Child Abuse in Los Angeles County - A series of reports in the Los Angeles Times

Persistent backlog in L.A. County child abuse probes has led to a crisis, report says

Four in 10 open inquiries are stretching beyond the two-month deadline, the review by the county chief executive's office says. The backlog, the study says, appears to contribute to 'poor outcomes.'

November 11, 2010

By Garrett Therolf

Los Angeles Times

http://articles.latimes.com/2010/nov/11/local/la-me-dcfs-backlog-20101103

A persistent backlog of child abuse investigations in Los Angeles County has led to a "crisis," with four in 10 open inquiries stretching beyond the state's two-month deadline, according to the county chief executive's office.

In a further indication of the problems faced by the county's Department of Children and Family Services, Chief Executive William T Fujioka said in a report released this week that shifting workers to combat the delays "appears to be slowly creating a back-end crisis," depleting resources for other critical tasks. Among the duties handled by back-end workers in the department are foster care placements and home visits.

The assessment by the county chief executive's office is the most detailed analysis to date by county officials of the backlog of cases—which involve more than 10,000 children according to recent figures—in the troubled department. The findings contradict department Director Trish Ploehn's statement earlier this year that the longer inquiries have resulted in higher quality child abuse investigations. The report, distributed to county supervisors last month, was not released until The Times appealed to County Counsel Andrea Ordin.

"The county's high [child abuse investigations] backlog appears to be contributing to poor outcomes in the [child abuse investigations] unit," the chief executive's report said.

The 21-page report is intended to "set the stage" for an independent audit of the department that was ordered in August by the Los Angeles County Board of Supervisors, one of a number of pending requests by the board to better assess problems in the department.

Elizabeth Brennan, spokeswoman for Service Employees International Union Local 721, which represents the county's social workers, said in a recent interview that the sizable backlog in open cases was fueled in large part by what she called an "out-of-control policy machine." Among the department's 370 procedural guides, she said, 140 have been created or revised in the last year. The main procedural guide for child abuse investigations has been changed 39 times.

The union was one of the first entities to raise the alarm about the backlog in a March letter to Ploehn. At that time, cases involving more than 15,000 children had not been fully investigated within the 30-day deadline then in effect.

Since then, state officials, citing the county's efforts to improve standards by interviewing more witnesses, better reviewing the family's history with other county departments and requiring more managerial review, granted Los Angeles County a waiver of the 30-day deadline. Even with double the time allowed elsewhere in the state, the department has struggled to complete inquiries within 60 days, although the report calls current figures a "significant reduction" from a peak this summer.

Since 2007, children found by the department to be victims of abuse who were left in their homes have increasingly experienced abuse again within a year, according to a researcher hired by the state. The increase was 19%.

Additionally, more than 67 children have died of abuse or neglect since the beginning of 2008 after being referred to the department, according to county statistics. The rate of such deaths has increased over that period, and county officials have acknowledged that many involved case management errors.

Throughout the county, the 7,300-person department handles 170,000 child abuse hotline calls a year.

Michelle Dominguez, of Lakewood, said she was frustrated by the department's response when she called on behalf of her daughter's 12-year-old friend. Dominguez said she was stunned by the squalor she found in the girl's home when she dropped the girl off in September.

"I was in tears and ran out of there. I felt something walking up my legs. I was covered in roaches from my knees down," Dominguez said, recounting conditions also described by the girl's father, who lives elsewhere.

The girl's mother, Dominguez said, was a hoarder. The home was covered with trash, dog feces and pests. The kitchen had little food, and the girl and her three siblings appeared malnourished, she said.

When she called to report the case to the Department of Children and Family Services, Dominguez said, she learned that alleged abuse and neglect had already been reported by police on Sept. 8.

Two months later, Dominguez said the investigation remains open. Although her daughter's friend and another sibling have since gone to live with their father — a decision unrelated to department action — two other children remain in the home, Dominguez said.

Department officials did not respond to questions about the case and are barred by confidentiality laws from commenting on it. Ploehn also declined The Times' requests for an interview regarding the backlog.

