Child Death Study Points to ‘Failure of the System’

Nearly one in three child homicides in Los Angeles County involves families already identified by authorities as abusive and supposedly receiving help, a special committee established to review child deaths reported Wednesday.

The committee, set up by the Inter-agency Council on Child Abuse and Neglect (ICAN), also said that more than one in five “suspicious” child deaths occurred in homes where county officials were thought to have intervened.

The study, based on a yearlong review of 123 suspicious or violent child deaths reported to the county coroner in 1984, is the first government effort to develop a countywide profile of young victims and is one of the largest such studies in the United States, according to ICAN director Deanne Tilton.

The committee found that 11 of the 36 deaths classified as homicides and 25 of the 123 overall suspicious deaths were of children in families known to the county Department of Public Social Services (now the Department of Children’s Services) before the death.

“Because a child’s death from abuse or neglect represents the most extreme result of maltreatment, it is often expected that child protective services activity somehow prevents such an occurrence,” the report says.

“It is likely, however, that this is not always the case and for a variety of reasons, such as failure to report or accurately identify child abuse or neglect and the universal lack of accurate predictors of abuse. . . .

“There was a significant number of children who it appears had been victims of maltreatment prior to their deaths. It also appeared that many of these children had not been visible enough or perhaps seriously enough injured to have received the types of services which might have prevented their deaths.”

The committee’s findings, which Tilton said point to “the end-of-the-line, ultimate failure of the (county) system,” confirm those of a Times investigation two years ago that disclosed that many child abuse deaths involved children under county jurisdiction.

Nearly two-thirds of the children came from families with previous contact with public assistance programs--points at which some intervention might have been possible--including welfare, food stamps, Medi-Cal or social services, the study found.

The young victims tended to be less than a year old and frequently from families involved in drug abuse, the study found. A disproportionate number of the children were black.

The report, prepared by Kathy Kubota, assistant director of ICAN, was released Wednesday at a meeting of the ICAN policy committee, which includes top officials of various government agencies involved in the county’s system for handling child abuse and neglect. Most members had not had a chance to read the report and were unable to comment on its findings.

The director of the Department of Children’s Services, Robert Chaffee, was not present and was unavailable for comment on the findings. But Carlos M. Sosa, chairman of ICAN’s death review committee and assistant Children’s Services director, cautioned that the report contains “very preliminary raw data” from which no conclusions have been drawn.

Still, he said, “it is our first attempt in this county to come up with some sort of profile of how children die in Los Angeles County.”

“Last year, we were one of the first in the nation to develop protocols (for reporting and assessing child abuse deaths),” he said. “Now, with this basic profile, we will begin a review of other factors and other variables (such as the role played by police, physicians and hospitals, schools and others with whom children come in contact).”

Among the findings:

- More than half of all suspicious child deaths involved children less than a year old, the majority of them infants under 6 months old.

- The proportion of black children whose deaths were identified as suspicious was twice as high as their proportion in the general population, while the proportion of white children was less than half of their proportion in the population.

- The single most common mode of child murder was “blunt force trauma to the head.”

- Geographically, the cases were spread across the county, with no apparent concentrations.

- Drug abuse by the mother appears to be associated with those cases diagnosed as Sudden Infant Death Syndrome.

- “Suspicious” child deaths were about evenly divided between homicides, deaths classified as “natural” from such causes as malnutrition and cocaine intoxication, and “accidental” deaths due to suffocation, bathtub drowning and the like.

- There were “a significant number” of surviving brothers and sisters, which raised concerns about the need for follow-up or protective action for them.

- A seasonal pattern of deaths emerged, with deaths peaking in January, September and December, a pattern the report said is possibly “related to stress-inducing factors” such as the beginning of the school year, the holiday season and bad weather.