“A Department of Investigation Examination of Eleven Child Fatalities and One Near Fatality” was jointly released on Aug. 9 by the city Department of Investigation and the Administration for Children's Services, which is the city agency charged with investigating allegations of child abuse and neglect and taking on prevention and protection roles where necessary.
According to the report, in all 12 of the cases the children died and one nearly drowned “while their parents were under investigation by ACS for abuse or neglect, or after ACS had completed investigations concerning their parents. In all but one of these cases, DOI has found that the investigations conducted by ACS were substantially inadequate and incomplete.” In the incidents, which occurred between Oct. 2005 and July 2006, two of the children were found to have died of natural causes, and three siblings from a fire that swept through their apartment – while others apparently were killed by beatings from guardians.
Deaths of children “known to the system” – which can mean anything from the child's parent being investigated for alleged abuse, to a parent being cleared of an unfounded allegation nine years ago – have trended up over the past four calendar years, from 24 in 2003, to 33 in 2004, to 30 in 2005, to 44 in 2006. These may result from natural, accidental or other causes, or homicide. Homicide numbers also have trended up over those years: from six in 2003, to seven in 2004, to 10 in 2005, to 13 in 2006. But looked at over a longer period, the ups and downs do not immediately reveal a trend. How to weigh, interpret and derive meaning from the many factors is a source of lively debate within the child welfare community.
One thing the numbers do generally accomplish in New York City is generate outrage. The report's release – which was bookended by other reports of mistreatment of children known to the system and another alleged child homicide – was followed by fiery headlines in local media and calls for the dismissal of ACS Commissioner John B. Mattingly – who just completed his third year as agency head – as well as an articulation of support for Mattingly from Mayor Bloomberg.
In fact, Mattingly asked for the investigation himself in Jan. 2006, to determine whether the deaths resulted from wrongdoing by ACS workers, and to formulate recommendations for improving practices to avoid similar situations in the future. It's an organization of some 6,800 employees, including 3,500 in the division of child protection. The commissioner and his agency worked with DOI on the report, and he supports it completely. City Limits Editor Karen Loew sat down with Mattingly last week to hear his take on the report, the response to it, and where ACS goes next.
CITY LIMITS: It seems that the popular conception would reduce your accountability to the number of child deaths. How do you define accountability? What decides whether the commissioner is doing the right job or not – is it that number?
JOHN MATTINGLY: Actually, they’re down this year, but that never got in. [From January through July of 2007, there were 21 fatalities; over the same period in 2006 there were 27.] It's a whole bunch of things. Child deaths, given the relatively rare nature of them in a city of over eight million people, are not necessarily the best indicator, although I don’t want to spend a lot of time trying to defend that statement. It’s quite clear, though. The numbers we track are the numbers of reports to the state central registry of a child death. And there’s two categories. One, we’ve had any relationship with the family, and one we haven’t. For some reason they think we should have some impact on this second group as well as the first group. But surely we all agree we have some impact on the first one.
An explained death that wouldn’t have been called in two years ago does get called in now. And that’s okay actually. But it drives this number up, and yet child fatalities have not gone up in the city. The child fatalities reported to the state central registry have. Because of news coverage, people begin to worry, oftentimes rightly, that they hadn’t called. And they call, and we find something going on. That’s one of the reasons we had a huge increase in both reports last year, unprecedented – over 63,000.
This is not about removal or not removal. It’s about early enough intervention to stop the pattern of abuse and neglect. And that’s the other side of this, I think, that workers through their managers have been learning from us what we expect of them. And what we expect of them is strong enough intervention so that a child doesn’t end up five years from now having gone through bad things for five years, and all of a sudden we then remove. And the family may not be recoverable at that point. It may have gone on too long, and the child may have been real badly psychologically damaged.
