Haas Distinguished Chair and Professor of Bioethics. Joint Medical Program. School of Public Health, Division of Community Health Sciences. Affiliated Faculty ...
Understanding and Measuring Child Welfare Outcomes FULL REPORT
Kathy Lemon, M.S.W., BASSC Research Assistant Amy D’Andrade, Ph.D., BASSC Research Director Michael J. Austin, Ph.D., BASSC Staff Director
July, 2005
Supported by the Bay Area Social Services Consortium and the Zellerbach Family Foundation
The Center for Social Services Research (CSSR) in the School of Social Welfare at the University of California at Berkeley conducts research, policy analysis, program planning, and evaluation toward the improvement of the publicly supported social services. The focus of the Center is on populations who are considered needy or disadvantaged, including victims of child abuse and neglect, the chronically mentally ill, the aged, the medically indigent, and the poor. Housed at CSSR, the Research Response Team of the Bay Area Social Services Consortium (BASSC) was organized in 1995 to respond rapidly to the emerging needs of county social service agencies for information for their changing environments. Structured reviews of the research literature are undertaken in close collaboration with agency administrators and program staff. BASSC was founded in 1987 and is composed of the Directors of Bay Area county social service and human service agencies, deans of the Bay Area graduate social work departments, and foundation representatives.
TABLE OF CONTENTS Introduction …………………………………………………………………………….. 3 Outcomes as Reflected in Research Literature…………………………………….…….. 4 Safety Indicators ………………………………………………………………… 4 Maltreatment Recurrence…………………………………….…………... 4 Maltreatment in Out-of-Home Care………………………………………9 Re-entry to Care………………………………………………………….. 12 Permanency Indicators…………………………………………………………… 14 Reunification……………………………………………………………... 14 Adoption…………………………………………………………………. 19 Placement Stability………………………………………………………. 23 Well-Being Indicators……………………………………………………………. 28 Physical Health…………………………………………………………... 28 Mental Health……………………………………………………………. 29 Educational Status……………………………………………………….. 33 Preparation for Independent Living……………………………………… 34 The Federal Outcomes Review Process ………………………………………………… 39 Overview………………………………………………………………………… 39 Measurement Issues …………………………………………………………….. 42 Administrative Data Indicators………………………………………….. 42 Onsite Review Indicators ……………………………………………….. 44 California’s Accountability Efforts……………………………………………… 45 Implications ……………………………………………………………………………... 47 Recommendations……………………………………………………………………….. 48 References ………………………………………………………………………………. 54 Appendix: BASSC Search Protocol…………………………………….….………….….61
UNDERSTANDING AND MEASURING CHILD WELFARE OUTCOMES Introduction Efforts to use data to monitor and improve social services are not new. As far back as 1930s, there were calls for accountability for social services.1 More recently, the Government Performance and Reporting Act of 1993 required federal agencies to establish performance goals and monitor performance results for all federal programs.2 In addition, the Social Security Amendments of 1994 required the Department to “promulgate regulations for reviews of states’ child and family services.”3 Finally, the Adoption and Safe Families Act of 1997 required the federal government to develop a set of outcome measures for public child welfare programs.4
This report, commissioned by the Bay Area Social Services Consortium (BASSC), is divided into three sections. The first section reviews the research literature related to child welfare outcomes, in order to provide a context for federal accountability efforts. The second section summarizes the 2001 federal mandate to hold states accountable for child welfare outcomes and describes California’s response. The third and concluding section includes implications and recommendations.
It is important to note the distinction between client outcomes and service outcomes. The federal outcomes and this structured review of the literature focus on client outcomes: outcomes for children as they move in and out of state child welfare systems. In contrast, service outcomes involve data from program operations, such as data on efficiency and effectiveness of such child welfare programs as independent living, therapeutic foster care, kinship care, domestic violence or substance abuse treatment. The most frequently cited child welfare outcomes in the research literature and in federal and state accountability efforts fall into three broad domains: 1) safety, 2) permanency, and 3) well-being. In the safety domain, outcomes assess whether children are protected from abuse and neglect, and whether they are safely maintained in their homes. In the permanency domain, outcomes assess whether children in out-of-home care have permanency and stability in their living situations. The outcomes related to well-being include education, physical health, and mental health of children while they are in care and upon emancipation from the system.
