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When things fall apart

(Originally published September 2022)

By Dee Wilson and Toni Sebastian

Many state child welfare systems are in distress, and some have moved beyond crisis to a virtual meltdown. A recent Missouri Independent news story regarding Missouri’s child welfare system describes a turnover rate among CPS caseworkers and foster care case managers of 55%, with an 88% turnover rate in Kansas City. Missouri’s child welfare system reportedly has hundreds of unfilled positions. As recently as 2018, experienced caseworkers in Missouri were paid salaries less than $40,000, according to this news story.


Similarly, according to stories in Baton Rouge news media (see references for links) Louisiana’s child welfare system has hundreds of unfilled positions despite increasing caseworker salaries in recent years to an average of $48,000, with the result that caseworkers are inundated with cases and respond only to emergencies. The child welfare agency currently has a 50% turnover rate and a25% vacancy rate. The Louisiana Legislature has pressured the state’s child welfare system to reduce its screen out rate, further overwhelming a system sinking under unmanageable workload demands. To add insult to injury, Louisiana legislators recently interrogated the state’s child welfare director regarding deficiencies in child welfare performance. What these legislators might have done is to place a mirror before their seats and asked themselves the question: “Why have we legislated public policy that has undermined the child welfare system and harmed the state’s most vulnerable children?” In Louisiana, as in many other states, legislators have made a habit of blaming child welfare leaders for the conditions they have created by paying caseworkers paraprofessional salaries, and by exploiting the child welfare workforce through unreasonable workload demands.


Recent studies of Florida’s child welfare system by Florida Tax Match and the Florida Department of Children and Families have found turnover rates of 35-37% for CPS investigators, turnover rates approaching or exceeding 50% for Community Based Care (private agencies which manage the state’s foster care system) and salaries of $39,000 to $41,500 for CPS investigators. However, unlike Missouri and Louisiana, Florida’s vacancy rate during the fall of 2021 was only 11%. A number of states currently have caseworker vacancy rates of one-fifth to one-third, which means that child welfare staff have to cover the caseloads of unfilled positions, adding to job stress and strengthening an understandable intent to leave a sinking ship at the first opportunity. Wherever you look, it’s the same story. The Pennsylvania Partnerships for Children (PPC) just released its annual report on the state of child welfare in Pennsylvania. The Partnership’s director, Kari King, stated: “Pennsylvania’s child welfare system is exhausted, unable to adequately respond to the needs of children, youth and families, or the racial disparities and disproportionality in the system.” Overwhelming, unreasonable workload pressures and nonstop attacks on child welfare staff from multiple directions have made high rates of emotional exhaustion endemic in child welfare agencies around the country.


Policymakers in both state Legislatures and governors’ offices bear much of the responsibility for inadequate salaries and benefits and for the refusal to staff child welfare agencies to reasonable workload standards. However, child welfare management teams share the blame for creating intolerable working conditions. Child welfare managers have steadily expanded policy and procedural frameworks in a persistent effort to eliminate all discretion from child welfare practice. Some state child welfare systems have tolerated (or endorsed) widespread bullying of caseworkers in their determination to improve on performance indicators despite impossible workload pressures. (Wilson, 2018)


The emphasis on metrics has led to a de-emphasis on interpersonal relationships between caseworkers, parents, foster parents and stakeholders and led to a deterioration in collaborative relationships among stakeholders in some states, including Washington. Put bluntly, most child welfare systems have been routinely mismanaged, not (mainly) because of the personal flaws of child welfare managers but because of a dysfunctional managerial paradigm which has discouraged initiative at the unit and office level and undermined the self-efficacy of caseworkers and supervisors. Child welfare management teams have created intolerable and disempowering work environments, where line staff feel completely responsible for their work without support or empathy from managers. Top managers are too distant from line units to understand the daily stress, exhaustion and desperation caseworkers feel when their caseloads are overwhelming and there is no end in sight. After decades of mismanagement, the karmic payoff in many states is a workforce that wants out and discourages young people from entering or sticking with the child welfare profession.