The complexity is central to this, that’s why the media and the politicians – they want it all to be simple, and it’s not. And that’s a message I think our managers have all gotten now after the course of a year. They come through Child Stat every 14 weeks or so. You can then in the case review press very hard on that kind of complexity. But in the data you can press hard for accountability. So, we have during the course of the past year seen a big drop in the rate at which cases are being closed without some intervention. It went from 25 percent, 35 percent in some boroughs, down to single digits. Now, there are always going to be cases where they should be closed [without intervention]. But it was much too high before.
We are implementing a tracking system by which we will know whether cases that were investigated by this field office or child protective managers lead to another report or another indicator report in six months or a year. That way there will be differences, and we can begin to hone in on who is leaving children at risk because they’re coming back in the front door with another report.
And also caseloads, which are essential to this work. We knew from the first Child Stat meeting right on through to now every worker’s caseload, every unit, every child protective manager, every field office and every borough’s caseloads. And we can compare them, so we now know, yeah, we’re down below 11 cases per worker on average in the city. But why is this field office’s cases higher than that? You can see it right in front of you. So, that tells you.
Caseloads in the past are sort of hidden, because the people who own the problem are out there. And yet it’s my problem. Now it’s my problem and we can see the impact of our actions. That’s why the Mayor’s providing us with the support we needed to hire so many more workers really paid off in that, because the reports are still up, but they’re only going to be about 10 percent less than our high point in 2006. So, we have to keep up with them, but the caseloads are down.
CITY LIMITS: To some people the number of deaths is all that matters: Thumbs up or thumbs down on Mattingly. What is your basic response to that?
JOHN MATTINGLY: A couple of things. First, it’s very important for everyone to understand that this is a complex business with difficult decisions. That it’s never going to be done perfectly, although we’re responsible for doing it right every time. Secondly, there are very, very many indicators of an agency’s success or failure, and that’s only one. And sometimes, because of the issues I raised before, not the best one. Thirdly, the fact is that there is no quick fix to these problems unless you want to step in and remove kids willy-nilly. You can always cover yourself that way. But that’s how you end up with kids languishing in foster care without permanent families.
There’s no silver bullet – “if you do this thing, everything will be better.” And there’s no free lunch. You can’t just simply change policies and expect one indicator to change. You have to focus on better decision-making. And that can’t be done overnight. That’s mind-bending, sometimes heartbreaking. It’s certainly hard work that has to be done in realms like Child Stat.
CITY LIMITS: And better decision making by case workers?
JOHN MATTINGLY: Oh, yes. Everybody throughout the system, but that’s what their first job is. If you look at the history here, going back to 1990, you can see a situation where because of the crack epidemic and the system’s poor response to it – and there’s reasons why it responded poorly – but you’ll see that huge spike in the number of kids coming into care, and the length of stay of kids in care. But more children dying who had some contact with the system.
Everyone will tell you this – it was the wild, wild west. There were hundreds of investigative cases stuck in peoples’ drawers, and nobody knew where they stood. There were people coming and leaving in droves. There were crack vials in the employees’ restrooms. It was crazy. Then in ’96 when Nick Scoppetta and Linda Gibbs, and William Bell was already here, when a new leadership team was built and ACS was separated, the first thing they did quite successfully was get control over the system.
So, they knew where every case was. They had daily musters where managers were held accountable for seeing to it that they knew where every case was. They had a new training program that was put in place at the academy. Enormous success came out of that.
But now when you look at the decision making processes in the field, that’s the step that we have to go through now. People need to understand it’s not just a question of doing the interview on time. It’s a question of doing an interview in a way that you can figure out what’s happening in this family. That’s what that report is quite correct about, that if you don’t know what’s going on, you can’t make the right decision.
So, if you knock on the door, list the allegations the first time you meet the family, just walk in there and say we’ve had a report that this, this, this, and sexual abuse, and the parent says, no, none of that’s true. Then what do you do? So, you must figure out what’s going on. And you have to talk to the children separately, and you have to believe them when they tell you something, even when they’re little.