Earlier this year, however, Ploehn said she needed additional personnel to resolve the backlog. More recently, her staff emphasized that although cases remain unresolved, social workers make first contact with the child's family within days of the hotline call and are required to pull the child out of situations as soon as they verify substantial danger.

But county officials also acknowledge that critical assessments following initial contact with the child might take weeks longer.

Evidence of abuse or neglect might diminish by the time social workers look for it. In Dominguez's case, she said she provided food and housing for her daughter's friend, and the girl gained more than a dozen pounds by the time social workers assessed her health.

Brennan, the SEIU spokeswoman, said the standards for investigation are applied unevenly in the department's 18 offices, and social workers on temporary assignment have little training in this type of work as they move from one office to the next in efforts to ease the backlog. The county chief executive's report found that the offices with the largest backlogs generally have the most inexperienced workers.

Fujioka, who oversees Ploehn, referred questions about the backlog to a deputy, Antonia Jiménez.

Jiménez said she was trying to develop a "sustainable" staffing plan that would address the issue. She also said some of the investigation standards imposed over the past year — such as more interviews of key witnesses and managerial review — might be "streamlined."

"Do you need all these safety enhancements for 100% of the cases or is there a way to triage them?" she asked.

The report, which Jiménez spearheaded, found some department policies "duplicative or contradictory," making it difficult for social workers to comply. The report also cited problems with newly implemented e-mail alerts designed to signal social workers when they missed deadlines for visiting children and writing reports.

"The problem is that the social workers are receiving so many alerts that people start to ignore them," she said.

Middle managers spend too much time out of the office at community meetings, the report found. When they are in the office, much of their remaining energy is dedicated to dealing with problem employees requiring discipline, the report said.

The report did not directly assess the effectiveness of the department's senior management team.

Meanwhile, many of the actions ordered in recent months by the Board of Supervisors, which has ultimate responsibility for setting policy for the department, have been placed on hold.

Supervisor Zev Yaroslavsky, a persistent department critic, said the board has ordered seven studies of the department since August, "most of which have not been acted on."

Supervisor Michael D. Antonovich, a board member since 1980 who pushed for many of the studies, said: "You need a little historical reference point … so you're going in the right direction and not repeating the failures of the past."

Antonovich said in a recent interview that he is waiting until an outside auditor reviews the department's management before deciding whether to continue his support of Ploehn.

The audit was ordered in August as an emergency measure, but so far, no one has been hired to do it.

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Deaths from abuse and neglect increase among children under L.A. County oversight

Confidential documents show the numbers climbing in recent years, contradicting previous reports by the Children and Family Services agency.

More children have died in each of the last two years from abuse or neglect after being under the eye of Los Angeles County's Department of Children and Family Services despite assurances by county officials that the problem was getting better, according to confidential county documents reviewed by The Times.

The number of deaths from abuse and neglect rose from 18 in 2008 to 26 in 2009, and 2010 so far is on track to be even worse, with 21 maltreatment fatalities in the first eight months of the year, according to the figures. The department publicly released some of the case files of child deaths Monday morning after repeated inquiries from The Times but has not yet released the overall statistics, which have been circulating among senior county officials.

The majority of the maltreatment fatalities occurred while county social workers were actively overseeing the child's welfare or just days or months after they had closed the case for the child, the records show.

The data represent the first time the public has gained access to the department's accounting of how many children in its care have died of maltreatment. The trend contradicts previous accounts the department had provided to other county officials.

As recently as August, department Director Trish Ploehn provided statistics to the Los Angeles County Commission for Children and Families showing that the number of maltreatment fatalities had dropped from 18 in 2009 to six in the first seven months of 2010. Her statement was provided to The Times in response to a California Public Records Act request. Ploehn declined repeated requests for an interview for this article.

One of the previously undisclosed child deaths was that of Miaamor Steen, a 5-year-old girl from Inglewood, who was found on Sept. 16 in the bathtub of an extended-stay motel, unconscious and not breathing, police said. The girl's mother, Jennine Steen, and her boyfriend, Solomon Walters, were arrested on murder charges.