The reduced impact of risk and safety frameworks


Perhaps it’s obvious that CPS units in offices with annual caseworker turnover of one-third to one-half and high vacancy rates are not consistently utilizing risk and safety tools and frameworks as set forth in their policy manuals. However, in state child welfare systems (such as Washington’s) which are not in the dire condition of Missouri’s and Louisiana’s child welfare systems, but which face the same challenges in recruiting and retaining casework staff, policy requirements regarding CPS assessment of risk and safety are largely aspirational at best, with little or no application to practice. The state’s Department of Children, Youth and Families’ 2022 Annual Progress and Services Report: Child Safety and Child Protection in Washington State documents the following concerns of stakeholders and internal auditors:

  • “Lack of comprehensive assessments of safety and risk versus incident-focused assessments”

  • “Safety and risk assessments are not being used to drive decision making.”

  • “The agency made concerted efforts to provide or arrange for appropriate services for the family to protect the children and prevent their entry or reentry into foster care in 23% (15 of 65) of cases.”


The report discusses serious concerns with the Family Assessment Response (FAR)

Program. The program is a differential response system implemented in 2014 to provide voluntary support services to low-risk and moderate-risk families in which children are not in danger. Regarding FAR implementation, the report cites the following problems:

  • “No additional services are provided despite recommendations,”

  • “Not facilitating timely engagement in services,”

  • “Safety concerns were identified but the agency did not offer safety related services.”


This report indicates that within a decade of its implementation in Washington, FAR has become ‘CPS lite’ — a way of managing workload rather than a more family-friendly approach to delivering early intervention services. The report states that the 12-month CPS re-referral rate for closed cases was 21-27.6%, (p. 16) with FAR cases having the highest rate of re-referral. A decade ago, this was the 18- to 24-month re-report rate in most states. (Fluke, et al 2008)


The agency’s safety framework has been applied erratically (at best) though concepts from the safety framework, e.g., safety threat, permeate agency discussion of child protection issues. The agency’s safety framework is highly conceptual and difficult for inexperienced caseworkers to apply without daily discussion of specific cases and coaching from experienced caseworkers or a supervisor, supports that were often not available during the first 18 months of the pandemic. In overwhelmed CPS units, there is limited time for learning, or coaching, or staffing cases due to the urgent need to react to emergencies. This is not an environment that emphasizes or rewards self-reflection. Inexperienced caseworkers must depend on intuition, gut reactions, common sense or the advice of their supervisors or community professionals. This is a formula for biased decision making that can endanger children or lead to unnecessary foster care placements.

The lack of concern with chronic maltreatment

In recent years, it has become common to read stories from around the country in news briefs published on the Child Welfare Gateway regarding child maltreatment deaths and the severe harm to children that follows months or years of chronic neglect, physical and/or sexual abuse and (always) emotional maltreatment as well. Compared to most child maltreatment deaths, these cases have unusual characteristics:

  1. The child who dies is often school age rather than an infant or a toddler.

  2. The child’s death occurred after multiple CPS reports, often from relatives, with no response, a token response or inadequate response from CPS units.

  3. The parent or parent’s paramour had repeatedly maltreated the child in multiple ways, including extreme emotional abuse. Children were sometimes locked out of the house in cold weather; or put into a cramped closet overnight; or locked in a shed or garage for lengthy periods of time.

  4. In some cases, the child had been systematically deprived of adequate food and water.

  5. The child had been separated from the mother at an early age due to illness, mental illness, drug addiction, imprisonment or foster care and then returned to the mother years later.


