglect. The serious and life threatening implications of fractures during infancy is never mentioned. "Shaken baby" (more properly shaken/impact injury) is mentioned, but not in context of the other injuries which commonly accompany it. It is not surprising therefore, that social workers who have received this training know little about the significance of certain types of severe injuries, or about the fatal or disabling potential of severe neglect during infancy.

Neglect comes in many forms in addition to lack of care, emotional, moral. and educational neglect can result in severe emotional and mental disabilities. Medical neglect can result in physical disability or even death. We found all of these forms of neglect to be present in this family's case history. Social workers involved with protective service cases require a much higher degree of knowledge about the nature of abuse and neglect.

Recommendations:

• A more extensive training in abuse and neglect considerations is clearly needed by workers and supervisors who will be involved with protective service cases. We recommend a comprehensive training devoted to the recognition and interpretation of child abuse and neglect, with particular emphasis on the significance of high risk forms of physical abuse (e.g. fractures, head injuries, internal organ damage, second/third degree burns), the nature of fatal child abuse, childhood injury prevention, the limitations of physical examinations in sexual abuse evaluation, and the dangers (including death) of severe neglect in all its manifestations.
• Another separate session should be devoted to the primary health care and special needs of DCF children. This should include training in childhood injury prevention.
• Training in recognition and understanding of abuse and neglect should be taught by people with recognized expertise in that area.

D.  Other Training Issues

• All DCF personnel should be made aware of regional resources available for consultation.
• All DCF personnel should undergo personal safety awareness training.
• Training curricula for all personnel should be periodically updated to reflect changes in recommended practice. Such changes should be reviewed with the Professional Advisory Committee.
• Supervisors hired prior to 1992 need to have mandatory training in the material currently contained in Modules 501-504.

6. Working with Foster Families

We recognize that increased assessment skills will increase, at least to some extent, the number of children who are removed from their parents homes. This would, in our view, have been the appropriate recommendation for the Emily and her siblings. Because of this, it is clear that foster families must be seen as professional partners of DCF and of other service providers for the children they care for.

During our investigation. we interviewed representatives of the Hispanic Foster Parents support group. This group perceived many problems in their interaction with DCF, which have resulted in a more than 30% decrease in their numbers over a several month period (over one hundred to approximately sixty-five). Many of their concerns reflect problems common to all foster parents, such as lack of information regarding how to seek reimbursement for expenses incurred through the actions of a foster child. Other concerns of this group relate to problems caused by language restrictions, such as the availability of foster parent in-service training (mandated by the state) in Spanish.

Recommendations:

• Priority needs to be given to recruiting and retaining good foster parents, especially Spanish speaking foster parents. There is a need for the division charged with recruitment and training of foster parents to be adequately staffed.
• More careful screening of foster parents, including on-going screening is needed.
• More careful matching of foster parent and child is necessary to prevent frequent and multiple placements in different foster homes. Such disruption at a critical time for a child, when he or she has been removed from their parent's home can be very damaging when superimposed upon the problems which led to the initial removal.
• Foster parents need better training and need to be seen as professional partners of DCF in the care of children who have required placement outside the home. It is not reasonable to expect a foster parent to adequately care for a child with complex medical, psychological or educational needs if they are not given the training or the case information necessary to properly care for that child.
• Foster parents need to be informed about all their rights, and about the needs of their foster children, in their principal language. Certainly Spanish is so commonly the principal language, that all such documentation should be routinely available in Spanish.
• All mandated training for foster parents should be available in Spanish at frequencies comparable to its availability in English. The use of videotaped training sessions may be helpful in this regard.
• Physical exams should be performed prior to, or extremely rapidly after, placement in foster care. The information in the Medical Passport should be available to foster parent and to the examining physician at the time of placement.
• DCF staff who are designated as liaisons between the department and foster parents must view themselves as advocates, supporters and spokespersons for foster parents, and help them make their needs known to the department.
• The liaison worker for a foster family should, during a Q.A. investigation of abuse in foster care, provide support for the foster family during the investigation process, as well as make sure that the family understands the results of the investigation.

