STILL BROKEN: DC's Child Welfare System, Part 1

Updated: Dec 30, 2021

Funded by SpotlightDC:Capital City Fund for Investigative Journalism and The DC Line


Outside the three-story, red brick apartment building at 935 Division Ave. NE, it must have seemed like an ordinary spring day on April 1, 2020, with an overcast sky and a temperature of around 45 degrees. Yet the tragic events unfolding that morning in Apartment 6 — hidden within what looks like a nondescript mid-20th-century structure in a worn residential neighborhood of Ward 7 — present a disturbing and untold story about the plight of many infants and children in the nation’s capital.


Two-year-old Gabriel Eason lay cold and unmoving. DC Fire and Emergency Medical Services (FEMS) personnel desperately tried to revive him, having arrived after his mother, Ta’Jeanna Eason, called 911 at 8:24 a.m., reporting “an unconscious person.” Minutes later, members of the Sixth District Metropolitan Police Department (MPD) arrived at the building, according to government documents provided to The DC Line.


FEMS attempted life-saving measures. They were too late — too late by several months. The autopsy conducted by Dr. Sasha Breland, then the District’s deputy medical examiner, captured a slow death and offered proof that Gabriel’s two short years on earth were tortuous.


He suffered multiple blunt force trauma to the head and central nervous system, marked by swelling to the head as well as abrasions and contusions with associated sub-scalp hemorrhages. There were contusions to the heart and thymus gland; liver lacerations; right kidney lacerations; a small subdural hemorrhage to the left side of the brain; and 36 bilateral rib fractures — 30 that were acute and six that were healing.


His two older brothers — 3 years old and 11 years old — also lived in the Division Avenue apartment and carried scars of extreme physical abuse.



Within hours of Gabriel’s death, his siblings traveled by ambulance to Children’s National Hospital on Michigan Avenue NW for examinations. Physicians found that each child presented with “trauma” to his body.


The 3-year-old, referred to as I.E. in court documents, suffered rib fractures, liver lacerations, a right kidney injury and blood in the abdomen. Doctors determined that his injuries were caused by “severe blunt force trauma” and admitted him immediately to the intensive care unit.


The eldest child, identified as M.E., displayed a “healing black eye” and “appeared to have older injuries.” Clearly underdeveloped for an 11-year-old, he weighed only 78 pounds and stood “a little over 3 feet tall.” He told the medical staff that his mother had asked him to perform CPR on Gabriel as they waited for FEMS to arrive — and that he could still taste his brother’s saliva in his mouth.


Police later determined that M.E. received that black eye two weeks earlier from a blow delivered by Antonio Dale Turner, his mother’s paramour and the father to the child she carried in her womb. M.E. told MPD detectives that his mother and Turner frequently hit him and his younger brothers. “If, in the morning, the children’s diapers were wet, [I] would be beaten,” he said.


MPD subsequently charged Eason and Turner with first-degree cruelty to children and felony murder. Cynthia Wright, an assistant U.S. attorney for DC, is handling the prosecution; a court appearance is expected on Jan. 20, according to court records. The younger children were placed in foster care — another case of too little, too late from DC’s child welfare system.



The Eason brothers are far from outliers, both locally and nationally. They are part of a larger population of infants, children and youth who each day experience frightening levels of violence across the country. In Houston, an 8-year-old boy was murdered — his body in one room while nearby his three siblings were forced to fend for themselves after being abandoned by their mother. Elsewhere in Texas, an El Paso woman allegedly repeatedly beat her 4-year-old nephew, leaving him in a vegetative state. In New York, 7-year-old Julissia Batties, 4-year-old Jaycee Eubanks and 4-year-old Aisyn Emerson-Gonzalez were all beaten to death by members of their family. All of these incidents — occurring within the span of a few months this year — mirror tragic cases locally.


This is not an epidemic caused by the ongoing pandemic. Rather, it extends back many years. In 2019, the DC Office of the Chief Medical Examiner reviewed the deaths of 51 DC children up to the age of 19. The fatalities reviewed that year actually occured between 2015 and 2018. Further, they did not represent the total number of children who died during those years; no one has that definitive list, according to sources interviewed for this series.


In 2020, the Child and Family Services Agency reviewed 40 deaths of infants, children and youth. Fifteen of those occurred in 2018 and 2019; there are no public records that disclose how many children actually died last year, either.


