The girl was 5. She set a kitchen garbage can on fire. Her mom, who had abused cocaine when she was pregnant with the girl, hit her with a belt. And then the girl and her 7-year-old brother both missed about 45 days of school apiece.

Last November, the city’s Administration for Children’s Services removed the two children from their mother, Elizabeth Norwood, and put them in foster care.

One might think this would improve the kids’ lives. One would have to think again.

Norwood doesn’t deny she hit her daughter, or that she used drugs some years ago. But it was only when they started living in foster homes, that the two children had those prolonged absences from school.

And that wasn’t all that was allegedly wrong in their foster homes. When the children did come to class, there were signs they were living in terrible circumstances. “Prior to their removal the children had attended school regularly. Both students were always groomed and well behaved,” wrote the principal in a letter this June. “Their quality of life has deteriorated dramatically. They no longer attend school on a consistent basis,” continued the letter. “Their teachers…have complained to me that the children appear to be neglected–coming in poorly dressed and unclean. Most distressing is the fact that these two children, who were once content and cheerful, are now either hostile or withdrawn.”

Norwood’s daughter, a student in the gifted and talented program of P.S. 191 on Manhattan’s West 61st Street, landed in a psychiatric hospital not once, but four times. Her son is now repeating second grade. Until they were removed from their mother’s care last November, the children had maintained nearly perfect attendance.

Between the two of them, they had ended up in six different foster homes in just nine months. It appears that those foster parents couldn’t, or wouldn’t, take the kids to school on a regular basis. Perhaps it was just too far for the new caretakers to travel. Their foster homes were all in Harlem, more than 80 blocks uptown from P.S. 191. Norwood had secured a court order keeping her children enrolled there. The result was they often didn’t go to school at all.

There were other problems. The children “were not treated good,” says Norwood. “If they didn’t eat their dinner, the foster parents made them stand in the corner all night,” she recounts, still outraged. One foster mother hit her son for urinating in the bed. “I offered to buy her a new mattress cover,” Norwood sighs. One of the homes, Norwood reports, was so dirty the children had to throw out their clothes after they left because their bags were filled with roaches. (The agency responsible for the children’s care, Edwin Gould Services for Children, did not return calls seeking comment.)

In July, a Family Court judge learned of the situation and ordered the children returned immediately to their birth mother. Now Norwood wants to know how her children could have fallen apart so badly. She suspects the caseworkers were not supervising appropriately or checking regularly with the school, in violation of foster care regulations, considering the children had missed so much school. Otherwise, she surmises, “they would have caught the educational neglect on the kids,” before the principal got involved. (ACS says no one ever called in a report of suspected educational neglect to the State Central Registry.) The author of the letter is no longer principal of the school and couldn’t be reached for comment.

One thing is clear: The Norwoods are not the only children in foster care to suffer in the city’s custody. Even as the number of children overall in foster care has decreased dramatically in the last five years, the proportion of children neglected or abused while in care may have increased during that time.

In fiscal year 2003, ACS’ Office of Confidential Investigation, which probes all reports of abuse or neglect within foster homes, determined that approximately 284 children out of a total of 25,701 were likely abused or neglected in foster care–or a total of 1.1 percent. Federal standards set 0.57 percent as the maximum acceptable rate of abuse and neglect in foster care. New York State ranks eighth-worst of the 29 states that report their rate of children abused or neglected in their foster homes.

What’s more, the mistreatment may have gotten worse in recent years, even as ACS has undertaken major reforms to promote better care. In 1999, 436 of the kids under ACS’ supervision–in both foster care and day care–were found likely to have been abused or neglected. (Until this year, the agency did not release separate numbers for abuse and neglect in foster care.) The current rate is as much as 15 percent higher.

Why does neglect in foster care persist? Child welfare experts offer many theories, including a bad economy pushing households into the foster care business, high stress on low-income families, and payments that remain extremely low. There’s also the city’s effort to house foster children in the neighborhoods they were previously living in, or at least the same borough. The hope was that by keeping children in their communities, they could continue to go to the same schools and churches and more easily visit their parents. But foster parents from these mainly low-income neighborhoods are often struggling with the same sorts of problems as the natural parents.

