How can child welfare leaders advance a 21st century child well-being system?

Q&A with Frank Alexander, Director, Boulder County (Colorado) Department of Health and Human Services1

Awareness is growing that the current child protection response is not working — particularly for the 7.5 million children involved in a report of maltreatment each year. The number of child abuse and neglect fatalities continues to increase nationally at a time when the overall rate of child fatalities is declining, and the lives of children and families involved with the child welfare system often are not improved as a result, with one-quarter of all children in foster care remaining there for more than two years. Concerned about these realities, we asked Frank Alexander, director of the Boulder County Department of Housing and Human Services in Colorado, to share his view and vision for a transformed 21st century child well-being system that better serves children and families. Director Alexander has been at the forefront of this transformation both through his local and statewide work, and through his national leadership on Casey Family Programs’ 21st Century Child Welfare System Steering Committee.

Q: What does a 21st century child well-being system mean to you?

A: Building strong and vibrant communities with healthy and thriving families. To make that happen, we need a 21st century approach to transformation, where “the system” starts to fade into the background, and families and children are naturally supported in communities long before crises arise.

Q: Why is transformation important?

A: Today, families and children are likely to fall deeper into crisis before they can get the supports they need. We now know that there is a range of different supports that can be offered much earlier and in a much less intrusive manner, within a community context, that can safely keep children at home with their families. That’s where transformation comes in: We envision an approach that creates the overarching conditions in a community where families receive the services and supports they need as early as possible, where families and communities are strengthened, and children can best thrive. Right now, we put most of our effort into improving the latest version of a response system that uses removal as the intervention, rather than a last resort.

Child protection agencies exist within a box that is impossible to get out of without a truly transformational process. We need to move our efforts upstream with the same level of effort, capacity, and expertise that we currently invest in child protection. If we applied even 50% to 60% of that effort to strengthening communities and preventing child maltreatment, then we wouldn’t need to continue to build stronger and stronger frameworks around reactive solutions. Our future community-building efforts and family-strengthening investments will reflect our understanding that upstream is where we need to be.

Right now we’re just waiting for the next call, the next crisis.

– Frank Alexander, Director, Boulder County Department of Health and Human Services

Q: Who are the key partners in constructing a new approach?

A: Based on my experience in Boulder County and in conversations with other leaders across the country, two key things must be in place:

First, we cannot separate the child protection agency from public health, the broader human services structure, and primary care and maternal and child health care partners. Those partners are in the center of the circle. We know that child maltreatment is a public health problem and this core cross-sector alliance must be in place for us to change the conditions in our communities.

Second, we must build stronger alliances with community-based agencies that provide supports critical to strengthening families. This includes affordable housing providers, food providers including food banks, family resource centers, and maternal and child health programs. Our community-based partners not only provide core economic and parental supports to help families thrive, they also actively raise the voice of our community and hold us accountable to be the best partners we can be in building the conditions that will keep families together.

The lack of common alignment, common strategy, and common definition between health care, public health, and human services, including child protection, is a root cause of families not achieving good outcomes. There are agencies and stakeholders who would like to do things differently, but because we haven’t built effective inter-connected structures, and we haven’t aligned efforts across systems, we get “stuck in the wish” and never activate in a way that builds deeper momentum.

In the long term, everyone becomes a partner in community well-being, where every family and individual is part of vibrant, integrated communities with access to housing, food, jobs, medical care, education, and other opportunities. Making this a reality involves everyone in a community — however you define community — working together to achieve this aim.

Q: How do we go about creating that shared alignment?

A: Historically, child protection has been exclusively focused on child safety, not on the well-being of whole families and the broader communities in which families live. In most areas, child protection is expected to be the agency that prevents child maltreatment, but child protection was designed to respond to an allegation of maltreatment, not to prevent it from occurring.

It’s also important for us to get clear about our use of the term “prevention” — we are often mixing and matching primary, secondary, and tertiary prevention. It is critical that we clarify whether we are talking about preventing repeat maltreatment, or preventing homelessness among aging-out youth, or are we referring to more universal primary prevention? We have to cement our language so that when we talk with cross-sector systems that are essential to our success, we are clear that we are talking about the same thing.