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Outcomes as Reflected in Research Literature This review uses pre-determined search terms and search sources to identify research literature within a given topic. This method of searching can reduce the potential for bias in the selection of materials. Using specified search terms, we searched numerous social science and academic databases available through the University of California library. In addition, we searched websites specializing in systematic reviews, as well as research institutes, conference proceedings databases, dissertation databases, and conducted overall internet searches. In order to gather information on research that has not been published, inquiries were sent to professional email lists serving professional evaluators and child maltreatment researchers (please see Appendix for a description of the search strategy). This section highlights the findings from the research literature regarding safety, permanency and well-being outcomes in child welfare. When child, family or case characteristics have been found to be associated with the outcomes, these are described as well.
Safety Indicators Child safety is a priority for the child welfare system. The measures of child safety that are assessed in the research literature include: 1) maltreatment recurrence, or the rate at which children experience maltreatment subsequent to an initial investigated event of maltreatment; 2) maltreatment in out-of-home care, or the rate at which children experience maltreatment while placed in foster care; and 3) re-entry to foster care, the rate at which children experience placement into foster care subsequent to reunification with their. Research findings related to these indicators are described below.
Maltreatment Recurrence Although maltreatment recurrence has been the topic of much research, comparison between studies is complicated by several factors. First, studies often use different definitions of maltreatment recurrence; some define recurrence broadly as any subsequent report of child maltreatment, while others consider recurrence to have occurred only in instances where the maltreatment has been substantiated. Not surprisingly rates of maltreatment recurrence vary depending on how it is defined. When recurrence is defined as a subsequent referral or report to the child welfare system, rates have been found to range from approximately 25 percent to 29
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percent.5 Recurrence rates using the definition of a substantiated report of maltreatment range from approximately 11 percent to 43 percent.6
A second factor affecting comparison between recurrence studies is the amount of time after discharge that is used to determine maltreatment recurrence. Some studies use as little as 60 days, while others use time periods up to five years. However, there is research to suggest that regardless of how maltreatment recurrence is defined, the risk is highest within the first six months after the initial incident.7 Additionally, maltreatment recurrence studies use different sources of data, which can affect results. Some studies use large administrative databases, while others use case record review, interview or survey data. Based on these different sources of data, different constellations of risk factors are typically examined, which can make comparisons between studies problematic.
Keeping these issues in mind, certain factors have been found to be associated with child maltreatment recurrence, including factors related to the child, family, case, and system-related factors. In an effort to help isolate factors that are independently related to maltreatment recurrence, most studies use multivariate statistical techniques. Multivariate techniques allow researchers to statistically control for the influence of other variables in order to help isolate the unique effect of a factor on maltreatment recurrence. All cited studies in this section use multivariate techniques.
Child Factors: Research suggests that certain child factors may increase the likelihood child maltreatment will recur. In general, there is evidence to suggest younger children are more likely to experience maltreatment recurrence than older children. One study using a large administrative dataset from Missouri found that younger children were more likely than older children to be both re-referred to the child welfare system, and to have a substantiated report within 4 ½ years of being discharged.8 Likewise, other studies using administrative databases have found that younger children are more likely to be re-referred to the child welfare system.9 Further, using administrative data in Illinois, another study found that families where the age of the youngest child was 0-2 were more likely than families in which the age of the youngest child was 6-18 to have a subsequent substantiated child maltreatment report.10
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In general, there is evidence to suggest racial/ethnic differences in rates of maltreatment recurrence. With respect to Hispanics, one study found that one study found that compared to Whites, Hispanic children were less likely to have a subsequent substantiated report of maltreatment and less likely to reenter out-of-home care.11 Interestingly however, Hispanic families initially in the child welfare system due to physical abuse have been found to have 2.3 times the risk of maltreatment recurrence when compared to cases without these characteristics.12 There is also evidence to suggest that Asian/Pacific Islander children have lower recurrence rates than children of other racial/ethnic backgrounds. One study using data from nine states found that within 8 out of 9 states, Asian Pacific Islanders had lower rates of recurrence than other racial/ethnic groups (defined here as a report of subsequent child maltreatment) while differences between Whites and African Americans varied by state. In some states, recurrence rates were found to be higher for African Americans than Whites, while in other states Whites had higher rates than African Americans.13 Other studies suggest that race/ethnicity may interact with family composition in risk for recurrence; one study of cases involving alcohol or other drug use, the risk of a subsequent maltreatment report in the first 60 days following discharge was higher among cases involving an African American single mother.14
In addition, other research suggests the children with health problems are at an increased risk of experiencing maltreatment recurrence. One study used an index of child vulnerability defined as child mental health problems, child developmental problems and the presence of a child under the age of six in the household and found that the presence of these child vulnerability factors increased the likelihood of a subsequent child maltreatment report.15 Likewise, another study found that children with developmental problems were more likely than children without these conditions to have subsequent referrals to the child welfare system.16
Family Factors: In addition to child-level risk factors for maltreatment recurrence, certain family-level factors may also increase the risk of recurrence. Specifically, some research suggests that poverty may increase the risk of recurrence. Other research has found that caretakers with no income (operationalized as unemployed and not on public assistance) had higher rates of re-referral to the child welfare system than families with some source of income.