Records indicate that the departments' child abuse hotline had received two calls about Mia. The most recent investigation was closed about a month before her death, with no finding of abuse. The girl's father, Donya Steen, said he made one of those calls after hearing that Mia was being beaten by her mother.

"Something has gone terribly, terribly haywire in the oversight of these children," said Supervisor Zev Yaroslavsky, a persistent critic of the department's handling of child deaths.

Yaroslavsky questioned whether the department's drive to reduce the number of children removed from their families and placed in foster care has led it to leave too many children in unsafe conditions.

The number of foster children has dropped from 52,000 in 1997 to 18,800 this year. During this period, the department has focused on keeping children with their parents by giving the adults drug treatment, parental training and other services.

The drive has been motivated by the belief that a child's welfare is best served by his or own family, even when that family is somewhat troubled. But the reduction of foster children is also a budgetary imperative.

Under an experimental federal and state program known as the Title IV-E waiver, Los Angeles County agreed to accept a fixed sum for foster care. If costs exceed that amount, the county must pay the difference. If the county spends less than the federal allotment, the county can use the leftover funds to pay for other programs designed to reduce child abuse and neglect.

Yaroslavsky said he agreed that children belong with their own families whenever possible but worried that the department has been so single-minded in its drive to reduce the number of foster children that social workers have been blinded to the fact that some parents are too dangerous to be left in control of children.

"The facts need to dictate how DCFS handles these marginalized children. Evidence can't be ignored because there is an orthodoxy that says kids need to be kept with their families," Yaroslavsky said.

Backers of the program have resisted suggestions that the drive to reduce foster care has contributed to a rise in abuse or neglect.

Oscar Ramirez, spokesman for the California Department of Social Services, said the state did not believe the IV-E waiver "has led to systemic instances of child maltreatment, but we remain committed to working with anyone who has concerns with the IV-E waiver and have a standing offer to meet to better understand those concerns as the state's implementation of this waiver continues."

Others who have studied the waiver program say that earlier indicators were already suggesting problems. Child safety indicators under the waiver have become "an area of concern," said Charlie Ferguson, a San Jose State University professor and the state's independent evaluator of the waiver program.

Ferguson said officials had studied data involving children who had not been removed from their homes after an allegation of child abuse had been substantiated. They found that those children experienced an increased rate of substantiated abuse within a year. The rate has increased by 19% since the Title IV-E waiver began in 2007, he said.

Ferguson's review does not include fatality data because he is reviewing only data that is comparable among all California's counties and with jurisdictions elsewhere in the country.

Carole Shauffer, executive director of the San Francisco-based Youth Law Center and one of the state's leading advocates for abused or neglected children, said she was hesitant to connect the waiver with the rise in child fatalities because she worried that too little information is available.

"What analysis has been done by the department?" she asked. "Have they really looked at this? Have they looked at the experience level of the social workers who handled these cases? If they are ignoring this type of analysis, they are foolish."

It's unknown how much analysis has been done, but there is some reason to believe that the department has not diligently collected the raw data needed for such evaluations.

The data on maltreatment fatalities were recently revised under the supervision of the county's Office of Independent Review. They are part of a larger group of fatalities tracked by the department, which includes children who died of causes other than abuse.

The county's record-keeping regarding the overall number of such fatalities has been flawed. Last month, for example, the county's records reviewed by The Times showed that 91 children tracked by the department had died, of a variety of causes, in 2003. This month, the department's records showed the 2003 fatality figure as 146. The number is subject to further revision, county records showed.

At Los Angeles County Supervisor Mark Ridley-Thomas's urging, the Board of Supervisors ordered Ploehn this month to compile fatality statistics for the last 20 years. The vote was 4-1, with Supervisor Don Knabe opposed.

To the extent that the department already has such information, it has been difficult for the public to obtain. At Supervisor Gloria Molina's behest, the Board of Supervisors asked the county's Office of Independent Review to look at whether the department was following a state law that mandates the release of case files when a child dies of abuse or neglect.

