Getting “Left of Bang” in Foster Care

Dr. Jamie Schwandt
31 min readFeb 23, 2020

by the “Very Revered” Dr. Jamie Schwandt

Quote from the Big Bang Theory TV Series

The foster care system is full of easy prey for predators to target. Those who are tasked with protecting children in foster care are looking the other way. We must open our eyes and look at the actual problem, or as Sherlock Holmes put it in “The Memoirs of Sherlock Holmes — Silver Blaze” by Arthur Conan Doyle:

“I only saw it because I was looking for it.”

To open our eyes, I propose we use a program developed by the United States Marine Corps (USMC) called the Combat Hunter program. The method used in the program is called Combat Profiling, and the USMC defines it as a method of proactively identifying enemy personnel or threats through human behavior pattern analysis and recognition.

Patrick Van Horne and Jason A. Riley discuss the program in their book Left of Bang: How the Marine Corps’ Combat Hunter Program Can Save Your Life. Van Horne and Riley write about the program:

Combat profiling is a practice-based proactive mindset that incorporates many specific skills. Four of these are situational awareness, sensitivity of baselines and anomalies, critical thinking, and decision-making.

Figure 1. What is left of bang? — Image via

When visualizing what left of bang means, Van Horne and Riley instruct us to think about an attack on a timeline, where the “bang” is the middle — bang is the explosion, the ambush, the thing we want to prevent. Van Horne and Riley inform us:

Left of bang means before the bad stuff happens. That’s where you want to be alert, ready, prepared to respond to protect yourself and your loved ones.

Right of bang means after the bomb has gone off, after the shots have been fired, after the damage has been done.

Now think of the foster care system. If we use Van Horne and Riley’s visualization, we can think of a child being abused or removed from his or her home in the same way as we think of an attack or ambush. The abuse and removal are essentially the “bang” or the thing we want to prevent.

Currently, the foster care system operates nearly 100% right of bang. The purpose of this discussion is to provide a method to help us operate left of bang, but before I discuss the method and how to apply it in foster care, let’s first examine the foster care system.

What is Foster Care?

“I never said that you’re not good at what you do. It’s just that what you do is not worth doing.” — Sheldon Cooper, Big Bang Theory TV Series

I will narrow my discussion of the foster care system primarily to the State of Kansas — which will serve as our logical starting point.

When a child is removed from their home, the State, through family court and child protective services, stands in loco parentis to a child. Since the child is a minor, the State makes all legal decisions while the foster parent is responsible for the daily care of the child. A governmental agency, such as Child Protective Services (CPS) or the Department of Children and Families (DCF) in Kansas, is responsible for providing and protecting the child.

The word foster means parental care though not related by blood or legal ties, while the word care, in this specific context, is similar to the words charge or supervision. In fact, in Old English, the word fostrian meant to supply with food, nourish, and support. Thus, foster care means to bring up a child with parental care outside blood or legal ties.

Kansas defines foster care in PPS Policy and Procedure Manual Printed Documentation for January 1, 2020, as:

24-hour substitute care for children placed away from their parents or guardians and for whom the State agency has placement and care responsibility.

Another standard definition states foster care is a system in which a minor has been placed into a ward, group home, or private home of a state-certified caregiver, referred to as a “foster parent” or with a family member approved by the state.

Since the State stands in loco parentis (or in the place of a parent), making all legal decisions for the child, the State is the legal guardian of the child. A legal guardian is a person holding the legal authority to care for another person called a ward. Whereas a ward is someone placed under the protection of a legal guardian.

Furthermore, PPS Policy and Procedure Manual Printed Documentation for January 1, 2020, defines the meaning of two more important concepts:

1. Guardianship. A status in which the court gives a person specified rights to the custody control of a child subject to ongoing review by the court of jurisdiction.

2. Custody/Custodian. Custody, whether temporary, protective or legal, means the status created by court order or statute which vests in a custodian, whether an individual or an agency, the right to physical possession of the child and the right to determine the placement of the child, subject to restrictions placed by the court. (K.S.A. 38–2202(g)).

Thus, the State is legally responsible for the safety, protection, and well-being of all children placed under their care. If a child suffers abuse or neglect while in foster care, who do we hold legally responsible for it? Is it the governmental agency, such as DCF, or the foster parent? Based on the discussion above, the governmental agency is the entity holding legal responsibility.

Penalties for abuse of a child are clearly defined in Kansas. In fact, Article 56 — Crimes Affecting Family Relationships and Children, Section 21–5602. Abuse of a child is defined as:

Abuse of a child is knowingly: torturing or cruelly beating any child under the age of 18 years; shaking any child under the age of 18 years which results in great bodily harm to the child; or inflicting cruel and inhuman corporal punishment upon any child under the age of 18 years.