And that’s not going to change overnight, especially when you have people who have been here 20 years and have learned a certain way of doing it, and whose focus has too much been on moving the case. One of the child protective managers told us in one of the earliest Child Stat meetings, there’s two kind of workers here. One that wants to service the family and say: Here’s what you’ve got to do. You’ve got to go to parent training, you’ve got to get some drug testing. Service the family. The second kind is the worker who wants to move the case.
Well, we don’t want either of them. We want a worker who wants to find out what’s going on and then find the right action to take to make sure these kids are protected. So, just going in to this mother and trying to help her. And when she rejects help, stepping back. Maybe the next time she’ll be willing to accept the help.
CITY LIMITS: That sounds like a big cultural change for the case workers.
JOHN MATTINGLY: Very much so.
CITY LIMITS: How do you make that happen? Are you making that happen?
JOHN MATTINGLY: Yeah, I think so. Everything from the training effort, which is being completely overhauled, because the state controls the training design, the curriculum. The curriculum is much too much focused on how to help a family first and then on child protective services, on functions.
The engagement with a family, the training about that, should start with how you knock on the door and what you say going in the door. Engaging families is part of that. But getting someone to accept help, while it’s essential to your work, isn’t the first thing you do in your training. So, we’re now getting a new curriculum in place.
The work we’re doing in Child Stat with the borough directors and all the managers has to lead toward that sense of what it is that we’re trying to do. And they then – especially as they get trained in the leadership academy – build teams of their supervisors and help them build teams of their workers. The caseloads are small enough. Five workers now per supervisor. Three supervisor teams. Now’s the time to build this based on what we know is good practice.
What we knew as good practice five years ago, or four years ago, was not good practice. It was moving the case. Or getting people to accept help and moving on. So, we’re trying to deepen that, and that is what takes time. And feedback. And accountability. So, whenever we have a child death, we bring people in and figure out what went wrong, if anything. Sometimes you did it right. And figure out what we can learn from that. So, that’s another process. You don’t just bring people in and discipline them or yell at them because a child died. You bring them in and find out what happened. If they didn’t do their job, that’s another thing. But first you’ve got to find out what happened. Same way we do with a family.
CITY LIMITS: To the extent that there is sub-par performance by ACS workers or a lack of motivation or follow- through, how much do you think that is affected by pay? If everyone were paid $20,000 more, would that fix the problem?
JOHN MATTINGLY: The pay scale is appropriate. I don’t see it being way out of line when the private agencies who have many more problems and are paying substantially less, I think it’s much more a question of having a system that is accountable from top to bottom and that holds people responsible for what we all believe in, not for moving the case to closure. And I think we’re well underway. We’ve got a whole bunch of new people. I think we have a chance to change the culture from top to bottom.
But there are people laying out there in the tall grass waiting for this commissioner to go. …Until two years ago in the division of child protection, there was no leadership that came from outside the agency. Because the work is so complicated, the assumption was you can only promote from within. And while that’s essentially important, it’s not the only thing. You have to open up and let some fresh air in. Otherwise you only have people who have learned the way it’s always been.
I actually apologized to a bunch of managers last week. In a way, they grew up in this system doing what they believed – and quite often what they were told from their immediate supervisors – was a way of doing the work. Now people come in from outside and say no. And really say no about cases. I get calls about kids in foster care, and I intervene and hold people accountable because that’s one way you spread the word when a kid isn’t getting the life he’s supposed to get from a foster care agency.
And this is all new here. This is all new, so in a way, people feel like it’s unfair – 'I was doing what I thought I was supposed to do, and now this little guy comes in from Baltimore and tells me it’s wrong.' So, I respect that. You’ve got to respect that. But also they have to understand what it is that the work really should be like. If you’ve only done it this way for 10 or 15 years, you don’t realize that there are people out around the country who actually know how to do a sexual abuse investigation in a way that protects the child first, brings the non-offending parent – usually the mother – into league with the daughter. And when they get together, the case is much easier.