While some child deaths are due to natural causes, many are the result of violence. Those that result from guns used on the streets may gain the most attention, but others happened inside the victims’ homes, behind closed doors. Because of scant media attention, there’s little public awareness of the insidious and brutal treatment of infants, children and youth like Gabriel Eason, Makenzie Anderson, Kyon Jones, D.J., L.D., S.C., and the 1-year-old boy found dead in July 2021 in an apartment on Ainger Place SE; many presume the latter infant was murdered but as of this writing an MPD spokesperson said detectives are still investigating.

For many of those children and countless others, there are no public memorials marked by stuffed animals, candles, homemade cards and heart-shaped balloons. Even their names remain unspoken; police or fatality reports often refer to them by their initials or simply as “decedent.”

Their deaths, or near fatalities, serve as billboards shouting about the decline of childhood for all too many — the degradation of what should be an extended period of innocence and joy protected by adults and the government. The result is that they are unable to engage in the simplest activities enjoyed by their peers: riding a scooter, playing ball with siblings, walking home from school, or standing at an ice cream truck waiting to buy a Dreamsicle.


Frequently, they are forced to navigate households where parents suffer with substance abuse or mental health disorders; forced to assume adult responsibilities because they are dealing with parents who lack critical and essential parenting skills; or forced to quietly plead for a government rescue that, as illustrated by Gabriel Eason, may never come.

A widely held directive of any government is to protect its citizens, particularly the most vulnerable or those at the margins. No group fits that description more than children.


The DC Line conducted a six-month investigation that involved an extensive review of government documents, court records, published and unpublished external reports, and agency operations and programs. The dozens of people interviewed included key DC officials, government insiders, a whistleblower and former ombudsman, and child welfare experts and advocates.


The DC Line’s investigation revealed that the District consistently fails to protect far too many of the city’s infants, children and youth.


Some might challenge that assertion given that this June, DC resolved a 32-year lawsuit focused on reforming the city’s child welfare system. Initially known as LaShawn A. v. Marion Barry Jr., this class-action litigation accused the District of violating various federal and local laws relating to foster care and of not addressing the abuse or neglect of children who were considered wards of the state. Over the years, the defendant’s name has changed with each successive mayor.


District officials celebrated the end of that case as an indication that reforms have substantially solved the issues at stake in the litigation. However, The DC Line’s investigation yields a different conclusion. The city’s child welfare system — which is comprised of the MPD, Department of Human Services (DHS), Department of Behavioral Health (DBH), DC Health Department, Office of the State Superintendent of Education, Department of Youth Rehabilitation Services, DC Office of the Attorney General, DC Superior Court’s Family Court Operations Division, Office of the Chief Medical Examiner, and Child and Family Services Agency (CFSA) — is rife with systemic problems:

  • Child abuse and neglect investigations often are delayed or suffer from a flawed investigative process, sometimes resulting in instances where children are murdered or severely injured and maltreated.

  • Mental health services for children and their parents are grossly insufficient.

  • The home visitation protocol is inadequate, often overlooking dangerous environments where there is significant drug use or domestic violence.

  • The monitoring of fragile or troubled families is poor and ineffective.

  • A hidden foster care operation is allowed to exist that not only denies children critical resources but also can jeopardize their safety and lives.

  • The process for reviewing child fatalities often is years behind and built around questionable determinations regarding the cause of death, allowing those who may be guilty of abuse or neglect homicides to escape accountability.

The families of a majority of the children whose deaths were reviewed in 2020 had direct interaction with one or more of the agencies mentioned above, according to government documents. That reality has prompted sources interviewed for this series to consistently argue that the underlying issues identified in the LaShawn A. case have not been fixed: Despite that court settlement ending the protracted litigation, the system still desperately needs a redesign or transformation. This investigative series focuses on particular areas that The DC Line found to be failing: investigations, the child fatality review process and foster care.


Ward 1 DC Council member Brianne Nadeau, who heads the committee that oversees large sections of the child welfare system including the Child and Family Services Agency, declined on three occasions to be interviewed for this series, despite knowing that The DC Line was examining issues related to the life and death of children in the city.


