By Douglas J. Besharov

This article originally appeared in The Washington Post, December 1, 1996.

LAST MONTH, as I have regularly for the past nine years, I traveled to New York City to try to make sense of a child's death.

I serve on New York City's Child Fatality Review Panel, a remarkable body that conducts no-holds-barred investigations into child abuse deaths. It is an experience that is both rewarding and dispiriting. In effect, we conduct social autopsies: Why did the child die? Could the authorities have prevented it? If so, should we recommend any disciplinary actions or systemic changes that might save children now in danger?

This time when we gathered inside the plain conference room where we hold our discussions, we already knew a fair amount about the case before us. Unlike many of the 100 cases I have reviewed, the gruesome death of 4-year-old Nadine Lockwood had received saturation coverage in the New York media.

Nadine weighed 15 pounds when the police found her shriveled, lifeless body in a Manhattan apartment last August. For many months, her drug-addicted mother had kept her in a blanket-covered crib, slowly starving her to death. What made it front-page news was that Nadine's mother and her six children had been reported to the city's child protective agency numerous times over the previous seven years.

A hospital first reported Nadine's mother to authorities in 1989, when her newborn tested positive for cocaine. The case was closed within six months after the mother started attending a drug treatment program. Nadine was born less than two years later, also with cocaine in her system. The agency confirmed this report as well but again closed the case after six months.

A year later came yet another baby -- this one abandoned in the hospital and later placed for adoption. Over the next three years, the agency received more reports, including several that the older children rarely attended school. Still, it did not take protective action. (As a member of the panel, I have access to confidential agency files, but all the details discussed in this article have already become public.)

Sadly, Nadine's story is not unusual. Nationally, about 1,500 children die each year under circumstances suggestive of abuse and neglect, according to the National Committee to Prevent Child Abuse. No matter what we do, some of these deaths cannot be prevented, because they happen without any warning. But about half the time, the children died after the family was reported to a child protective agency. In such cases, one can fairly ask: What went wrong?

I have spent much of my professional life trying to answer this question -- first as a young prosecutor in New York City, then as the founding director of the federal government's National Center on Child Abuse and Neglect and more recently as a consultant to public and private agencies across the country. But it's easy to lose touch with the real world. That fear, as well as the chance to make a small contribution, has kept me on the Child Fatality Review Panel. Case after case has taught me about the immense challenges child welfare agencies face each day -- and has forced me to reexamine (and often modify) my most deeply held beliefs about how best to protect children.

The conventional wisdom blames most of these deaths on inadequate funding and on poorly trained and overworked caseworkers. On the basis of my experience, however, I do not think that more money will help matters much. Decision-making problems plagued New York City, for example, even when it had one of the lowest per worker caseloads in the nation. Although most agencies can certainly use more (and better) resources, the real culprit is wishful thinking about parents and the efficacy of treatment.

Think about how the system handled Nadine's mother, a confirmed drug addict with years of well-documented problems in caring for her children: As soon as she began a drug treatment program, the system concluded she could make it on her own. Worse, it continued in that belief in the face of repeated reports from concerned professionals and neighbors.

Since I started out in the field almost 30 years ago, child protective programs have expanded enormously. Thanks to stronger child abuse reporting laws, the number of children reported to the authorities in the United States has increased from only about 150,000 children a year to the over 3 million today (although many reports turn out to be unfounded). Most communities now have specialized investigative agencies, so that those reports that once languished in piles on workers' desks are usually investigated within a day or so. Moreover, for better or worse, millions of children have been placed in foster care. Between 1982 and 1995, for example, the number of children in care almost doubled, from about 262,000 children to about 494,000 children. And, back in the 1960s, child welfare expenditures were a fraction of the approximately $ 5.7 billion spent last year just for investigations, foster care and adoption services.

These expansions have made a dramatic difference. By most estimates, child abuse deaths are half or less of what they were three decades ago, even as social problems such as drug addiction have worsened. And thousands of other children have been saved from injuries short of death. More money for additional caseworkers and other services would surely improve conditions. But it would do nothing to fix the system's decision-making problems, which have a deeper root: A pervasive unwillingness to acknowledge that some mothers are unable to raise their children and that only adoption or long-term foster care can give their children a chance.

Isaw this most dramatically in a case I handled in the early 1980s as a volunteer attorney in the Family Court Division of D.C. Superior Court. I was representing five children, ages 4 through 15, who had been in foster care for three years. Their drug-addicted mother had repeatedly beaten them so badly that they had been hospitalized a number of times for their injuries. She had recently incited her then 15-year-old daughter to run away from her foster home, and then prostituted her until she got pregnant.