CITY LIMITS: Turning to the report specifically, I’m wondering if anything in the report really was news to you. Shocked you, surprised you, told you something new.
JOHN MATTINGLY: In terms of the findings, no. Remember, we do a managerial investigation on every case within 60 days. And within 90 days, a separate accountability review panel with doctors on it does a report. So, these cases – and many of them I’ve discussed publicly – the findings did not come as a surprise. For example, we caught the two guys actually who were saying they did something in the case when they hadn’t. Wrote up a false interview. The first guy was a manager, who, after the child death, went back into Connections [the computer system] and wrote all these instructions that he had given to the supervisor to make sure, and they were all related to things that we now knew had happened. Putting the worker and the supervisor on the hotline, not him. Unfortunately for him, we can tell when things get inputted. So, he was gone. Right away.
CITY LIMITS: So, the findings were not a surprise. Were some of the recommendations a surprise?
JOHN MATTINGLY: No, I don’t think so. I think the recommendations in general were quite welcome. I think the focus on the need to gather facts more effectively was exactly right. And a mutual back and forth with DOI about what to do about that led to these 100 additional investigative consultants so that every child protective manager will have one, which I think is a great step forward, because we’ve now had a year’s worth of experience with these guys. They have been fabulous. They don’t want to become caseworkers. They want to help caseworkers learn how to do their jobs.
CITY LIMITS: Tell me about that. It would seem that that’s bringing more of a law enforcement atmosphere, even a criminalizing atmosphere and often to people who are innocent. Do you think that that has any bad effect?
JOHN MATTINGLY: It has not. Unless you think that a bad effect is finding out that a child is being hurt that you didn’t know about.
CITY LIMITS: But if I’m innocent, and some guy comes in with his police demeanor…
JOHN MATTINGLY: These are investigative consultants who are backing up training and supporting and modeling, in some cases, for the workers. They are trained together. Plus, keep in mind these are mostly Special Victims Unit people who are used to working in child protection kind of things. They’re not hotrods who want to treat this as another part of criminal justice. They’re not coming in as investigators. They’re coming in as consultants.
And if you talk to the workers who work with them, you’ll see what I mean. If you don’t watch yourself, if you just hired a bunch of former police officers and put them in the field and said go investigate, you’d end up with these two parallel systems. The workers resent it, and they would probably decide, well, they are responsible for safety, and I’m responsible for helping the family. And that would be a disaster. That’s not what this is. There are so many example of how they have helped. The best example I’ve given is very recent, where we had six kids abducted from their grandmother foster parent by their parents. And they disappeared. Because the worker who was with us only six months linked up with the investigative consultant, they effectively contacted the police who took it seriously, didn’t just take the report. … The NYPD found the family in Baltimore. They found them in Baltimore because of connections that staff had made, and because they knew where to look in the cheap hotels. They found them. They arrested the parents. Our worker went down and brought the kids back.
The Major Crimes Division in this borough sent the message back to me that this worker was fabulous. There’s usually two different perspectives between us and the NYPD. I did this on a much smaller scale back in Ohio, and it was very effective. And it need not turn us into a criminal justice agency at all. But it does mean we’ll found out the facts more than we have in the past.
The retired special victims people know how to interview kids. Workers may not and oftentimes don’t. But special victims, they know how to interview kids. That’s what I mean by this. It’s not criminal justice versus child welfare.
CITY LIMITS: Why was the report released now?
JOHN MATTINGLY: It took them this long to complete it. But they put a lot of people into this, a lot of energy and time. This meant a lot to them. I noticed that when we did the press conference. There had to be like 35 people from the DOI there. They were really upset about what they saw. People get involved in child welfare, the prices are so high with these children. Families are so important to us. And when they saw this, they got more and more involved. Personally, you could just feel it from the commissioner on down.