When a Child Dies

Dig Deeper: Interview with a Child Welfare Expert



When a child dies in the child welfare system, service providers, caseworkers and officials are often blamed for the death.  Child welfare advocates say that sometimes a tragedy sparks knee-jerk reactions from public officials who push through policy changes that may hurt children more than help.

When JCCF asked Annie E. Casey Foundation Senior Fellow John Mattingly for his perspective on the public policy implications of child welfare crises, he told us that he probably “had more child deaths on my watch than any other official in the country.” Mattingly served as Commissioner for the Administration for Children’s Services (ACS) in New York City from 2004-2011. ACS is a massive agency that includes foster care, child protective services, juvenile detention and placement, childcare and Head Start.

Mattingly explained that when a suspicious child death is reported to the agency ­­­­– typically by a hospital­ – the first response is to check if that family had a history of abuse or neglect. Then, the agency will go through a fatality review process to determine if mistakes were made in the handling of the case that might have led to the death.

“Child protection is enormously complicated and difficult on the front line,” said Mattingly. “People have to knock on doors and get families to the point where they share information with them about the most intimate situation. They are feeling very angry and under attack because somebody made a report on them.” Child welfare workers are often poorly paid, go into dangerous situations and have to make difficult judgments  ­– even life and death decisions ­­­– with limited or contradictory information.

Mattingly lamented the stereotypes promoted in popular TV crime shows, which typically portray a child welfare worker as “officious, uncaring, often African American woman, who won’t do whatever the protagonist wants them to do to protect a child.” Child welfare workers are rarely shown to be effective, caring public servants who prevent tragedies every day.

In an interview with JCCF’s Julie Drizin, Mattingly shared some of his experiences running one the nation’s largest child welfare administrations under the microscope of the New York City press.

Q: Journalists are public advocates in that they are the watchdogs of government agencies. In the wake of a child death, what are the questions reporters should be asking and of whom?

Mattingly: The political leadership of the system as well as the public agency heads should be asked about the history that the agency has had with the family, what happened in this particular case and what lessons are be learned from this case about the behavior of the organization. The typical response will be to clam up and simply say (correctly in many cases) that the agency doesn’t have the right to share information. The laws in most states typically surround the agency with confidentiality, so the agency will say they are unable to speak to the issue. That tends to drive media to look more intensively and in every place they possibly can. Reporters will pick up many stories, some of which are quite wrong, such as from the neighbors who said they called the agency when they never did. The agency tends to be just silent until enough information comes out from the police, coroner or public prosecutor that they can’t stay out of the limelight any longer…Child welfare scandals are particularly brutal, publicly, and [elected officials] may go about of their way to be self-protective and will begin to look for scapegoats at the top of an agency and on the frontline.

Q: How did you manage to survive?

 Mattingly: First and foremost because our political leadership was strong. Mike Bloomberg insisted on hard work, dedication, and competence form his leadership. He was known to stand by his people when they were trying to get control of these agencies.

 We had 10-11 serious child deaths (over seven months). In nine of those, we had not done everything we should have done to protect the children involved. When I looked at those cases I saw serious shortcomings.

After the death of Nixzmary Brown (which was particularly egregious), we took the Mayor’s funding as an opportunity to create a child safety plan that overhauled the agency from top to bottom…Commissioner Nick Scarpetta, one of my predecessors, was able to get the law changed in New York to allow the Commissioner to comment in these cases if it didn’t hurt siblings. So we were able to stand up within days or a week, and speak about Nixzmary Brown’s case and talk about the failures. We said that as a public agency, we felt responsible and intended to make substantial changes in the organization.

By the time I left, and the media had seen a couple of these situations, there was some support for the way in which we had used child deaths to actually learn and change how we operated. So that’s how I was able to stay as long as I did, because of political leadership and because we were serious about making real substantive changes.  If you try simple solutions, you won’t really solve the problem and too often public agency heads last 18 months because they are looking to get out as soon as they can to avoid the next crisis that comes, frankly.

You’ve said that New York City had 50-60 deaths each year in the child welfare system. As the head of the agency, what is it like when you get that telephone call, what’s the scene like in the agency when you get a report like this?