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Similarly, caretakers on public assistance and those with inadequate housing have been found to have an increased likelihood of both re-referral and reentry into out-of-home care.17
Some studies suggest that a number of caregiver risk factors including substance abuse, criminal history, domestic violence, or caregiver experiences of childhood abuse increase the likelihood of maltreatment recurrence. One study found that cases in which a risk assessment factor indicating caretaker substance abuse was checked as “yes/present” were nearly 13 times more likely to have a subsequent report of child maltreatment within 60 days than cases in which this factor was not indicated. Moreover, cases classified as “high risk” with respect to caretaker criminal activity were approximately 770 times more likely to have a subsequent report of child maltreatment than cases not involving this characteristic.18 Additionally, other research indicates that caregivers who experienced child maltreatment in their own childhood were more likely to have their children subsequently referred to the child welfare system.19 While one study found that the presence of partner abuse in the family increased the risk of a subsequent substantiated child maltreatment report.20
There is also evidence to suggest that family composition may impact recurrence. For instance, one study found that an index of family stress that was operationalized as three or more children in the home, mother under age 18 at the time the first child was born, and a span of child bearing years that was six year or more, was related to an increased risk of a subsequent substantiated maltreatment report.21 Other research indicates that initial child maltreatment cases that involve multiple victims have an increased likelihood of re-referral.22 Additionally, another study found that single parents with children were more likely than all other family types to have a subsequent substantiated child maltreatment report.23
Quality of social support may also impact maltreatment recurrence. One study found that social support deficits (operationalized as no support system in extended family, no support system in friends and neighbors and ineffective use of informal helping systems) were related to an increased risk of a substantiated child maltreatment report.24 Case Factors: Research indicates that case factors, such as history of maltreatment, disposition of initial maltreatment report, initial type of maltreatment, placement characteristics, and number
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of placement changes all affect the likelihood of maltreatment recurrence. Not surprisingly, research suggests that the risk of maltreatment recurrence increases as the number of subsequent maltreatment incidents increases.25 Other research has found that substantiated child maltreatment reports are more likely than unsubstantiated reports to have a subsequent substantiated maltreatment report.26 Additionally, another study found that having a child placed out of the home increased the risk of a subsequent substantiated maltreatment report when compared to those families whose children where not placed out of the home.27
There is also evidence to suggest that type of initial maltreatment predicts recurrence of maltreatment; in general research suggests that children initially in the child welfare system as a result of neglect are more likely than children who experienced other forms of maltreatment to experience a recurrence, possibly suggesting that conditions related to neglect, such as poverty, are more chronic in nature than conditions associated with other types of maltreatment. One study has found that children initially neglected were the most likely to have a subsequent report of child maltreatment; followed by physical abuse and then sexual abuse.28 Other research confirms the finding that children initially in the child welfare system as a result of sexual abuse are the least likely to experience a recurrence.29 However, using an administrative database in Houston Texas, one study found that cases involving physical abuse were more likely than cases involving other types of abuse to have a subsequent substantiated maltreatment report.30
System-Related Factors: System-related factors including service provision and attendance at services also impacts recurrence rates. In an analysis from 10 states that excluded children placed out of the home, within 9 out of the 10 states, children who received post-investigation services in their initial contact with the child welfare system had a higher rate of recurrence (defined as a report) than those not receiving these services.31 Likewise, another study found that families receiving in-home protective services or short-term services were more likely than those not receiving these services to have a subsequent substantiated maltreatment report.32 Another study found that cases closed at intake had fewer recurrences (defined as substantiated maltreatment) than cases opened at intake,33 while other research indicates that the longer the length of service provision, the greater the likelihood of a re-referral to the child welfare system.34 These results could suggest that families who receive services or whose cases are opened experience more
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difficulties that place them at risk for maltreatment recurrence, which may be why they were selected to receive services. Alternatively, these results may also suggest that child welfare services may not be effective in preventing some families from experiencing maltreatment recurrence.