To develop a new framework and foster shared alignment, there are several key questions to ask: What’s the best message to get people on board? Who might be impacted? What might it cost? Who might our non-traditional partners be? Understanding what drives different systems is a painstaking but critical part of building new partnerships: What are their financial incentives? Where is there a need for shared language? Where are they stuck? For example, our use of the health impact pyramid has been helpful in our partnership with public health to help identify our collective challenge. Similar to child welfare, public health has not been universally providing primary and secondary prevention supports to reduce child maltreatment and the prevalence of adverse childhood experiences. Like child protection and other human services systems, our partners in public health have many challenges re-defining themselves for the primary prevention of child maltreatment. But it is precisely because we are grappling with this and assessing this together that the partnership between public health and child protection is where we’re starting to see increasing momentum.

We can build a national movement around this — leaders and partners who are capable of putting aside slight differences to build an alliance that is so strong it will create the momentum necessary to change the structure and the incentives that are forcing the current type of response and reactivity in most communities. This is where foundations, public health partners, child protection teams, and advocacy organizations need to align so that we can be deliberate as a group about how to move forward. This alliance is the most essential component, and this is precisely what is missing right now.

Q: What role do constituents play within this transformation work?

A: This is a great example of where we need to be strong with our language. We use the terms “family engagement,” “family voice,” “constituent engagement,” and “constituent voice.” But what does that mean? In our transformation process in Boulder County, we have started to better engage birth parents, relatives, foster families, and youth to help guide us and, in a sense, wake us up to the conditions and consequences of the systems that we’ve built. It is an essential part of the process, and also somewhat painful for folks who have been working in the system for a very long time, to hear that the families and children we serve are suffering as a result of the work that we may or may not be doing.

Embracing the voice of everyone who has been impacted by the system can not only drive how the system should improve when it does need to react and respond, but also help us determine what it could look like if it isn’t just reacting and responding. What would it have looked like for those families if the system was built to be supportive at the front door, to be proactive, to provide the supports that would strengthen their lives earlier?

The trauma that children are experiencing as a result of us not strengthening families and not strengthening our communities is a national health crisis that is deep and profound and exceeds the social and economic cost of literally every other health condition in our country.

– Frank Alexander, Director, Boulder County Department of Health and Human Services

Q: Are there other components of a 21st century approach that you would add?

A: Partnerships are critical, and the current isolation of child protection from other health and human services agencies penalizes everyone, and makes all of our work less effective. As a result, child protection agencies are forever working to improve within their own four walls. Without a transformation and disruption process, child protection agencies will continue to spin in that context. Conversely, other health and human services agencies have really suffered from not understanding what child protection teams see inside our doors every day — the repeated trauma, the dislocation, the consistent themes of both need and risk, as well as where protective supports and factors can be strengthened. By sharing expertise and experience and rolling up our sleeves together, every agency can improve the family-strengthening services they provide.

At its core, a 21st century approach should be simple, and there are two ways to think about this. One is a clear definition of prevention — primary, secondary, and tertiary. The second is understanding the impact of child maltreatment across the life course. One thing we’ve struggled with in child protection is the overwhelming number of young parents and young children: Abuse and neglect has a direct correlation to negative health outcomes during a child’s life. Child maltreatment is a public health problem, and it is disproportionately experienced by young children. Child maltreatment is also incredibly expensive, carrying a total lifetime economic burden estimated between $484 billion to $2 trillion each year across our country.

The data regarding young children involved with child welfare is clear and overwhelming: The rate of removal is highest for children ages birth to 3 years old, as are fatality rates, near-fatality rates, and the rate of sentinel injuries. Once young children do enter care, it can take a long time for them to return home or find another permanent living arrangement. We are consistently missing the opportunity to strengthen families, especially in prenatal to age 1, when moms and dads are highly receptive to proactive efforts to develop the parental bond in a way that will reduce child trauma.

Our country is highly traumatized, with much of that trauma occurring early in life. So we should focus intensely on prenatal to age 3. If we begin to build a child well-being system with a clear definition of primary, secondary, and tertiary prevention, and if we build systematic maternal and child health supports beginning at prenatal care through the very early years of life, then we can more easily build the supports for older children because we are not starting at age 21 and then trying to work our way back.