Mattingly: Often times, the first report comes from media or the police coming upon a situation like Nixzmary Brown’s death. We had been called repeatedly for six weeks and had not gotten out there until the day she was found basically tortured to death over the Christmas holidays. Police get upset by that stuff and pretty quickly it will spread throughout the media, so you got an immediate crisis on your hands…and the Mayor has to know about it and has to be able to respond to it almost immediately. And of course the facts you get immediately will be spotty and often times wrong. You have to drop everything you are doing and pursue the facts in the case. That’s the most important thing. If you failed or had done everything that could be done. You have to find that out. …You see those failures better than most anyone could because you know the field. Let me give you an example.

We had a particularly sad situation where a little boy was walking to school with his younger sister, dropped off his books and jumped into the East River, killing himself. He was about 14. The public wouldn’t have known immediately, although they did find out subsequently, that this boy came from a neglectful family. He had been trying to care for everyone in the family and our inability to effectively intervene over those years led to this horrible situation. This kind of case makes agency leaders and middle managers and workers question why they are in this work when they just didn’t get the job done when it needed to. So, you carry a terrible emotional burden in these jobs from the top to the bottom.

After Nixzmary Brown’s death, we had a child protective worker who got on a bus still wearing her ID and had to get off within a couple of blocks because she was being screamed at by the citizens who wanted to know how she failed Nixzmary Brown. We’ve had workers come home to find the doors of their apartments spray painted “killer” and stuff like that. You have no idea just how bad it is.

Q: Tell me more about what journalists don't understand about child protective services and the child welfare system.

Mattingly: I think the most important thing to keep in mind is that while there could have been terrible failures, irresponsibility, even real stupid mistakes, the cause of the child’s death and an agency’s failure is  much more complicated. Yes, there are situations – I’ve experienced them – where a worker didn’t go out for many months to check on a very fragile child under his protection and essentially tried to lie about it. Those things will happen and there are things you can do about that. There is a much deeper question and that is why is an organization in a situation where that happens with some regularity. There is usually a series of organizational failures each of which you must confront If you don’t you will be applying a patch to a wound that needs much more attention.

These are not hidden things. But journalists need to look deeper to find out what’s going on to find out why did this person make what looks ex post facto like such a stupid judgment. What was her caseload? Was she out four nights that week trying to handle other cases? Why, because it was nine o’clock, did she not check to see if this one additional child was in the home, a child who turned up dead later that night? That was a real Florida case. Are there not enough workers because politicians have frozen hiring over the last two years. You have to dig deeper to get the handle on what causes these things.

A series in The Denver Post pointed out that some Colorado counties were screening out 60-70 percent of the child abuse reports, they weren’t even considering them, whereas another county opened investigations on 70 percent of the cases reported to them. Now there’s a systems issue in Colorado that’s driven by the political power of the counties to avoid being held accountable and The Denver Post dug that up. That gives the public something to work with that’s useful instead of just saying somebody didn’t do their job.

Q: You’ve had a chance to look at different child welfare systems around the country. What is common in the best child welfare systems?

Mattingly: You are looking primarily for a group of people who know the work, know that you will make mistakes all the time, know that you can make the best judgment in the world and it turns out terribly, and who can live with that… people who move forward every day because a new child at great risk is coming in front of your caseworker and we have to do something about it today. You get an esprit built up over time among those workers, but you will lose that esprit if you don’t deal with things like caseloads and allow people a job that can be done.

You will also see leaders who last who continue pushing forward and protecting their agency from predatory politicians who are just looking to save money somehow and not be held accountable for it. If you look, for example in Arizona, Janet Napolitano and her child welfare leaders had really had turned around the system…A new governor comes in and devastates the agency, hundreds are laid off, and now, four years later, there’s a huge uproar because there aren’t enough caseworkers. The very same governor who made these cuts is taking the lead and saying, “I’m going to reform the system.” As a reporter, you’ll come in at the very end and wonder how it got that way and usually it’s because of the politics of the situation.

Q: Can you give examples of media coverage of recent child death cases in the U.S. that you think is a cut above the rest and why?

Mattingly: I think The Denver Post was, because they not only looked at the big picture long term, and reviewed the last seven or eight cases and looked for systemic causes, not just for someone to blame. They discovered things like the weakness of state government in overseeing its counties and the enormous political power of counties to stave off reforms which they did under Governor Ritter. And so, you don’t just have simple solutions, but you have a real display of the problems and how difficult they can be to resolve. One of the changes The Post and specialists recommended was a central hotline that made decisions about accepting cases based on a single set of standards for the whole state. Because, remember if you accept a case, you have to investigate it, if you don’t, you don’t. And if you have serious workforce problems, it’s in your interest not to accept cases. The state announced it’s going ahead with the hotline but because of concerns on the part of the counties, they are just going to take the calls and send them down to the county and the county can still decide whether to accept them or not. The Post is on it and has raised concerns about whether that will work. That’s impressive to me.

