Suffer the Little Children

…How lack of transparency in a state agency endangers children

By Shirley Iverson

Oregon’s Department of Human Services (DHS) is charged with many health and welfare responsibilities. One important mission is protecting children in their care from harm. In response to a number of high-profile incidents, Governor Ted Kulongoski has issued two strong directives to the Child Welfare program. First, he has demanded that the problems in the program be fixed (2008). Second, he wants “Critical Incident Response Team” (CIRT) reviews made available to the public within 60 days (2004). DHS Director Dr. Bruce Goldberg has promised caseworkers will have monthly face-to-face contact with children in 80% of their casework. How well is the agency meeting these directives? From all information available, it has failed. Moreover, DHS has failed to provide the citizens of Oregon with a transparent view of its problems.

Oregonian Headline February 4, 2008 — “Feds Give Oregon Child Welfare Failing Grade”

The Child Welfare program failed a federal review in 2001 and failed again six years later. The 2007 federal review of services found Oregon failed to meet federal standards in 11 out of 14 measures. The review concluded that DHS Child Welfare failed or is in “substantial conformity” with NONE of the national standards for seven client outcome measures.

Oregon’s failures include the reoccurrence of maltreatment within 6 months and maltreatment of children in foster care. Some of this low performance was attributed in part to the lack of frequent and meaningful contact between DHS staff and children, parents or foster parents. Monthly quality contact with children occurred in only 55% of cases reviewed, and only 39% of the parents in reviewed cases had contact with their caseworkers. Dr. Goldberg promised an 80% monthly face-to-face contact rate by this year. Data is not yet publicly available to gauge any progress toward this goal, but transparent government demands that DHS release it soon. The 2001 and 2007 federal reviews note an ongoing concern that state services were not adequately provided to keep children safe in their homes (or in their foster homes) in 40% of the cases reviewed.

Other measures that failed in the 2007 federal review include:

“¢ Children are first and foremost protected from abuse and neglect — FAILED. Only 62.5% of the cases reviewed met this standard.
“¢ Children are safely maintained in their homes when possible — FAILED. Only 60% of the cases reviewed met this standard.
“¢ Children have permanency and stability in their living situation — FAILED. Only 46.3% of the cases reviewed met this standard.

Headline March 14, 2008 — “DHS Investigates Girl’s Death”

One month after the 2007 federal review was made public, The Oregonian reported that the director of DHS had opened an internal investigation into the death of a Salem toddler whose family was known to the agency because of past reports of abuse. Similar prior cases had caused Kulongoski to direct that Critical Incident Reports be initiated and available to the public within 60 days of the incidents. There have been 14 Critical Incident Reports initiated since 2004.

Headline April 7, 2008 — “Oregon Remains Secretive About Child Abuse Cases”

Many Critical Incident Reports remain secret, and neither the governor’s office nor DHS have told Oregonians whether problems uncovered in these investigations are being solved. Neither has publicly unveiled a plan for solutions, either. The recent federal review and a Child Welfare Staffing Study were left to summarize the problems.

The Child Welfare Staffing Study is one outcome of a DHS $3.2 million contract with consultant McKinsey and Company, meant to take a fresh look at the entire department. According to the published study, “caseworkers were available for case-related work only 70 percent of the time, or less than 6 hours per day. 30%, or more than 2 hours per day, was non-available time including breaks, leave time, training, vacancies and non-case-related work. On average, less than 1 hour and 15 minutes a day were found to be spent communicating directly with clients. This means Oregon’s caseworkers spent less time on direct client contact than any other state completing a staffing study and that the goal of 80% monthly client contact must be achieved in less than 1.25 hours each day.

Since Governor Kulongoski is personally committed to the improvement of Child Welfare practices, and since both the federal reviews and the McKinsey staffing study point to continued dismal progress, the governor should now consider the following recommendations:

“¢ Declare a state of emergency in the Child Welfare department.
“¢ Require a weekly update from the Director of DHS regarding management actions to meet federal standards and the promise of achieving 80% client contact this year.
“¢ Appoint a legislative and citizen review team to monitor program improvements, Critical Incident Reports and the implementation of the recommendations in the McKinsey and Company report.
“¢ Mandate that Critical Incident Reports be made public in 60 days, as promised by Governor Kulongoski. Review program gaps and error trends from all completed Critical Incident Reports, implement a corrective action plan and report on management actions.

Implementing these recommendations will go a long way toward making the state’s Child Welfare operations more transparent to all Oregonians and to improving the lot of the most vulnerable children under state care. Just as Governor Kulongoski shares his compelling stories of growing up in an orphanage, so may future governors share their stories of growing up in a family served by the Child Welfare department. Let’s do everything we can to ensure these future leaders, and all children under state care, live to tell their stories.


Shirley Iverson is a consultant for the Government Transparency Project at Cascade Policy Institute, Oregon’s free market think tank. From 1988 to 2005, Ms. Iverson held several high-level leadership positions within the Oregon Department of Human Services.

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  • John Fairplay

    I think you’re pretty wide of the mark here. The standard of success for any government agency in Oregon is not whether it accomplishes some goody-two-shoes “mission” like protecting children or building roads. DHS provides hundreds of very generous salary and benefit packages for its government union employees. In Oregon, that qualifies it as a success, even if every single child in its care dies.

    • Crawdude

      Sad but true 🙁

    • A. C. Whalen

      Protecting children is a “goody-two-shoes ‘mission'”?! What a hard-hearted, uncaring attitude! But you are being ironic, right? And well you should be. [Sometimes irony can accomplish what literal logic can not.] I’m from Arizona, and so much of what Shirley writes is true of Arizona’s system. The main problem is that children are not valued; I guess because there are so many of them in need–it’s the rare and scarce that’s valued–and not enough of those generously paid and fringe-benefited government union employees to care, physically and emotionally, for them.