In addition, abuse of a child is a severity level 5 felony, and a person who violates the provisions of this section may also be prosecuted for, convicted of, and punished for any form of battery or homicide.

The Kansas Office of Revisor of Statutes: 38–2202 Definitions defines placement into foster care as the designation by the individual or agency having custody of where and with whom the child will live. 38–2202 also defines neglect as follows:

Neglect. Acts or omissions by a parent, guardian or person responsible for the care of a child resulting in harm to a child, or presenting a likelihood of harm, and the acts or omissions are not due solely to the lack of financial means of the child’s parents or other custodian. Neglect may include, but shall not be limited to:

(1) Failure to provide the child with food, clothing or shelter necessary to sustain the life or health of the child;

(2) Failure to provide adequate supervision of a child or to remove a child from a situation that requires judgment or actions beyond the child’s level of maturity, physical condition or mental abilities and that results in bodily injury or a likelihood of harm to the child; or

(3) Failure to use resources available to treat a diagnosed medical condition if such treatment will make a child substantially more comfortable, reduce pain and suffering, or correct or substantially diminish a crippling condition from worsening. A parent legitimately practicing religious beliefs who does not provide specified medical treatment for a child because of religious beliefs shall, not for that reason, be considered a negligent parent; however, this exception shall not preclude a court from entering an order pursuant to K.S.A. 2019 Supp. 38–2217(a)(2), and amendments thereto.

My point here is as follows: How is the State of Kansas or DCF not held legally responsible or liable when a child, in their care, is abused, neglected, raped, or even killed based on the definition of neglect provided above? If they were held liable or accountable for some of these issues, would this force them to start acting proactively to get left of bang?

For example, examine The Horrific Story of: The Boy Who Was Fed to Pigs. If neglect includes failure to provide adequate supervision of a child or to remove a child from a situation that requires judgment or actions beyond the child’s level of maturity, physical condition or mental abilities and that results in bodily injury or a likelihood of harm to the child, then why do we not hold DCF, the State of Kansas, or even the State of Missouri responsible or accountable for neglect in the case of Adrian Jones?

Figure 2. Left of Bang Timeline for Adrian Jones — Image created by Dr. Schwandt via Plectica

Furthermore, as you can see in Figure 2, there were numerous pre-event indicators in this story. Young Adrian Jones was examined for abuse, a caseworker in Missouri made Kansas DCF aware of physical abuse, Adrian’s grandmother made authorities aware of abuse, the stepmother abusing Adrian made comments over Facebook, their landlord was aware, another person was living in the residence where abuse was taking place, and Adrian’s father even tried to give Adrian to authorities. Yet, no one intervened, and the child was killed. There were so many opportunities to get left of bang, yet the system failed, and now we have this horrific story.

Kansas Foster Care

“Hold on. It takes me a minute to process stupid.” — Sheldon Cooper, Big Bang Theory TV Series

Let’s now turn our attention to the failing system known as the Kansas foster care system. The Kansas Legislative Research Department provided a brief history of privatization in Kansas:

In 1996 and 1997, the Department of Social and Rehabilitation Services (SRS), now known as the Department for Children and Families (DCF), privatized family preservation, adoption, and foster care services. This decision was based in part on longstanding concerns about the quality of services for children in SRS custody, including a class-action lawsuit filed in 1989, and subsequently joined by the Children’s Rights Project of the American Civil Liberties Union, alleging SRS failed to adequately care for children who may have been victims of abuse or neglect.

The solution was to privatize foster care in Kansas. However, merely privatizing a system does not deflect legal responsibility. PPS Policy and Procedure Manual Printed Documentation for January 1, 2020, states:

Legally, all DCF agencies are considered one entity. Everyone who works for the Department is considered a part of the whole. When the Secretary has entered into a contract or memorandum of agreement or understanding the terms are binding on the entire agency. All DCF staff and all contract staff are expected to work together in a coordinated fashion to carry out the agency mission. This requires communication among the various divisions, regions, contract agencies and individuals. Disputes within DCF or with DCF contractors are settled via our chain of command and grievance procedure. Use of the courts to settle internal disputes diminishes, and perhaps destroys our ability to carry out our responsibility as an equal branch of government.

Thus, the failure of one is the failure of the entire agency, starting with the Secretary of DCF. Moreover, to remove a child from his or her home is categorized in Kansas as either FINA or Abuse/Neglect removal.

1. Family in Need of Assessment (FINA). Family In Need of Assessment (FINA) assignments are specific family conditions, which do not meet criteria to assign for abuse/neglect but are assigned to assess to determine whether services to the child and family are indicated. Or

2. Abuse/Neglect. Reports assigned for Abuse/Neglect require an investigation to determine the validity of the report and an assessment to determine if further action may be needed.

