Critical thinking skills could have saved Sacramento child's life

A lack of critical thinking skills among Sacramento County’s child welfare agents and not enough communication from mental health providers may contribute to kids ending up in dangerous situations.

So asserted a tough yearly evaluation by the Child Protective System Oversight Committee, an all-volunteer group charged with reviewing the county’s embattled Child Protective Services agency.

The oversight committee, an extension of the Sacramento County Children’s Coalition, actually did far less investigation into CPS’s work than in previous years. According to coalition co-chair Gina Roberson, that’s because a big chunk of the panel’s time was spent going over the scope of its role with the county counsel.

But even with only nine critical incidents to examine—those that involved a child’s death or near-death—committee members uncovered many of the same issues they’ve been raising for years. All but one of the cases involved prior CPS contact and all but one concerned children the age of two or younger.

“It was far fewer than we have reviewed in the past, so we weren’t able to make any broad findings or recommendations,” Roberson told the board of supervisors during the February 25 hearing. “But we were able to identify some of the same trends and issues from reports past that align with our previous recommendations.”

Those trends included decision-making errors, flawed policies and procedures, and an inadequate understanding of how domestic violence, addiction and mental health issues often overlap in child abuse cases.

Some of those problems arise because of a lack of communication between the county’s CPS and mental health divisions. In two cases—one involving a child’s death and the other involving a near-death—the panel said the mental health system had direct information that, if conveyed to CPS, could have steered things a different way. The Department of Health and Human Services oversees both units, but that has yet to result in more direct relations.

“This committee’s observation is that mandated reporters in the mental health system are hesitant to report due to a misunderstanding of their responsibilities under mandated reporter laws,” the report states.

DHSS director Sherri Heller said efforts are underway to address that. She and CPS deputy director Michelle Callejas also spoke of creating an evidence-based database for tracking multiple risk factors in families, revamping the agency’s critical review process and addressing the issue of confirmation bias, in which social workers pursue evidence that supports a preconceived conclusion.

Heller also acknowledged that CPS hadn’t been paying attention to prior contacts with families when allegations were deemed unfounded or unsubstantiated, which could help inform future investigations.

But there are other issues as well, said Roberson.

“What we’ve seen over the years, where we think the gap is, is really in the critical thinking skills of the social workers,” she told supervisors.

Supervisor Phil Serna suggested that might be due, in part, to micromanaging the work of social workers through detailed policy forms and decision trees that take away their discretion. “Perhaps we’ve institutionalized the asking of the wrong questions,” he suggested.

But it seems that, in at least one instance, discretion was the cause of the problem. In one of the cases reviewed by the oversight committee, a social worker verified allegations that parents left their child with an unsafe caregiver, but labeled the investigation as “unfounded” to keep the family intact, possibly because the parents expressed a willingness to work with CPS.

“That same child was later left with a different unsafe caregiver and murdered,” the report states. “While CPS may not have had an opportunity to evaluate the second unsafe caregiver, a substantiated disposition on the first referral would have provided the young parents with services that might have been beneficial.”

That kind of thing may not be a one-time issue, either.

“That is a theme of what our report said last year,” Roberson explained. “Is there a reluctance to substantiate?”

For her part, Callejas didn’t deflect the findings.

“It’s a wrong disposition,” she told supervisors. “It’s an error and it’s important for us to fix.”

Callejas and Heller expressed their willingness to keep chipping away at the issues facing Sacramento’s child welfare agency, and bringing in outside agencies, like Children’s Law Center of California and UC Davis, to revise policy manuals and train emergency response supervisors.

Next year’s funding allocation for the impacts of state prison realignment also promises to help the downsized agency add some needed staffing, supervisors said.

“A project in continual motion,” is how Supervisor Jimmie Yee put it.

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