Suffering in Plain Sight

This piece continues the personal story I began in My Why, where I share the experiences that shaped my commitment to macro social work and empowering lived experience leaders.

The US child welfare system is deeply flawed. For many children, the greatest and most lasting harm does not come from the events that triggered involvement, but from the system itself. Caseworker turnover and the revolving door of service providers creates a cycle of instability. Each new professional asks children to recount their trauma, and each transition erases the understanding the previous worker painstakingly built.

I did not come by this truth through research or policy reports. It was hard won, advocating for my half-brothers as the system lost sight of their needs time and time again. Same children, same histories, same needs, yet every new caseworker treated them as blank slates. Each transition meant starting over, because the child welfare system could not remember.

When Systems Forget

In 2018, my youngest brothers entered Iowa’s child welfare system for the second time and were placed in my care. The removal itself followed familiar patterns; crisis, intervention, placement. What came after, however, was something more insidious: institutional amnesia.

The revolving door of service providers began almost immediately. Caseworkers changed. Service coordinators came and went. Each transition brought the same exhausting ritual. New faces asking old questions, requesting information already documented. Strangers forming impressions without context, making decisions that contradicted previous plans.

It felt like we were starting over from scratch every time their caseworker changed, because we were.

The system wasn’t just failing to build on existing knowledge. It was actively forgetting what it had already learned about my brothers’ specific needs and trauma histories. Each new professional entered with good intentions but without institutional memory. Armed with case files but missing the lived context that makes those files meaningful.

The Permanency Plan That Wasn’t

The worst manifestation of this amnesia came during the transition between the second and third caseworkers on my brothers’ case.

After more than two years of active child welfare involvement, we finally had a plan. The second caseworker had been critical of my stepmother’s ability to maintain a healthy and positive relationship with the boys. Given the infrequency of visitation and ongoing mental health struggles, he recommended termination of parental rights and my adoption of my brothers.

At the time, I agreed. He presented a compelling argument, and I trusted his professional opinion. After years of uncertainty, it looked like my brothers would finally have permanency. They could stop holding their breath in anticipation. We could all exhale.

Then the third caseworker took over.

During our first conversation, she asked what I wanted to see regarding permanency. Trusting the established plan, I repeated the previous worker’s recommendation of termination and adoption. She didn’t push back. She didn’t comment on it at all.

Instead, her initial report to the court stated that my “adversarial regard” for my stepmother was harmful the boys. She further recommended that the case should not close until this issue was resolved. She painted me as a harmful agent in my brothers’ lives for the sin of trusting her predecessor’s plan.

The light at the end of the tunnel was effectively snuffed out, as we started over from scratch yet again.

Right Outcome, Wrong Method

Despite that initial antagonistic treatment, I am actually grateful to the third caseworker. Her perspective helped myself and the court recognize the value of the relationship between my brothers and their mother. The case ultimately closed with my stepmother retaining parental rights while I became permanent guardian. My brothers gained stability with me while maintaining a safe and meaningful relationship with their mother. Looking back, it was the best possible outcome.

But being right doesn’t excuse the methods.

Had the third caseworker approached me openly, I would have seen the logic and validity of this permanency option. I would have supported it from the start. Her choice to leave me in the dark and paint me as an aggressor was unnecessary, frustrating, and further eroded my trust in the child welfare system.

This is the insidious nature of institutional amnesia: it doesn’t just lose information, it loses trust.

The Human Cost of Starting Over

For my brothers, this nearly three-year case felt like perpetual limbo. Each caseworker transition brought fresh waves of uncertainty about their future. It meant new strangers making decisions about their lives and repeated questions about painful histories.

The consequences lingered long after the child welfare case closed. My youngest brother lived in a state of emotional limbo for years. The system’s inconsistent messaging around permanency left him uncertain, even after closure. He continued to put his life on hold. He avoided forming friendships, joining activities, or putting down roots in his new community.

I remember when, nearly two years after the case ended, he finally began to come out of his shell. He made friends at school, planned sleepovers, and became excited about his life again. It was a joyful shift, but it underscored the cost of years spent waiting for an outcome that would never come.

If the system had provided consistency around permanency from the beginning, I believe he would have acclimated much sooner. The years of his childhood lost were not inevitable, they were preventable.

The One Who Remembered

There was one critical exception to this institutional amnesia: my brothers’ Court Appointed Special Advocate (CASA).