B. Problems Outside of DCF

1. Medical

The most highly valued report to DCF from an outside source is a report from a physician, stating that he or she believes an injury is the result of abuse or neglect. All physicians are mandated reporters, and any who make a report will, presumably, be asked for an opinion about the cause of an injury and whether the explanation provided by the caretaker is credible. Unfortunately, most physicians are not particularly knowledgeable in the area of child abuse. This should not be surprising, as most physicians have less than five hours of formal training in recognition and evaluation of child abuse during their medical school years. Pediatricians receive more intensive training during their residency years, and so do radiologists, but little time is spent on recognition of child abuse during the training of general surgeons, orthopedists, and neurosurgeons, who may be the treating physicians for bums, fractures and brain injury . When an unknowledgeable physician reports to an unknowledgeable social worker, high risk injuries can be misinterpreted, especially in infants, the group most vulnerable to fatal abuse, who cannot speak for themselves.

Another problem facing physicians is that of treating children who are in foster placement. Foster parents often have little or no information about the physical or emotional problems of their charges, and the so-called medical passport is often not available or incompletely filled out. Imagine the difficulties of a physician in this setting. If the child has an ear infection, is he allergic to penicillin? Was an infant premature, and therefore more vulnerable to certain respiratory infections? Is a child HIV infected, and does that change the evaluation and treatment indicated for an apparently minor illness? Does the child have a life-threatening sensitivity to eggs or nuts or milk? It is understandable that children may be removed from a home in a hurry , but more frequently the case has been open for weeks, if not months or years prior to removal. In such a case, the absence of appropriate medical records is insupportable. Foster parents need to know enough about their foster children to be able to care for them safely-food allergies, insect allergies, immunizations, susceptibility to infections. This information must be provided to the foster parents, who should be advised of state confidentiality regulations. DCF must not put children at risk by depriving their direct and medical caretakers of information necessary to provide safe care for
these children.

Recommendations:

• Mandated, state-designed (with appropriate consultative assistance) training for physicians and all other, licensed, mandated reporters. This training should cover recognition of physical abuse, sexual abuse, and neglect, as well as the requirements for and method of making a report. Demonstration of knowledge and understanding of the material contained in the training should be tied to relicensure. The nature of the training should reflect the practice of the reporter, i.e. the level of medical information provided to physicians should be higher than that supplied to teachers or law enforcement officers.
• Certain medical tests which may assist in the evaluation of high risk physical abuse should be incorporated into a protocol so that an inquiry is made at the time of telephone report as to whether these tests have been performed or ordered. An example of such a test would be a skeletal survey whenever a fracture or other severe physical injury is being reported in a child less than two years of age. This is an official recommendation of the American Academy of Pediatrics.
• Allegations involving possible severe abuse (fractures, head injury, second or third degree burns, internal organ damage) should be reviewed with particularly knowledgeable physicians. Just as DCF utilizes the particular expertise of certain physicians to do sexual abuse evaluations, uncommon expertise in the area of severe physical abuse would be very useful in assessing risk to children. Each region should have a list of physicians under contract and available for such consultation.
• All hospitals should be required to have a policy that governs recognition and reporting of child abuse. The hospitals should also be required to ensure that this policy is followed by its employees or medical staff. Adherence to this policy should be expressed in the hospital's Quality Assurance Plan. The accrediting state agency should be responsible for review of this plan.
• All children in foster care should have a complete medical record available in case the child requires medical care.
• Professional societies (such as the Connecticut Academy of Pediatrics) should be encouraged to cooperate with DCF and other state agencies in promulgating policies, programs and legislation which will better protect children.
• As a long-term goal, hospitals should be encouraged to develop medical information systems which facilitate the easy access of Emergency Department personnel to outpatient or inpatient records of prior injury.