EVADING RESPONSIBILITY

The DC Child and Family Services Agency is widely thought to be synonymous with the District’s child welfare system — although, during an interview earlier this year, CFSA’s Acting Director Robert Matthews sought to correct that perception: “I believe the public sees CFSA as the child welfare system, [but] we’re just the agency.”


Matthews became the agency’s acting director in July after the retirement of CFSA’s longtime director, Brenda Donald. In October Mayor Muriel Bowser nominated Matthews as the agency’s permanent leader. The council’s Committee on Human Services held a confirmation hearing on Dec. 9, but Nadeau did not ask him about the concerns discussed by advocates in this series. Further, she did not challenge Matthews’ philosophy on issues related to the system. Mathews has worked in CFSA intermittently, beginning in 2012; he left in early 2015 and returned in late 2016. The council has until Jan. 27 to act before the appointment takes effect automatically.


“I don’t see us as ‘the system’ — I do see us as an agency within the larger system,” Matthews told The DC Line during one of two interviews conducted earlier this year.


“The [child welfare] system is made up of a number of other DC government agencies, as well as community-based organizations that work with these families,” he said. “We don’t work with these families alone. Many of these families are connected to DHS. They’re connected to DBH. They’re connected to community-based services. We’re not alone on an island.”


It’s true. There are at least 10 agencies that are key spokes in the child welfare wheel, although the bureaucratic architecture has CFSA as its linchpin. None of this, however, suggests that the system’s components operate effectively and efficiently together.


“The agencies are broken. The monitoring system is broken,” said Christian Greene, a whistleblower who was CFSA’s ombudsperson from 2015 to 2017. “Even though CFSA touts [itself] as being the best in the nation, behind closed doors, people I know across the nation don’t want to be DC.”


Greene was fired after demanding the agency comply with legal mandates to notify children of their rights under the system and to issue certain reports publicly. A judge ruled against her resulting whistleblower lawsuit, which she initially filed in DC Superior Court on May 14, 2018, and later amended on June 29, 2018. Greene, whose appeal in the DC Court of Appeals is pending, recently helped persuade the DC Council to approve legislation creating an ombudsperson for children over the mayor’s objections.


However, many experts and advocates are not completely satisfied with the breadth of the bill — which focuses only on CFSA, rather than the entire child welfare system — or the pace of its implementation. They recently sent a letter to Nadeau, whose committee pushed through the law, to demand that recruitment begin immediately for the ombudsperson, who will be selected by the DC Council rather than the executive branch.


“I’ve seen chronic problems within the [CFSA] as a whole,” said Magdalena Acevedo, a DC resident who adopted her two foster children and advocates on behalf of other foster parents. “Those problems aren’t caused by any particular individual [or] any particular social worker. There are gross systematic issues within the agency that need to be visited and reworked.


When alerted to dangers and risks to children, observers say, DC’s child welfare system managers and staffers appear unable to make the tough decisions necessary to shield children, including removing them from homes where their parents lack the skills to care for them or suffer substance abuse or mental health disorders — sometimes both.


“It’s clear from the history of some families with CFSA that the agency is failing to identify and protect some children who are in danger in their homes,” said Marie Cohen, a policy analyst and former CFSA social worker who reports on the local and national child welfare system in her blog, Child Welfare Monitor DC.


Judith Meltzer, president of the national nonprofit Center for the Study of Social Policy, served as the official court monitor of the CFSA for decades, a role that has meant hundreds of thousands of dollars in payments over the years. Her appointment by U.S. District Court Judge Thomas F. Hogan stemmed from the filing in 1989 of the LaShawn A. lawsuit, whose named plaintiffs — seven children, ranging in age from 3 to 11 years old — were imprisoned by a disinterested, flawed and chaotic child welfare system anchored in the DC Department of Human Services.



The case went to trial in 1991. The plaintiffs sought specific changes that set a high bar. Judge Hogan agreed to impose strict limits on how many cases social workers could maintain and how quickly investigations should occur. Over time, however, the plaintiffs compromised on certain demands. Together with the city, they devised multiple roadmaps or strategies to exit; the last one was developed in 2019. In it, the District agreed to detailed performance goals and reforms in order to end the litigation. The settlement agreement — and the ability of plaintiffs to enforce its provisions in court — will expire 181 days after the CFSA files its final report. Until then, the plaintiffs could push for the judge to revoke it if they can show the District is out of compliance.


