Before Maddox Williams, there were Marissa Kennedy and Kendall Chick. And before them Ethan Henderson. And before him Logan Marr.

Every few years, one or more high-profile child deaths that were preceded by some involvement with the Maine’s child protective system cast a critical eye on the agency tasked with protecting the state’s most vulnerable.

Logan Marr, in an undated file photo, died while in the care of her foster parent.

The response is often the same: Lawmakers and advocates, with amplification from the media, call for reactive reforms to ensure another death doesn’t occur. Sometimes the reforms are major, as was the case after Marr’s death in 2001 at the hands of her foster parent. Other times, the changes are incremental, or they reverse reforms that were made only recently. The pendulum swings. Months later, the world moves on.

Until the next death.

Last month, Maine’s Office of Child and Family Services contracted with a national firm, Casey Family Programs, to review its practices following the June 3 death of Williams – a 3-year-old from Stockton Spring who police allege was killed by his mother – as well as two other child deaths where the parents have been criminally charged.

And last week, the Legislature directed its watchdog agency to launch an expedited investigation into the state’s complex child protective system. It will be third time in four years that the Office of Program Evaluation and Government Accountability has studied some aspect of child protection.

Maddox Williams Photo from the #justiceformaddox GoFundMe page

The investigations raise complex issues, but the core question is simple: Is Maine’s child welfare system making sure children are safe, either in their own homes or in homes where they may be placed?

OCFS director Todd Landry has defended his agency and the recent reforms it has undertaken during his tenure while also pledging to do more.

“We recognize the passion and commitment of many people (on this topic),” Landry said in an extended interview last week. “We share that, and we share with them the absolute belief that there are improvements we have to continue to make as a child welfare agency.”

However, in interviews with several individuals who have been involved in that system, both inside and out, many fear they have heard these words before and are not confident the problems are solvable. Part of the issue, some contend, is that OCFS is weighed down by bureaucracy and unwilling to acknowledge mistakes. They also say the agency also often retreats from accountability behind confidentiality laws designed to protect the privacy of children and families.

But there also exist societal factors outside governmental control: the prolonged opioid crisis, generational poverty and the lingering effects of the pandemic. Can OCFS really save every child?

“My chief concern is that we’re headed in the right direction, and I think perhaps we’ve not been over the last few years,” said Christine Alberi, the state’s child welfare ombudsman, whose job is to hold the OCFS accountable by reviewing specific cases and offering suggestions on what might have gone wrong.

Two of Alberi’s board members were so frustrated that her warnings have not been heeded that the resigned last month in protest. One of them, James “Allie” McCormack, said one of his biggest frustrations is that the department “does everything it can to avoid revealing things they don’t want revealed.”

Kendall Chick

“I’m not very optimistic that anything is going to change. I made the mistake of thinking they would after Kendall Chick and Marissa Kennedy,” he said.

Over the past few years, in response to the deaths of Chick and Kennedy, the agency has added dozens of new caseworkers, increased their pay and improved training. But those caseworkers also have more work.

The number of substantiated cases of abuse increased by 39 percent, from 2,160 in 2017 to 2,994 in 2020. The number of children who were in state custody increased from 1,644 in January 2018 to a high of 2,374 in October 2020, or 44 percent. That has come down to 2,191 as of July.

Marissa Kennedy

Some of the increase can be tied to more awareness, some to the opioid crisis and some can be attributed to cuts to a wide array of social service programs during the previous administration of Gov. Paul LePage that have only recently been restored.

One lawmaker, Sen. Bill Diamond of Windham, tried unsuccessfully to pass legislation this spring that would have removed OCFS from the Department of Health and Human Services. He still thinks the best thing to do might be to tear the agency down and build it from scratch.

“Since Logan Marr, they have always said it’s a problem we can fix, but they have never admitted that that system is broken,” he said. “And until they admit that, and we all come together, we’re never going to get anywhere. They could hire 1,000 new caseworkers, but the system they work in is broken.”

Despite criticisms from lawmakers, the ombudsman and others, Landry has been consistent in his messaging.

“We recognize we don’t have all the answers,” he said. “One thing we have always said is that any systems, any business, any company, can only be successful if they can continue to improve.”

CASES INVESTIGATED

It’s difficult to compare state child protection systems because they all look different and there are so many factors. But the federal government collects data from each state as part of the National Child Abuse and Neglect Data System. The most recent comprehensive data is from 2019, but it shows where Maine is relative to other states and the national average for some metrics.

From 2015 to 2019, Maine saw a 29 percent increase in the number of children whose cases were investigated or who were provided alternative response. Only four other states saw bigger increases in that time – South Carolina, Oregon, Iowa and Alaska. The national increase was 3.5 percent.

In 2019, the rate of child abuse victims per 1,000 children was 17.7 in Maine, more than double the national rate of 8.9. Only three states were worse – West Virginia, Kentucky and Massachusetts. Higher rates don’t necessarily mean more abuse is occurring, only that state agencies are aware of more abuse, so there is an argument to be made that Maine is doing well in finding children who are being abused.

Ethan Henderson

For child fatalities, Maine recorded three in 2019 where the child had prior contact with child protection. That’s 1.2 per 100,000 children, or less than half the national rate of 2.5 per 100,000. Maine didn’t report child fatality data during most of the LePage administration, according to the national data system.

The dramatic rise in the number of children in state custody suggests the state is doing better in removing children from unsafe homes, although removing kids creates another set of challenges. Sometimes there is a family member who can take them, or a foster family. Other times, caseworkers have to wait, which often means staying in a hotel with a child for days.