Figure 3. Statewide Primary Removal Reason Types Across Years SFY2009-SFY2019

According to a Kansas DCF report on Statewide Primary Removal Reason Types Across Years SFY2009-SFY2019, the % of FINA Removals went from 55% in 2009 to only 26% in 2019 (see Figure 3).

So, why was there a drastic shift in how Kansas categorized the removal of children? More specifically, what happened from 2013 to 2014 to start the trend toward a 74% removal of children due to Abuse/Neglect in 2019? Especially since a FINA removal is more in line with “Left of Bang.”

Kansas Office of Revisor of Statutes, Section 38–2242 states that the court may issue ex parte an order directing that a child be held in protective custody and if the child has not been taken into custody, an order directing that the child be taken into custody. The application shall state for each child (for a FINA removal):

(1) The applicant’s belief that the child is a child in need of care;

(2) that the child is likely to sustain harm if not immediately removed from the home;

(3) that allowing the child to remain in the home is contrary to the welfare of the child; and

(4) the facts relied upon to support the application, including efforts known to the applicant to maintain the family unit and prevent the unnecessary removal of the child from the child’s home, or the specific facts supporting that an emergency exists which threatens the safety of the child.

Thus, the purpose of a FINA removal is to prevent a child from being abused or neglected. So, why such a sudden shift? Is it easier to remove a child if you label or categorize it as Abuse/Neglect?

In Foster Care, a Child = Product

“If at first you don’t succeed, you may be at your level of incompetence.” — Laurence Peter, from The Peter Principle: Why Things Always Go Wrong

If you were in the business of selling automobiles and you found you could cut costs by using cheaper products, even if those cheaper products increased the risk of fatal injuries, would you make the switch?

Let’s imagine the switch to cheaper products allows you to produce a vehicle for less, yet you could ask for more from the customer. The switch meant you sold 45% more vehicles and you could demand an increase in the value of 36% for each vehicle sold.

Now, what if I told you that using the cheaper product would increase revenue by 31%, bringing in nearly $45 million more every year, would you do it? What if I told you this would increase the value of every vehicle sold from $19k to $26k, would you do it then?

Finally, what if I told you that you would not be punished but paid even more if a customer died while driving one of your vehicles, and it was found the cheaper product caused the death of the customer? Would you do it then?

Privatizing Children

“I’m not insulting you. I’m describing you.”

In 2017, I wrote two articles related to this discussion:

1. Privatized Foster Care: Profit Over Humanity

2. Profiting From Foster Care

In both pieces, I analyzed the increase in the number of foster children entering care and the amount of money Kansas was paying contractors from FY10 to FY17. I also examined the verbiage in the contract.

Note: There is a chance for real change in Kansas, as Governor Laura Kelley has halted new contracts for the two contractors running foster care in Kansas: KVC Kansas and Saint Francis Community Services. However, the contract at the end of Calendar Year 2019 looked just like the contract when I read it in 2017. The only exceptions were:

1. We have more foster children in care; and

2. We have paid a lot more money for the horrible care of our youth.

The fact that nothing has changed amuses me and reminds me of a quote by Moliere,

“The duty of comedy is to correct men by amusing them.”

Let’s now examine the contract with Saint Francis Community Services and the “Very Revered” leader of the organization. By the way, the word revered means to regard with respect tinged with awe — synonyms include adore, apotheosize, deify, glorify, and worship.

Contract # 37680 — Contract Title: Reintegration, Foster Care and Adoption Services — Agency Department for Children and Families — Awarded to St. Francis Community and Family — Signed by the President / CEO of Saint Francis Community Services “The Very Revered Robert N. Smith”

Note: The following analysis only includes one contractor: Saint Francis

Billing and Contract Details (prior to Amendment 1): The monthly prospective base rate shall be $822,120.00 per month. The monthly prospective case rate shall be $1,541.00 per out of home placement per month.

Let’s examine some key points and definitions before we move on.

1. Permanency. The child is being released from DCF custody after achieving reintegration, guardianship, finalization of adoption.

2. KVC Kansas defines foster care as: Foster care in Kansas provides a temporary arrangement for a child when they are not able to live with their biological parents or other natural caregivers.

3. KVC Kansas states the primary goal of foster care is: When youth cannot remain safely in their homes and must enter foster care, the first goal of foster care is to safely reunite them with their families as soon as possible.

Now let’s examine a critical problem in foster care increasing the number of children in care and the amount of money we pay the foster care contractor(s).


“A learned fool is more a fool than an ignorant fool.” — Moliere

Figure 4. Problem and Root-Cause — Image created by Dr. Schwandt via Plectica

Payments will cease (no payment will be made) for the service month in which one of the following events occurs:

a. The child is reintegrated with their family, i.e., returns to their home.

b. The child achieves Finalization of adoptive placement.

c. The child is placed in permanent custodianship.

d. The child is transferred to Department of Corrections. (This action nullifies the 12-month aftercare requirement).

e. The child is transferred to Tribal custody (This action nullifies the 12-month aftercare requirement).

f. The child is released from DCF custody for other reasons not specified above.