As part of the settlement, the District agreed to ensure the CFSA “maintain [current] caseload standards,” said Meltzer. “They’re going to continue to do quality reviews of cases and produce that data. They’re going to expand mental health services. They also agreed to make changes to improve [foster case] placement stability.”


Further, CFSA must prepare two reports indicating its progress on outstanding issues. The first was to cover the period from Jan. 1, 2021, to June 30, 2021, and the other from July 1, 2021, to Dec. 31, 2021. Meltzer said the agency is preparing a draft of the June report.


Under the terms of the court settlement, Meltzer’s organization is responsible only for validating facts and data that the government claims as accomplishments. It is not required to track CFSA as it did while serving as court monitor during the final 20 years of the lawsuit. It’s also important to note the agency isn’t required to elaborate on its shortfalls or failings.


“Right now, we don’t even have all the data for the June 30 report,” Meltzer said during an interview in August with The DC Line. “So, it will be another couple of months before they and we will produce that report. Then, there is a second report that goes through December 2021; it will probably be close to June 2022 before we have a validation report on that.”


Notwithstanding the procedural limitations, the LaShawn A. plaintiffs — represented by attorney Marcia Robinson Lowry from A Better Childhood, a nonprofit watchdog organization — could still object to issues in those reports, said Meltzer. They could also scrutinize the city’s claims of meeting the goals outlined in the settlement.


“Hopefully, they won’t object because the District will have done what it said,” added Meltzer.


The government’s own numbers, however, offer a disturbing depiction of malfunction, even though some advocates question the veracity of the statistics as overly rosy.


In 2019, the CFSA received 17,960 calls on its hotline from people who said they were concerned about the care or physical treatment of District children. Nearly 12,000 of those total calls were screened out for assorted reasons, according to a CFSA spokesperson.


Another 599 of the calls were referred to community organizations or government agencies for assistance, and 588 involved previous investigations. Meanwhile, 5,005 were accepted for new investigations, including one call that came from a day care that Gabriel Eason attended.


CFSA provided the following details about the hotline calls in documents submitted to the DC Council’s Committee on Human Services:

  • 1,993 were related to children being subjected to physical abuse.

  • 1,475 involved substance abuse by someone around a child.

  • 1,227 were related to inadequate supervision.

  • 657 dealt with exposure to domestic violence.

  • 643 were about potential sexual abuse.

  • 571 were related to neglect.

  • 436 were centered around a caregiver’s incapacity because of incarceration, illness or physical or mental incapacity.

At minimum, the data suggest the lives of nearly 6,000 children under the age of 18 were imperiled in 2019.


THE OFFICIAL VIEW: THINGS ARE FINE

Despite the picture painted by the data, CFSA’s Matthews asserted that the system is on a “pretty positive trajectory,” deflecting responsibility with bureaucratic and figurative language while claiming significant advancements.


“We’re moving toward building out our prevention model,” he said. “It’s not a perfect system, but it’s a system where we are able to definitely track our progress, track trends, and as we see issues arise, we’re able to shift pretty quickly because we have a pretty dynamic and talented team of workers.”


DC Department of Behavioral Health Director Barbara Bazron, whose agency serves children as well as adults, agreed. “We live by the guiding principle of creating an integrated system of care and really moving to whole-person care,” she said.


The Department of Human Services has a role as well. “When a family comes in — and particularly to homeless services, which is where there tends to be the most trauma and instability — we are looking at whether they have a history of involvement, or current involvement, with CFSA and the Department of Behavioral Health,” said DHS Director Laura Zeilinger.


Those relationships, she explained, often indicate economic or health-related problems like “severe mental illness or severe addiction, which may be mental illness masked by addiction or other co-occurring disorders.”

“That’s when we’ve seen the highest risk factors for children. And then we shift to a teaming approach with all of those agencies so that we are working together,” added Zeilinger.


“Teaming” is often used when a family is in crisis. Agencies ostensibly collaborate in their response to a family, so it’s more reactive. But its deployment is yet another signal that the government arrived late — maybe even too late, as it did with Gabriel Eason and his brothers.


Generally, DC’s child welfare system relies on community organizations to assist families that may be having issues but are considered “low risk” because they are not in crisis. That, said a CFSA spokesperson, allows “child protection services to focus on the more serious cases in which abuse and neglect have been confirmed.”


