Child Welfare’s Death Penalty

It’s the ultimate nightmare for child welfare administrators: Tied to a bedpost and weighing just 47 pounds, a 9-year-old Baltimore County, Md., girl who’d been receiving child welfare services dies of starvation and dehydration. Soon thereafter, the county’s director of child welfare is tossed out.

It didn’t matter what good Camille B. Wheeler had accomplished in her 19-year tenure before that June 1997 tragedy. It didn’t matter that she’d increased the number of caseworkers with master’s degrees and that no child had been killed on her watch for 15 years. The public saw a tortured child and a mum bureaucrat.

Then it happened again: In March 2005, a 3-year-old Baltimore County boy who’d been the subject of abuse investigations died after being beaten by his mother, just four months after his infant brother had died in her home.

Today, the child welfare director still has his job.

Why the different fates? One major factor is that while confidentiality laws forbade Wheeler from publicly discussing her agency’s role in the fatal case under her watch, a subsequent law allowed the current director to talk about the second case, and to provide reams of documents to show how the agency tried to help the boy by, for instance, trying to place him in foster care over his mother’s objections.

While child welfare directors lose their positions for lots of reasons, the death of a child is among the most common factors.

Child deaths were a factor last year in the firing of the child welfare chief in Washington state. In 2004 – after the starvation and abuse death of 7-year-old Faheem Williams – the governor replaced director Gwendolyn Harris. In 2003, it happened in Georgia. In 2002, after the unnoticed disappearance and assumed murder of 4-year-old Rilya Wilson in Florida, director Kathleen Kearney was ousted, along with seven regional administrators.

No wonder running a child welfare agency is perhaps the most insecure job in youth work, rivaled only by running a juvenile justice department. A survey by the Council of Juvenile Correctional Administrators in 2000 found that the average tenure for youth corrections administrators was 3.6 years. A survey by the National Association of Public Child Welfare Administrators in 2004 showed that the average tenure of agency directors was three years. Half of the directors in 47 states had held their positions for two years or less.

That’s not enough time to accomplish real reform, says association Director Anita Light. “Most organizational development specialists say when you make changes in an organization, it takes five to seven years,” she says.

“It is part of the business of child welfare that you cannot prevent every child tragedy,” says Nicholas Scoppetta, who survived six years as head of New York City’s Administration for Children’s Services, despite numerous children’s deaths. “You can lower the number if you improve the system. But you can’t improve the system if you replace the director every year.”

The handling of deaths in New York and other places – including Baltimore County, the suburban area surrounding Baltimore city – illustrates how talking about the tragedies can help save a director’s job.

While confidentiality laws are based on the important value of protecting the privacy of children and their families, many child welfare experts have concluded that invoking the confidentiality of a child who’s dead looks like the agency is protecting only itself. “When a tragedy happens and a person in authority must say ‘no comment,’ it sounds like guilt,” Wheeler says.

On the other hand, explaining the agency’s role in a fatal case, admitting errors and promising corrections often quells the outcry from the public, the media and lawmakers.

Shay Bilchik, executive director of the Child Welfare League of America, sees openness increasing around the country. “There is more willingness to be transparent and disclose publicly the inner workings of child welfare and not hide behind confidentiality,” he says. “That is the mark of a strong leader.”

Elisa’s Death, Elisa’s Law

The movement to let directors discuss child deaths and other cases can be traced largely to the infamous murder of 6-year-old Elisa Izquierdo by her mother in November 1995.

Kathryn Croft had taken over New York City’s Child Welfare Administration in August 1994. Fifteen months later, after Elisa’s mother had sexually abused her with a hairbrush and used her head for a floor mop, the child was dead. While every tabloid and talk show in the city screamed about the case, Croft remained silent.

When the city council ordered Croft to appear two weeks after the killing, she failed to show, forcing the body to take the rare step of issuing a subpoena compelling her appearance. Once there, she complained to the council, “I am appalled at the level of misinformation that continues to appear in supposedly responsible press accounts.”

Then Croft, like many embattled child welfare administrators, refused to set anything straight. She invoked confidentiality then, as she had done earlier before a committee of the state legislature, saying repeatedly, “Confidentiality prevents the City Child Welfare Administration, which is responsible for investigating complaints and protecting children from abuse, from discussing this case.” She wouldn’t even say whether her agency had completed its investigation of the child’s death.

Her stonewalling propelled passage of legislation allowing discussion of child deaths, which had been languishing since its proposal four years earlier. The so-called Elisa’s Law took effect in January 1996.

Croft was demoted when Mayor Rudolph Giuliani created the New York City Administration for Children’s Services and appointed Scoppetta to run it. She quit five months later.

Scoppetta used the freedom of the new law, which took effect days before his appointment, to concede errors and to help implement reforms. Today, many observers call the city agency a model for the nation.

“He was transparent about the strengths and weaknesses of the department and what it needed to succeed. He did not hide when there was an incident,” Bilchik says.

And there were plenty of incidents. An average of 27 children died each year, in a system that annually received more than 50,000 allegations of abuse about more than 80,000 children.