If the stated goal is to safely reunite children with their families as soon as possible and foster care is viewed as a temporary arrangement for a child, then why are they not incentivized when permanency is achieved? As you can clearly see, a contractor is not paid when a child is reintegrated, adopted, placed in permanent custodianship; hence, a contractor is not paid when permanency is achieved.

This leaves two potential unintended consequences:

1. The contractor will need to maintain a consistent rate of foster children to get paid;

2. The contractor will need to bring children in faster than they lose them to permanency. Here’s the funny part — this is the thing they are good at!

The contract went through thirteen amendments:

Amendment 1: Provide a Rapid Response Team to conduct an assessment for appropriate and timely placement when any law enforcement officer takes into custody any child the officer reasonably believes is a victim of human trafficking, aggravated human trafficking or commercial sexual exploitation of a child. Placement, wherever referenced in this amendment, refers to such child victims whether they are in police protective custody or in the custody of the Secretary of DCF.

Amendment 2: Billing and Payment Increase. Monthly base rate change ($823,850.00); Monthly case rate change ($1,603.00).

Amendment 3: No significant changes.

Amendment 4: Was skipped (exact verbiage).

Amendment 5: Extends Section 1. Term of the contract.

Amendment 6: Policy and staffing revisions.

Amendment 7: Billing and Payment Increase. Monthly base rate changed ($725,000.00); Monthly case rate change ($1,666.00).

Amendment 8: Allows contractors to hire/employ unlicensed staff members.

Amendment 9: Billing and Payment Increase. Monthly case rate change ($1,837.00) and provides placements with relatives or kin, in the amount of $10.00 per day per placement. In addition, Saint Francis reported to DCF that the rates they were being paid were insufficient.

Amendment 10: One-time Payment of $816,600 to Saint Francis.

Amendment 11: Billing and Payment Increase. Monthly case rate change ($2,087.00).

Amendment 12: Term extension and Billing and Payment Increase. Monthly base rate change ($750,375.00); Monthly case rate change ($2,102.00).

Amendment 13: Contractor will have in place a dedicated special response position to search for missing children (missing children they were already being paid for). DCF will reimburse this position no more than $56,982 for salary and benefits and no more than $14,508 for other operating expenses to perform the work, for a total not to exceed $71,490. The actual costs of such expenses shall be submitted with the regional monthly reports sent in for Amendment 1 of this contract regarding Human Trafficking Rapid Response Team. Upon receipt of complete reports, reimbursement will be made directly to the Contractor through the same mechanism as Amendment 1.

Making Millions in Foster Care

“It infuriates me to be wrong when I know I’m right.” — Moliere

As billing and payment increased, along with DCF operating expenses, so too did the average number of foster children in care (see Table 1).

Table 1. Average Number of Children in Care — Operating Expense — by FY — Image created by Dr. Schwandt

The payment for every out of home placement per month increased from $1,541.00 to Amendment 1 ($1,603.00) to $2,102.00. Even without the increase, if we were to use the FY20 average number of foster children in care, which is 7,513 children, then we would pay the contractor $12,043,339.00 per month. However, we would pay $3,748,987.00 per month more with an increase to $2,102.00, which would pay the contractor a significant increase over the year: $189,507,912.00 annually (compared to $144,520,068.00 annually at $1,603.00). This is an increase of $44,987,844.00.

Saint Francis might argue they reduced the monthly base rate from $823,850.00 per month to $750,375.00 per month. However, this decrease of $73,475.00 per month is nothing compared to an increase of $3,748,987.00 per month with the increase of the case rate for per out of home placement.

Even if we had fewer foster children in care, such as the average number of foster children in FY12 (5,182 children), we would still be paying the contractor a significant amount. For example, if we paid $2,102.00 for the number of children in care (5,182 children), then we would pay $10,892.564.00 per month and $130,710,768.00 per year.


1. 45% increase in the number of children in foster care from FY12 to FY20.

2. 36% increase in the dollar value of each foster child in custody throughout the contract.

3. 31% increase in operating expenses throughout the contract.

4. Increase of $45 million annually throughout the contract.

Bottom line: there is a positive correlation indicating that when we pay more for foster care contractual services, the average number of children in care also tends to increase. As you can see in Figure 5, there is a positive correlation indicating that when the foster care contract increases, so does the average number of children in care.

Figure 5. Regression for Average Number of Children in Care vs. Foster Care Contract — Image via Minitab

One Foster Child = $26k

If we pay Saint Francis $2,102.00 per out of home placement per month for 12 months, then each child is worth $25,224.00. If we add the base monthly rate of $750,375.00 and divide that by the average number of children in foster care in FY20 (7,513 children), then we can add an additional $99.88 per child. If we then take $2,102 + $99.88 = $2,201.88 x 12 months = $26,422.56. Thus, every foster child is worth $26,422.56 for Saint Francis while they are in care. They are worth $0 to them once they leave care.