Earlier this year, the Bloomberg administration announced a major advertising and outreach campaign to recruit new foster parents, and acknowledged that it did not have enough homes in several neighborhoods.

“We never have enough foster parents,” says Barbara McMurray, assistant executive director of Cardinal McCloskey Services, a private child welfare agency that supervises foster homes in the Bronx and Manhattan. “Many of the [community districts] that we work in are low-income communities where people live in apartments or projects.” There is, says Murray, a “space issue.”


But it’s also clear that there’s also a supervision issue–a big one.

Part of the challenge in keeping an eye on New York City’s tens of thousands of licensed foster homes is that the city doesn’t maintain direct responsibility for supervising them. It hires private nonprofit organizations to do the work–42 of them, currently, down from 60 in 1999. With the number of foster children decreasing rapidly–there are now one-third fewer kids in care than in 1999–ACS will almost undoubtedly cut that number down again very soon. [See “Racial Downsizing,” November 2003.]

ACS judges these agencies primarily based on their measurable “outcomes,” including how quickly, and successfully, children are moved from foster care into permanent homes. But about one-quarter of each agency’s score is still based on a qualitative review. According to ACS spokeswoman MacLean Guthrie, city auditors scrutinize about 50 random cases at a time. Interviews with foster parents are part of the review. So is the rate of substantiated abuse or neglect in foster homes supervised by that agency.

Really, though, it’s all about the paperwork: “Uniform Case Reports” and other documents in a family’s file. These records contain “progress notes”–assessments of foster home safety and comments based on meetings with children.

“There’s a tremendous amount of pressure,” says Gladys Carrion, executive director of the agency Inwood House. “It’s pressure over the wrong things–that’s what galls me.” Auditors, she says, are looking to make sure progress notes are in the proper part of the report forms, and in the proper format; the actual quality of care doesn’t enter into it.

And that pressure may be a big problem. In theory, the close scrutiny of paperwork serves to make sure agencies are doing the work they’re paid to do. But it actually creates an incentive for those contractors to make sure their paperwork is in perfect order–even if that doesn’t reflect the real story.

For instance, a report that simply states that a caseworker visited a child and determined he was “thriving”–a ubiquitous word in case records–can satisfy the city’s demand for paperwork, even if the reality is that the home was filthy and the child was emaciated. After all, who is ever going to know what the actual conditions in the home were that day, other than the caseworker, foster parent and children themselves? For that matter, who will be the wiser if the caseworker didn’t even make the home visit?

Caseworkers have some of the hardest jobs that exist. They deal not only with children, but also birth parents and foster parents. One case can easily involve eight to 10 people, all of whom need some type of assistance. This means that workers with 25 cases–the estimated average in New York City–are easily dealing with dozens of people on a regular basis.

“We’re mother, father, therapist and it’s not just to kids–it’s to the birth parents,” says Tanya Barnes, a caseworker with Seaman’s Society for Children and Families. High caseloads and low salaries–“we’re one paycheck away from being homeless,” says Barnes–drive many workers out of the field. The resulting high turnover means families have to adjust continually to new caseworkers, who in turn have to get up to speed on complicated family histories very quickly.

McMurray of Cardinal McCloskey Services acknowledges that high caseloads mean “some contacts can fall through the cracks”–and with that some essential monitoring, like making sure children attend school.

One former caseworker who has worked at a private agency says the cracks were sometimes chasms. Caseworkers are required to visit foster children in their homes at least once a month. More often than anyone likes to admit, this individual says, they don’t. “A lot of caseworkers look for shortcuts,” says the ex-caseworker, who notes that the information in the records “wasn’t verifiable.” Others are downright negligent. On Friday afternoons, two colleagues used to say they were going on field visits, but would actually go to the racetrack–and managed to keep “perfect records.” The loud and clear message from management was that the paperwork had to be in order, no matter what.

