How Safe the Service?

During a recent two-year period, one foster child died on average every seven and a half weeks in the state of Arizona. Four of them were reported as having been "viciously beaten to death" by their foster parents (Jacoby, 1995). Among the deaths in Arizona was that of China Marie Davis, of Phoenix. An autopsy revealed that over her 11 months in the care of her foster mother, Dorothy Jean Livingston, China Marie suffered a compression fracture of the spine, breaks in both forearms and wrists, two broken collarbones, fractures of both thighs, and a broken left arm, right rib and left hand. China Marie finally found her relief in death, after Livingston repeatedly kicked her down a staircase because she refused to clap her hands to gospel music (Harker, 1997). Among the deaths was that of Tajuana Davidson, also of Phoenix. While in foster care the three-year-old suffered a broken shoulder blade, a black eye, and bruises on her stomach, back, legs and arms. But it was the "seven crushing blows to the head" that finally killed her (Wexler, 1995, p. 315).

"The state's foster care system has been racked by tragedy in recent years," reports the Boston Globe. "In the past three years, several foster children have been murdered or have died from neglect, while others have been horrifically abused" (Murphy & Vaillancourt, 1996). In 1995, at least eight children died while in foster care in Massachusetts, and federal officials were threatening a private lawsuit against the agency if changes weren't made (MacQuarrie, 1996). But the most telling statistic of all may be that of the seven deaths directly attributable to child maltreatment in Massachusetts in 1995, three of them-nearly half-were in foster care (Grunwald, 1996).

Determining the actual incidence and prevalence of child abuse, neglect and fatalities in foster care is problematic given child protection agencies' apparent unwillingness to investigate or document such cases. In California, for example, the Department's legal division discovered a "secret room" in the Los Angeles Department containing 15 fling cabinets holding approximately 3,000 case files on foster care facilities that had problems which were not reported to the state. In one case, 10 foster children slept on the floor of a garage, while 10 more were crammed into an upstairs bedroom. Three had been abused, one with a fractured skull and two broken limbs. Yet the home was not closed until months after the conditions were discovered (Little Hoover Commission, 1992).

Child welfare departments are rarely forthcoming with information about the actual extent of harm that comes to children in their care. It is largely through audits and casereadings associated with legal actions that the actual extent of the abuses in the foster care system come to light. The reasons for this may not be as complex as they are made to appear. Child welfare officials who have managed to entrench themselves in lifetime civil service positions in the more desirable nooks and crannies of the child welfare system have a vested interest to protect, and those who run public bureaucracies have devised their own "rationalized myths" to protect their interests, argues John Hagedorn (1995). The myths of "doing good" benefit those who are advantaged by existing institutional arrangements. Even as politicians are constantly criticizing "bureaucracy" and "bureaucrats," they approve millions of dollars worth of public funds to keep the bureaucracies running. As Hagedorn explains: "It's simply too risky for bureaucrats to admit that their agency may not be 'doing good.' The erosion of that myth may lead someone to investigate them or even propose cutting their budgets" (p. 99).

In Florida, caseworkers in the Florida Department of Health and Rehabilitative Services reportedly run files relating to a botched investigation through a paper shredder. "Documents were being altered, shredded," testified a former HRS employee who watched the destruction of the documents. "It went on and on and on . . . It was nothing but a cover-up" (Mathers, 1996). In Oklahoma, an agency administrator dismissed two agency employees accused of the sexual abuse of foster children without so much as a blot on their records (Trammell & Clay, 1992). In Illinois, we find a report of systemwide abuses at the Columbus-Maryville emergency shelter suppressed by Cook County Public Guardian Patrick Murphy (Golden, 1997). In New York City, a caseworker indicated as unfounded the repeated rapes of a young girl in institutional care, notwithstanding the testimony of credible witnesses. One such case involved a young girl who was repeatedly raped by other children at the St. Joseph's Children's Services Agency. A 1993 report prepared by New York State Senator Franz S. Leichter (Skrak, 1993) explains:

One of the cases this office claimed to be unable to substantiate involved a seven-year-old girl who was apparently repeatedly raped last year by other children at St. Joseph's Children's Services Agency in Brooklyn. When deposed in a lawsuit brought by the little girl's mother, the DSS investigator testified that boys at the facility had told her about their sexual contact with the girl, staff members had admitted witnessing the abuse, and one staff member had admitted engaging in sexually provocative behavior with the girl. In addition, medical evidence which the investigator failed to request confirmed that the little girl had been raped since she arrived since she arrived at St. Joseph's. Nevertheless, the DSS investigator's official finding in the case was that there was "no credible evidence" of child abuse or staff neglect.

