Illinois' child welfare agency is so intent on keeping children with their parents even when they have strong evidence of abuse that it has sometimes left those children in grave danger, a study released Wednesday found.

Democratic Gov. J.B. Pritzker ordered the study of the Department of Children and Family Services' Intact Family Services unit after the recent deaths of three children. That unit is responsible for overseeing households in which children are left at home after allegations of abuse or neglect.

Illinois has been lauded for having one of the lowest foster care entry rates of any state in the U.S. Yet researchers found a profound failure to communicate within the department; overburdened staffers; staffers so convinced that prosecutors wouldn't agree with requests to remove children from homes that they didn't bother to ask; and cases in which evidence and suspicions of abuse or neglect were brushed aside.

Keeping children with their families is "a laudable goal," said Michael Cull, one of the study's authors. "But over time for a variety of reasons it becomes an overriding priority that leads to decisions that (the agency) may not even know they are making."

The study by the University of Chicago's Chapin Hall research center was ordered before last month's beating death of A.J. Freund, a 5-year-old whose parents are charged with first-degree murder. Nonetheless, issues surrounding his short life and violent death — from extensive contact the family had with child welfare workers to a determination that there wasn't credible evidence to support placing the boy in protective custody even though he suggested his mother was responsible for bruises on his body — are examined by the researchers.

Illinois is not the only state with a child welfare system under fire. In fact, according to the study, the rate of death due to child maltreatment in Illinois in 2016 — 2.16 per 100,000 children — was actually a bit lower than the national figure of 2.36 per 100,000 children. Some 501 children died between 2014 and 2018 while being involved with the Illinois Department of Children and Family Services or previously involved with it.

In one case, allegations of abuse were determined unfounded because the welts that an investigator had seen on a child's torso were no longer visible when the child was examined at the hospital.

That same case also illustrates just how toothless Illinois' child welfare system is. According to the report, the child's mother, who had a history of domestic abuse, agreed not to allow her boyfriend near her children only to simply "not honor the informal agreement" and give her boyfriend further access to her children. The report does not include the names of the children, but one of the three children whose deaths prompted the study was allegedly killed by his mother's boyfriend.

Another major problem is that investigators and case workers are often in the dark about the extent of the problems in households where abuse or neglect is alleged. In two cases in which children were killed, "Both families had extensive history with DCFS but reviews noted a substantial amount of history was inaccessible due to cases being expunged or purged," the researchers wrote.

Absent such details, child welfare staffers are forced to "rely on family's accurate self-reporting on their history," the report said.

At the same time, important information sometimes does not make it to the case workers whose job it is to monitor and manage the families. In two recent cases in which the children who died were allowed to remain in the home but under the agency's supervision, "there was no evidence of ongoing collaboration" between investigators and Intact Family Services case managers.

According to the study, most Intact Family Services cases are handled by private providers, with the state keeping only the "high risk cases." While not critical of the private providers, the study found that because the pay rate decreases after the six months that intact cases are expected to last, "the process to extend the initial rate, which requires justification and approval, is not often pursued."

Further complicating the matter is that the department also sends high-risk cases to private providers when its caseload is too high, said one of the lead authors of the study, Dana A. Weiner.

The department's director, Marc D. Smith, acknowledged that children who remain in their home after allegations of abuse or neglect are in greater danger than any other children his agency deals with.

"Intact is the place where the risk is the highest," Smith said at a media briefing on the study.

Chapin Hall made a number of recommendations, including making it more difficult to close Intact Family Services cases. Researchers also recommend improving the quality of supervision and beefing up communication throughout the child welfare system.

"While Illinois' low removal rate has received national (positive) attention, it is nonetheless important to retain a critical lens when examining risk and safety in each individual cases," the report says.