Michael Gennaco, the office's chief attorney, found the department inappropriately hid dozens of cases from public view. Whether the failure to make the files public was intentional or not remains under review. At the time, Ploehn said she was in full agreement with the report, but it took a month and a half before the department had a single case file ready for review.

In a written statement, Ploehn said, "although there has been a considerable workload associated with the release of these documents, we do acknowledge that the release of these files has taken longer than we had hoped — and the public has consequently had to wait longer than it should."

Two senior department managers have alleged that the department deliberately concealed information, and Gennaco said he is investigating their claims. Thus far, however, he has not verified an intent to hide, and he suggested that the workers responsible for public disclosure may have been unaware that state law mandated disclosure.

Officials failed to publicly disclose fatalities resulting from abuse or neglect, an audit finds.

Los Angeles County officials have failed to follow state law that requires them to publicly disclose child fatalities resulting from abuse or neglect, according to an independent audit released Monday.

The violations involve "potentially dozens" of child fatalities, County Supervisor Zev Yaroslavsky said.

"The board has been misled, but more importantly the public has been misled and that is really inexcusable," Yaroslavsky said. "There is only one possible motivation here, other than the right hand not doing what the left hand is doing, and that is an intent to withhold information from the public."

Department of Children and Family Services Director Trish Ploehn, reached by telephone Monday evening, declined to comment, saying she was still reviewing the auditors' findings. She agreed to an interview with The Times on Tuesday.

The finding by the Los Angeles County Office of Independent Review comes amid a growing debate about whether child welfare officials are underreporting deaths of children whose families previously had come to the department's attention.

Yaroslavsky said auditors uncovered the discrepancy when they reviewed the case of Jorge Tarin, an 11-year-old Montebello boy who hanged himself with a jump rope in June. In confidential court filings, social workers declared his death to be the result of abuse or neglect, but when it came time to report abuse or neglect deaths to the public, the department left his case off the list.

In the audit, Michael Gennaco, chief attorney for the Office of Independent Review, noted a dramatic change last year in the amount of information released by the department, with disclosure in only four of 18 cases. Gennaco said the pattern has extended into 2010. The Times has been denied in repeated public records requests for information.

A 2007 state law requires release of numerous records in such cases unless doing so would jeopardize a criminal investigation. Gennaco found that child welfare officials were asking law enforcement agencies to object to the release of documents before investigators had the chance to review the case files. The effect has been blanket objections to disclosure that resulted in "a virtual paralysis of the statute's intent."

The independent audit was released just days after county officials closed an investigation ordered by the Board of Supervisors into who provided The Times with information about children who died while their families were child protective services scrutiny.

A single-page report on the inquiry written by County Chief Executive William T Fujioka said officials found nothing.

The investigation was launched behind closed doors in what supervisors acknowledged was a violation of the state's open meetings law. It was later approved in a public vote in what supervisors said was an effort to "cure" the initial breach.

The supervisors said they were responding to Ploehn's complaints that The Times had reported on material she described as confidential and inappropriate. Yaroslavsky, who voted against the leak inquiry during the public discussion, criticized Ploehn for pressing for the probe, saying "the obsession with leaks … exceeds the obsession with child deaths."

In an op-ed in The Times last week, Ploehn called it "simply untrue" that the "inquiry into illegally disclosed confidential case information is to mitigate bad publicity or improve social worker morale."

Ploehn said she and her employees had a duty to uphold state law and protect confidentiality. The unauthorized release of information, she wrote, "erodes public trust and contributes to the oversimplification of the work that social workers do. In very real ways, this increases the potential for harm to children."

Fujioka's assistant, Ryan Alsop, declined Monday to say how many staff hours were spent on the investigation.

Meanwhile, there were signs that a backlog of child abuse investigations continues to grow and county officials have acknowledged that some children have lived in a Department of Children and Family Services conference room in excess of the 24-hour limit.