Assigned at the onset of my brothers’ case, the CASA volunteer became their constant through nearly three years of system chaos. While caseworkers rotated and service providers changed, she remained. She was the only agent of the system that my brothers truly trusted. The one adult who showed up, who remembered, and who actually saw them.

She was a godsend, providing the continuity that the formal system failed to maintain. She knew their story not from case notes but from relationship. When new caseworkers entered, she could provide context that files couldn’t capture. When permanency plans shifted, she was the bridge helping my brothers make sense of changes that adults struggled to explain.

I am forever grateful to my brothers’ CASA. Her involvement in their case inspired me to spend three years as a CASA volunteer myself. I later dedicated my graduate practicum to the CASA program, designing and piloting a comprehensive data system to better track child outcomes, needs, and the systemic barriers they face. This was my first direct effort to ensure the needs of other children and families did not remain invisible, as my brothers’ once had.

The Systemic Design Flaw

This is not a story about bad caseworkers, but that of a system designed to fail.

The professionals involved in my brothers’ case were dedicated, competent people doing their best within impossible constraints. Every one of them cared deeply about my brothers’ wellbeing.

The problem is that child welfare is designed as if children exist in a perpetual present. As if each assessment captures a stable truth rather than a moment in a long narrative.

Case files document decisions, but not the reasoning behind them. They record permanency plans, but not the dynamics, observations, and deliberation that shaped those plans. When workers leave, all of that vital context disappears. New workers inherit conclusions without understanding how they were reached.

This creates a perverse dynamic where each new worker, lacking context, feels compelled to form their own independent judgment rather than risk perpetuating a predecessor’s mistakes. The result is what my family experienced. Not thoughtful course corrections based on new information, but wholesale abandonment of existing plans because the reasoning behind them died when the worker left.

What Research Tells Us

An ethnographic study of day to day child protection work helps explain why caseworker turnover and inconsistent staffing are so damaging. The research found that effective child welfare practice depends on intimate engagement with children. It requires the ability to enter a child’s world through careful listening, observation, and relational depth. This level of practice requires sufficient preparation time, organizational support, and reflective supervision. Without these conditions, workers quickly become overwhelmed or cognitively overloaded. The emotional and relational grounding that meaningful assessment requires becomes impossible to maintain.

The study also found that many workers arrive at visits in a bureaucratically preoccupied state. They are still mentally tethered to administrative demands, computer screens, or the pressure to complete tasks quickly. This state of mind makes it difficult to engage deeply with children or to absorb the sensory and emotional complexity of family environments. When workers lack reflective containment, they struggle to process the anxiety, conflict, or emotional intensity they encounter. This leads to rushed interactions, superficial assessments, and a reliance on procedural checklists rather than thoughtful relational practice.

The research emphasizes that this is not a matter of individual competence. The same workers practiced skillfully in some cases and detached in others, depending on the emotional demands they faced and the organizational support they received. Caseworker turnover forces workers to start from deficit. They lack the contextual and relational foundations required to truly understand the children in their care.

Rebuilding Systems That Remember

If we want child welfare to function, we need more than better documentation or reduced caseloads. We need systems built on the assumption that caseworker turnover will occur, so children do not pay the price.

A number of promising approaches already exist:

• Team based models that distribute knowledge across multiple workers.
• Narrative focused documentation that preserves both decisions and the reasoning behind them.
• Supervision structures that provide the containment workers need to think clearly and maintain child centered focus.
• CASA programs that offer relational continuity that agencies struggle to provide.

These innovations are real, but they are also far from systemic.

From Amnesia to Accountability

My brothers are mostly grown now. The final permanency plan served them well, and they are thriving. However, the harm from the system’s inconsistency still matters. They lived with adults repeatedly disagreeing about their future. Professionals disappeared from their lives without explanation. Promises shifted without warning.

Those experiences shaped them as much as the trauma that led to removal.

This understanding is the foundation of The Macro Lens. Lived experience is essential to systemic reform. Relationships are not soft skills, they are infrastructure. Systems must be redesigned by those who have lived their consequences.

Institutional memory is not optional. When systems forget children’s stories, they lose the children themselves.

Child welfare will continue to fail until we build systems that remember with intention. Ones that protect continuity as fiercely as safety, and recognize that every lost piece of knowledge becomes a wound the next worker must rediscover.

My brothers deserved a system that built on what it learned, not one that forgot with every transition. So do the thousands of children experiencing discontinuity whenever a caseworker’s email auto reply announces they have moved on.

To build systems that remember children, we must elevate those who know what it is to be forgotten.

Originally published at https://themacrolens.com on November 19, 2025.