However, other research suggests that a lack of service provision may be associated with recurrence. One study used administrative data in California and compared cases with prior contact with the child welfare system to cases without prior contact and found no differences between the two groups with respect to service provision. The authors speculate that a lack of service provision may be related to repeated referrals to the child welfare system.35 Additionally, using administrative data in Illinois, one study found that cases provided services during the first 60 days after case opening were less likely than other cases to have a subsequent substantiated maltreatment report.36 Similarly, another study found that families who attended services decreased their rate of maltreatment recurrence by 32 percent compared to families who did not attend services.37
Maltreatment in Out-of-home Care In general, there is little research documenting rates of maltreatment among children in out-ofhome care, although some have argued that rates of maltreatment may be higher in foster care or institutional settings because staff and foster parents are under greater scrutiny than family members who generally have more flexibility in parenting.38 Research on this topic has tended to focus on descriptions of the types of incidents most often reported and in general, much of the research focuses on maltreatment occurring in institutional settings.
In the U.S. Department of Health and Human Services’ most recent national study of child maltreatment, information on perpetrators of child maltreatment indicates that foster parents comprise 0.5 percent of perpetrators and residential facility staff comprise 0.2 percent of perpetrators. Among foster parents, neglect (50%) is the most frequently occurring type of maltreatment, followed by physical abuse (16.9%), and sexual abuse (6.3%). Similarly, among residential facility staff, the most frequently occurring type of maltreatment is neglect (46.3%), followed by physical abuse (19.0%), and sexual abuse (11.5%).39
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Other studies suggest higher rates of maltreatment while in out-of-home care. A recent study by the Annie E. Casey foundation of alumni of family foster care found that 32.8 percent reported that they experienced some form of child maltreatment while in care; neglect was the most commonly reported type of maltreatment (10.1%), followed by neglect and physical abuse (9.4%), physical abuse only (5.6%), sexual abuse and other maltreatment (4.0%), and sexual abuse only (3.7%).40 These results suggest that levels of maltreatment while in family foster care may be higher than levels reflected in official maltreatment reports.