Landry said the number of foster families has increased by 30 percent since 2018 and he’s grateful for all of them. But the number of children who have been removed from homes during that time has increased by even more than 30 percent.

Alberi’s most recent report, submitted to OCFS in January, said despite improvements, the agency still struggles in two major areas: deciding whether a child is safe during an initial investigation and deciding whether a child is safe once he or she is reunified with parents.

That report, submitted in January, seemed to foreshadow Williams’ death, as well as the deaths of 6-week-old Jaden Harding in Brewer and 3-year-old Hailey Goding in Old Town, both of whom died at the hands of parents, police believe.

Dean Crocker, now retired, spent his career working in child welfare, first for DHHS and later as the state’s first child welfare ombudsman. He also directed the Maine Children’s Alliance, a nonprofit focused on child welfare.

“The current difficulties seem to boil down to: Why do we continue to miss kids who are in trouble and why do we place kids with relatives who are unsafe?” he said. “That has eroded confidence and expectation in the system itself.”

Virginia Marriner is a current ombudsman board member, but she also spent 30 years in child protection for the state. She shares the frustration of her former colleagues who resigned and supports what they did.

“I think it has helped to bring light to the problems,” she said. “It seems like the last few years the ombudsman has produced a well done report that just sits on a shelf.”

“You have a big influx of new workers and there is a significant learning curve because these are challenging jobs. It’s important that caseworkers can focus on the safety of children and not focus on so many other different things.”

Marriner said people should resist the urge to blame OCFS, because they are only one piece. But she also said OCFS can be more receptive to certain reforms.

Lou Ann Clifford was an assistant attorney general in the child protection division from 1990 to 2011 and then served as a guardian ad litem after that. Guardians ad litem are tasked with representing a child’s interest in court proceedings.

She said she’s followed along as the agency has dealt with crises and said it seems not materially different from the strategy during her time. Top officials lurch between different policies and practices, often in response to tragedies.

“They are only accountable when the public eye is on them and that only happens when there is an unnecessary death,” she said. “I think there are lots of good people trying to do the right thing, but I think the department needs not to be so reactionary.”

PREVENTION SERVICES

Landry has resisted any urge to lay blame on the previous administration or make excuses, although others have pointed to steep cuts in social services under the LePage administration as a major contributing factor to existing problems.

In early 2018, just days before Marisa Kennedy’s death, LePage’s DHHS abruptly ended a $2.2 million statewide prevention program that advocates said was critical in assisting households where child abuse might be a risk.

LePage did agree to add additional funding for more caseworkers after the deaths of Kennedy and Chick, but that felt to many like a reactive move and it conflicted with many years of whittling down state government, especially in social services.

Under the current administration, Maine was the first New England state to submit a plan under the federal Family First Prevention Services Act on 2018. The plan will allow Maine to access $2.5 million every year for prevention services to help keep children safe.

Landry said that work is slated to begin in the fall.

He also said that because of the nature of child protective caseworkers, new hires often need as much as 18 months before they are “fully proficient” in the job.

“I appreciate the work of all our staff – these are very challenging jobs,” Landry said. “We know it’s going to take some time.”

Those calls for patience come at the same time he has said the recent deaths are a “call to action.”

The review by Casey Family Programs is set to be completed in 90 days, which means it will be done by late September or early October. The first part of the OPEGA investigation won’t be public until January 2022.

Alberi said Landry has certainly said all the right things whenever he’s been asked about the challenges. But she also said the state may be focused too much on quantitative assessment and less on quality.

“You can’t do this job by numerical assessments,” she said.

Some caseworkers agree. One who works at the Portland district office – who agreed to talk only if her name wasn’t published – said so much time is spent on paperwork, caseworkers aren’t left with enough time to visit families.

It is telling that OPEGA’s investigation will focus on exactly the same issues the ombudsman has been raising over the last two years.

McCormack, one of the board members who resigned, said he wishes the ombudsman had more authority to keep OCFS in line.

“As long as I was on the board, they’ve treated the ombudsman like a problem that needs to be dealt with,” he said. “It’s window dressing.”

Diamond, who pushed to separate OCFS from DHHS, said he sees too much “circling of wagons” after tragedies and said the department uses privacy laws to avoid talking about specific cases.

It isn’t until long after criminal cases are over that the public ever finds out what happened. By then, reforms have begun, but how can anyone know if they are the right reforms?

The case of Kendall Chick is a good example.

Chick was removed from her mother’s care at a young age and placed with her paternal grandfather and his fiancee. Caseworkers visited the home once and closed the case about 10 months before the girl died. The grandfather’s fiancee, Shawna Gatto, was charged and convicted of murder and is serving 50 years in prison.

“I’m convinced, one more visit would have saved her life,” Diamond said, adding that the same might be true of Maddox Williams.

Crocker, the former ombudsman, admitted he has a “jaundiced view,” but said the timing of the state’s decision to contract with Casey Family Programs felt to him like “they were trying to get out ahead of this.”

He supports Diamond’s tear-it-down approach.

“Every single task force has recommended reorganizing a separate agency,” he said.

Asked why he keeps beating the drum on this particular topic, Diamond said he can’t stop thinking about his days as a teacher and school administrator and the things he might have missed.

“I look back and I know I saw some of those signs of (abuse) and could have done something and didn’t,” he said. “If we don’t get traction this time, it’ll be very discouraging. You’d have to say the bureaucracy won.”