Compare this to paying the contractor $1,541.00 (monthly case rate at the initiation of the contract) plus $99.88 multiplied by 12 months, and you get $19,690.56 per child in care. This is a 34% increase in the dollar value for each child in care.

It should be no surprise after reading the verbiage in the contract that the FY average of foster children in Kansas is steadily rising every year along with DCF operating expenditures. Figure 6 is a perfect illustration of this trend. The more we spend to fix foster care, the more we incentivize each contractor to bring in more foster children — and it will get worse until we do one of two things:

1. End privatization in foster care; or

2. Change the verbiage and incentives in the contract (this one is common sense).

Figure 6. Average Number of Foster Children Compared to the Foster Care Contract — Image created by Dr. Schwandt

Left of Bang

Figure 7. Left of Bang — Image via Left of Bang: How the Marine Corps’ Combat Hunter Program Can Save Your Life

In Left of Bang: How the Marine Corps’ Combat Hunter Program Can Save Your Life, Van Horne and Riley ask the following questions, which apply to problems in foster care:

Question 1: How can you discern those who want to harm you from those who are just afraid or just going about their business before the attack?

We could just as easily ask: How can a social worker discern which parents are placing their children at risk of abuse or neglect with those who simply need some form of assistance?

Question 2: How can you defuse a threat before it happens?

We could ask: How can a foster parent defuse a threat to a child who visits their biological parents before something terrible happens?

Question 3: Is that even possible?

We could ask: Is it even possible to get left of bang; is it even possible to prevent a child from being abused or neglected; thus, preventing the need to place the child in foster care?

Van Horne and Riley write that operating left of bang requires intense concentration to identify pre-event indicators. These pre-event indicators are the way to answer “Yes” to question number three above. Van Horne and Riley write about identifying pre-event indicators:

Attacks do not happen “out of the blue.” Even what may be considered spontaneous violence is almost always the result of a gradual progression of aggression and precursors to violence.

Three Pillars of Combat Hunter

Van Horne and Riley discuss the three pillars of Combat Hunter.

Pillar #1: Enhanced Observation. Ivan Carter is the individual who developed this pillar of the program. By recognizing how a hunter views his or her prey, we can identify how to be proactive in identifying threats based on human behavior and other cues from our surroundings.

Pillar #2: Combat Tracking. David Scott Donelan designed this pillar of the program. Van Horne and Riley write that this teaches us how to read and understand the physical environment and provides skills in gathering information to determine future actions and intent.

Pillar #3: Combat Profiling. This is not racial profiling and is different than criminal profiling. Greg Williams developed this pillar to allow us to recognize the subtle aspects of human behavior in uncovering the enemy.

Baseline + Anomaly = Decision

Figure 8. Anomalies and Baseline — Image via Left of Bang: How the Marine Corps’ Combat Hunter Program Can Save Your Life

The USMC provides students a student handout for its Combat Hunter program. In the handout titled Profiling and Tactical Tracking Student Handout, we are provided with an equation: Baseline + Anomaly = Decision. In the handout, we are provided with the following:

Combat profiles are indicators based on the enemy’s techniques, tactics, and procedures (TTPs); and their observable and measurable behavior patterns. When Marines identify the enemies’ TTPs and behavior patterns, they can assist you to identify the enemy among the civilians. Profiles are deviations (anomalies) from a normal or typical behavior (the baseline) which would lead you to believe that an observed situation (persons, events, vehicles and objects) may have the potential for harming you or other people. These deviations are anomalies that stand out from the surrounding area’s baseline.

In the handout, we are informed everything has a baseline (places, events, cultures, human terrain, etc.), and a baseline is the reference point to compare and evaluate things against.

The USMC uses the Boyd Cycle (otherwise known as the Observe-Orient-Decide-Act (OODA) Loop) and teaches that we must continuously update our baseline to incorporate changes in the environment and to identify anomalies. This is the Observe and Orient phase of the OODA Loop.

Furthermore, we are provided the following definition of an anomaly in the handout:

An anomaly is a deviation from the baseline, anything that rises above; something that is there that should not be there. Or it could be something that falls below the baseline; it is something that is absent that should be there. Examples of an anomaly could be a vehicle out of place (rises above), the lack of people (falls below), or a sudden change in the mood of an area (both). The presence of such anomalies indicates a potentially important change; every anomaly must be analyzed. This represents the orient phase of Boyd’s Decision Cycle.

