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Death Knell: Colorado wants reforms for its child-welfare system, but the biggest change is off the table

Last fall, a committee appointed by Governor Bill Ritter made 29 recommendations for how to fix Colorado's child-welfare system. The committee was formed after the deaths of thirteen children who had been involved with the system in 2007, including seven-year-old Chandler Grafner, who was starved to death by his county-appointed guardians.

Chandler's story was egregious: According to state reports and court testimony, the boy never met his biological father, and his mother was found to be so neglectful that she lost custody of him a year before he died. He was sent to live in Denver with his mother's ex-boyfriend and his common-law wife, who forced Chandler to sleep in the bottom of a linen closet on an air mattress stained with his own feces. They also denied him food; Chandler was so thin that a homicide detective described him as a "walking skeleton" with shoulder blades that stuck out like icicles.

Denver newspapers and TV stations followed the twists and turns of the case closely, prompting hundreds of readers to post comments on media websites. They lambasted Chandler's killers — Jon Phillips and his wife, Sarah Berry, both of whom are now in prison — and called for reform of the broken child-welfare system.

Government officials were listening.

In April 2008, Governor Bill Ritter created the state Child Welfare Action Committee to study how Colorado's system could be improved. Its first charge: to "analyze Colorado's current state-supervised/county-administered child-welfare system to determine whether this system is most effective in protecting children."

As of this year, 27 of the committee's recommendations, including a statewide training academy for caseworkers and supervisors, are moving forward — though the progress of some, especially those with high price tags, has been slow.

But the fate of the remaining two recommendations is uncertain. And now the largest and most controversial of the two — a proposal that would overhaul Colorado's entire child-welfare system to give more power to the state and less autonomy to the counties — appears to be off the table.

As it stands now, each of Colorado's 64 counties handles its own child-welfare cases. Some do it better than others, and the state can discipline those that consistently get it wrong. But the state can only do so much, especially with limited staff. So in September 2009, the committee suggested a hybrid approach: Smaller counties would be lumped together into regions and their child-welfare services would be delivered by state employees. Bigger counties, such as Denver, Jefferson and Arapahoe, would continue to act on their own, but the state could take over if it felt like a county was failing.

The recommendation was supported by a 66-page report written by the Denver-based consulting firm Policy Studies Inc., which specializes in the field of health and human services. Calling the system "disconnected" and "inconsistent," the report says that the quality of child-welfare services varies wildly from county to county and that many county social workers believe the state human-services department has little understanding of or impact on what they do. The study's authors recommended that Colorado adopt a state-supervised and -administered system. "Simply put," they said, "without a change to the structure of the current system, meaningful reform to service delivery will continue to elude the state."

The committee cited those findings when making its recommendation, and suggested that legislation to overhaul the state's child-welfare system be introduced in January 2010. But the counties immediately balked at the idea. They wrote to Ritter, urging him to reject the recommendation, and told other lawmakers the same thing. At four public hearings held in November and December to gather input on all 29 recommendations, scores of county commissioners and county human service directors testified against the restructuring idea, calling it too expensive, too cumbersome, too Big Brother.

A state-run system would "deprive us of the ability to resolve local issues the way we're currently resolving them," says Jose Mondragon, the head of the Pueblo County Department of Social Services. "To do a state-run operation, we'd have to reinvent the wheel. There's too much work that's gone on over the years."

"We think, in general, the current system works pretty well," says El Paso County Commissioner Sallie Clark. "If [an El Paso County] caseworker gets a name, they'll know it. If someone in Denver gets that name, they won't know it, and more kids will fall through the cracks."

The counties also criticized the recommendation as last-minute and said the committee, which included county leaders, hadn't vetted it properly or calculated its cost. "There was never any justification that came out of the Child Welfare Action Committee as to why such a radical change...should occur," says Arapahoe County Commissioner Susan Beckman.

Despite having called the plan "exactly the kinds of things we put this committee in place to do," Ritter backed off. He promised to move forward with 27 of the recommendations, but to study that one, along with a similarly controversial idea for a centralized call center that would receive all reports of abuse and neglect throughout Colorado. He pledged to investigate the issues for a year, with county input.

But for the next several months, Ritter focused instead on pushing for legislation related to other recommendations. This year, lawmakers created a statewide child protection ombudsman office and passed a law to speed up the transfer of child-welfare cases from county to county in cases in which a family moves. They also passed a law that requires social workers to provide feedback about a child's abuse or neglect case to the person who originally reported it — often that child's teacher, doctor or neighbor. (Last month, a subcommittee assigned to deal with the intersection of child abuse, mental health, domestic violence and substance abuse submitted to the governor six more recommendations dealing with those topics. All six are reportedly moving forward.)

While child advocates were happy with the new laws, many were left wondering if the recommendation to restructure the entire system was dead — a possibility that worried them. "It's a political battle," says Shari Shink, founder and president of the Denver-based Rocky Mountain Children's Law Center, who served on the committee and was also a strong proponent of the ombudsman office. "The fear it generated, the outrage it generated, was all based on this notion of 'We like it the way it is; don't interfere.' And it's not working the way it is. It's not working for children. It's not working for families."

In fact, more children died in 2009 than in 2007. While Ritter called the 2007 deaths "outrageous," eleven more children died in 2008. In 2009, that number jumped to fifteen. No numbers are available yet for 2010.

In May, Ritter appointed another twenty-member committee called the Governor's Working Group on the Structure of Colorado's Human Services System and the Centralized Call Center for Child Abuse and Neglect Referrals. Its goal is to determine the fate of the two controversial recommendations. Its deadline: September 30, 2010.

