Created by Governor Ted Kulongoski in 2004 and put into statute by the Oregon legislature in 2007, the public reports created by the Critical Incident Review Team (CIRT) are an important and unique tool to help protect Oregon's children in state care. Since the CIRT process was created in 2004, there have been improvements and changes to how information is gathered and reported in order to be more timely, more transparent, and more useful in preventing child abuse, and DHS will continue making improvements into the future.
Updates to CIRT
On July 15th, 2019, Senate Bill 832 (amends ORS 419b.024) was signed into law requiring substantial changes to the Critical Incident Response Team, now known as the Critical Incident Review Team (CIRT). DHS began implementing these changes as of July 15, 2019 and will be fully operative by Oct. 1, 2019. The work of CIRT is focused on identifying when systemic issues may present barriers to adequate child welfare service delivery and/or child safety decision making. When a critical incident is reviewed, the team seeks to understand the circumstances surrounding the death of the child, as well as the history with the family in the community and the child/family-serving system.
CIRT Status Reporting
This web page will also offer updates about the efforts related to preventing child abuse fatalities through a data informed approach to early intervention strategies, cross system education and coordination and fatality review processes. Over the last 12 months, CIRT Coordinators have invested time in addressing systemic issues already identified through previous CIRTs. Here are some updates regarding current work identified by the CIRTs:
Child neglect is the most frequently identified type of maltreatment in substantiated reports of child abuse. On average, child neglect has contributed to just under 75% of abuse-related fatalities in Oregon and nationwide over the last five years.
Oregon's in-depth review of child fatalities in families with recent Child Welfare history (an open case, CPS assessment or closed at screening report in the last twelve months) shows in many of these cases, there have been multiple maltreatment reports on the deceased child or the child's siblings over the years, suggesting a pervasive pattern of neglect. Oregon Child Welfare has set forth efforts to engage staff and the community around the problem of child neglect, particularly chronic neglect.
Enhanced training on child neglect is occurring at two levels in Child Welfare. The first level provides a 90-minute overview of chronic neglect, the impacts to children and intervention strategies with families. This training is being delivered over the spring and summer of 2019. The second level of training is a two-day advanced course for assessing patterns and behaviors of neglect. This training is being developed in partnership with the Butler Institute for Families, out of the University of Denver Graduate School of Social Work. Safety and Permanency Consultants, along with other champions will be trained as trainers in the advanced curriculum during July and August of 2019. Training is expected to begin for Child Welfare supervisors and MAPS in the fall of 2019. Staff with over 24 months of service will begin to receive advanced training in late fall/early winter of 2019, with expected completion by the end of 2020. The training will then enter the sustainability phase with a plan to train staff in their third year of service ongoing.
Child Welfare recognizes the need to engage with partners around understanding and responding to chronic neglect. Specific work must be done with judicial partners and contracted providers to ensure professionals in partnership with Child Welfare are making decisions and plans based on the most up to date information about the scope and impact of neglect on children and families. There are toolkits available to facilitate these conversations and selection of a specific approaches will take place in late 2019, with conversations set to begin by 2020.
The national movement of suicide prevention and suicide postvention has made significant gains in the last decade. Federal legislation has paved the way for states to offer a variety of services and educational opportunities for the public. Despite these efforts, Oregon continues to have higher rates of youth suicide than the national average. The Department of Human Services, Child Welfare Program, began exploring this issue in 2017 and concluded that many of the children dying by suicide have had some contact with child welfare systems. In response, several efforts have begun to train DHS staff on suicide prevention.
To date, the Child Safety Program has identified two CPS program coordinators to implement a plan to offer suicide prevention services for Child Welfare. Additional efforts to provide suicide prevention training for any Department of Human Services employee is also being spearheaded by the Chief Administrative Officer of DHS Shared Services. Currently, three evidence-based suicide prevention trainings are being offered: Question, Persuade and Refer (QPR); Applied Suicide Intervention Skills Training (ASIST); and safeTALK.
Child Welfare identified QPR as an appropriate suicide prevention training for Child Welfare and over 100 individuals have been certified as QPR trainers to carry out the effort to train all staff. This includes Portland State University Child Welfare Trainers, Child Welfare Consultants across programs, and staff working in the role of MAPS – Mentoring, Assisting and Promoting Success.
In addition to training, each Child Welfare district has been asked to identify individuals to serve as Suicide Awareness for Everyone (SAFE) champions. SAFE champions will be offered more comprehensive training through ASIST or other suicide prevention programs and serve their local office in the following ways:
- Develop and maintain a list of community-based suicide intervention services
- Become certified to provide QPR training to DHS staff as well as community partners
- Offer case consultation for families dealing with the issue of suicide
- Organize trauma response efforts related to suicide
Child Welfare's efforts around youth suicide prevention have also included collaboration with external partners, in particular the Oregon Health Authority's Zero Suicide Coordinator, for continued improvements in suicide intervention statewide. This collaboration also includes the creation of a suicide intervention protocol specific to local Multi-Disciplinary Teams (MDT). This protocol will include what cases are appropriate to bring to an MDT forum and actions taken by the MDT.
Unsafe sleep conditions are one of the leading causes of deaths for infants in the state of Oregon. An infant is considered a child between birth and age one. Many of these infants and/or their families have had some contact with the Department of Human Services, Child Welfare Program. The majority of these deaths are due to asphyxiation, as a result of a hazardous sleep environment. The department is working proactively to improve casework practice standards in an effort to effect positive change.
One of the primary unsafe sleeping conditions is bed sharing. This refers to an infant and one or more adults or children sleeping together on any surface, not necessarily a bed. This could be sharing a surface such as a couch, a chair, or a futon. According to the American Academy of Pediatrics the safest place for an infant to sleep is alone in their own crib with a firm mattress, a tightly fitted sheet, on their back, and in a smoke-free environment.
Child Protective Service workers will receive in person training through branch unit meetings. This will be provided in collaboration with contracted local nurses, CPS supervisors, and child safety consultants. The training will consist of Child Welfare Safe Sleep procedures and best practice standards. Additionally, the Child Safety Program is currently researching the possibility of incorporating the use of Safe Sleep Coaches to work with local branches on cases that involve concerns with infant sleeping environments.
Child Welfare will also increase efforts to partner with the community to provide families with appropriate education surrounding safe and unsafe sleep. These partners may include contracted Addiction Recovery Team providers, contracted nurses, Oregon Health Authority, local hospitals, Women Infants and Children Program (WIC), Healthy Start, Early Head Start and other community home visiting services.
CIRT and Sensitive Review Committee Reports
For more than a decade, DHS has conducted sensitive reviews. Over time, the reporting structure has changed. This searchable index includes sensitive review committee reports as well as individual CIRT reports. All reports are posted in PDF format.