In the most grievous of foster care neglect cases, it’s hard not to ask whether a caseworker actually showed up with any frequency to inspect the home. Take the death of Stephanie Ramos this past summer. Ramos, a disabled 8-year-old who was blind and had cerebral palsy and diabetes, was found dead in the Bronx, her corpse in a plastic bag in a garbage truck. In October, the city’s health examiner determined that she died of natural causes. But there’s also evidence that where she lived was not the most suitable of homes for such a severely disabled child: Law enforcement authorities said the foster mother’s house in Queens was squalid, carpeted with clutter, trash and dirt.

Ramos’ foster mother, Renee Johnson, was also caring for two other foster children. The little girl was supposed to receive home visits from a nurse but, according to the New York Times, the nursing service was terminated last November. The agency responsible for Ramos’ care, the Association to Benefit Children, did not know the nurse service was canceled.

A host of other questions remain unanswered. Why didn’t the Association to Benefit Children–rated as “satisfactory” in its last evaluation–notice the situation was abnormal? Did caseworkers think the foster mother was falling apart under stress and cut her some slack? Or was she exceptionally good at hiding her problems? The case is still under investigation.

In New York and New Jersey, cases that heartbreakingly testify to inadequate supervision of foster homes are piling up. In Newark, Faheem Williams, found dead in a box. In Camden, the four starved Jackson boys. Earlier this year, O.J. Simpson lawyer Johnnie Cochran sued New York City for half a billion dollars on behalf of an 8-month-old girl who allegedly died of shaken-baby syndrome in foster care.

And then there was the tiger. And the alligator.

The Harlem apartment that housed the most notorious pets in recent New York history was also home to five foster kids, and there’s evidence that until the matriarch of the house picked up with them and fled to Pennsylvania, at least one foster child cohabited with the animals. Whoever the caseworker was, he or she didn’t spot the wild animals–assuming, of course, that the caseworker was in the apartment at all.


ACS has made one very important improvement, among many in recent years: The agency has become aggressive about making sure that every foster home is properly certified. In May 1996, 7,341 kids in foster care lived in homes that were not licensed. By 2000, that number had decreased to 510.

Licensing involves running background checks on the adults in the home, and making sure they have a source of income and enough room for children. But having a license doesn’t guarantee a home is fully checked out. If adults move in after the initial certification is done, caseworkers have to do a background investigation on them, too.

That doesn’t always happen, says Madelyn Freundlich of the legal advocacy group Children’s Rights, Inc. Her organization recently examined child fatalities in New York City that occurred between 1999 and mid-2001, based on records obtained from the state Office of Children and Family Services. “Fatalities, obviously, are the most extreme and dramatic results of services and systems that aren’t working well,” says Freundlich. Fatalities overall have fluctuated in the last several years, rising in 2000 and 2001, then declining again last year.

One of the cases examined by Children’s Rights was that of an 11-month-old who died of a cocaine overdose while in foster care. The foster mother’s boyfriend–who used drugs–lived part-time in the home, but there’s no evidence caseworker ever investigated him.

Freundlich says the problem is at least twofold. Caseworkers don’t always visit often enough to know everyone who is living in the home. And foster parents don’t volunteer the information. Overall, the Children’s Rights report identified several themes in cases where foster children died, including poor communication between the agency and foster parents, poor training of foster parents and inadequate monitoring of foster homes.

Hank Orenstein, director of the city Public Advocate’s child advocacy project, C-Plan, agrees that foster care agencies don’t always have a good grasp of who’s living in the foster home. “We’re talking about thousands of foster homes,” says Orenstein. “Unless you have really tight monitoring of all these things, they’re going to be risk factors.”

But whether homes and foster parents are licensed is only one piece of the picture. In some cases, a license limits the foster home to having two children, but there are four, and sometimes a foster parent’s own children as well. In one recent incident, a foster mother who had more children than she was licensed to house accidentally ran over and killed one of them with her car. Other licenses limit a home to children without special needs, but children with severe problems are nonetheless placed in the home, say attorneys with Lansner & Kubitschek, which represents families suing the city for neglect and abuse in foster care.

ACS says it now now tracks families by computer to make sure they have no more kids than they’re licensed to house.

