This is a child who died in Florida despite possible ways in which the child protection system may have saved her. Like so many cases before her, this is not a case where her death should lead to over reaction by CPS resulting in over apprehension of children - it should act as a way to reconsider how well we are doing with cases that do need protection. Like so many cases before, there were many opportunities to intervene if the voices being raised had been heard:
"The red flag of caution and warning was raised many times: By teachers and principals,by a Guardian Ad Litem (GAL) and her attorney, by a nurse, by a psychologist, byNubia's "family" stonewalling the search for fundamental information.But nobody seemingly put it all together" (p.2).
The case raises a number of flags that we have seen before:
* parents who stonewalled
* parents who withdrew from systems (e.g. school in this case) where behaviors were getting noticed -- "After the end ofthe 2009-2010 school year, the Barahonas chose to home school the children,taking away most of their visibility to outside eyes and increasing the dangerthat abuse and neglect would go unrecognized. This was further compoundedby the lack of formal requirements relating to the monitoring of students being home schooled" (p.7)
* professionals who failed to bring together data that would create a more global than partial picture of what was happening. As the report states at p. 5: " failed to consider critical information presented by thechildren’s principal and school professionals about potential signs of abuseand neglect by the Barahonas."
* parents refusing services
This death review offered something different than has been seen in many prior reviews which is a comment on the parenting assessment that had been done. There was a failure to properly gain data from multiple reliable sources that would have shown the assessor a broader picture. It also would have shown contradictory information such as school progress. A poor parenting capacity assessment creates the opportunity for child protection authorities to make bad clinical risk judgments that leave children vulnerable. As they state on p. 11, "What’s needed are clearly articulated expectations for any psychologicalevaluation as well as clear criteria for reviewing the performance of anycontracted psychologist or other expert called on to evaluate children on behalfof the court." Such guidelines do exist in the professional literature as well as a variety of publications.
The authors also note that delays in assessments leave cases without appropriate consideration. Such delays may not be the fault of anyone person but rather of processes that just move slowly. If assessment is going to be effective, then it must have access to a wide range of data. This point has been made by many authors and is repeated by this review. In addition, this assessor appears to have wrongly considered that attachment in a care home should have priority over the safety of the child. This is a growing area of concern given that legal processes leave young children in alternate care for long periods creating attachment between the child and the alternate caregivers that will need to be broken if a child is to come back to family.
A further area of concern that we have again seen too often in death reviews is the failure of CPS staff to properly assess and coordinate information coming in. Fragmented data has been behind many CPS failures. As the authors state on p. 10, "A serious deficiency, however, was the failure of individuals involvedin the case to talk with each other rather than relying on inadequateinformation technology. Many of the communications problems that can beidentified in this and other cases can be overcome by prompt and coordinatedinterpersonal interaction among those involved in the care of the child."
As one says with so many of these cases, let us hope that Nubia did not die in vain.
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