The Human Services and Behavioral Health departments along with CFSA often contract with the same groups, including Healthy Family/Thriving Communities Collaboratives and the National Center for Children and Families. Those contractors can have a 1:15 ratio between employees and families, which leaves little time for expansive interaction.


CFSA and its partner nonprofits describe their approach using figurative language that some might dismiss as jargon. For example, according to the agency spokesperson, “front yard” refers to “primary prevention services often provided by community organizations like the 10 Family Success Centers”; “front porch” deals with “secondary prevention programs,” which frequently means referrals to existing government resources; and “front door” is related to “tertiary prevention services provided directly by CFSA’s in-home administration,” which generally means a social worker is assigned to the case.


Evaluations of the nonprofit community organizations with which CFSA contracts do not shed light on how successful any of them are in thwarting neglect, abuse or maltreatment of children. Documents obtained by The DC Line revealed a heavy emphasis instead on hiring practices and CFSA’s pre-approval of employees.


Often those organizations help families prepare “development plans” that may include attending parenting classes, seeking needed mental health or substance abuse assistance from District agencies, or improving their chances for employment. The CFSA evaluations reviewed for this series do not indicate what happened to the families after completing their development plans; those cases are listed as closed. In some instances, the families opt not to create such a document. When they walk away in the middle of the process and choose not to continue their interaction, the nonprofits appear not to conduct any follow-up to find out why.


CFSA no longer handles family assessments in-house. Greene, the former CFSA ombudsperson, argued that by jettisoning that responsibility, CFSA is dodging its legal obligations to safeguard the rights of and protect children in the community, which is heightening the dangers for them.


“They get rid of family assessment. They get rid of the specialized unit for special abuse cases, like sexual abuse and near fatalities. They water it down to spread across clinicians who aren’t properly trained to do the sex abuse investigations,” said Greene. These are all services that she considers key to protecting children and that conform with national child welfare best practice standards.


“Now they’ve embraced this thing that they call diversion,” she continued, referencing a process the agency uses to keep children out of traditional and kinship foster care by placing them with unlicensed, informal, and not legally binding placements with relatives or friends of the family.


The problem, Greene pointed out, is that when “CFSA determines a child needs to be placed outside of their immediate biological family, legal custodian, and/or guardian, the agency is supposed to follow specific laws,” including those governing the services owed to that child — services not provided when “diversion” is used and no case is opened for oversight.


However, she asserted that the District is violating local and federal requirements in this and other areas. “The law’s very clear: If the child needs placement, then if the government is making that decision, the child has been coded as abused or neglected. The agency has a responsibility to place that child, to ensure [its] safety” and to offer appropriate services, she added.


The issue of when and how children should be removed or returned to their biological families is controversial. But it is a key element in whether the District is actually protecting children from abuse and neglect or putting them in harm’s way — with the potential of becoming homicide victims.


Matthews said he wasn’t surprised by the criticism coming from advocates and child welfare experts. After all, he said, the agency regularly deals with “the actual life and death of children. Some of [the criticism] is helpful to improve the system.” When comments aren’t really constructive, he considers it appropriate to “challenge” them.


“I speak highly about what it is the agency does well,” he continued, citing foster care as an example. “We currently have 650 children in foster care; 10 or 12 years ago, we had over 3,000 children in foster care. So, we’re continuing to have a decline in our foster care population.”


That doesn’t tell the whole story, however. What he categorizes as the “in-home foster population” is large. In fiscal year 2021, there were 1,757 such children living with their families. In many cases, the agency’s Child Protective Services division has investigated these homes and substantiated one or more allegations of abuse or neglect. Nonetheless, the CFSA did not remove the children; it considered problems a low or moderate risk.


“They are assigned a social worker from CFSA, and we provide a case plan, or we put in the supports necessary to keep that family together,” said Matthews. “What we’re building, I think, is a prevention continuum.”


What his assessment doesn’t address are the 2019 fatality reports prepared by CFSA and the Office of the Chief Medical Examiner, which clearly indicate children continue to die — many of them from either similar or undefined causes. No widespread attempt at prevention is occurring. Of the 51 deaths reviewed by the Child Fatality Review Committee, nine involving infants were classified as undetermined — a classification used by the ME when despite a “thorough medical and legal investigation, a conclusive manner of death is not determined.”


