In addition to investigating complaints, the Office of the Family and Children's Ombudsman is required by state law to develop recommendations for improving the child protection and child welfare system. The recommendations in this section are based on Ombudsman analysis of information derived from investigations, surveys and research. They are aimed at strengthening the state's protection of children.

Background: The Office of the Family and Children's Ombudsman 1999 Annual Report ¹ identified the State's failure to timely intervene in chronic child neglect cases as a major issue of concern.² The Ombudsman found that the child protection system is often ineffective in preventing or protecting children from parental neglect that is ongoing and serious. By the time the system intervenes, children often are already showing signs of developmental and/or physical harm. According to research sited in the report, children who are chronically neglected often experience lasting adverse effects on their physical, emotional and cognitive development. The Ombudsman noted "the impact of chronic neglect on children-especially young children-can be devastating. We know from research on children's early brain development that the first few years of life are critical. Chronic neglect can severely damage the potential of children to grow and learn."³ Further, child neglect accounts for an estimated 40 percent of child maltreatment fatalities.⁴

The Ombudsman has found that Child Protective Services (CPS) often screens out reports of child neglect without an investigation. This issue was highlighted earlier this year with the death of a seven-year boy who drowned in a lake while playing unsupervised with his brother and several other children. The boy and his eight-year old brother had been the subject of 19 reports to CPS. Many of the reports were from community professionals expressing concern about the boys' speech delays, the mother's mental instability, and her failure to provide the boys with appropriate care and supervision. CPS screened out 14 of these reports without an investigation. According to CPS, neglect reports are often screened out because the specific act or omission alleged in the report does not meet the legal definition of neglect, i.e., does not constitute a "clear and present" danger. Thus CPS often will not investigate a neglect report despite being aware of a documented pattern of conduct indicating that the child may be at risk. Further, CPS caseworkers report they often feel they lack a sufficient basis to invoke a legal intervention to protect neglected children.

Many caseworkers have told the Ombudsman that they have been advised by their legal counsel (assistant attorneys general or prosecuting attorneys) that clear evidence of a neglectful act resulting in imminent danger is required to justify the filing of a petition in court to compel parental participation in services or remove the child. Consequently, these workers say they feel that until they have such evidence, they have no option but to pursue less aggressive and effective interventions.

Rationale: State law defines child neglect as "an act or omission that evidences a serious disregard of consequences of such magnitude as to constitute a clear and present danger to the child's health, welfare and safety."⁶

Washington is one of only five states whose statutory definition of neglect specifies that the risk of harm to a child must be imminent.⁷ Because the danger or harm from neglect is often cumulative, and thus may not be immediately apparent, the Legislature should delete this language. Consideration should be given to amending the definition to state clearly that neglect may result from an act or omission, or a pattern of conduct, that constitutes a substantial danger to the child's health, welfare or safety. These changes would provide CPS with clear authority to pursue more timely investigations and interventions. In addition, RCW 13.34 should be amended to authorize courts to consider cumulative harm when determining whether a child is dependent. This change would help the system address and prevent ongoing harm to chronically neglected children.

Background: In the 1999 Annual Report, the Ombudsman identified the failure of professionals and other service providers to report suspected child abuse and neglect, or cause a report to be made, to Child Protective Services (CPS) or law enforcement as required by state law (RCW 26.44.030).⁸ The Ombudsman has encountered several situations in which professionals required by state law to report suspected child abuse or neglect (including physicians, dentists, mental health professionals, and teachers) have failed to do so, thus leaving children at risk, and in some cases, subjected to ongoing abuse or neglect. This issue was highlighted in the Zy'Nyia Nobles fatality case in which a foster parent, family support worker, and DSHS contracted in-home day care provider failed to report their suspicions that the three-year old girl was being abused by her mother. Research surveys indicate that reports from mandated reporters are much more likely to be substantiated than reports from other individuals.⁹

With the exception of certified teachers and some State-contracted in-home service providers, mandated reporters in Washington State are not required to receive notice or training on their duty to report child abuse and neglect. Moreover, for most professionals-including physicians, nurses, and mental health professionals-child maltreatment and reporting is an optional training topic for continuing education credit. Most mandated reporters therefore receive little or no training on their duty to report suspected child maltreatment. As a result, they are not fully aware of their legal responsibilities, what, when, and how to report, or to whom a report must be made.

