As the biological child of foster parents, Lisa Cauley saw the child welfare system from the inside at an early age. She got a sense of what worked well and what didn’t, which her later experience as Division Director for Child Welfare in Wake County validated.

“Coming from a less-resourced county in Eastern North Carolina, I was struck by the inequities that exist across the state in terms of access to services,” Cauley said.

As Senior Director for Child and Family Services, Cauley now leads all child welfare services across North Carolina. Since beginning her work at the Division of Social Services in 2017, Cauley has made it a priority to improve child welfare practice, develop a strong prevention services continuum, and increase coordination across all child and family ser­vices systems to support positive outcomes for every child.

The lack of child welfare practice consistency and access to resources has historically presented a challenge to child welfare agencies that are part of the larger ecosystem of fam­ily support. The systemic need for improvement has been a focus for state child welfare since the passing of Rylan’s Law (Social Services and Child Welfare Accountability Act) in 2017. Rylan’s Law was named for a young boy who drowned in April 2016 after he was returned to the custody of a parent with pending child abuse charges.1 This legislation pro­vided Cauley the opportunity under former North Carolina Secretary of Health and Human Services Dr. Mandy Cohen to help reform the state’s child welfare system. This oppor­tunity continues under the leadership of Secretary Kody H. Kinsley.

“I moved into this position because I believed that we needed a better child welfare system,” Cauley said. “One of the greatest opportunities right now in North Carolina is the potential to improve the overall health of children and fami­lies in our state through our Medicaid program.”

As an example, Cauley points to the proposed Medicaid Children and Families Specialty Plan, which would provide targeted supports for children receiving child welfare ser­vices who are still with their parents and for children in foster care. The plan also makes it easier to access evidence-based services that address trauma and build resiliency in children while also focusing on prevention, early identification of needs, and engaging the whole family in care management.

Cauley spoke with this issue’s co-guest-editor Dr. Kenya McNeal-Trice, professor of pediatrics at the UNC School of Medicine and North Carolina Pediatric Society President, about how the state’s child welfare system is becoming more trauma-informed and what is next on the horizon for improving the health and well-being of all children in North Carolina.

Dr. Kenya McNeal-Trice: What is the trauma-informed child welfare practice model, and why is it important in North Carolina?

Lisa Cauley: North Carolina did not have a practice model prior to the passage of Rylan’s Law in 2017. That legislation was passed in response to the tragic death of a child in 2016 and sought to address multiple issues in the child welfare system. Prior to 2017, the state had not done well on federal child wel­fare performance measures. Under Rylan’s Law, there was a third-party assessment of our child welfare system that brought to attention some of the inconsistencies in child welfare practice across the state and underscored the need for a defined prac­tice model. Having a practice model gives child welfare services workers the tools and skills necessary to work most effectively with families. The child welfare practice model developed by North Carolina has defined core values that support workers and are safety-focused, trauma-informed, family-centered, and culturally competent. The practice model lays out the expected behaviors of workers who interface with children and families through a trauma-informed lens. North Carolina is implement­ing evidence-based services that not only focus on identifying trauma but also on how we can build resiliency in families and children.

McNeal-Trice: What do you see as the biggest policy challenges facing child welfare in our state now?

Cauley: A major challenge is resources. Child welfare is pri­marily supported by federal funding passed through to coun­ties, so you have to have people on the ground who are able to carry out any policy. Right now, there is a workforce chal­lenge. We are looking at having some salary floors, because if you know you’re going to get a master’s level social worker in one county but someone who has a human services degree and no experience in another, it’s hard to really have affordable ser­vices for everyone.

Another thing is that most states have a single child wel­fare information system where you can see what’s happening with different services in different counties. Families move from county to county, but North Carolina only has 25 counties in that statewide system. The other 75 counties are not in that system and are still collecting data in a legacy system that is close to 30 years old. It’s difficult to gather enough information to know what new policies to put out. We are working to engage in each county or region and make sure there’s utilization of the programs there.

One of the really good things that happens at the North Carolina Department of Health and Human Services is inter-divisional collaboration. With that, it’s possible to collect infor­mation about who is using Food and Nutrition Services, who is using WIC, and how to better get those services to families throughout the state. We know that being able to meet eco­nomic needs is one of the ways that children are protected from maltreatment. When your needs are met, and your children’s needs are met, there’s a better outcome.