Outspoken veteran Juvenile Court Justice Judy Sheindlin (1996) attributes much of the problem to confidentiality laws. "The only people being protected here are caseworkers and other officials, who regularly hide behind a wall of secrecy," she writes. Sheindlin notes that dozens of New York City cases where children have been maimed or murdered never reach public attention, and it is not just because they are poor minority children. Rather it is "because of confidentiality rules, which protect inept bureaucrats and a faltering social services system" (pp. 200-201).
"In the name of protecting children, we have kept it a secret how we as a society deal with our most vulnerable children," explained American Civil Liberties Union attorney Eric S. Maxwell to the Massachusetts Senate Committee on Post-Audit and Oversight. "There is a great gap between protecting a child's identity and keeping the process and acts of our government secret" (Murphy, 1995). "Foster care systems are cloaked in secrecy that often is used to conceal illegal and unconscionable practices," observed Children's Rights attorney Marcia Robinson Lowry during Congressional hearings. "Every state in the country cloaks its foster care system in secrecy, prohibiting the disclosure of any information about children's experiences in foster care. Though these statutes often were enacted to protect children, they routinely are used by state officials to conceal illegal and unconscionable practices" (Committee on Ways and Means, 1995).

Indeed, confidentiality laws serve the system well, if the figures from the state of Georgia are to be taken as an indication. Nancy Schaefer, twice a gubernatorial candidate for governor, has repeatedly called for a fundamental restructuring of the state's foster care system, including the dismantling of the Georgia Department of Family and Children Services. Schaefer charges that an astounding 433 children have died while in state care over the last several years (Thompson, 1997). "Words cannot describe the travesty of justice suffered by these children who, rather than receiving the protection of the state, gave their lives in a most horrible and painful death because of a failed and unaccountable system of administration," said Schaefer to Macon Telegraph reporters.

Some sense of the dimension of the problem is to be obtained from the accounts of those who sit on the bench in the juvenile court. "Many kindly couples have given love, guidance, and homes to strange children," writes former Philadelphia Judge Lois Lorer (1991). The reality of the courtroom, as she explains, differs markedly from the idealized image of foster care:

In court we see countless children who have been abused by their foster parents. Some have been killed. We see troubled children who have been rejected by one foster parent after another and have been moved from home to home, from school to school every few months. I have seen in criminal court foster mothers who have cheated and stolen and engaged in prostitution. I have seen foster fathers with serious criminal records who have beaten their foster children and introduced them to lives of crime (Lorer, p. 193).

Lorer is sympathetic to the view expressed by Judge Daniel D. Leddy, of New York Family Court, who she cites as having told the New York Times: "It's gotten to the point where we're sending kids home to bad circumstances because foster care is such a terrible alternative."

When Judge Leonard Edwards first sat on the bench in Santa Clara, California, he routinely ordered children to remain in the children's shelter while social workers completed reports. This practice, intended to show parents how serious the proceedings were, stopped when he visited a shelter himself, finding children exhibiting signs of shock: "I realized then that removal from a parent is a terrible event for a child," he explains. "They found themselves in a new world of strangers, and they had the terrible fears of not knowing where their parents and brothers and sisters and other loved ones might be. I regularly come across children who have been removed for a weekend and then return home to suffer from months of nightmares. They refuse to be out of the presence of their mothers" Indeed, Judge Edwards has himself presided over cases in which children had been raped, beaten, starved and badly neglected in foster homes (Hubner & Wolfson, 1996, pp. 72-73).

"We have to ask ourselves whether we're doing children a service by taking them out of their homes and placing them in a system that's just as unable to meet their needs," says District Judge Bill Jones of Charlotte, North Carolina. "Are we doing them more harm than good?" Says District Judge Deborah Burgin of Rutherfordton, North Carolina: "If you take on the responsibility to take care of someone-and are paid to take care of someone-the least we can ask is that they come out of it alive" (Williams, 1994). Notes former Juvenile Court Judge Judy Sheindlin (1996, p. 111):

Every year in every a state a commission meets to attempt to identify the scores of children killed and maimed while in foster care. And each year a report is published with suggestions for legislative and systemic change. Although the number of victims is increasing, there has been no nationwide overhaul of the systems that permit these in-house tragedies to occur.

There is no shortage of such reports. A blistering 280-page report issued by the 1993 Massachusetts Governor's Special Commission on Foster Care recommended abolishing the civil service system used by the Department of Social Services in the hiring and promotion of workers, finding the agency to be on the verge of organizational collapse, with management and leadership failures having left the department virtually paralyzed. As a result, the Commission said, the Department is unable to effectively serve the needs of children and families and many children, while in the care of the department, suffer continued and repeated abuse and neglect. The Commission called for a complete restructuring of the agency, saying that without an overhaul, any other recommended changes will be nearly impossible to undertake. "This commission is asking for nothing less than a serious reformulation of the objectives of the state's child protection and child welfare systems," said Dr. Eli Newberger, a Commission member and director of family development programs at Children's Hospital (Benning & Ribadeneira, 1993). Two years later, after a five-month investigation based on hundreds of interviews with Department of Social Services workers, court personnel and families, a legislative committee found that children in state care were often worse off than they were in the original homes from which they were removed (Lakshmanan, 1995).