Alaska, Iowa and New York, require mandated reporters to complete training on the identification and reporting of child maltreatment within six months of initial employment (Alaska and Iowa), or to fulfill their professional licensing requirements (New York). Alaska and Iowa also require completion of two hours of additional training every five years. California and Illinois require mandated reporters to sign a statement acknowledging their duty to report as a prerequisite to employment. Oregon requires professional licensing, registration and certification boards to notify mandated reporters every two years of their duty to report. The notice, which is developed by the state social services agency, must include what the person is required to report, where to make the report, symptoms of child maltreatment, and a contact number for further information.¹²

Implementation of notice and training requirements would greatly strengthen ongoing efforts by the Children's Justice Interdisciplinary Task Force to increase education and awareness about the child abuse reporting law among mandated reporters. The Task Force recently developed a 20-minute mandated reporting informational video. The video was developed in an attempt to provide a standard and consistent informational resource for Washington's mandated reporters. Under the Task Force's distribution plan, mandated reporters will have "ready access" to the informational videos through the groups and organizations with which they have regular contact.¹³

• Children age 12 and older residing in licensed foster care; and state-licensed, certified and operated facilities and institutions;
• Licensed foster parents, and;
• DSHS-contracted providers of in-home services.

Background: The Office of the Family and Children's Ombudsman was established by the Legislature to act as a safety net for vulnerable children. The Legislature was particularly concerned about the safety of children living in substitute care, as well as those living with their parents under State supervision because of abuse or neglect issues.

Rationale: Very few young people residing in foster care or other residential facilities or institutions know about the Ombudsman. The same is true for foster parents and DSHS contractors who provide in-home services to families under State supervision. Only 12 percent of the complaints filed with the Ombudsman during the current reporting period were filed by foster parents, while one complaint each was filed by a young person and an in-home service provider. A young person in foster care recently told the Ombudsman "I think kids need to have somebody on the outside like you to talk to." Moreover, a foster parent reported that she did not know the Ombudsman was available as a resource when a caseworker allegedly failed to respond to her concern about the safety of Zy'Nyia Nobles after she'd been returned to her mother.

Like many other foster parents, this foster parent reported that she did not receive information about the Ombudsman during her mandated foster parent training. Children residing in substitute care, licensed foster parents, and contracted providers of in-home family support services often know best when a child's health or safety is in jeopardy. Yet, DSHS is not required to provide them with information about their right to contact the Ombudsman if they believe that the department is not adequately addressing a child health or safety issue.¹⁴ The need for such a requirement is underscored by the fact that only 11 percent of all individuals that filed a complaint with the Ombudsman during the current reporting period indicated that they had been referred by DSHS.

Background: According to the Children's Administration, caseworkers carry on average 29 cases. This average caseload size far exceeds the national standards established by the Council on Accreditation (COA) for Children and Family Services of 20 cases per caseworker. The Zy'Nyia Nobles Community Fatality Review Team found that the current average caseload "severely limits social workers' ability to thoughtfully manage each family's case." Moreover, the committee "strongly" recommended that the Children's Administration hire "sufficient clerical and paralegal staff to allow social workers to focus on case management and family contact." In their contacts with the Ombudsman, caseworkers often report feeling overwhelmed and stressed by their workload.

Rationale: The child protection system can no longer be expected to meet its demanding and vitally important responsibilities without adequate resources. At a minimum, the system needs caseworkers with sufficient time to carefully investigate and appraise their cases.