McNeal-Trice: What do you see as the biggest policy challenges facing child welfare in our state now?

Cauley: A major challenge is lack of resources. North Carolina ranks last in per-child funding among other states with decentralized child welfare systems.2 We are also fac­ing a severe workforce challenge. Because salaries of workers vary from county to county, less financially resourced counties find it difficult to recruit and retain qualified staff. But since the pandemic, all counties have really struggled to keep positions filled.

Without a statewide system, we face challenges in under­standing what is working well and what issues or concerns need to be addressed. Fortunately, we are in the process of rolling out a statewide information system that will provide this informa­tion as well as support our workforce by giving them more tools to support the important work they do on behalf of children and families.

One of the other challenges is making sure that families’ eco­nomic needs are met so that they can have better outcomes. We know that when families can meet their economic needs, chil­dren are less likely to be maltreated.3 With that in mind, we have worked hard at the North Carolina Department of Health and Human Services to foster collaboration between divisions that administer programs that support children and families.

McNeal-Trice: What is being done specifically to address disparities among children across race and ethnicity?

Cauley: One of our key efforts has been a new training for child welfare workers that includes a focus on racial equity and disparities. It uses an historical lens and looks at disparities across the system, including who comes into foster care and who leaves foster care to a permanent home. Then the next step is to look at what strategies we can implement to make a real difference in addressing disparities. Many jurisdictions see positive changes with initiatives focused on supporting fathers, for example, because too often child welfare just looks at the mother. Also, how can we create a diverse pool of foster par­ents who are open to adoption for all children, and how do you prepare them for that? It’s both an acknowledgment and under­standing of the disparities as well as a call to action.

McNeal-Trice: What can be done to change the percep­tion of child welfare as a negative, punitive measure into one that identifies needs and provides services?

Cauley: Our practice model really shapes how child welfare workers interface with families in a more positive and proac­tive manner. There is a focus on understanding what the fam­ily is experiencing and engaging in problem-solving through a trauma-focused lens, and addressing the need for parent­ing skills. We are really figuring out what matters to parents. Typically, it’s that they want their child to do well in school, and they want to have the resources needed to take care of their family.

I often go back to one time I did a home visit and realized the parent didn’t know how to get their child’s homework com­pleted. We worked out how some of it could be done every night. She was a new parent. Nobody teaches us how to be parents. I think it’s about attending to people’s needs and thinking about what would make them strong, and a trauma-informed practice model helps do that.

Providing supports to parents before they reach the child welfare system is also critical. Professionals like school social workers and nurses provide services to families and prevent some of the need for families to be reported to child welfare services. Adding more of these positions across our state is one way of preventing families from becoming involved with the child welfare system.

Even with strong prevention services, child welfare is an essential service and when someone suspects maltreatment, they should certainly make a Child Protective Services report.

McNeal-Trice: What are you most hopeful about when it comes to strengthening the child welfare system in North Carolina?

Cauley: There is a recognition that the best placement for children is with their parents when they can safely provide care. The focus is on prevention of maltreatment, and for children who experienced maltreatment, prevention of foster care. Right now, if you are in a well-resourced county, you have county programs that do that. But if you are in a less well-resourced county, you can see the difference. What makes me hopeful is the potential, through the federal Family First Prevention Services Act of 2018,4 to build a services system with real consistency and equity across the state. We know that when parents have resources, they’re able to change children’s lives and prevent maltreatment. Maybe you start with child welfare, but you find a family resource center. If there’s a place you can go when you need something, child welfare doesn’t get a call; instead, you call the school social worker or the counselor you feel comfortable with.

The other thing that brings me hope is having a funded kinship care program. Senate Bill 20 [the Care for Women, Children, and Families Act] included funding for kinship care so that if children can’t live with their parents they can do the next best thing, which is live with other family members, and these families will have additional financial support to provide for their care.5 The new legislation allows us to offer half the foster care board rate to kinship-care families, and it means that when it is safe and appropriate a child can live with their family and not in a foster home or group home.