Scoppetta says his ability to discuss child deaths, along with the total support of the mayor, were crucial to his being able to last six years in office. (It helped that he was a former foster child and a charismatic leader.) He held press conferences about high-profile cases.

“It was very valuable in New York that I could talk about the investigation to the press,” says Scoppetta, now the city’s fire commissioner. “We promised when we had a child fatality, there would be a full investigation and full disclosure. If someone did not do what they were supposed to do, I held everyone accountable, even myself. That establishes some credibility with the media.”

The current children’s services chief, John B. Mattingly, has remained in office through five recent high-profile child deaths for some of the same reasons.

“The public is more forgiving when there is a belief that there is an effort to improve the system and do better,” says Jerry Friedman, executive director of the American Public Human Services Association. “The more openness the director has, the more forgiving the public is.”

The bottom line is that the public, which is paying for the agency’s services, has a right to know how well the system is functioning, he says.

About a dozen states have adopted similar measures, allowing directors to speak under various circumstances. The differing results are stark in Baltimore, while an incident in Missouri shows how the law by itself sometimes isn’t enough.

Getting the Story Out

Maureen Robinson has been on the front lines in the crisis that hits a child welfare agency after a death. She served as spokeswoman for the Baltimore County Department of Social Services when Wheeler was ousted as director after the death of 9-year-old Rita Fisher, and was in the same post when 3-year-old Roy Lechner Jr. died under the watch of Timothy Griffith, the current director. Robinson has learned that it’s crucial for the agency to admit its vulnerabilities and culpabilities.

“If you don’t tell anyone what the problem is, no one is going to help you fix it,” she said.

Wheeler was frustrated by her forced silence in the Fisher case. She wanted to tell her workers’ side of the story and explain the extenuating circumstances.

For example, the child’s relatives were expert liars and manipulators who deceived caseworkers and police, the latter of whom couldn’t find sufficient evidence to file criminal charges when the child told teachers her mother had beaten her with a stick. A doctor said the girl’s facial discoloration was an “allergic shiner.”

Even so, the agency made mistakes, such as failing to visit the child’s home in the seven weeks before her death. Wheeler says she would have admitted those errors if she’d been allowed to talk. “You have to say, ‘We screwed up’ when you did,” she says.

Before she was booted, Wheeler, now an adjunct professor at the University of Maryland’s School of Social Work, made it clear that part of the problem in the case was overburdened caseworkers, Robinson says. The state legislature provided money to hire more workers and raise salaries.

Eight years later, when Lechner died, Robinson’s response was the opposite of “no comment.” She released some stunning documents that showed, for example, 130 visits by various social workers to the boy’s home over three years. She also provided a six-page summary of the agency’s involvement in the case, explaining its decisions and actions every step of the way, including what it did when it couldn’t convince a judge of abuse allegations involving the boy.

While Robinson’s aggressive use of Maryland’s version of Elisa’s Law helped the agency weather the storm, Missouri showed how stonewalling in a state with an Elisa’s Law can make matters worse.

The Missouri Legislature passed a disclosure law in 2000 after two children were starved to death by their mother in Kansas City. Even so, two years later, after a foster father was charged with shaking 2-year-old Dominic James to death, child welfare officials refused to provide information, saying repeatedly, “We can’t talk about this specific case.”

They then found themselves in the awkward position of being sued by a newspaper with the vocal support of the child’s parents and two lawmakers who had pressed for the disclosure law, one of whom by then was lieutenant governor. “The director should in this instance release those records,” Lt. Gov. Joe Maxwell told the Springfield News-Leader. “The director does not have discretion in this case.”

Child welfare directors on the state level and in the county where Dominic James died were forced out. The newspaper won its lawsuit, forcing the agency to release 800 pages of records.

So sold is Bilchik on the importance of talking that he urges directors in states without an Elisa’s Law to seek judicial permission to talk. “In many jurisdictions now where there is a child death, you can go to the court, even where there are confidentiality statutes, to get relief to disclose publicly what happened in the case and what the department is doing about it,” he says.

A director must find a way to talk about a child death, he says. “Work with your legal department, because the lawyers will tell you not to talk about it,” he says. “Push back and tell them you have to work out what you are going to say.”

Then, he advises, say something real: Describe what happened and detail how the agency plans to fix it.

Jessie Rasmussen, who lost her job directing the Iowa Department of Human Services after a child’s death in 2000, says child welfare officials should observe the Boy Scout motto: Be prepared. “Every director should have a plan of action for when this happens to them,” she says. “If you are there long enough, it is likely to happen.”

Self-Defense: An Agency Releases Case Details

After the death of 3-year-old Roy Lechner Jr. last year, the Baltimore County Department of Social Services publicly released a “case summary of services” provided to the family. Following are selected excerpts from that summary. To see the full summary and other documents released by the agency, go to, and click on News Links.

6/2/03: Social worker conducted a site-based and home-based assessment, which included the Infant and Toddler teacher as well as both parents. It was determined that in-home social work services were needed due to family history, Mrs. Lechner’s parenting limitations, Mrs. Lechner’s self-described emotional problems for which she was not receiving treatment, Mr. Lechner’s tendency to distance himself from active involvement in the home, and Roy Jr.’s special needs.