An example of an anomaly in foster care could be a child fails to attend school for weeks (falls below the baseline) or a child shows up with visible bruises (rises above the baseline). Here the baseline is that the child is typically present in school and has not been previously seen having bruises. The anomaly is the fact that the child is absent from school or that the child has visible injuries.

Six Domains

“Before a person takes any action or makes any gesture, the decision is first made in his brain, either consciously or subconsciously. When that decision is made, people will begin to prepare their bodies for that act and will begin to telegraph their intentions and let others know what they are about to do. Time spent developing the ability to read and understand body language, both quickly and accurately, will provide much insight into other people’s intentions and emotions.” — Van Horne and Riley, Left of Bang

Van Horne and Riley write that the Combat Hunter program uses six domains: Kinesics, Biometrics, Proxemics, Geographics, Iconography, and Atmospherics. They inform us that:

To make quick decisions, combat profilers need to know what to look for. Current battlefields bombard operators with massive amounts of information. Without the ability to filter out the nonsense and noncritical information, Marines and soldiers cannot effectively identify threats. Combat profiling focuses on the important details of human behavior, which can be viewed from six basic viewpoints. We label these dimensions the six domains.

Let’s quickly examine how Van Horne and Riley define and discuss each domain.

Table 2. Six Domains — Application in Foster Care

The Method

Van Horne and Riley provide a three-step approach to establish baselines and apply the combat profiling method. They state that:

By consistently and explicitly going through this process, you will quicken your ability to understand your surroundings, speed up your ability to identify anomalies, and ultimately increase your decision-making abilities. The more you use this process, the quicker you’ll begin to tacitly evaluate your environment and the less mental energy you’ll require to establish baselines and identify anomalies.

Step 1: Ask, “What is going on here?”

Table 3. Key Questions and Rational for Step 1

Van Horne and Riley inform us that the first step is “designed to quickly determine if there is anyone blatantly deviating from the baseline.” Table 3 provides key questions to ask, based on the advice supplied by Van Horne and Riley.

Step 2: Ask: “What would cause someone to stand out and why?

Table 4. Key Questions and Rational for Step 2

Van Horne and Riley write:

The second step moves the combat profiler toward more focused and specific observations, with the distinct goal of being prepared to identify anomalies. While the first step provides the combat profiler with a picture of the “norm,” during step two, the combat profiler focuses his or her observations on those things that would go above and below the norm — the things that don’t fit the situation.

Step 3: Ask, “What would I do about it?”

Van Horne and Riley inform us that we are required to act if we observe three indicators or three behaviors that warrant a response. They write:

Remember, when you observe three indicators, you must act! Decide which type of behaviors would warrant different responses. Action may simply be contacting the person to ask some questions and observing them up close. But do not wait until further indicators are exhibited because it may be too late.

Application in Foster Care

“It is not only for what we do that we are held responsible, but also for what we do not do.” — Moliere

I have personally used this method in foster care. For example, after being contacted by foster parents seeking my help, I asked myself a simple question: “What is going on here?

You can see a portion of this in the following articles:

1. The Clock is Ticking: Save an Infant Girl Living with Intellectual Disabled, Sex Offender Father

2. Broken System: Kansas Determines a Child Rapist is in the Best Interest of a Child

Although this was not a deliberate action, I went through the following questions, similar to Step #1 (see Table 5).

Table 5. Key Questions and Rational Example in Foster Care Step #1

The following is a summary of the situation provided by the foster parents requesting my assistance (discussed in the two articles above):

Mandy (foster parent) first contacted me regarding her concerns for a foster child. In The Clock is Ticking: Save an Infant Girl Living with Intellectual Disabled, Sex Offender Father, I wrote about Mandy’s concerns. Essentially, one of her foster children was being placed back with her biological parents, where the father was a convicted sex offender. Mandy was also concerned that the child was being molested by her father during home visits.

Mandy informed me: “In January, after an unsupervised visit in her parents’ home, the child was returned to me and the child’s mother told me that she had included a new tube of diaper cream in the child’s bag. When I changed that child’s diaper, there was not any diaper cream on her skin. Moments later, the child had a bowel movement, so I began to change her diaper again. This time, I noticed diaper cream mixed in with her stool.”

“When I examined the child further, I saw diaper cream in her vagina and the area appeared very red. I called the child’s worker and she requested that I have the child examined by a professional. I took the child to Stormont-Vail Hospital and requested an examination from a Sexual Assault Nurse Examiner. I was required to first speak to a police officer and then the child was able to be examined by the nurse. After the examination, the nurse spoke to me in the presence of the police officer.”

Here is what the nurse told her. “She told me that she was unable to find any physical evidence of abuse, but she believed that the parents were exhibiting “grooming” behaviors towards the child. Because of the lack of evidence, no DCF report was filed.”

Mandy informed me that she brought these concerns to KVC and nothing had been done. She brought up the concern of molestation and the father’s history as a sex offender. She was told since he was convicted in a different state that this was not a concern. When she brought up the concern of molestation, she was told there was no proof, even though a nurse had validated her concerns.