Other studies have examined official maltreatment reports from out-of-home settings and described characteristics of these reports. For instance, in one study of maltreatment in out-ofhome settings in Colorado, 272 reports of maltreatment were analyzed and results indicated that 55 percent were for physical abuse, 24 percent sexual abuse and 21 percent neglect. Thirty eight percent of reports came from foster homes and 38 percent from residential treatment centers, while 14 percent came from group homes, and 11 percent from institutional settings. Overall, 29 percent of reports were substantiated. Sexual abuse cases were most likely to be confirmed, as were those from foster homes or institutional settings. Most reports involved male victims (64%) and male perpetrators (64%). Forty four percent of substantiated reports involved perpetrators who had previous allegations of maltreatment and 78 percent of substantiated reports resulted in children being removed from their settings. Children were most often removed from family foster homes; 95 percent of substantiated reports from family foster homes resulted in removal; 43 percent of substantiated reports from institutional settings resulted in removal; and 20 percent of substantiated reports from residential treatment centers resulted in removal. Thirty four percent of confirmed reports resulted in placement closings.41
Another study conducted in Indiana found rates of substantiated maltreatment incidents to vary by placement setting. In foster homes, the mean number of substantiated reports of child maltreatment was 16.93 per 1,000 children; physical abuse was the most frequently occurring type of maltreatment in foster homes (9.31 per 1,000 children), followed by sexual abuse (5.23 per 1,000 children) and neglect (2.38 per 1,000 children). Residential homes had the highest rate of substantiated maltreatment (120.35 per 1,000 children), with sexual abuse being the most
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common type of abuse in residential homes (70.20 per 1,000 children), followed by physical abuse (33.43 per 1,000 children) and neglect (16.72 per 1,000 children). State institutions had the lowest overall rate of substantiated maltreatment (8.88 per 1,000 children), followed by hospitals or other residential out-of-home placements (15.66 per 1,000 children).42
In an investigation into factors associated with maltreatment in residential care settings, 510 maltreatment reports were analyzed and compared to maltreatment occurring in familial settings. Differences in type of incident were apparent between residential care setting and maltreatment occurring within families. Lack of supervision was alleged in 26.5 percent of familial reports, compared to only 5.1 percent of residential care setting reports and lacerations were alleged in 34.8 percent of residential settings, compared to 18.2 percent in family reports. Ninety-five percent of reports of maltreatment from residential care settings involved children 10 years of age or older, while less than 32 percent of maltreatment reports from families involved children 10 years or older. Males were also more likely to be victims in reports within residential settings than reports in family settings, and males were also more likely to be alleged perpetrators in residential settings.43
Additionally, a study using case record review data from a large southwestern state agency that investigates maltreatment allegations of children in state-operated facilities or those who are in the custody of the state found that the majority (55.4%) of allegations involved “inappropriate” treatment, a category not defined in the study; 22.1 percent involved physical abuse, 15.8 percent involved neglect and 6.6 percent involved sexual abuse. Overall, 18.3 percent of allegations were substantiated and among these cases 77.3 percent involved inappropriate treatment, 11.8 percent involved physical abuse, 8.2 percent involved sexual abuse and 2.7 percent involved neglect. The authors note that although only 6.6 percent of allegations involved sexual abuse, these cases were substantiated 22.5 percent of the time. In general, children involved in substantiated cases were teenagers; the mean age of victims of inappropriate treatment was 15.2 years, physical abuse 15.3 years, sexual abuse 16.0 years and neglect 11.7 years. Males (79%) represented the majority of alleged victims, and White children (66%) were more likely than non-White children to be an alleged victim.44
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Taken together, these studies suggest that in general, official reports of maltreatment occurring in out-of-home care is more likely to involve physical abuse than other types of maltreatment, between 18.3 percent and 29 percent of allegations are substantiated and sexual abuse allegations are more likely to be substantiated than other types of maltreatment. Most alleged victims are male and most alleged perpetrators are male, and victims tend to be older than 10 years of age. There are conflicting findings regarding the prevalence of maltreatment within different placement sites. While one study found that foster homes and residential treatment centers have equal rates of maltreatment allegations,45 another study found that residential homes have higher rates of maltreatment reports than foster homes.46 These differences could be due to state differences in rates of maltreatment, or in the ways in which the studies defined each of these settings.
Reentry into Out-of-Home Care Another indicator of safety is the rate at which children who were previously placed in out-ofhome care re-enter the system and experience another out-of-home placement. As is the case with recurrence studies, research on rates of reentry varies depending on the time periods under investigation and data sources. Overall, research suggests that rates of reentry into out-of-home placement range from 13.7 percent to 22 percent. 47 Various child, family, case, and systemrelated factors have been linked to reentry into foster care.