Ploehn had pledged to take steps to reduce the backlog in June, after the death of a 2-year-old whose family was under investigation by her department. According to sources familiar with the case, the county's inquiry into allegations of abuse or neglect had been open for 57 days, exceeding the state's 30-day deadline. By the time of Joseph Byrd's death, the backlog had grown so large that state officials granted a temporary extension to L.A. County, giving them 60 days to close inquiries.

Since then, the number of children whose cases have run past the 60-day deadline has grown by 1,000. More than 13,000 children are the subjects of abuse investigations that have been open two months or longer.

Department spokesman Nishith Bhatt blamed the growing backlog on a rise in the number of calls to the county's child abuse hotline.

Yaroslavsky, however, said the backlog resulted from a "management problem" that indicates "the department needs to better manage the resources it has." He said the agency has 35% more social workers than it did seven years ago.

At the same time, department officials acknowledged that they established a makeshift shelter in a conference room near downtown L.A. with cots, food and a nearby shower, violating a state rule that children spend no longer than 24 hours in agency offices.

Bhatt gave varying accounts of the number of children who had stayed in the shelter and for how long, first saying that "about 20" extended stays occurred since 2009 and that no child spent more than two days in the conference room.

But he later said that 31 extended stays occurred in the room since January 2009, with one child spending five days there before social workers found the child a place to live.

Officials first pledged to address the issue of holding children in makeshift areas in 2003. Two years later, after reports of another 100 children kept too long in temporary quarters, officials renewed promises to fix the problem.

L.A. County's child welfare agency has a backlog of some 3,700 cases open 60 days or more. Department and union officials say they're 'at a breaking point' with current staffing levels.

Los Angeles County's child welfare system has failed to complete investigations into child abuse hotline tips involving more than 18,000 children within the time mandated by the state, according to county records.

Because of the backlog, state regulators recently extended L.A. County's deadline for completing investigations from 30 days to 60, but Department of Children and Family Services officials have been unable to meet the new timeline as well. Some 3,700 cases — many involving multiple children — have been open two months or longer without determining whether abuse or neglect is taking place in the home.

The delays — which might leave children in dangerous situations until social workers complete their work — are the result of too few staff burdened with a litany of new tasks intended to reduce the deaths of children whose families already had come under the department's scrutiny.

"The social worker staff simply cannot keep up with everything we are asking them to do," department Director Trish Ploehn said. "All of the things that equate with quality do take time."

John Tanner, executive director of Service Employees International Union Local 721, which represents the social workers, said, "The emergency response system is at a breaking point. We have to reinvent it to best help social workers ensure child safety."

The crisis began last year after The Times reported that more than a dozen children had died of abuse or neglect in each of the two previous years after coming to the attention of the department. Internal investigations subsequently determined that most of those cases involved errors by the department that probably contributed to the fatalities, and that the errors were concentrated in the unit that handles emergency response.

Department officials responded by ordering more interviews, additional managerial oversight and other duties intended to improve the thoroughness of investigations.

But the work proved to be too much for the county's 596 emergency response unit workers — up only 80 from a year ago. They are charged with investigating about 160,000 tips that arrive each year through the child abuse hotline. Since July, about 7.5% of the cases opened based on those tips remained unresolved after 60 days or more.

A recent internal study also found systemic flaws in the unit's investigations.

The study found that evidence was often insufficient to fairly judge the situation or had been improperly gathered. Children were interviewed alone in only 66% of cases. And social workers on average spoke with fewer than two so-called collateral contacts — neighbors, friends, school officials and healthcare providers who know the children best.

On the positive side, it concluded that workers correctly assessed the evidence they gathered in 93% of cases.

Further complicating the investigators' work are the department's persistent technology problems. Computer databases with information about family histories are notoriously incomplete and cumbersome to use.

When workers go out into the field, they are not able to access the databases because they have no county-issued cellphones and little information about the child other than an Internet map printout for the last known address.

Despite an investment in laptop computers for field work, most social workers are not trained to use them and do not take them in the field because of unresolved connectivity issues, department spokesman Nishith Bhatt said.

Ploehn has worked for much of the past year to rebuild the emergency response unit. She expanded the unit's training program and ordered many cases to go through an extra layer of review by senior staffers who are held accountable for the inquiries' conclusion and often send investigations back for further work before closing a case.