In my first article, I provided contact information for different organizations and people. I encouraged everyone to call and voice their concerns, for which people did voice their concerns. What was extremely disappointing was that KVC actually started hanging up on people if they mentioned the article.

Furthermore, the Topeka Capital-Journal picked up the story a few weeks later and spoke with Mandy — Kansas foster mother believes DCF, KVC ignored signs of abuse.

In the end, the child was placed back with her biological parents.

Figure 9. Facebook conversation (individual names and portion of the conversation has been removed)

I published the last article on January 22, 2018. However, I was contacted by the biological mother through Facebook on November 19, 2018 (see Figure 9). I then sent an e-mail to the Secretary of DCF, a journalist, and a couple of senators from Kansas (one is now the governor) on November 22, 2018. The purpose of the e-mail was as follows:

The reason I am writing to you today is that I was recently contacted by the biological mother living with the non-compliant sex-offender father. I have attached our Facebook conversation. You will notice it begins with… “You were right…”

I honestly do not know what should be done here, but I had to say something and provide you all an opportunity to do the right thing (whatever that might be).

I sent the e-mail after I asked myself: “What would cause someone to stand out and why?” Essentially, the biological mother sending me the Facebook message was an anomaly. Again, this wasn’t deliberate, but I moved through Step #2.

Table 6. Key Questions and Rational Example in Foster Care Step #2

I then moved to Step #3 and asked: “What would I do about it?” This was the e-mail I sent. The first response I received was from the Secretary of DCF, stating that she will “look into it” (received on November 22, 2018).

On November 29, 2018, I received a message from the Director of Customer Service / DCF Foster Parent and Youth Ombudsman. Before I discuss her response, let’s examine what an Ombudsman is and their duties.

Ombudsman. An official appointed to investigate individuals’ complaints against maladministration. In Kansas, the Ombudsman serves as a liaison between foster parents and the foster care providers.

Jonathan Shorman wrote about the Kansas Ombudsman in Kansas foster parents with problems can no longer go to DCF ombudsman for help:

DCF created the position in 2014, but it has proven controversial, with some child advocates questioning its effectiveness. Because the ombudsman was a DCF employee, skeptics doubted the position had the “independence” to actually hold the agency accountable.

It’s clear the position did not have the “independence” to hold the agency accountable. After all, she lists “Director of Customer Service” for DCF in her e-mail signature block — and if you look at the definition of the word independent, then you can clearly see the Ombudsman is not independent of DCF.

Independent. Free from outside control, not depending on another’s authority — not subject to control by others.

Also, I encourage you to examine her remarks in Figure 10:

My job is to ensure policy and procedures are being followed and that we are doing what is in the best interest of children and families. This includes foster parents. “We” have made numerous positive changes in the last year and have opened communication between the foster parents and myself and would be pleased to meet with you and discuss the good work the agency performs or any other concerns you may have.

Let’s quickly analyze her comments. First, how can you be independent when you are also DCF’s Director of Customer Service. Second, if I am independent of something, then I wouldn’t use the word “we” as in “We have made numerous positive changes…” This implies you are not independent of DCF. Third, you state that you would be pleased to meet with me and discuss the “good work the agency performs or any other concerns you may have.” How can I discuss any concerns if you are already prefacing it with the “good work the agency performs”? Thus, if you are not independent of DCF, and are an employee of DCF working for the Secretary of DCF, then how can you hold DCF accountable?

I have highlighted the Ombudsman’s response in Figure 10. She told me she has looked into this matter and that the information I received (from the biological mother and I am assuming the foster parent) wasn’t accurate — and that it was unclear why it was sent to me (which doesn’t remove the fact that it was sent to me). She also remarked that this concern was before her taking over as the Ombudsman and that she had open communications with the foster parents.

Figure 10. E-mail correspondence with Ombudsman (individual names and portion of the conversation has been removed)

So, she is unfamiliar with the case, reviewed the case in 7 days (from the time I sent the e-mail to the date of her response), and had never communicated with the foster parents in question (see Figure 11).

I received the last message from the Ombudsman on December 20, 2018. In the message, she stated she had not spoken with the foster parents in question, and she would see if they had any additional information to add (see Figure 11).

Figure 11. Response from Ombudsman (individual names and portion of the conversation has been removed)

If the Ombudsman had never spoken with the foster parents and the biological mother sent me a message starting with “You were right…” then it’s hard to follow her logic in that “I have looked into this matter and what I can share is that the information you received is not accurate.”

Yet, the most troubling response was when she said that it was unclear why the biological mother reported this to me and that she has reached out to the biological mother. Instead of looking into the real “why” behind the biological mother’s message to me (for which she initiated), the Ombudsman decided to disregard the message and “shut her up” (the biological mother).