The group was given just four months to vet the proposals, partly because Ritter's term ends in January and he's not running for reelection. "We want to give folks enough time to look and...to analyze and absorb the recommendations with acknowledgement to the fact that the administration will be leaving office," says Ritter spokesman Evan Dreyer.

Though it was formed in May, the group, chaired by Colorado Department of Human Services director Karen Beye, didn't meet for the first time until June 17. That day, the members decided to table the recommendation to overhaul the structure of the entire state system and to focus solely on determining the viability of a centralized call center.

"It just felt like it was overwhelming," says Skip Barber, the director of the Colorado Association of Family and Children's Agencies in Denver and a member of both committees. "We have a three-month turnaround. We decided there was no way we could deal with the administrative structure when we'd gotten that [negative] feedback from the counties."

It was the outcome the counties had been hoping for. "The worst thing that could happen out of this group is, once again, you have recommendations that aren't vetted," says Beckman, a member of both committees and the chairwoman of the Health and Human Services Steering Committee of Colorado Counties Inc., a nonprofit membership association for county leaders that weighs in on state policy. "No system is perfect. But if you move to another system with more problems, you've done harm."

Beye declined to comment, and DHS spokeswoman Liz McDonough wouldn't say whether the department was pleased or displeased with the decision to table the restructuring recommendation. "The only thing I can say for certain is this group is not going to deal with it," she says.

Some advocates, however, are frustrated. "I'm very disappointed," says Mary Lewis, a former foster mother from Aurora and a member of both committees. But Lewis says she understands that the deadline to vet the plan was just too tight — and she feels like the message that the system needs to change has been heard, regardless. "My feeling is we've gotten the counties' attention," she says. "And we've gotten the state's attention as to what their oversight role is. I think the discussion served a useful purpose — and I think it'll come back at some point."

So does Becky Miller Updike, the director of strategic initiatives for the Tennyson Center for Children in Denver, which serves abused and neglected kids. "I don't think it's going to go away," she says. "Whoever the governor is after November, I hope this issue continues to be pushed on."

Anyone who needs convincing that reform is necessary need look no further than the stories of children involved with the system who die each year, advocates say. Stories like that of Ashaquae Foster.

Of the nine times teachers and passersby called the El Paso County Department of Human Services over ten years to report that Ashaquae was being abused, none resulted in caseworkers opening an ongoing investigation into the alleged abuse, according to a fatality report released by the state in March after Ashaquae died last year.

Not the time it was reported that two-year-old Ashaquae was grinding on the floor in a sexual manner and inserting objects into her vagina. Not the time that caseworkers were told Ashaquae's parents chained her to her bed at night so she wouldn't steal food. Not when someone called to say they'd seen seven-year-old Ashaquae digging in the trash and eating raw meat. Not when it was reported that the child slept on a soiled mattress, wore dirty clothes and was prone to pulling her hair out. Not when eleven-year-old Ashaquae told school staff that her stepmother often called her a "bitch" and an "asshole" and hit her until her nose bled.

A few times, the reports were "screened out," meaning social workers didn't consider the allegations serious enough to investigate. More often, a caseworker talked to Ashaquae and her parents, but then closed the investigation as "inconclusive for abuse."

Shirley Rhodus, the child protective services administrator for El Paso County, says that in general, the decision to investigate is a judgment call. Social workers must weigh a child's safety against the intrusiveness of the government intervening in a family's life. "There's no formula that says 'If this, then that,'" she says. "There's no way we can add all these things up and know that it results in a [particular] response."

She also says that there's often no way to predict when a child's situation will turn fatal. "Hindsight is really 20/20," she says. "Cases that we describe as generalized neglect or not a good home life, we might get one hundred of those and only one will result in a child being injured or dying."

In August 2009, one month before her thirteenth birthday, Ashaquae was found bleeding on a urine-soaked mattress in the small bedroom she shared with her developmentally delayed aunt. Her father and stepmother waited six hours before seeking medical attention because they were worried they'd get in trouble for locking Ashaquae in her room, where she'd gone to sleep the night before with a bloody nose. The coroner found that she'd choked to death.

The state Department of Human Services, which issues fatality reports on every child who dies after having been involved in the child-welfare system, found that El Paso County erred several times in handling Ashaquae's case. The department criticized the county for not responding quickly enough to reports of abuse over the years and not following up in instances where Ashaquae's parents were uncooperative. It also questioned why referrals in 2006 and 2007 were screened out when they reported a similar pattern of abuse and why a subsequent report alleging the same pattern was not reassigned when the original caseworker left the agency.  

The state required El Paso County to take several corrective actions. It mandated that supervisors go over certain rules with their caseworkers and meet monthly with them to review their entire caseload, a practice Rhodus says most supervisors were already doing. The county also implemented reforms on its own, she says, including adopting a group triage model to review child-abuse referrals and hiring two field investigators to gather background documents on individual cases so caseworkers are free to interview children and parents.

The Colorado Springs police have an open investigation into Ashaquae's death, says spokesman Sergeant Steve Noblitt. But Rhodus argues that even if Colorado switched to a state-run child-welfare system, it wouldn't prevent child deaths like Ashaquae's — a stance the El Paso County commissioners officially endorsed with a vote earlier this month. "We really believe that at a local level, we are more responsive to our community," Rhodus says. "It just seems like there will be more layers of bureaucracy in a statewide system."

Layers that some say could catch kids who would otherwise fall through the cracks.


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