From New Jersey comes a 270-page report issued by a panel of 26 experts appointed by the Governor-one which makes hundreds of recommendations for revamping the state's failed child protection system. Among the panel's findings was that children alleged to have been abused or neglected are abused once again-by the very system intended to help them. The report followed on the heels of another scathing report issued by the Association for Children, in which 75% of the 772 respondents-among them police officers, foster parents, caseworkers and other individuals involved with the system-rated the agency's performance as inadequate, ultimately forcing the agency's director, Patricia Balasco-Barr, to resign (Parello, 1998).

Two California Grand Juries report: "Professionals working in the field of child abuse voiced strong concerns that the children removed from abusive homes were being abused again by a system designed to protect them" (San Diego Grand Jury, 1991, cf. San Diego Grand Jury, 1989). A Santa Clara County Grand Jury (1993) would reach a similar conclusion: "Sometimes, foster care placements are made that are just as abusive, if not more so, than the home from which the child was removed. The Grand Jury learned of placements where sexual and physical abuse took place. There was even a case where the infant died." From Washington State, a blue-ribbon task force concludes: "The effect of our present foster care system is disastrous. Children are moved from one foster home to another, their school attendance is disrupted and health care needs often go unmet. They are sometimes exposed to abuse by other children in care" (Governor's Task Force on Foster Care, 1989).

The California-based Little Hoover Commission, in examining the functioning of the foster care system determined: "That children can come to harm-and even die-while supposedly under the protection of foster care is not in dispute." Some cases cited by the Commission included a foster mother arrested in Los Angeles on charges of beating to death her 23-month-old foster son, allegedly over toilet training problems; a Los Angeles woman arrested for the attempted murder of a 19-month-old foster child who she said fell from a jungle gym-doctors believed the severe head injuries, which may result in blindness, could only have come from abuse; and a Sacramento woman who was injured in a car accident who voluntarily placed her daughter in a foster care facility. During a tantrum by the child, an employee of the facility wrapped her in a blanket and squatted on her. She was later discovered dead.

On a national perspective, a recent Time Magazine article (Van Biema, 1994) references a troubling report commissioned by the Reagan Administration in the late 1980s, which concluded: "Foster care is intended to protect children from neglect and abuse at the hands of parents and other family members, yet all too often it becomes an equally cruel form of neglect and abuse by the state." The Associated Press (Bayles, 1995) reports on a 1994 Department of Health and Human Services audit conducted in six states which found foster homes that were crowded and unsafe. The report illustrates that cases of foster parents inflicting harm on their wards is anything but uncommon:

A Sacramento, Calif., man was charged last December with raping and murdering one of his three foster children, a 16-year-old girl. He was arrested after holding the other two children at gunpoint during a standoff with police.

The Cook County public guardian's office recently sued a Chicago private social agency for placing an 11-year-old girl in the home of a convicted rapist who allegedly raped the child.

In a separate case, Chicago police say 2-year-old Corese Goldman was killed in February by a foster mother who held him under a faucet to toilet-train him. The woman, a distant relative, was not required to go through training, background checks and a home inspection before taking the child.

Abuse and neglect of children in out-of-home care are common (Spencer & Knudsen, 1992). Yet even for those children fortunate enough to enjoy an environment free of overt physical abuse or neglect, conditions vary tremendously, often putting children at genuine risk of harm from other environmental factors. A report by the Office of Inspector General of the U.S. Department of Health and Human Services (1995b) determined that the Texas Department of Protective and Regulatory Services "has no assurance that the quality of care being given to foster children placed by child-placing agencies was adequate." Federal reviewers found "many cases" of children "in potentially harmful situations." At least one fire or health deficiency was found at 40 of the 48 homes reviewed. In 28 of the 48 homes, no record could be found to prove that required criminal background checks had been made. The report continues, noting that conditions endured by many foster children are far from the ideal:

For 19 of the 43 foster homes visited, the home and/or neighborhood environment appeared to put the safety of the foster children at risk. Neighborhood homes were boarded-up and the yards were overgrown with tall grass and cluttered with debris. Some of the foster home yards were cluttered with old tractors, lawn mowers, and cars. The foster homes were also cluttered with wastepaper, clothes, and debris.

Foster children were living in three homes identified by the child placing agency as being located in high crime areas and drug environments. During our visit to one of these homes, the foster parent explained there had been a shooting behind her house the night before. For another home, the case file showed that the neighbors to the foster home were drug dealers and the foster child associated with them. No action was taken to move the children from these surroundings to a safer environment.

