Leading Child Welfare Systems Past the Worst Tragedies

Tom Rawlings, Georgia’s director of the Department of Family and Children Services.

How do you build and maintain an effective child protection system when faced with the challenge of a high-profile child death? While leaders often react by making immediate changes and promising reform, a calm, measured approach is much more effective. Research supports that approach for several reasons.

Child welfare systems need a stable workforce of dedicated child welfare professionals. It’s not enough to have them in sufficient numbers; they need to stay with the agency long enough to get good at the work. Part of that learning comes from good training, but even more comes from experience, from making mistakes, and from having supervisors who coach employees through those mistakes and help them learn from them.

Research shows, however, that instead of an acceptable staff turnover rate below 10 percent annually, most U.S. child welfare systems experience annual turnover between 20 and 40 percent. That means that every three to five years, the front-line staff might be entirely new. The result is a green workforce with supervisors who haven’t had the time to gain the experience, knowledge and skills needed to do this work well.

Stable leadership plays an integral role in the health of a child welfare system. We need leadership that recognizes this work involves not only a child’s right to be safe from abuse, but also his right to be in his own home with his parents, in her own neighborhood where she can play with her friends and go to her school. Balancing those priorities is at the heart of determining a child’s best interests, and it requires leaders who give case managers the freedom to make tough calls, and backing them up even when a tragedy results.

But consistent leadership in child welfare systems is unfortunately rare. In 2007, Dr. William Bell of Casey Family Programs testified before Congress that the average tenure of a child welfare director in the U.S. is somewhere between 18 months and two years.

A major contributor to this lack of stability? The high-profile death of an abused child who suffered horrifically despite being “known to” the child protection system. The headlines typically follow …

First: “Agency Reeling After High-Profile Death.”

Followed by: “Social Workers Fired Following Major Failures”

And finally: “Child Welfare Director Sacked as Leaders Promise ‘New Direction’.”

Before I was honored with the privilege of being appointed to be the director of the Division of Family and Children Services (DFCS), I served as the independent State Child Advocate, the “watchdog” over the agency. So I’ve been in the role of being the critic, and I’ve also been in the hot seat when a child’s death attracts the public’s understandable shock and concern. And here’s the advice I’d try to give the public, the media, political leaders and child welfare agency executives when such incidents occur.

Don’t throw your front-line case managers under the bus.

When the public calls for someone to be “held accountable,” too often the workers who were closest to the case when the child died are the ones held responsible: fired and sometimes even prosecuted. Usually, termination does nothing except instill fear in the remaining staff, increasing their stress and skewing their decision making process. Few and far between are those instances in which one individual’s malfeasance or gross negligence caused the death.

One of the brightest minds on the issue of handling child welfare system failures is British expert Eileen Munro. As she has noted, tragic failures in other systems – whether it’s a plane crash, a collapsing bridge or a patient who dies at the hospital – rarely involve one major mistake by one person. Rather, she writes, these tragedies result from many small system errors, most of them harmless by themselves but that come together to create a disaster.

“Solutions, then, do not take the form of rebuking the front-line worker who happened to perform the final mistake in this long causal sequence,” Munro says. “It is, instead, necessary to examine the system to see if a better match can be achieved between the tasks and the workforce’s skills, knowledge and resources.”

It’s nearly impossible to examine properly a system that’s constantly in flux due to high worker turnover or leadership changes. Stability is key to the improvement process. Leaders must explain this stability principle to the media and public and help them understand just how counterproductive it can be to react in a way that limits your staff’s courage, freedom and sense of psychological safety.

Build Community Relationships Before the Tragedy Occurs

In the wake of a recent high-profile child death, one letter writer to a newspaper demanded to know how that child, who had previously been in foster care, “could have been sent home.” The implication, of course, was that if a child is removed to foster care, he or she should never be reunited with his or her parents.

We as child welfare leaders too often talk “above” the public and fail to explain our work in a way that most people fully understand. Most folks, though, know that children are better off with their parents or extended family. They understand that if we remove a child from the home for her own safety, it’s still an emotionally traumatic experience for the child.

We also need to share the stories of our successes. Just as our children in kindergarten come home with pictures of firemen, policemen, doctors, EMTs and other “community heroes,” we need to explain the incredibly important and sometimes dangerous work that our employees do each day. In Georgia we’ve begun this process, holding public “reunification celebrations” with willing families and creating “community hero” videos highlighting our work.

DFCS closely collaborates with the Court Appointed Special Advocate program, our court improvement project, and our State Office of the Child Advocate to ensure our communities understand the value of the child welfare system as a whole. Through our “State of Hope” program, we are partnered with over 150 individuals and nonprofits across the state to bolster the community’s ability to address the needs of children. By building these relationships, we are building trust, which is key to our weathering the storm of a system failure.

Make Sure the Public Understands Our Role in Protecting Children

Our friends and neighbors who make up “the public” are reasonable. They understand the police can’t prevent all crime, even when they’ve had prior contact with a suspect. They understand physicians can’t save every patient. And if we take the time to explain our role, they are able to understand that the child welfare system will make mistakes. Here are three points I try to make whenever I talk with folks interested in our system:

  • Our managers have a mandate to balance the child’s right to be safe and the child’s right and need to be cared for by their family.
  • Child deaths from abuse or neglect are rare – there were around 1,700 nationally in 2017 – and overall child protective services do a good job of protecting children when we receive a report. Our research in Georgia shows, for example, that DFCS contact was associated with seven fewer infant child deaths per year than in families who had no contact with DFCS.
  • A child protection system cannot be all things to all people. We do well when we are able to focus on protecting children in serious danger of harm and help them find safety, stability and permanency

Any child’s death from abuse or neglect is a tragedy, especially one that our systems had the opportunity to prevent and did not do so. But we must not simply react to those situations by pointing fingers and promising change. Rather, we must respond by recognizing the errors, identifying the systemic issues involved, assuring our employees that they are important, and forging ahead.

Tom Rawlings is the director of Georgia’s Department of Family and Children Services.

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