According to CFSA’s internal fatality report that reviewed 13 fatalities of children involved with the agency, 11 of those children were living at home at the time of their deaths. Three of the 11 deaths involved abuse or neglect; one cause of death was ingestion of fentanyl. The cause of a fourth death could not be determined.


ABUSE’S UNENDING MEMORY

Not every abused child dies. Some of the most severe cases are described as “near fatalities.” Consider this: A little after 11 p.m. on Dec. 22, 2020, a call went from an apartment at 517 Harvard St. NW to the CFSA hotline, indicating a child there was being physically abused. When no city agency came to the home where six children, ages 2 through 13, lived with their mother and her paramour, a second call was made at 8:40 a.m. the next day. MPD officers subsequently responded; however, the mother, Arkazia Davis, said that her oldest daughter was with her father and that the youngest daughter, L.D., who had a different father, was with hers. While she provided precise information about the oldest, the story about the location of the youngest kept changing, according to court documents.


Eventually, it was revealed that her 2-year-old daughter had been missing for several days, ever since a severe incident of domestic violence occurred between the child’s mother and father, Maurice Meniefield. As police began looking for Meniefield, they visited the residence of his sister Quanice in Northeast DC. When they arrived, she was just getting home. She tried to prevent the police from gaining access. When they entered, they discovered her three children were alone hiding in a bedroom with all the lights off.


The missing 2-year-old girl, L.D., was under a bed. When she crawled out, an officer removed the child’s face mask and found that “blood was coming out of her mouth.” Tears were streaming down her face. The MPD officer requested an ambulance.


On the ride to the hospital, the little girl kept touching her face and her stomach. The officer asked her if it hurt; she nodded yes. He asked her if she had eaten anything that day. “She shook her head, ‘No,’” according to court documents.


Meniefield lived in the Harvard Street apartment with Davis and her children, according to court records. On the fateful day, he had been alone with the child. He became angry because L.D. urinated in the bed. “He forcefully punched [her] with his fist numerous times in the face, head and body. He also kicked her in the chest repeatedly and threw [her] against the bedroom walls several times, causing the child’s blood to splatter on the wall. [He] then cut the electrical cord from a television and used it to whip [her].”


When Davis returned home, Meniefield pushed her from the front door to the back door and then threw a frying pan, hitting her in the head. She went to Howard University Hospital for treatment. Upon her return, he again assaulted Davis, who went back to the hospital. Meniefield ordered the children to walk with him to the hospital. He was carrying L.D. and punched her in the face during the walk. After leaving the other children at the hospital, he called his sister and told her he was bringing L.D. to her home, which is where police found the child.


Once L.D. arrived at the hospital by ambulance, doctors found she needed immediate surgery to repair her jaw. She had a “complete fracture through the right side of her jaw, and multiple fractures of the left side of her jaw.” Further, she was diagnosed with contusions to her right kidney and “extensive bruising to the underlying muscles of her abdomen.” She also had five rib fractures — one new and four older, healing fractures, according to court documents


Meniefield was initially charged with first-degree cruelty to children. However, as a result of a plea agreement reached on Sept. 27 with the U.S. Attorney’s Office, the charge was reduced to aggravated assault, which has a maximum penalty of 10 years in prison and/or a $25,000 fine. He also pleaded guilty to the assault of Davis, which carries a maximum penalty of 180 days in jail and a $1,000 fine.


The U.S. Attorney’s Office agreed to a sentence of “supervised release of not less than three years.” It also stated that prosecutors “will not seek indictment on any remaining or greater charges arising from the facts in this case.”

The plea agreement must still be approved by the judge; a hearing is scheduled for Feb. 4, according to the court docket.


Two days before L.D.’s brutal beating, another District child nearly lost his life. On Dec. 21, 2020, MPD responded to a call at an apartment at 3848 South Capitol St. SE. S.C., a 2-month-old boy, had suffered bilateral skull fractures; bleeding on both sides of the brain; extensive brain injury; multiple rib fractures at multiple stages of healing; and a blown right pupil.


The abuse may have begun with a domestic violence incident on Dec. 7 involving the child’s mother, who was slapped and physically assaulted by her husband, Donovan Ahmir Gilchrist. The court issued a stay-away order at her request. However, nearly two weeks later, he was back at the apartment.