Background: Although State law requires the appointment of a guardian ad litem (GAL) or volunteer court-appointed special advocate (CASA), the Ombudsman found in a 1999 report that about one-third of the children who were the subject of a dependency proceeding did not have GAL or CASA representation.¹⁵ Over one-half of the children involved in proceedings in King, Snohomish, and Spokane counties did not have a GAL or CASA. Moreover, the Ombudsman found that the caseloads of GALs in some counties, including Pierce, Spokane and Yakima, were exceedingly high. The Ombudsman recommended the appropriation of funds to establish or expand volunteer CASA programs as a means for ensuring representation for all children. The 1999 Legislature responded by appropriating one million dollars to recruit, train and support additional volunteer CASAs. This helped to increase the number of children represented by a CASA, although many children still lack representation. More recently, the Zy'Nyia Nobles Community Fatality Review Team found that the Pierce County GAL assigned to Zy'Nyia's case was carrying about 144 cases at the time of the child's death. According to the Review Team, "this caseload clearly does not allow enough time for the assigned GAL to adequately investigate cases and simultaneously attend to other case obligations." The Review Team recommended that Pierce County "aggressively seek to expand its volunteer CASA program," noting that the National CASA Association recommends three cases per volunteer CASA.

Rationale: The child protection system can no longer be expected to meet its demanding and vitally important responsibilities without adequate resources. At a minimum, the system needs an independent GAL or CASA for each child to obtain first-hand information about the child's situation and report it to the court.

Background: In its 1999 Annual Report, the Ombudsman identified as a major concern the lack of available and appropriate family foster homes, group homes and residential treatment facilities for children. The Ombudsman noted that the lack of this resource often results in children being left or placed in unsafe situations. For example, children for whom a placement is not available have been and continue to be housed overnight in DCFS office buildings in Everett, Seattle, and Vancouver. The Washington State Institute for Public Policy is conducting a study on children's placement needs. The study is intended to help policymakers and agency officials identify what resources are needed to ensure an adequate range and supply of placement options for children.

Rationale: The child protection system can no longer be expected to meet its demanding and vitally important responsibilities without adequate resources. At a minimum, the system needs an adequate range and supply of placement options for children who cannot live safely at home.

Background: Community mental health services for children are provided through a complex system comprised of county-based regional support networks (RSN). Currently there is a chronic lack of community mental health resources available through RSNs for dependent children across the State. This problem has become acute in some areas. Children in the Spokane area reportedly must wait two months or longer for mental health assessments.

Access to children's residential treatment services is even more daunting. The Ombudsman encountered several cases in the last year in which dependent children were left with or returned to abusive parents, or placed in other unsafe or inappropriate situations, due to the unavailability of residential assessment and treatment services. Further, the Ombudsman has found that the extreme difficulty of accessing long-term psychiatric residential care through the Children's Long Term Inpatient Program (CLIP) discourages and often prevents caseworkers from obtaining this service for dependent children. Washington State currently funds 96 beds through the CLIP program, which serves both voluntary and involuntary admittees. Like other children seeking voluntary admission to a state-funded CLIP facility, dependent children often have to wait three months or longer for admission. Many dependent children experience acute crisis and/or behavioral problems while waiting for a residential opening to become available, often leaving themselves and others at significant risk of harm. In addition, children often experience one or more disruptions in their foster placement.¹⁶

Rationale: The state mental health system is not providing children with adequate access to appropriate services. At a minimum, the state should ensure that it meets the mental health needs of children who are dependent because of abuse or neglect.

Background: The Family and Children's Ombudsman was one of several reforms instituted by state policymakers in the wake of reports of child maltreatment that occurred over a period of years at the OK Boys Ranch, a state-contracted group home.

In an effort to prevent similar problems in the future, the Legislature established the Ombudsman office and directed it to "review periodically the facilities and procedures of state institutions serving children, and state-licensed facilities or residences."¹⁷ The Legislature intended for an independent entity to periodically review and assess agencies' oversight, monitoring and investigations of children's health and safety in residential care.

The Ombudsman recommends adding a children's residential health and safety ombudsman to the Ombudsman staff to carry out these mandated reviews. The review process would include periodic assessments of agency policies, procedures, and practices relating to the oversight, monitoring and investigation of children's health and safety in residential settings, as well as periodic site visits. The additional ombudsman would have expertise and experience in children's residential health and safety issues and work under the direction of the director Ombudsman.