7/30/03 to 9/4/03: CPS social worker … assessed Roy Jr.’s safety. She interviewed him, physically observed him, and interviewed his parents. Roy, Jr. had no bruises, no signs of physical abuse or neglect, and was well groomed. The home was clean, with no safety hazards.

March 2004: The family continued with SFC [Services to Families with Children] service beyond the 3 year old age limit for the Infant and Toddlers Program due to ongoing concerns about Mrs. Lechner’s parenting, Mr. Lechner’s continuing overestimation of Mrs. Lechner’s abilities and the fact that Mrs. Lechner was now pregnant.

7/30/04: The Lechners’ neighbor told the CPS social worker that Roy, Jr. had been to the hospital on a number of occasions for various injuries. The CPS social worker reviewed the Franklin Square Hospital medical records and consulted the Child Protection Team Coordinator. The hospital’s Coordinator indicated that those records pointed to a vigilant mother who brought her child to the hospital for appropriate reasons, with appropriate explanations. Roy, Jr. was observed by the CPS social worker to be extremely hyperactive with poor impulse control.

11/8/04: The parent aide, by coincidence found both Lechner children locked in the family truck outside a convenience store in the Lechners’ neighborhood. The parent aide confronted Mrs. Lechner at the time and both Mr. and Mrs. Lechner when she saw them next on 11/10/04.

11/18/04: There was a contested shelter care hearing in which [the department] argued for shelter for Donald [Roy’s baby brother]. After hearing from all parties, including the mother’s attorney, the father representing himself, and the child’s attorney, the Juvenile Court, with a Juvenile Master presiding, ruled against the agency and returned Donald home. [Donald dies soon thereafter.]

2/11/05: The DSS decision to pursue an Order of Protective Supervision rather than to place Roy, Jr. in foster care was based on the following factors: the absence of proof that Donald’s death was the result of abuse or neglect; no provable physical abuse of Roy Jr.; the degree of family cooperation with the interim plan that had been established; Roy, Jr.’s continued strong emotional connection to his father and his emotional vulnerability since the death of his brother; Roy, Jr. was now enrolled in both a school program and a daycare program; Mrs. Lechner had indicated that she would cooperate with a mental health assessment and treatment; Mr. Lecher agreed to assume responsibility for Roy, Jr.’s safety; both parents were now accountable to the Court for compliance; both parents sought the continued involvement of DSS social work and parent aide services.

3/1/05: Telephone call from Homicide Unit at 3 p.m. indicated Roy, Jr. had died.

The Cost of Silence: A Director Speaks

Nine months after Jessie Rasmussen took over the Iowa Department of Human Services (DHS), a 2-year-old girl known to the child welfare system was beaten to death in her home.

Rasmussen was heartbroken. But she followed the advice of her staff and remained publicly silent.

Three years later, she was out of a job. She thinks her silence eventually did her in.

“I was terrible with the press when this all first happened,” she recalls. “I was fairly new there. I was trying to learn my way around. I got strong advice not to say anything.”

Such silence, she says, comes off as callous.

“Instead of standing in front of a mike and expressing my agony about this child’s death, I just said nothing. I should have said what my heart said: ‘This is a horrible thing. I am extremely distressed that this child was part of my system and this happened.’ ”

In the days after Shelby Duis died in January 2000, the public and lawmakers clamored for answers. Gov. Tom Vilsack (D) said they’d get none, because state law prohibited Rasmussen, whom he’d appointed, from giving anyone – including him –answers about DHS’ role in the toddler’s life and death.

That didn’t play well in the news media. “The media phrase was that we were being secretive, as opposed to obeying the law of confidentiality,” Rasmussen says. “The general public feels you must be hiding something if you do not say anything.”

A newspaper columnist phoned to say that he’d be calling for her to be fired. “He said heads must roll,” Rasmussen recounts.

“He needed a sacrificial lamb.”

She was not immediately fired, and successfully pressed the state legislature to adopt a law allowing DHS directors to speak about cases under certain conditions. But she believes the law is too restrictive, as does DHS spokesman Roger Munns.

“On occasion, we can talk, but we need the prosecuting attorney’s permission, and he never gives it,” Munns said. “In my view, it does not serve us well when we do not appear to be forthcoming in these cases.”

Rasmussen, who was not reappointed after Vilsack was re-elected in 2002, agrees with Munns. “We should be able to investigate and tell the public that we will tell them what we did and did not do,” she says.

Rasmussen, who is now early childhood policy director for the Nebraska Children and Families Foundation, says that even if an agency director can’t give details, he or she can tell the public that agency officials care and will do all they can to prevent more deaths.


Child Welfare League of America
(202) 638-2952,

Jerry Friedman, Executive Director
American Public Human
Services Association
(202) 682-0100,

Anita Light, Director
National Association of Public Child Welfare Administrators
(202) 682-0100

Nicholas Scoppetta, Commissioner
New York City Fire Department
(718) 999-2056

Camille B. Wheeler
Adjunct Faculty Member
University of Maryland
School of Social Work
(410) 706-7922


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