As a result, investigators are filing far fewer unsubstantiated cases, a factor cited by California Department of Social Services Director John Wagner in his decision to temporarily suspend the 30-day deadline.

"This is significant, as it recognizes the extensive child safety enhancements we have implemented to ensure quality investigations and the time it takes for a social worker . . . to actually complete the required tasks," Bhatt said.

It's difficult to determine how much additional staff is needed, particularly in a time of steep budget cuts throughout many county departments.

In February, Ploehn told The Times that she would add 300 workers to the emergency response unit to aid completion of the investigations. But last month, in a presentation to the county's Commission for Children and Families, she reduced that target to 100 additional workers.

In a recent interview, Ploehn said she needs funding for 133 more workers — which would bring the total added to about 210 from a year ago — in order to bring caseloads to acceptable levels. The estimated cost of making those hires is $15.7 million.

"We have basically done all the reshuffling we can do internally," Ploehn said. "Our board and CEO are juggling a number of priorities and we need to make the case why these additional staff are critical."

Miguel Padilla ran away from a licensed group home in April 2008, but he didn't go far.

Unknown to anyone at the time, the 17-year-old amputee made his way to a stand of trees near the main driveway. Using his one arm, he climbed into the branches, tied a makeshift noose to a limb and hanged himself.

Nine days passed before a staffer found his body at the sprawling LeRoy Haynes Center in LaVerne, coroner's records show -- and then only by chance.

"To our knowledge there was no search by LeRoy's or any other authority," said Dave Rentz, the boy's minister.

Miguel Padilla died much as he had lived: alone and out of sight, his suicide the final step in a failed journey through Los Angeles County's child welfare and juvenile justice systems.

At least 268 children who had passed through the child welfare system died from January 2008 through early August, according to internal county records obtained by The Times. They show that 213 were by unnatural or undetermined causes, including 76 homicides, 35 accidents and 16 suicides.

Eighteen of the fatalities were deemed the direct result of abuse or neglect by a caregiver, subjecting them to public disclosure under a recent state law aimed at prevention.

But Miguel and many others perished all but invisibly, their deaths attracting little or no public scrutiny.

Through interviews and previously confidential records, the newspaper examined his death and that of Lazhanae Harris, a 13-year-old girl slain in March. Both underscore systemic failings, particularly the risks of losing track of abused kids as they commit crimes and "crossover" to the justice system, or as they move through multiple state-licensed homes.

Together, they also illustrate the range of flaws in a system where choices sometimes boil down to leaving children with families that can't or won't care for them, or placing them in foster homes that are no better -- and are sometimes worse.

Trish Ploehn, director of the L.A. County Department of Children and Family Services, said such deaths, though horrific, do not represent the vast majority of the thousands of cases her agency handles each year.

"The tragic lives and deaths of Miguel and Lazhanae only begin to scratch the surface of the extremely difficult, complex and complicated family circumstances that DCFS social workers are faced with every day," Ploehn said.

"It is very rare for a child to die of abuse or neglect while in the care or under the supervision of DCFS," she added, "and we consistently work to perfect our performance to help keep children safe, even after they leave our protection and supervision."

Ploehn said efforts are under way to improve collaboration between juvenile justice and child welfare officials and to intervene swiftly in the lives of troubled families.

By almost any measure, Miguel's life would fit the definition of mistreatment: He was abandoned by his mother, largely neglected by his father and left to struggle with untreated medical problems and depression most of his life.

By the time he died, however, he'd broken the law and moved from the care of the children's services department to that of its Probation Department, which oversees 20,000 juvenile offenders.

Up to half have a history with the child welfare agency, Probation Department Director Robert Taylor said. Ploehn said the proportion was far lower.

In Miguel's case, interviews and records show, the county failed him time and again -- not finding him a stable home, not addressing emotional problems that contributed to his delinquency, not even looking for him when he disappeared.