In recent weeks, The San Jose Mercury News has run several stories regarding the death of Sophia Mason, an 8-year-old child murdered by the mother’s boyfriend after he sexually abused her and engaged her in child pornography. Sophia was locked in a shed and burned by her mentally ill mother who did not raise Sophia for the first seven years of the child’s life. Relatives made at least six CPS reports during the 14 months before she was murdered. At one point, a CPS caseworker interviewed Sophia in the presence of law enforcement officers when she was distraught and had inflicted injuries. The dynamics in Sophia Mason’s death resemble what occurred in the death of Gabriel Fernandez in 2013, an 8-year-old boy murdered by his mother’s boyfriend in Los Angeles County after horrific torture. Gabriel’s death has been the subject of a Netflix documentary.

Cases of child torture are uncommon, but they are no longer rare. On the other hand, chronic maltreatment that includes combinations of neglect, physical and/or sexual abuse is extremely common; every medium to large child welfare office has many of these cases. There is no indication that child welfare agencies have learned much from their many years of experience with chronically maltreating families. U.S. child welfare systems appear to be engaged in stubborn denial regarding the harm done to children by combinations of neglect and abuse that do not rise to the level of a perceived safety threat. It is also possible that some child welfare staff and parent advocates regard the refusal to pay attention to histories of CPS reports and substantiated investigations as a virtue, a way of combating structural racism in child welfare decision making.

Chronic maltreatment and child deaths in Minnesota

At the request of a child advocacy organization, one of the authors recently reviewed case information regarding several child maltreatment deaths that occurred in Minnesota during recent years, with the goal of identifying practices that might have prevented these deaths. This advocacy organization has identified 88 child maltreatment deaths that have occurred in the state since 2015. The media has covered these deaths; information in these records is in the public domain. A decade or two ago Minnesota, a county administered system, was a beacon of child protection reform and has been a leader in the implementation of Signs of Safety, a solution-based practice model that emphasizes parental engagement.

Two of the several cases reviewed involved the death of school age children, ages six and eight, which is highly unusual among child maltreatment deaths. However, what is most shocking in the case material and police reports is not information regarding how children died. Rather, it is the lengthy histories of multiple types of maltreatment, not just of the deceased child, but whole sibling groups perpetrated by mentally ill and/or addicted parents, other family members and friends of the family. There were many CPS reports in these cases, some from relatives, which were screened out or investigated by CPS for many years. These case histories describe chronically mentally ill substance abusing parents, frequent interpersonal violence, extensive criminal histories, zero interest of the parents in services, occasional foster care placements, along with substantiated physical abuse, sexual abuse, emotional abuse, and in a few cases elements of torture. Neither CPS caseworkers nor judicial officers gave much, if any, weight to histories of maltreatment that extended from birth through adolescence for all children in the families.

One of the deceased children, TD (age 8) died of hypothermia after his mentally ill mother forced him to sleep in a garage overnight; he had multiple inflicted bruises and lacerations on his back at the time of his death. TD’s siblings remained in the home following his death until one of his siblings ran away after (the child reported) her mother threatened to kill her. The mother, TT, is described in one document as acting from “a methamphetamine-fueled psychosis.” Her children accused her of hitting their hands with hammers and forcing them to sleep outside in freezing weather. According to police records, the children were sexually abused by multiple family members. These conditions persisted for years despite multiple CPS interventions, in part because a Juvenile Court judge returned the children to the mother’s custody in 2016, over the objection of the child welfare agency.

These cases reflect little or no interest among decision makers regarding the developmental impact of growing up with chronic maltreatment, no use of developmental screening or assessment, limited interest in the children’s perspectives or in therapeutic service, inadequate in-home safety plans that did not include safety monitors, and a lack of contact with kinship care providers who occasionally returned children to the parent without informing the child’s caseworker. The question which might be asked of child welfare managers and judicial officers is: If this is child protection, what is child endangerment?

In the counties where these child deaths occurred, as in most state child welfare systems, CPS caseworkers applied a narrow definition of child safety that focuses on risk of imminent harm, ignores evidence of cumulative harm from child maltreatment and pays little attention to assessing the ability of parents with untreated mental illness or substance abuse to meet their children’s developmental needs. These cases reflect no understanding of the dynamics of chronic neglect and chronic maltreatment and no grasp of the danger to children created by the collapse of social norms around parenting in chronically maltreating families. What sensible person could believe that children of any age in the families described above were ever safe? Nevertheless, CPS caseworkers and some judicial officers concluded that they were safe during numerous interventions.