2. Law Enforcement

Effective investigation and justice for abused and neglected children requires a close interaction between law enforcement and DCF. Connecticut state law mandates joint notification for sexual abuse and for serious physical abuse or neglect. Law enforcement officers are mandated reporters of abuse, and can and should provide needed investigative skills in these cases. Federal law mandates interagency cooperation in the investigation of sexual abuse and serious physical abuse, under the Children's Justice Act. In Connecticut, this has resulted in the establishment of an Interdisciplinary Team in each (DCF) Region. The utilization and cooperation of these Regional Teams has been inconsistent across the state, dependent upon the attitude and commitment of the participating agencies in each region; this is not tolerable.

Recommendations:

• A closer interaction between local law enforcement agencies and the regional offices of DCF. A liaison officer should be appointed from each law enforcement agency, to act as a reliable conduit for necessary information in both directions.
• Both DCF and each law enforcement agency must verify that cross reporting for sexual abuse, serious physical abuse, abandonment and cases of imminent risk to children is occurring.
• Law enforcement officers, like all mandated reporters, should have periodic training in the recognition of child abuse and neglect, and in the reporting requirements they are obligated to follow.
• DCF Investigators should have easy access to data from the "COLLECT" computer system, as a source of state arrest and conviction information.

3. Legal and Court Issues

We believe the court process can better protect children. In fact, the same concerns expressed by Governor O'Neill's Task Force on Justice for Abused Children (1989), Governor Weiker's Task Force on Justice for Abused Children (1994), and Attorney General Blumenthal's Commission on Permanency for Children (1993), continue to persist and have never been fully addressed. Attorney's for children should receive adequate training and be held acceptable in their roles as guardians ad litem (GAL). Judges assigned to juvenile courts should be trained in and sensitive to important principles of child protection. Under the present system, judges rotate in and out of juvenile court, often leaving just as they have developed some expertise in the area of practice. Juvenile courts are ill-equipped and ill-designed to handle the increasing volume of cases.

In addition, there is no statutory specification for the role of specially trained citizen volunteers also known as court-appointed special advocates (CASA), in court proceedings, and in judicial and administrative reviews. In Connecticut, Children in Placement (CIP) has been providing these services under contract with the Judicial Department.

Recommendations:

• Children's attorneys should have a training designed to give them a clear understanding of their responsibilities as a Guardian ad litem, including their duty to meet with their clients, review the case record, and speak with pertinent service providers prior to trial or court review.
• A child's attorney/GAL and the appropriate Assistant Attorney General (AAG) should be notified of any new reports made to DCF in an ongoing court case.
• Juvenile court judges should be authorized and willing to assume the responsibility of timely permanency planning for children including the need for termination of parental rights when reunification or family preservation is not in the child's best interest.
• There should be a select group of juvenile judges with specialized knowledge and sensitivity to the issues of child protection. This is the third state task force to recommend the institution of a separate panel of juvenile court judges.
• All attorneys, juvenile court judges and CASA volunteers should have training relative to understanding of physical abuse, sexual abuse, neglect and a child's need for permanency. This training needs to stress the importance of risk factors such as substance abuse, domestic violence and the implications of certain types of physical abuse - such as fractures, severe burns, head injury and damage to internal organs.
• Juvenile courts should have the resources to process cases in a timely manner and should fully utilize CASA volunteers to facilitate the ongoing court-based monitoring of cases active in juvenile court. A procedural role for the CASA should be specified. This role must, with judicial authorization, permit contact with parents and children.
• DCF and the Assistant Attorneys General should work together more closely, as the Attorney General's Office represents DCF in all court matters. Although the department makes social work decisions, these decisions should be informed by the views of the assigned AAG, particularly as they implicate court proceedings. In cases of disagreement on matters affecting court proceedings, the disagreement should be reviewed at the Program Director level at DCF.
• When Protective Supervision or Commitment is granted, DCF should demand very clear court expectations based upon the identified family problems. These expectations should be documented (in Spanish, if necessary), distributed to all parties and service providers, and monitored by CIP/CASA. When such expectations are not fulfilled, there should be prompt notice given to court and to all attorneys. DCF should seek contempt citation or removal of the children in those instances.