Another question I had in this situation was:

How did she know the report was not accurate if she was not familiar with the case and had never spoken with the foster parents involved? Did she simply regurgitate what DCF and KVC told her?

The Foster Care Feedback Loop

“It’s okay for you to believe what you believe. It’s not okay for you to demand others believe what you believe.” — Sheldon Cooper, Big Bang Theory TV Series

To use the methods discussed above in foster care, we would need to first address getting left of bang with the foster care contract. In the State of Kansas, getting left of bang begins with a significant change in policy, more specifically, a substantial change in the way we write contracts.

Figure 12. State of Kansas Feedback Loop for the Number of Children in Foster Care version 1 — Image created by Dr. Schwandt via Loopy

If we continue to incentivize a contractor by only paying them when a child is in care, they will bring more children into care. As you can see in Figure 12, the number of children will increase if we pay the contractor only when a child is in custody. The more we pay them to bring children into care, the longer they will want to keep the child in care to maximize the amount of money they bring in. In Figure 12, we see what happens as the contract is paid more — more children enter and remain in care.

If we seek to change this cycle, then we must change the contract and how we incentivize contractors; mostly, we must get left of bang. In this case, “bang” is awarding the contract, which will set in motion years of wasted money trying to fix a problem that we are reinforcing.

Think of a thermostat. If we think of how a thermostat keeps a room warm, the thermostat acts as a receptor. If the temperature goes too high, then the furnace turns off. If the temperature goes too low, then the furnace turns on. In foster care, we need to identify something to control this similar to a temperature setting that, if it (i.e., dollar value of a contract) reaches a certain point, then it shuts off.

Figure 13. State of Kansas Feedback Loop for the Number of Children in Foster Care version 2 — Image created by Dr. Schwandt via Loopy

If the State of Kansas sticks with privatization, then I propose the following changes (see Figure 13):

1. The foster care contract pays only a monthly base rate and not a monthly rate for each out of home placement in foster care.

2. The contractor is incentivized by how many children leave the system and reach permanency.

3. Push for FINA removals over Abuse/Neglect removals.

4. Incentivize the contractor for working with families before removing a child and placing them into care.

Significant changes are possible when an individual or organization is proactive rather than reactive. Where reactive people deal with outcomes right of bang, proactive people predict outcomes left of bang. Yet, we can only be proactive and get left of bang if we are looking for pre-event indicators then seeing what is going on.

Looking vs. Seeing

“Life is a tragedy to those who feel and a comedy to those who think.” — Moliere

Figure 14. Looking vs. Seeing — Image from The Back of the Napkin: Solving Problems and Selling Ideas with Pictures

There is a distinction between looking and seeing, and it is vital for those working with and caring for foster children to understand this. Dan Roam writes in The Back of the Napkin: Solving Problems and Selling Ideas with Pictures:

1. Looking. Is when you know something is wrong, but you don’t know what. Looking is collecting information.

2. Seeing. Is when you notice what and where something is wrong. Seeing is the narrowing of putting the visual pieces together in order to make sense of them. Seeing is selecting and identifying patterns. Seeing is problem recognition.

Roam writes, “Looking at a problem is how we start, but just looking doesn’t present any solutions. In order to know what to fix, we need to be able to see what’s broken.”

If we want to get left of bang in foster care, then we must stop refusing to see what’s broken. We know there is a problem and we look at the problem daily. If we simply take the time to see what’s under the hood, we will clearly see the problem.

Figure 15. Look-See-Imagine-Show — Image from The Back of the Napkin: Solving Problems and Selling Ideas with Pictures

Think of teaching your children to cross the road. We teach them to look both ways before crossing, but how many times have we told them to stop and actually see if anything is coming? Children simply make the motion of turning their heads without actually seeing what’s coming. This is exactly what we are doing in foster care. We are making it appear as though we are looking at the problems in foster care, but we don’t take the time to see what is actually there.

Figure 16. Looking vs Seeing — Image from The Back of the Napkin: Solving Problems and Selling Ideas with Pictures — created by Dr. Schwandt via Plectica

We are trying to solve problems after we are hit by a car. But, what if we took the time to see if a car is coming so we do not get hit in the first place? What if we stopped operating right of bang in foster care and started to actually see the pre-event indicators right in front of us? We could then start to operate left of bang in foster care.

The Noise I Love to Hear

Finally, if this discussion offended you in any way, then let me leave you with a quote from Eric Cartman: America’s Favorite Little $@#&*% via NPR:

Question: “What sound or noise do you love?”

Cartman: “The sound of people who I don’t like crying because the tears running down their cheeks actually make a noise that’s like a sweet sound.”



Dr. Jamie Schwandt

Dr. Schwandt (Ed.D.) is an American author, L6S master black belt, and red teamer.