When the County Children's Commission, a panel appointed by the Board of Supervisors, took the extraordinary step of reviewing Miguel's death and four others among abused children on probation last year, it found "serious and consistent deficiencies" in their care. Four were suicides and one died of disease.

"Had the system met its responsibilities, the committee believes that some of these suicidal youth might have made healthier choices and the fifth might have had his health complaints acted upon more timely," the commission said in a confidential draft report prepared for county supervisors and obtained by The Times.

The draft was never issued in final form.

Abandoned at 10

Miguel Angel Padilla Jr. was born in February 1991 at a Sylmar hospital and later moved with his family to Mexico, where he had two accidents that would shape his life.

When he was about 9, he touched a metal rod to a power line while playing on an apartment building rooftop. He was seriously burned and lost his right arm below the elbow. He later lost the sight in his left eye when a firecracker shattered a pop bottle in his face.

At age 10, he lost his mother, who took his three siblings to Texas and started a new life without him, according to interviews and child welfare records obtained through a court petition.

"Minor's mother left him when he was little and has never made any attempt to visit or call," a social worker's report noted in August 2004.

Shortly after Miguel's mother left, the boy and his father, Miguel Padilla Sr., moved back to Southern California, to the Santa Clarita Valley community of Newhall.

The father worked odd jobs and spent much of his time in Mexico. The boy was raised mainly by his elderly paternal great-grandmother, Maria Arriaga Hernandez, who by all accounts, including her own, was ill-equipped to care for him.

"She had no real control," said Rentz, a minister who was close to the family, "but she provided the best she could."

The family first came to the attention of the children's services department in April 2003, when social workers substantiated allegations that Miguel's father had neglected the 12-year-old's medical, dental and emotional needs.

Their report cited the father's "lack of cooperation," poverty and limited job skills. Records also noted Miguel's suicidal tendencies, which his father attributed to ridicule from other children about his disability.

"Miguel sometimes seems to have a hard time processing information," a follow-up report stated, adding that he used poor judgment and seemed depressed.

Records show that Arriaga, then in her late 80s, went to Mexico with his father for long stretches, leaving the boy with friends or relatives.

Although social workers visited regularly and drafted a mandatory action plan, even its clearest goals -- to get Miguel to school regularly and to get him a prosthetic arm -- were never achieved, documents show.

Arriaga told social workers repeatedly that she had trouble comprehending what they said, even though they spoke Spanish. On the signature line of the parenting plan, she scratched an X.

Even so, there is no evidence that the children's services department tried to remove the boy and find him a more stable environment.

When a reporter visited Arriaga recently at her apartment in Newhall, she referred questions to Miguel Sr., 45.

In an interview, he acknowledged that he lives much of the time in Mexico, where he has two other children. He was unable to drive Miguel to his appointments, he said, because he'd lost his license and was jailed for driving under the influence.

But he denied that he neglected his son or that the boy was emotionally troubled. He suspects foul play in the death, not suicide.

"My son didn't have no problems," Padilla said. "He was just a fighter, that's all, and when I wasn't around for a while he got away from his grandma. She's old and she couldn't handle him too good."

Child welfare records paint a bleaker portrait, saying Miguel sometimes refused to eat and locked himself in the bathroom for hours, crying. At school, he'd skip recess.

"He said at school he stays in the classroom because he can't make friends, except for the second or third graders because they are nicer to him," a social worker wrote in June 2004, when he was 13.

That spring, Miguel was measured for a prosthetic arm he desperately wanted. Months later, he had to be re-measured; he'd missed so many appointments his size had changed.

Meanwhile, he wore a down jacket to hide his disability, said Denise Tomey, executive director of the Carousel Ranch in Santa Clarita, where he spent six months in a riding program for disabled kids.

"He had no self esteem," Tomey said in an interview. "He walked with his head down and he wore that heavy jacket, even if it was 105 degrees out. He thought people judged him because he was missing an arm."

Tomey and Rentz both remembered the boy showing a softer side, such as when he helped other kids at the ranch learn to ride and groom horses.

"I have a heart," he told a probation officer in March 2006. "I care about people. When I have opportunity to do something really bad I think about it."