4. Legislative Defects in Connecticut Statutes

There are several areas where the Connecticut statutes governing child abuse and neglect are inadequate for the protection of children. First and foremost, the confidentiality statutes for DCF and the agencies with which it interacts are barriers to the effective protection of children. Secondly, there is no unified Children's Code, resulting in the haphazard and patchwork nature of our statutes. Dual and different guardianship and termination statutes govern juvenile and probate Courts, and probate court involvement is frequently recommended inappropriately in cases of abuse or neglect by DCF staff in lieu of accepting a case. Permanency planning and termination statutes need to be reviewed and amended. Reporting statutes should be examined as well as statutes implicating judicial intervention on behalf of a child at risk, particularly high risk newborns.

Uniform Fatality Review is also an important issue for Connecticut. Because we have a central Medical Examiner system in our state, we probably identify the vast majority of abusive homicides. However, because there is no effective way to document, in a central and retrievable manner, the important information relevant to injury deaths (so-called accidents), we probably miss the great majority of child deaths due to neglect. For example, it is known that in Missouri (the state with the most effective fatality review system) 78% of children dying from fires or bums in 1993 were less than five years of age. It is also known that 54% of such deaths occurred in children who were unsupervised. It is obvious that a death of an unsupervised child less than five years of age in a house fire is the result of negligent supervision by the parents or other caretakers. Other siblings in such a household are at risk, but DCF may never know about them. Such information should be obtainable in Connecticut. Secondly, while child homicides are identified at autopsy, the lack of interagency cooperation in investigation results in far too few arrests and prosecutions for such crimes, and interferes with the ability of DCF to protect siblings. In the Hartford Region, the requirements of the Children's Justice Act have been interpreted as justifying (or even mandating) an interdisciplinary Child Fatality Review Team. Although this team could benefit from some legislative changes, it has already had an impact in the quality of investigations performed when a child is discovered to be unexpectedly dead.

Recommendations:

• We recommend that a Children's Code be developed before the next legislative session, by the Attorney General's Office acting in consultation with DCF and other child welfare experts.
• The confidentiality statutes of Connecticut must be altered to permit mandated reporters to effectively communicate with DCF and with each other so that children may be adequately protected in our state.
• Permanency planning statutes should reflect that "short" intervals of time, such as one year, are exceptionally long in the context of the life and development of an infant. The time periods for assessment of rehabilitation of abusive or neglectful parents should reflect this fact.
• Termination statutes should reflect a presumption that in certain cases, removal from a home and termination of parental rights can occur based upon heinous, prior behavior of the parent(s). Examples of such cases should include (but not be limited to) cases where a child has died as the result of abusive or negligent behavior, where prior TPR has been obtained with regard to a prior sibling because of a sustained and unremediated pattern of severe abuse and neglect, or where prior TPR has been obtained with regard to multiple siblings based upon a clear pattern of inability to care for children. An exception should exist for the cases where a clear and demonstrable change has already occurred in the behavior of the relevant parent(s). In the case of such an exception, nothing less than 18 months of Protective Supervision should be acceptable.
• Legislation supporting the recommendations to the Commissioner on matters of DCF Quality Assurance and Policies by a Professional Advisory Committee should be enacted.
• Mandated training in recognition and reporting of child abuse and neglect must be established for all mandated reporters. Such training should be approved by DCF, but need not be administered by it. In the case of mandated reporters who are licensed by the State of Connecticut, compliance with training requirements should be necessary to maintain licensure. Penalties for failure to report should be stiffened and enforced.
• A fully staffed State Child Fatality Review Team should be established by statute, with all childhood deaths reported to a central registry. The State Team should be mandated to establish an appropriate number of Regional Teams to coordinate the interdisciplinary investigation of childhood deaths. The State Team should also be mandated to participate in the development and implementation of policies to prevent unnecessary childhood deaths.

5. Other Recommendations

• We strongly feel that a 5 person subcommittee of this panel be convened at six monthly intervals for no more than two years to review the results of these recommendations, to provide guidance in interpreting these recommendations and to assist in overcoming any obstacles to implementation.