By Tony Gonzalez, The Tennessean
Investigations into severe child abuse were left incomplete and
failed to address the complicated needs of families, according to a new
report by experts tasked with examining the "worst incidents of child
abuse in Tennessee."
The Second Look Commission's 2012 annual report recommends more training for child abuse investigators, including Department of Children's Services caseworkers, mental health providers and police.
those professionals must communicate better to close "gaping holes" in
the child welfare system, which still misses opportunities to protect
kids, including in cases in which abusive families are already known to
officials, the report says.
"The SLC determined there are
significant problems with the manner in which severe child abuse cases
are being handled in Tennessee," the report states. "It will take a
concerted and sustained effort to peel away the many layers of this
complex issue to get to the core."
The findings highlight how all
child welfare officials can improve, especially by undergoing training
sessions together, said Carla Aaron, DCS executive director for child
safety and a member of the commission.
"What I can impact within
DCS, certainly, we will try to weave it in," she said. "Several of the
recommendations we have already begun working on."
Lawmakers, judges, doctors, lawyers, police and child advocates make up the 17-member commission, which lawmakers created in 2010 to examine cases in which children suffered severe abuse more than once.
23-page report details eight areas where Tennessee can improve and
summarizes six cases the commission reviewed in depth - including
investigative files, police reports and medical records.
child abuse investigators gave up too easily and didn't share
information, allowing serious concerns to go uninvestigated, the panel
In one case, a child was left with drug-using caregivers
because they wouldn't cooperate - although police were able to glean
information. In another, a mother and child in a domestic violence
shelter could not be located. Seven months passed before another neglect
report sent an investigator to search for them again.
alarming details, Aaron said DCS would be careful not to rush to revise
policies because the findings stem from so few cases, each with unique
But the examples do show areas where training,
better communication and policy reviews may be warranted, said Craig
Hargrow, director of the Second Look Commission.
"It's been the
philosophy that training and policy are likely the places that we and
everybody else will have the most impact," he said.
criticized investigations that were closed too soon - before a full set
of services could be lined up to help families.
seeing this year is caseworkers identifying an issue or a safety hazard
and addressing the hazard but not particularly addressing why the hazard
is there in the first place," Hargrow said.
As an example, the
report describes a girl placed with an out-of-state relative only to end
up moving across multiple states and in and out of foster care.
two years later, she found herself back in Tennessee, off her
much-needed medication, without a home and not in school," the report
Aaron said DCS has already begun a shift toward issues-driven investigations.
harder, and it's a philosophical change," she said. "For many, many
years, you went in and investigated the incident and made your decision,
closed your case and moved on. Now you're not only having to view the
neglect that is presented to you, but the underlying issues of the
family. To get at that you really have to engage with the family and
gain some trust, and once you've uncovered that, you need to have the
The report has been delivered to lawmakers, Gov. Bill Haslam and
other child welfare officials, including those who may need to consider
possible changes to laws, policies and staffing.
wants more consistency among county Child Protective Investigative
Teams, which make decisions about criminal child abuse prosecutions. A
statewide coordinator and advisory board could help preserve evidence
for future prosecutions, experts found.
The report also found:
• Domestic violence investigations need to be improved, and offender penalties increased;
• The state should be more thorough in examining the health of children exposed to methamphetamine;
DCS should review policies regarding how foster families and
custodians are approved to care for kids, to avoid cases like one in
which a girl was left to live with a man who had sexually abused her
One area that remained a concern is that, in too many cases, an
allegation of abuse had to be reported to DCS multiple times before an
investigation began. In repeat abuse cases, on average, children are
referred 6.4 times before the case is investigated.
three regions are trying a new way of handling cases. Any time a child
under 3 is referred a third time, a deeper review by regional
supervisors takes place.
According to DCS, less than 4 percent of
children brought to the department's attention through an allegation of
abuse or neglect experienced repeat maltreatment within six months,
which the state says is better than the federal standard.
governor did not have an immediate response to the report, but a
spokesman pointed to his support of enhanced domestic violence and
methamphetamine penalties as consistent with the findings. The report
backs Haslam's push for new family justice centers, where professionals
work together in one place to service family violence victims.
The commission also reported that some of its 2011 findings
about DCS caseworker turnover and low pay could be partly addressed by
the department's recent budget proposal, which asks for frontline staff
Meanwhile, a commission analysis of abuse statistics was hampered by faulty numbers provided by DCS.
The commission had worked with numbers that showed a dramatic increase in severe re-abuse cases, but DCS conceded in October the numbers were not correct - that 2010 numbers were undercounted and 2011 overcounted.
said the commission has learned of about 270 repeat-abuse cases in
fiscal year 2012, although the data problems make it impossible to
analyze whether that's up or down.