On Dec. 21, she took their two older sons — nearly 6 and 3 years old — to day care, leaving the 2-month-old with her husband, although he was not supposed to be at the home. When she came back 45 minutes later, she found the child’s body “limp and floppy,” according to court documents. She subsequently called 911. Paramedics arrived and immediately took him to Children’s National Hospital.


A social worker at the hospital called MPD, which dispatched members of its Youth and Family Services Division. That same social worker also called into the CFSA hotline; health care workers are required by law to report any incidents where a child is displaying signs of abuse or neglect.


Doctors at the hospital conducted a series of neuropsychological tests on the infant, which revealed “multiple skull fractures.” There were also “multiple rib fractures that appeared in multiple stages of healing.” The child was admitted to the pediatric ICU, according to court documents.


Gilchrist said that he had heard his son cry and subsequently went to get him a bottle. He said he left him alone propped up in the couple’s bed. When he came back, the child had tumbled over to the side of the bed and his head was against the wall.


Dr. Anita Patel, who conducted the medical assessment to measure the child’s brain injury, said that a 2-month-old infant is incapable of such independent movement. Further, the multiple rib fractures were unlikely to be caused by the accident Gilchrist described.

Given his condition, medical personnel at Children’s concluded that there was “no potential for recovery,” according to court records.


Gilchrist was allowed to plead guilty to second-degree child cruelty, which can carry a potential maximum sentence of 10 years in prison and/or a $25,000 fine. Instead, he initially received a suspended sentence of 20 months. DC Superior Court Associate Judge Juilet McKenna ultimately shortened that, giving Gilchrist a penalty of 18 months of supervised probation and a fine of $100 that must be paid to the Crime Victims Compensation Fund by Oct. 15, 2023.


A CFSA spokesperson refused to answer any questions about whether the agency was involved in the lives of any of the children mentioned in this investigative series, asserting that District and federal confidentiality laws preclude it. “I am unable to confirm any individual child or family’s involvement with the agency,” said Kera Tyler, who cited that same explanation for her refusal to provide any details about the status of the siblings of the injured or murdered children.


Many of the people interviewed for this series regard these stories of child deaths, maltreatment and neglect as an indisputable indictment of DC’s child welfare system. “I think the [CFSA] in many ways is failing to take care of the District’s children,” said foster parent and advocate Acevedo.


Just as the DC child welfare system’s failures make it culpable in past cruelty or murders, they are writing the story of abuse, neglect and homicides foretold.

Court monitor Meltzer’s 2020 report echoes the complaints made by advocates, lawyers and child welfare experts when she lays out CFSA’s failure to meet critical standards that she had identified and the agency had agreed to:

  • CFSA failed to link families to critical services.

  • Investigations were not completed on time.

  • Mental health care services for children and families are insufficient.

The latter issue, along with substance abuse, leads to critically dangerous situations for many children. Both are active ingredients in every child abuse or neglect murder or maltreatment story presented in this series.


“It is not good if it takes months to link a child, youth or family member up with a [mental health] provider. Then, two months after that, the provider quits [or] the therapist quits, and you have to find another one,” Meltzer said. “That’s an area for much work.”


Assistant U.S. Attorney Cynthia Wright said likewise, noting as well that many people in DC are using marijuana, with recreational use legal in the city. “[However], I see personally in my experience that they’re using it to self-medicate for some kind of mental health issue.


“Then, they get angry with the child — they can abuse it or, as they’re getting high, they’re [ignoring] it. They don’t feed it; they don’t give it water,” continued Wright, adding that drugs and alcohol also are used by pregnant women, which can result in an infant being born addicted.


Matthews said that since he became CFSA’s acting director, he has spoken frequently with the Department of Behavioral Health’s director, Barbara Bazron, about the need for coordination. “As a system, I don’t believe [mental health] is just CFSA’s responsibility. We’re not the behavioral mental health agency,” he said.


“My job is to inform the agency that’s tasked with that on some of our needs,” continued Matthews, adding that he doesn’t want to supplant what DBH already provides.


“It’s really taking a look at, OK, here’s what the overall city provides for both children and adults around behavioral, mental health. What is it that we can inform DBH versus CFSA taking on those responsibilities? It’s less of a CSFA [issue]; it’s more of a system, as I talked about earlier,” added Matthews.