If caseworkers don’t know who or how many people are living in the home, it’s doubtful they’ll have a clear picture of what’s really happening there. Orenstein says the Public Advocate’s office, which issued a report last year on child fatalities, examined records in one case where three children in foster care died in a fire. The fire marshal had found the home “fraught with hazardous conditions.”

Caseworkers can dutifully show up at a home every month and still fail to get an accurate picture. Elie Ward, executive director of Statewide Youth Advocacy, an Albany group, says that workers become complacent once they get to know a foster parent. “If there are no obvious problems, the caseworkers don’t look for problems,” says Ward. If they did, she points out, they might be forced to find a new home for the kids. But good foster parents are so hard to find that agencies don’t want to move children “if there isn’t something staring you in the face.”

The dual mandate to keep children safe but also minimize disruption in their lives also makes it hard for caseworkers to know when to relocate children, says Freundlich. “You don’t want to precipitously move a child if you’re simply having an instinct, but you can’t quite get the information,” she says. She agrees that the shortage of good foster homes dissuades caseworkers from moving children without rock-solid evidence of a problem. “Presumably, if you want to move a child out of a home,” says Freundlich, “you want to be sure you can move that child into a better setting.”

And some foster parents are very good at hiding problems, notes Fred Wulczyn, a former analyst for the New York State Department of Social Services who helped design ACS’ current agency evaluation system. “The likelihood that [a caseworker] will see something that triggers in them an appreciation that it’s a high-risk situation”–a gut feeling, a sense that a foster mother is overwhelmed–is small, Wulczyn says.


But there are some signs impossible for caseworkers to ignore. Wilson Coakley’s son entered foster care in November 1999, at the age of 3, after a police officer found him home alone in the Bronx. The following February, he was taken to Lincoln Medical and Mental Health Center, with bruises all over his body. One month later, he was returned to his father–with bruises, two black eyes, cracked teeth and head injuries, according to a lawsuit settled with the city and a private child welfare agency last year. (Neither admits liability.)

When ACS removed Coakley from his mother’s home, it placed him with a private agency, St. Christopher’s, Inc. St. Christopher’s was recently ranked third to last of private agencies and given a grade of “needs improvement.”

When Coakley ended up at Lincoln, hospital personnel reported their suspicions of child abuse, and the Office of Confidential Investigation launched a probe of the Bronx foster home. The recommendation was that the foster mother should be trained in non-physical methods of discipline. (In fact, St. Christopher’s closed the home. Chris Pardo, associate executive director of St. Christopher’s, says his agency fingerprinted adults in the home and cleared them, finding no prior criminal history or other warning signs. The foster parent had 18 hours of training, in accordance with policy at the time.)

The internal investigations office is not always this easy on foster parents. It can also recommend that the children be removed and the home closed–meaning that the foster parents are no longer eligible to care for foster children. Much is left to the discretion of the individual workers, says Orenstein. “There is a high degree of inconsistency in terms of quality of casework and assessments, so what you get is extremes,” he says. “We also get complaints from foster parents saying the children were abruptly removed from their homes for no reason.”

What’s also clear is that the Office of Confidential Investigations has a narrowly defined role: It tries to make sure kids don’t stay in unsafe situations. But it’s not there to more fundamentally address the systemic problems that keep its investigators busy. Asserting a need for greater scrutiny, the Public Advocate’s office maintains there should be an independent inspector general to monitor foster care agencies; Children’s Rights made a similar recommendation in its report.

Orenstein is also a strong proponent of including families in the assessment process. Children age 10 and older have the legal right to be present when their cases are reviewed, but this rarely happens. “We’re at a crossroads with the foster care system,” says Orenstein. The city, about to cut the number of agencies, can take this opportunity to assess caseworkers for quality of services. One way is by asking children, parents and foster parents to participate in rating their workers.

Why doesn’t the city already do this? One reason is that even though ACS stresses family preservation as an agency priority, saving children from their parents often remains the underlying ethos in practice. Until the city succeeds in shifting the paradigm to preserving families, says Orenstein, children will continue to enter an overburdened foster care system that can’t adequately protect them. “Until we can evolve a fundamentally different type of system,” he says, “there are always going to be these kind of problems.”

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