Another good example of excellent journalism was done back in the mid to late 90s by Jean DuBail at The Cleveland Plain Dealer. In the midst of a series of child deaths, he spent maybe three months going out with caseworkers and wrote a series of articles talking about cases and came to the conclusion that this may be one of the toughest jobs anybody has anywhere. It doesn’t mean that the agency isn’t accountable when things go wrong, but he actually took the time to look in-depth at what the frontline practice looked like and how it can be so difficult to make some of these decisions. Those are two of the best examples I’ve seen in a while.

Q: Anything you’d like to point out as a worst example?

Mattingly: One of the worst cases was a NYC paper. Periodically, with public agencies, private agencies or hospitals something will happen in the disposal of files which will cause them to end up on the street in bags waiting for the trash truck. One of those situations happened to us … some 10-year-old records ended up being put out in the trash. I don’t know how the particular reporter found out about it. Not only did they dig through these personal files, they found a sexual abuse case from years before, ran down the young woman (who was now in college) and called her up to ask what it was like for her confidential information to be spread all over the street like that. That’s the worst I’ve experienced.

Q: It’s been suggested that one of the responses to child deaths is that agencies wind up putting more children in foster care, when they might not really belong in foster care to avoid the negative publicity of another incident. Is that something that you’ve seen?

Mattingly: I think that the evidence for that is pretty weak. After a really difficult public case, there is typically an uptick in the number of removals that lasts for about six months. New York was a little different in that we went from 49,000 to 65,000 reports a year, after Nixzmary Brown’s death. To my mind, the public became more aware, and maybe appropriately so. Our rates of removal did not go dramatically up. Our rates of intervention in families went up and has stayed up. Although there was an uptick in investigations and in filing of cases, it didn’t necessarily lead to more children being dumped into care. There’s always that concern, but there’s not much data to support that.

Q: It would be reasonable then, to conclude, that the media attention that has led to public awareness and reporting, which would be a positive outcome.

Mattingly: In New York, that would be true. We went out and did our own publicity about such things as “never hit a child” or “call when you see something” but I think the media’s attention on that series of deaths had a real impact on the public’s awareness and on our getting more cases carefully considered. The family court judges had a fit because we were bringing more cases to them, not for removal but for ordering the family to accept help. But when I asked the judges to give me a few examples where we had overreacted, I got nothing.

Q: After the Milwaukee Journal Sentinel series about Christopher Thomas’ death, you wrote an op-ed that stated “Experience across the country indicates that there is no quick fix (such as more or fewer removals); there is no silver bullet (such as privatization); there is no free lunch (caseload sizes always matter); there is no knight in shining armor (a new and better leader from out of town.) There is only the work: building a large public agency with all of its weaknesses that will focus on making the right decision for each and every family, time after time after time.”

Mattingly: I mentioned in that piece a very good parallel in how the NTSB looks deeply into crashes, much more deeply often times than the media do into the causes of a child death. If you remember that plane that went down in Buffalo a few years ago, they determined that the mistakes were made by the pilot and copilot, but they dug deeper and found that the pilot had been trained by fly by night operation, not by Continental. The copilot had flown in on the red eye the night before from her home in Seattle. She was paid $19K and very sleep deprived when she got in that pilot seat. That kind of stuff is what you find when you are close enough to it and look into a child death situation.

Q: Final thoughts about media coverage of these cases? How can journalists be better equipped to do better work?

Mattingly: I know it’s exceptionally difficult now with the state of journalism. You have to look deeper. If you really are upset by what you see in a case, you have to dig deeply to come up with why this situation exists and hold the proper people accountable even when it might not be what people want to hear. I got into this business when I was running a settlement house in Cleveland; we had made a call about this boy we thought was in danger. We found out a month later, after we had made our calls that he was found frozen to death, chained to his bed in the middle of a Cleveland winter, and we went crazy, and caused all kind of trouble for the public agency. When we uncovered the caseload sizes, they were just incredibly bad. The commissioners, because we had them in the paper a couple times a week and on TV three or four times a week, they went ahead and hired more people. Two years later, we came upon another case in the neighborhood, a sexual abuse case. And we found out that the commissioners had quietly frozen hiring, so caseloads were right back where they used to be. People need to be held accountable for that kind of stuff and they very rarely are.