Another key component of a 21st century system is that we should be continuously sharing information across communities about what families need, and what children need to be strong and healthy. Sharing this information is a non-negotiable part of the work and will help us create and invest in a broad suite of primary prevention supports that are universally available and accessible to every parent, every child, and every family. Doing so will reduce the need for the deep and broad child protection response that we have now.

Q: How might a family experience a 21st century child well-being system differently?

A: A family would not experience a “system” at all. If I were waving a magic wand, a family that is highly likely to have their child removed would instead have a pediatrician capable of identifying risk. Through natural community structures, they would quickly receive the parental and social supports necessary to build and maintain the dyadic bond with their child. They would be supported in developing protective factors and parental skills such that they barely noticed that they were accessing services. There would be no separation between those that have and those that have not, and it would really become an almost invisible structure of strengthening and support. If that parental bond is solidified between birth and the age of 3, the likelihood of repeated trauma, dislocation, and removal would be so significantly reduced that the need for us to do what we repeatedly do for and to thousands of kids, day in and day out, would be cut to a small fraction.

Q: What is the driving factor pushing you to lead transformation in child welfare?

A: Years ago, I managed a domestic violence and homeless family shelter. A very loving and heavily traumatized mother (we’ll call her Jane) had a personal crisis that resulted in an acceleration of substance use and behavior that put her 1-year-old at risk. The child protection system had no ability to see Jane in the ways that I could see her because I saw her in the place where she and her son lived, and I knew her on an emotional level as part of her support system at the shelter — and as a friend. I was a mandatory reporter at the time, and I had to be there and watch the trauma of removal, the separation and the screaming, for Jane and her child. Thousands of people experience this every day. In a moment like that, it’s blatantly obvious that there are better ways to provide help and support that could have made the removal and separation completely unnecessary.

I’ve seen those experiences in thousands of different ways. In addition to our child welfare system, I’ve seen them in our homeless, juvenile justice, and criminal justice systems, and in our aging and disability systems. There’s a proclivity to use an institutional hammer for a response, instead of a human-centered, family-strengthening, individual-strengthening response.

The data are incredibly clear and overwhelming: We know that 50% of all removals in the U.S. are under age 5, more than 80% of all child fatalities are under age 5, and 50% of those are under age 1. We need to move a proportion of our effort dramatically up to the place where we see the highest risk and the highest need.

– Frank Alexander, Director, Boulder County Department of Health and Human Services

Q: Are there any other challenges in doing this transformative work?

A: The current environment is laden with disincentives. Transformation requires an “eyes wide open” approach to building partnerships with leaders and partners and members of your communities. There are significant fiscal and regulatory challenges, and a huge part of overcoming them is to bring people together in a way that allows them to grapple with these concepts, such as redefining child safety as the prevention of maltreatment, not the prevention of repeat maltreatment. Another challenge is our history of viewing child maltreatment in the context of “bad” parents, rather than in the context of harmful community conditions.

Q: What would you say to another leader who says, “I agree that this is important, but I don’t know where to start?”

A: I get this question a lot and I love it. My answer is simple: Be clear about where you are. Situationally diagnose and understand what is happening with your team and the organization you are in — the structural context. Rely on peers who can help you have a brutally honest assessment of the conditions within which you’re operating. The first step is asking the question, the second is taking the time to situationally diagnose where you are, and then the third is to identify where to take action. That might mean you diagnose your organization and what you find is that there is no flexible funding or organizational structure to do anything proactive at all, so your first task is to take that on. Or, you may find that the way your teams are practicing is leading to high levels of removals. Or, you have no community partnerships at all and need to go build them.

Once you assess your organization, you can work to build partnerships and identify the precise place to act. Honestly, my preference is not to go with the low-hanging fruit. There is sometimes easy benefit to going for the easy wins but I don’t believe that change can be done in a way that lasts without going to the heart of the matter. If this is done well, you will have the ability to craft a meaningful roadmap for transformation. By diving into the biggest challenge at the beginning of the roadmap, you will find the strength you need to lead transformation. It may seem counterintuitive, but I’ve found the core of the system change work that you most need to do is right there.

1 Adapted from interview on October 4, 2019. Alexander was director of Boulder County (Colorado) Department of Health and Human Services at the time of the interview. He is currently Managing Director of Judicial and National Engagement at Casey Family Programs.