On May 15, Chapin Hall, the University’s independent policy research center, released a report titled “Systemic Review of Critical Incidents in Intact Family Services.” The report reviews the Illinois Department of Children and Family Services (DCFS) over a six-week period and “identifies the systemic factors that have influenced outcomes in individual cases of child deaths and critical incidents.”

The review was conducted at the request of Governor J. B. Pritzker in March after the death of two-year-olds Ja’hir Gibbons and Ta’Naja Barnes. Investigations of the two deaths revealed possible departmental misconduct and lack of oversight within the DCFS.

The report is focused on DCFS’s Intact Family Services Program (“Intact”), an initiative “designed to work with at-risk families who have been referred for continuing assistance and monitoring following a child abuse or neglect investigation.” A large majority of Intact services are provided by contractors and community organizations affiliated with DCFS.

Methods employed in the writing of the report include analysis of Child Death and Serious Injury Investigation (DSII) reports, systems analysis of child deaths through case-specific observations, a review of DCFS protocols, and interviews with key stakeholders of the Intact Family Services Program.

A review of all DSIIs over the last five years found a total of 501 documented deaths of individuals 20 years old or younger. It was found that 48 percent of these deaths occurred in children younger than one year old, and 52 percent of the accidental deaths documented also occurred in the same age group.

When investigating systemic issues, the report identified “interrelated structural, procedural, and cultural opportunities for improvement.” DCFS remains motivated to avoid removing children from their parents, but the review reveals the volume and complexity of cases handled by Intact “challenge the meaningful engagement and planning needed to prevent removals.” Many cases are decided on without access to data, and supervisors are instead forced to rely on intuition and precedent.

The review highlights a misalignment within the “matrix” model of supervision based on geography. The mismatch between Intact referrals from the area administrators and the Intact utilization supervisors result in the opening of Intact cases for families with an extensive history of physical abuse, even when Intact staff express reservations toward such cases.

Other systemic issues uncovered by the report include ineffective checks and balances, increasingly unsustainable caseloads for Intact workers, ambiguity in the role of Department of Child Protection (DCP) investigators who are often “inundated with caseload pressures to make referrals to Intact,” and an information gap where Intact workers are unable to access investigator’s notes or key features of a long case history.

Intact is expected to provide services to families for a six-month period, but this can be contested based on a judgement that the family requires further assistance. The report found cases where the Intact provider may simply close the case on a complex or difficult-to-engage situation, leaving children’s safety in jeopardy as they fail to “engage DCFS in consultation or planning for the disposition of the most high-risk cases.”

Several recommendations specific to the shortcomings uncovered were outlined. The report calls for the development of a refined protocol for closing Intact cases, clarification of staff roles, utilization of evidence-based approach to casework, improvement of the quality of supervisions for Intact teams, and a restructure of preventive services and Intact to address the imbalances of matrix supervision. The report also recommends a systemic intake process for the Intact program and refined criteria for child removal, especially when addressing chronic and complex family cases.

As a result of the review, Pritzker has called for an “overhaul” of DCFS, promising to implement all improvements suggested by the Chapin Hall report. In a news conference earlier this month, he said, “I am committed to carrying out that overhaul as quickly and effectively as possible and ensuring that [Marc Smith, acting director of DCFS,] has the necessary resources and support to do that work.” Pritzker also said that DCFS has begun an urgent review of more than 1,000 open cases involving young children. Pritzker also promised a $75 million increase in budgeting for DCFS more additional staff and caseworkers.