It’s not as if the city isn’t spending money in those areas. CFSA spends millions of dollars on contracts with outside groups. It also hires other government agencies like the DBH to provide services. In FY 2021, DBH had a budget of $34 million to help children with mental health and substance use disorders, with $23.8 million of that funding in-school services. “So, where kids are every day, there’s somebody who can do prevention, intervention, treatment and follow-up for that child, with the permission of the parent,” continued Bazron.


The DBH budget increased in FY 2022 to $40 million with an extra $5.8 million added for schools, according to Bazron and documents from the DC Office of the Chief Financial Officer. A DBH spokesperson, Derrick King, said that in FY 2019, it served 4,318 children; in FY 2020, the number of children enrolled with DBH-certified behavioral health providers was 4,176, not counting those referred by CFSA. The agency’s complete numbers for FY 2021 were not available by The DC Line’s publication date.


Advocates, including students in several DC high schools, have said the number of clinicians, psychiatrists and psychologists is insufficient for the population, meaning that students often aren’t able to see their therapists in a timely manner.


Still, Bazron cited the growth of in-school services as indication the agency is meeting the needs of the city’s children. “The staff will do a number of things: provide prevention, [conduct] activities to support resilience. They do intervention if it looks like the child needs some support, and they provide treatment with the signed permission of the family.”


Neither Bazron nor CFSA’s Matthews would discuss how the city addresses the impact of adult disorders on children in DC. A spokesperson for the latter was unable to tell The DC Line the number of children involved with the CFSA who have a parent with a substance abuse disorder.


The CFSA “does not have broad access to parental mental health diagnoses. Parental substance use disorder is not a data point that CFSA aggregates,” said Tyler, adding that the agency does “gather data on child abuse allegations involving substances, e.g., exposure to illegal drug-related activity in the home, fetal alcohol spectrum disorder, positive toxicology of a newborn, or substance use by a parent, caregiver, or guardian.”


One indication of the low priority CFSA appears to give mental health: In all of FY 2020, it referred only 141 children to DBH, according to an email from the CFSA spokesperson. No details were provided about the specific issues or diagnoses, however.


And regardless of CFSA’s celebration of services provided to families, court monitor Meltzer’s report on the agency’s performance in 2020, released earlier this year, made clear that CFSA was not meeting some of the standards to which it agreed in the LaShawn A. lawsuit.


The agency was supposed to ensure that “90% of families who have been the subject of a report of child abuse and/or neglect, whose circumstances are deemed to place a child in their care at low or moderate risk of abuse and neglect and who are in need of and agree to additional supports” were referred to “an appropriate [Healthy Families/Thriving Communities] Collaborative or community agency for follow-up.”


Of the sampling of CFSA investigations reviewed by the monitor that were closed in July and August 2020, only 62% of families actually received the required referrals.


In 12 of the 23 investigations with no indication of a referral, “the reviewer identified a need,” but the family was not linked to a community agency, the court monitor noted in her report. In the other 11 investigations, “either the worker identified a need, or the family requested a service; documentation does not reflect a linkage was made.”


Former CFSA ombudsperson Greene characterized the family assessment as falling within the purview of child protective services investigations. “It allows for you to go into someone’s household, do an involuntary safety assessment. As long as the child is safe, you change it to a voluntary service. You mitigate a lot of the concerns that bring people to our [child welfare system’s] attention.”


A preliminary assessment could result, however, in a child remaining in a home even when a family is in crisis. Some people believe the government should err on the side of protecting the child and removing them from an environment where they are at risk.


Greene’s point is that children are left to navigate a dangerous environment on their own if CFSA fails to adhere to its legal duty to investigate and take official action on allegations of abuse and neglect, and then to protect the children based on those findings by qualified social workers. It could mean life or death to a child who is being abused by a parent, the paramour of a parent, or anyone else.


Considering all the information that points to the deplorable state of the child welfare system, it’s difficult to understand why federal Judge Hogan and the plaintiffs would agree to end the LaShawn A. case. One local attorney had this explanation: “They were all tired of it. It went on for 30 years, my God.”


Next: Part 2 —Abuse and neglect investigations open late, close early



The team for this investigative series, first published on TheDCLine.org, included jonetta rose barras, editor/researcher Deirdre M. Bannon, and editor Chris Kain.


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