On January 2, 2002, Joseph Daniel S. hung himself in a cluttered bedroom closet at his home.  He was 12 years old.  Although we may never know why this child took his own life, the Office of the Child Advocate and the Child Fatality Review Panel tried to determine how his death could have been prevented.  The purpose of fatality review is to determine whether public agencies and professionals can do a better job keeping Connecticut children safe and well cared for.

J. Daniel was a very small boy for his age, weighing only 63 pounds at his death.  He tested with superior intelligence but also had an identified learning disability that prevented him from being able to express himself on paper. When he was in the 6th grade, J. Daniel’s grandparents died within one month of each other.  His grandfather was the only male figure in the boy’s life.  In addition to being small, J. Daniel’s appearance was dirty.  He wore mismatched, dirty clothes.  He acted different from the other children at school. 

As J. Daniel entered middle school and the schoolwork became more complex, special educational supports and oversight were stopped.  At the end of 5th grade, he had been exited from special educational services without the benefit of testing to determine any change in his needs.  J. Daniel’s academic performance plummeted in the 6th and 7th grades. 

At some point in the middle school transition, schoolmates began to pick on J. Daniel.  Reports indicate that the boy was pushed, hit, choked, kicked, made fun of, and had his belongings stolen (to name a few offenses).  J. Daniel fought back ineffectually.  In addition to school suspensions for fighting, J. Daniel began skipping school.  In the 6th grade he missed 37 days and was tardy 42.  Before the winter holidays of 7th grade he missed 44 days.  When he did go to school he was shunned and picked on because of his appearance and odor.  J. Daniel seemed to be soiling his pants.

The school and J. Daniel’s mother responded ineffectually to J. Daniel’s needs for a full academic year and into the next before the school finally took mandated action and alerted the Department of Children and Families as well as the Superior Court for Juvenile Matters.  Until that time, there was no medical evaluation, no involvement of the school nurse, no therapist, and no intervention targeting hygiene.  School personnel at all levels were aware of J. Daniel’s appearance, behaviors and poor academic performance.  He seemed to be held responsible for his circumstances.

When the Department of Children and Families and the juvenile court became involved, both agencies documented the problems, as if to confirm them, but did little.  There were still no medical or mental health evaluations, school nurse involvement, therapist, or help with hygiene practices.  There was very little communication between the school and DCF.  There was no communication between the school and the court. DCF did not substantiate allegations of physical and educational neglect, even though they documented that the boy continued to be truant and that he was emotionally disturbed.  Similarly, the juvenile court chose to only monitor the case, yet even monitoring was lacking. 

There is an intricate system in Connecticut designed to keep children safe.  That system or safeguard is made up of professionals trained to recognize when a child is at risk.  Teachers, guidance counselors, doctors and nurses are some professionals who should recognize and intervene on a child’s behalf.  In fact, they are required by law to do so.  State agencies such as DCF and the juvenile court make up the child welfare system specifically prepared and expected to ensure children’s safety.  While the network of professionals continues to be obligated to ensure a child’s safety, DCF is ultimately accountable to children’s safety and care. 

As a 12-year-old boy, J. Daniel’s safeguards included his mother, his teachers and guidance counselor, the school nurse, the school administrators, his pediatrician, the school outreach worker, a DCF investigative social worker, and a probation officer.  OCA examined the systems each represented according to specific concerns identified as warranting action in J. Daniel’s life.  Those concerns included: a) risk of suicide and depression; b) bullying; c) physical health and personal hygiene; d) school success; and e) home safety.  The safeguards failed to protect J. Daniel S. 

DCF was the one agency that could step right into J. Daniel’s life and determine what was wrong.  Instead, they ignored the evidence of dysfunction and chaos at home and the fact that a truant was scared to return to school.  They did not follow up on reported threats against the boy’s life.  They ignored obvious symptoms of medical and mental health needs.  When police arrived at the scene of J. Daniel’s suicide, the officers were aghast at the conditions the boy was living under, the same conditions a child abuse and neglect investigative social worker had visited just one month before. 

Eventually, J. Daniel’s mother was arrested.  DCF personnel were cited for poor documentation and lack of resource use.  The juvenile court did not review their handling of the case, and the school system was “satisfied” they had done all they could for the boy.  No one took responsibility for the child’s death.  Everyone was responsible.  J. Daniel’s safeguards never came together to explore his problems or strategize solutions.  On December 4th, 2001 a Planning and Placement Team meeting was held.  Everyone involved with the boy knew about the meeting.  That was one opportunity to clarify concerns and discuss J. Daniel’s circumstances.  The probation officer was not at the meeting.  No one from DCF attended.  There were no health professionals at the meeting.  No one seemed to recognize or acknowledge the breadth of J. Daniel’s problems.  In fact, many people held the 12-year old accountable for his woes.

Findings 

Upon review of J. Daniel’s death, the Office of the Child Advocate and the Child Fatality Review Panel made the following findings and recommendations regarding the most concerning aspects of J. Daniel’s circumstances, including depression and suicide; bullying; health and hygiene; school success, and home safety.  Specifically,  

Recommendations

Recommendations are put forth for improvements in practice among three systems, the educational system, the child welfare system (Department of Children and Families) and the court system, (Court Support Services Division of the Superior Court for Juvenile Matters).  

      Improvements for the Educational System

     Improvements for the Department of Children and Families (DCF)

• The DCF administration must review the role and responsibilities of supervisors within their infrastructure in order to ensure adherence to state and federal law, agency policy and best practice standards.
• The DCF internal review process must reflect the department’s commitment to quality practice by providing a thorough and accurate analysis of case practice for the purpose of improving practice and safeguarding children.
• Disciplinary action should be pursued when it has been determined through a comprehensive review process that there has been a breach of relevant law and/or policy.  All DCF personnel must be held accountable for knowing and abiding by agency policy and state and federal law.
• The current pre-service and ongoing in-service education curricula must reflect current trends and issues affecting children as well as best practice standards, applicable state and federal law and agency policy.  Staff must be knowledgeable regarding physical and mental health of children, available resources, child and home assessment, and bullying.