But he also had a penchant for trouble: He faced charges for allegedly threatening and assaulting a teacher. He also was accused of burglarizing a home, vandalizing cars and tagging a fence with gang graffiti.

Cumulatively the charges were enough to land Miguel in the care of the Probation Department and in a succession of juvenile hall and group home placements.

Along the way, probation reports show, he joined a Newhall gang; picked up the nicknames "Little Shadow" and "Lefty"; and told authorities he used marijuana and alcohol. He liked school but was "not that smart," he said, and during one stretch of heavy absenteeism he pulled straight Fs.

By May 2006, his great-grandmother was overwhelmed. "I cannot take him," she told probation officials. "He is not well. He asks me to make him well. . . . He yells out loud to me, 'Cure me.' "

Miguel spent the last two years of his life in multiple placements, running away at least once before going to the Haynes Center. One probation report called him "a continual behavior problem."

While Miguel was in juvenile detention, psychiatrist Saul Niedorf concluded that the boy's impulse control had been impaired by brain damage from the electrocution. Until then, apparently, no one had considered that possibility.

Niedorf recommended a "structured, therapeutic setting" for Miguel, and he was sent to the Haynes Center, which is licensed to house 72 boys, in January 2008.

The day after his last court hearing that month, his father and great-grandmother left for Mexico, asking a social worker to visit him in their absence. In a March 2008 letter seeking official permission to stop by, the social worker said Miguel had had no weekend visitors for two months.

"I have been informed that the minor has been struggling lately and I believe he may benefit from the interaction," she wrote.

A month later he hanged himself.

Taylor, the county's probation chief, defended his department's handling of the case but acknowledged that the death highlighted the need to better understand why so many children who pass through the child welfare system end up in the care of his agency.

In hindsight, Taylor said, it might have been better if Miguel at a much earlier age had been placed with someone other than his elderly great-grandmother.

"Finding someone who would have been a better caregiver might have resulted in a different outcome," he said. "You just don't know."

As for youngsters who go AWOL from Probation, Taylor said, about 300 were missing at the time Miguel disappeared and he doesn't have the staff to track them down.

Dan Maydeck, president and chief executive of the LeRoy Haynes Center, declined to comment, citing legal and contractual restrictions.

Miguel's death signifies a much broader problem, said Miriam Long, a Los Angeles deputy mayor who worked on children's issues as an aide to former supervisor Yvonne B. Burke.

"A lot of these kids have mental health problems that should have been addressed much earlier in their lives," she said. "Without sounding too much like a bleeding heart liberal, because I'm not one, they could have been redeemed."

But Long said they can be difficult, and many adults would rather not deal with them.

"The teachers were happy when they were finally washed out and gone," Long said. "DCFS was happy when they were gone to Probation, and Probation was glad they were gone and went AWOL."

Before her retirement last year, Burke got board approval to have Probation search for AWOL children and report any deaths confidentially to supervisors.

Seeing no action, her successor, Mark Ridley-Thomas, got the board last month to reiterate Burke's order.

"They don't get it," he said of the department.

Tomey, the ranch director, knows only that children like Miguel can be helped.

"He really was one of those kids that, if he'd been in the right situation, he would have ended up being a totally different person," she said. "His life could have turned out OK, or not. Tragically, it did not."

The map below records the homicides of 55 children whose families came to the attention of Los Angeles County’s Department of Children and Family Services prior to their deaths. Some died of abuse or neglect, others were the victims of street violence.

The cases represent homicides of children who the Los Angeles Times has been able to connect to L.A. County’s child welfare system through coroner's records, county documents and other sources. Some date back to 2007, but the most complete data is for the first eight months of 2009, a time period for which The Times obtained a death log.

This is the Department of Children and Family Services' internal log of 98 fatalities in 2009 (through early August) among children who had passed through the county child-welfare system. It was obtained by The Times and has not been altered, except for the deletion of children's names to protect families' privacy. In most cases, The Times was unable to verify the circumstances the log describes and has not corrected misspellings and typographical errors.