A subsequent review (Office of Inspector General, U.S. Department of Health and Human Services, 1996) provides insight into some of the dynamics underlying these failures. In auditing a number of private child placing agencies, it was found that the agencies retained 38% of the Title IV-E maintenance payments intended to benefit foster children, diverting the funds instead to pay for such services as "costs of operations, case management, therapy, counseling, respite care, psychiatrists, training, transportation, day care assistance, medical needs not covered by Medicaid, recreation, and other administrative costs." Money intended to benefit children was routinely appropriated to other programs, auditors found, and not only did the amounts in question total into the millions, but the problems identified were pervasive, affecting the majority of children among the sample group:

For example, for a child entitled to a daily maintenance payment of $36.65, one placement agency provided only $10.00 to the foster home. The difference of $26.65 was retained by the child placing agency. In another example, a child placing agency was paying its foster care homes $26.00 a day for children who were entitled to a maintenance payment of $67.10 a day. The agency was keeping the difference of $41.10 for non-maintenance costs. Eight of the nine child placing agencies reviewed consistently paid their foster homes less than the maintenance payment they received from the State agency. Of the 441 children included in this review, a portion of the maintenance payment for 424 of these children was retained for non-maintenance purposes.

One of the most comprehensive surveys of abuse in foster care was conducted in conjunction with a Baltimore lawsuit, L.J. v. Massinga. In her analysis, Trudy Festinger, head of the Department of Research at the New York University School of Social Work, determined that over 28% of the children in state care had been abused while in the system. Reviewed cases depicted "a pattern of physical, sexual, and emotional abuses" inflicted upon children in the custody of the Baltimore Department. Additional cases reviewed as the trial progressed revealed children who had suffered continuous sexual and physical abuse or neglect in foster homes known to be inadequate by the Department. These included cases of sexual abuse of young girls by their foster fathers, and one of a young girl who contracted gonorrhea of the throat as a result of sexual abuse in a unlicensed foster home.

In Missouri, a 1981 study found that 57% of the sample children were placed in foster care settings that put them "at the very least at a high risk of abuse or neglect" (Kaplovitz & Genevie, 1981). Lowry describes the findings of a subsequent review: "The most troubling result of the Kansas City review was the level of abuse, undetected or unreported, in foster homes. Twenty-five percent of the children in the sample were the subject of abuse or inappropriate punishment. Eighty-eight percent of those reports were not properly investigated" (Subcommittee on Public Assistance and Unemployment Compensation and the Select Committee on Children, Youth and Families, 1988).

In Louisiana, a study conducted in conjunction with the Del A. v. Edwards civil action found that 21% of abuse or neglect cases involved foster homes (Stein, 1988). In another Louisiana action, one in which thousands of pages of evidence were reviewed, and extensive testimony and depositions were taken, it was discovered that hundreds of foster children had been shipped out of the state to Texas. Stephen Berzon of the Children's Defense Fund summarized the findings of the court before a Congressional subcommittee, explaining that "children were physically abused, handcuffed, beaten, chained, and tied up, kept in cages, and overdrugged with psychotropic medication for institutional convenience" (Subcommittee on Select Education, 1976). To provide the committee a favor of what these children were suffering, Berzon ended his testimony by quoting extensively from a report prepared by the Louisiana Welfare Department, which itself investigated out-of-state facilities:

There are telling signs that these children in general are far from being fulfilled. The yearning for home-or whatever they conceive of as their home-is ever present in all of them. This feeling came through poignantly as I talked to some of the children. Their tone and wistfulness left me with the feeling that they are "serving time" away from home and for reasons they perhaps do not understand nor fully accept. Some accept their plight passively, others simply run away. Incidents of runaway seem especially high among the adolescent group.

Our first visit was undoubtedly very meaningful to the children with whom we were able to talk. That they may not have ever seen us before did not matter. The simple knowledge that we were from Louisiana was instantly soothing for them, for we were a tangible and personal link with home.

They seemed to swarm around us (even those not from Louisiana) as though to consume us. We were someone to whom they could ask questions about home. They invariably did ask about home. "Did we know the name of their home town? Their address? . . . or even, Did we know the name of their street? How long would they have to remain here? Would we come back to see them? Would we tell acquaintances hello?" etc. It was almost a desperate plea for assurance that "home" still exists for them.

If these children told us anything at all, it is that they are not where they are, away from home, by simple preference.

As Children's Rights attorney Marcia Robinson Lowry explains, physical abuse is only the tip of the iceberg on which foster children are cast adrift: "There are a lot of injuries, a lot of abuse. The most significant thing is the psychological death of so many of these kids. Kids are being destroyed every day, destroyed by a government-funded system set out to help them" (Ambrose, 1994).