We have purposely omitted information regarding the race/ethnicity of children in the chronically maltreating families discussed above. Is it socially just to allow children in some racial/ethnic groups to grow up in chronically maltreating families without being afforded basic protections? We don’t think so.


We have zeroed in on the child welfare response to chronic child maltreatment, i.e., combinations of neglect, and physical, sexual and emotional abuse because this is the weakest part of CPS practice nationally, and because most child welfare agencies are utilizing conceptual frameworks that stand in the way, or discourage, a more effective response to this type of maltreatment. We have not noticed a recent interest in improving the CPS response to chronic maltreatment, either in Family First implementation plans, in scholarly articles or among child advocates. Instead, we perceive a strong intent to further narrow the scope of child protection programs, and to minimize and misrepresent the harm done to children by child maltreatment, especially chronic neglect.

Both of us have worked in or around public child welfare for decades. During our professional careers, there has never been a time when there was less concern with child maltreatment among influential advocates, less interest in expanding knowledge, less of a commitment to research unless research serves an advocacy goal, and less commitment among policymakers to improving child protection programs. For the first time since the creation of the modern child welfare system, there appears to be a diminished commitment among child advocates to the goals of child protection. If less child protection is better than more, then why invest in CPS reform? Absent a more competent CPS response, how can communities respond to chronic maltreatment of the type described above? This is not a rhetorical question. There is an urgent need to develop an alternative intervention framework for chronic maltreatment and evaluate the framework in both rural and urban communities in each state.


“A system in crisis: stabilizing Florida’s child welfare workforce, Florida Tax-Watch, Feb. 2022.’s-Child-Welfare-Workforce


2022 Annual Progress and Services Report (APSR), Washington State Department of Children, Youth and Families, Olympia, Washington.


Bates, C., “This job is impossible: high turnover, low morale plague Missouri child welfare agency,” Missouri Independent, September 19, 2022.


“Child Protective Investigator and Child Protective Investigator Supervisor Educational Qualifications, Turnover, Professional Advancement and working Conditions Status report: Annual Report, Department of Children and Families, Office of Child Welfare, Oct. 2021.


Fluke, J., Shusterman, G., Hollinshead, D. & Ying-Ying, T., “Longitudinal Analysis of Repeated Child Abuse Reporting and Victimization: Multistate Analysis of Associated Factors” (2008), Child Maltreatment, 13, 76.


Gallo, A., “Huge caseloads, high stakes; the dire situation Louisiana’s child welfare workers face,” The Baton Rouge Advocate, Sept. 25,2022.

"Huge caseloads, high stakes: the dire situation Louisiana's child welfare workers face'. Baton Rouge Advocate, Sept. 25, 2022


Johnson, A., “Months before recent failures at DCFS, leaders sounded alarm over staffing problems,” WBRZ 2 Baton Rouge, Louisiana, August 6, 2022.

"Months before recent failures at DCFS, leaders sounded alarm over staffing problems". WBRZ-2, August 6, 2022.

Pennsylvania Partnership's for Children. "2022 state of child welfare, system under stress: Examining how to better support Pennsylvania's child welfare system and the children and families it serves".


Rodgers, J., “Sophia Mason case: family files legal claims against Alameda County with horrifying new details of alleged child abuse, neglect of the Hayward 8-year-old,”, The Mercury News, Sept. 10, 2022.

"Sophia Mason case: family files legal claims against Alameda County with horrifying new details of alleged child abuse, neglect of the Hayward 8-year-old".


Wilson, D., “Bullying and Intimidation in Child Welfare Management,” Sounding Board, July 2018.

See past Sounding Board commentaries     

©Dee Wilson 


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