Rationale: Several state agencies operate, contract, certify and/or license institutions, group home facilities and residences for children. These include: DSHS Children's Administration, DSHS Juvenile Rehabilitation Administration, DSHS Health and Rehabilitative Services Administration, Department of Corrections, Washington State School for the Deaf, and the Washington State School for the Blind. The oversight, monitoring and investigations of these institutions and facilities vary within and across agencies.

This recommendation would help establish consistency and improved coordination within and across agencies by providing the Ombudsman with the capacity and expertise to identify and recommend steps to address inconsistencies, duplication and gaps. No other entity currently performs this independent, cross-agency monitoring function.

Background: In October, the new DSHS Secretary, Dennis Braddock, released the Kids Come First Action Agenda.¹⁸ The Agenda includes a directive establishing that the safety of children takes top priority over other goals related to children and their families. It also includes a number of provisions aimed at improving the safety of children. One of these is to improve the use of Child Protective Teams (CPTs) by "clarify[ing] expectations" and "tracking their performance," as well as "providing training and new tools to improve their effectiveness."

Rationale: Secretary Braddock's focus on child safety is timely and appropriate. The Ombudsman has grown increasingly concerned about the lack of clarity within the Children's Administration about the agency's mission. Lacking clear direction, casework practice has varied greatly across the State with respect to the sensitivity and response given to child safety issues. Secretary Braddock's child safety directive is a vitally important first step in addressing this situation. The next step is for Children's Administration leadership to work closely with managers, supervisors and caseworkers across the state to develop a clear and collective understanding of the meaning, implications and expectations of this directive in their daily work.

The use and effectiveness of CPTs have also varied widely and are of great concern to the Ombudsman. CPTs are often used as intended-to assist caseworkers with risky or complex placement and case planning decisions. However, CPT members from across the state report that they are also often used to rubber stamp placement or case planning decisions that caseworkers have reached on their own. This issue was highlighted by the Zy'Nyia Nobles Fatality Review Team, which noted that the caseworker presented information to the CPT and others "in a manner to support [the caseworker's] belief that the children should be returned to their mother." This practice, which is not uncommon, clearly undermines the purpose and value of CPTs, and it can place children in serious danger. The Agenda's provisions to improve the use and effectiveness of CPTs are critical, and their implementation should be given high priority by the Children's Administration. Of particular importance are those provisions aimed at clarifying expectations and training caseworkers and CPT members on the use of CPTs.

Background: In July, Riveland Associates completed an administrative assessment of CPS.¹⁹ The assessment, which was requested by Governor Locke, contains several recommendations for improving CPS. One of these focuses on the role of supervisor. The assessment found that "many [supervisors] do not consider themselves as part of management. We would argue that supervisors are managers" and should be given the responsibilities, authority and accountability needed to carry out "what needs to be done to assure a high level of performance from their staff." The assessment recommended that DSHS "clarify the management responsibilities and roles for supervisory staff. Create greater alignment between authority, accountability and responsibility for supervisors. Supervisors are the critical link in the chain of accountability that begins with the CPS worker and goes through the DSHS Secretary to the citizens. Increase the time for supervisors to guide and grow staff."

Similarly, the Zy'Nyia Nobles Community Fatality Review Team found that "supervisors must take an active role in questioning the conclusions that social workers make about a given family, and in reviewing and challenging the social worker's case plan." The Fatality Review Team recommended that the Children's Administration convene a Continuous Quality Insurance team "to address issues such as how the supervisory role can encourage critical thinking and consideration of alternative points of view."

Rationale: Supervisors play a pivotal role in ensuring the protection of children. As the Riveland assessment stated "They are the glue that binds staff and management by effectively translating management expectations into staff performance." Yet the Ombudsman has found that supervisors' views about their role vary greatly, as do their supervision practices. DSHS leaders should follow up on the Riveland and Fatality Review Team recommendations by initiating a serious and comprehensive effort to explore how to clarify and strengthen this key position.