Because the official case record said almost nothing about the mother, I made a home visit to see how she was doing. The hallways in the mother's apartment building had feces smeared on the walls and smelled of stale urine. Her apartment had broken windows, inoperative plumbing and an unlocked kitchen door that opened to a missing fire escape -- three floors off the ground. Without tremendous improvement, this mother was never going to regain custody of her children.

When I returned to my office, I called the family's caseworker, recounted what I had seen and suggested that he consider initiating adoption proceedings for the younger children -- who were still young enough and emotionally healthy enough to be adopted. He said he appreciated my report since he had not seen the mother for many months but that, no, adoption was premature. I shall always remember his reason: "I don't like to give up on a mother."

Don't fault the caseworker. His actions only reflected the prevailing attitude, embodied in state and federal law, that the prime objective of child protective agencies should be family preservation.

Attitudes have changed little since I was involved in this case, as national statistics show. Each year, about 250,000 children are placed into protective foster care, according to the American Public Welfare Association. Although many children are returned in a matter of days, many others languish in foster care with little hope of adoption. The most up-to-date data are from 1990, when about 40 percent of the 400,000 children in foster care had been away from home for at least two years. About half of these children had been in at least two foster homes.

Fewer than 5 percent of these hundreds of thousands of children are freed for adoption each year. Too many children are returned home, where they frequently are abused again and once more placed in foster care. This revolving door is particularly common in cases of parental crack addiction, where despite the best treatment programs parents tend to relapse into addiction.

Some blame this failure to take more decisive action on a misplaced commitment to parental rights. That surely contributes. But, as the statistics suggest, the system is unwilling to accept the uncomfortable truth that some parents are beyond the reach of even the best treatment programs.

We need to take the necessary steps to help their children grow up safely and reach their full potential. Caseworkers have to be able to say to a severely abusive mother: "You have had two chances (or three or four). Now, we want to give your kids a chance. We need to take them from you and place them in a safe, nurturing home."

My service on the Fatality Review Panel convinces me that making this change won't be easy. Our panel is no toothless tiger. Over the years, many of our recommendations have been adopted, particularly those urging improvements in training programs, supervision of workers and caseload standards. The authorities have even paid attention to suggestions about which individuals to discipline or prosecute for endangering children.

But we have gotten nowhere in our efforts to get New York City and state officials to respond more forcefully to cases of severe abuse, including parental drug abuse. In writing this article, I went back and looked at our past reports. We have regularly called for changes in law and policy to make it easier to terminate parental rights, and for an expansion of long-term residential options for children who can't go home and don't have much hope of being adopted.

One obstacle, no doubt, is the fear of the cost of taking responsibility for severely abused and neglected children until they grow up. But doing the right thing need not cost more than current practices. Take Washington, for example. Its child welfare system was considered to be in such bad shape that the federal courts placed it under the supervision of a "receiver," Jerome Miller. After examining the agency's budget, Miller calculated that it was spending roughly $ 40,000 per year per child. Many of these children could be placed for adoption, which would save money; others could be placed in stable residential settings, which should cost the same or less.

Program advocates are another obstacle. For years, they have made unsupported claims -- repeated unquestioningly by some politicians and some in the media -- that programs like family preservation can repair even the most dysfunctional families. Moreover, many of the children most in need are too old or too troubled to be adopted and would have to be placed in long-term foster care or residential institutions (which opponents would quickly call orphanages).

Race only aggravates the difficulty. Since the crack epidemic of the late 1980s, which hit disadvantaged African-American communities like a sledgehammer, child welfare caseloads have become progressively more black. Between 1982 and 1990, the last year for which there are data, the proportion of foster children who were African American rose from 34 percent to 41 percent, two and one-half times their number in the general population.

The reality that a "get-tough" policy would fall disproportionately on poor, black mothers rightly should make everyone think twice before adopting it. But the present course -- ignoring the long-term harm being done to black children -- may be an even more insidious form of racial discrimination.

So the next time you read about a child's death, don't blame just the caseworker who perhaps did not do everything possible to protect the child. Some blame belongs to the rest of us. Until we collectively accept that many severely abused and neglected children need a permanent place to live away from their parents, and until we make such placements a real option, we should expect to read about many more Nadines.

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