Child Factors: There is some evidence to suggest that young children are more likely than older children to reenter care. Using a sample of infants in California, one study found that those who were less than a month old were more likely to reenter out-of-home care than those who were 2 to 12 months old.48 Similarly, using a large administrative dataset from California, another study found that 23 percent of infants returned to out-of-home care, compared to 16 percent of children ages 7-12 years of age.49 However, other studies have found that older children may be more likely to reenter care; in an analysis of children reunified and discharged in Ohio results indicated that every one-year increase in a child’s age at initial exit from care increased by 9.7 percent their rate of reentry to out-of-home placement, indicating that older children reenter outof-home care at a higher rate than younger children.50 Still other studies have found no link between age and reenter to out-of-home care.51
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Other research indicates that child characteristics such as race/ethnicity and health problems are linked to reentry. Research suggests that African American children reenter out-of-home care more quickly that white children.52 Additionally, child health problems are consistently linked to reentry. One study found that child health problems (defined as “easily identified physical, emotional and mental disabilities”) were more likely to return to out-of-home placement within three years of being reunified than children without these health problems.53 Similarly, another study found that an index of child’s problems that included health problems, school difficulties, learning disabilities, mental health problems, substance abuse or other psychosocial problems was related to re-entry into out-of-home care.54
Family Factors: Certain family factors are also linked to reentry, including poverty, substance abuse, a criminal history, poor parenting skills and low social support. For instance, one study found that families eligible for AFDC had children who reentered out-of-home care at a higher rate then those not eligible for AFDC.55 Moreover, in an analysis of factors related to reentry into out-of-home care among infants in the child welfare system, one study found that children whose mothers had a criminal history were more likely to reenter out-of-home care than children whose mothers had no criminal history. Similarly, maternal substance abuse was associated with an increase in the rate of reentry to out-of-home care.56 Other research suggests quality of parenting skills may be a key factor in reentry. Using a caseworker questionnaire, one study examined rates of re-entry to foster care among children in New York and found that those children with parents who were rated as having poor parenting skills returned to foster care at a greater rate than those whose parents had better parenting skills.57 Likewise, parents with less social support (as rated by their caseworkers) and those who participated in fewer organization and community groups were found to have an increased likelihood of having their child re-enter foster care.58
Case Factors: Certain case factors, such as type of maltreatment, last placement type, and number of placement moves are also associated with reentry. One study found that children initially removed from the home due to physical abuse reentered out-of-home care at a rate that was 70.9 percent slower than those initially removed due to dependency.59 Additionally, research
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also suggests that children placed with kin prior to reunification are less likely to reenter foster care. For instance, one study found that children whose last placement before reunification was nonrelative foster care reentered out-of-home care at a rate 226 percent faster than children whose last placement was kinship care. Those children whose last placement was a group home reentered out-of-home care 232 percent faster than those in kinship care.60 Similarly, other research has found that children whose last placement was with kin experienced lower reentry rates of out-of-home care than those whose last placement type was a nonrelative foster home.61 Research also suggests that the more placement moves a child experiences, the greater likelihood of reentering out-of-home care.62 Permanency Indicators The second primary goal of the child welfare system is permanency: reunifying children with their parents or finding them adoptive homes as quickly as possible. While children remain in care, an important aspect of permanency is the degree of stability they experience; namely, as few placement changes as possible. The research findings related to permanency indicators are described below. Reunification Reunifying children with their biological parents is often considered the preferred permanency outcome for most children in out-of-home care. National data suggest that reunification is the case goal for 44 percent of children in foster care and that 57 percent of children existing care in 2001 were reunified. Rates of reunification in studies using longitudinal designs generally find lower rates of reunification than the point-in-time rates used in the federal data. However, rates of reunification have been found to vary based on the time period under investigation. Studies using a 6 year time period have found rates of reunification to range from 29.2 percent to 52 percent.63 Studies using administrative data for time periods between 3.5 years and 4 years and 3 months have found rates of reunification between 35 percent and 39.7 percent.64 Other studies using 12-month or 18-month time periods have found rates of reunification to be between 23.0 percent and 32.5 percent.65
Research on factors affecting reunification outcomes have identified a variety of case characteristics that increase or decrease the likelihood of reunification, including child, family,
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system-related, and contextual factors. Although there is some general agreement in the research literature on factors related to reunification, differing methodologies make comparisons between studies difficult. As is the case with research on maltreatment recurrence, reunification studies use different types of samples, including large administrative databases, interviews or case record reviews and based on these varying samples, different constellations of factors are often examined, which often makes comparisons between studies problematic. Additionally, studies conducted before the implementation of policies such as the Adoption and Safe Families Act (ASFA) may not be as valid as those conducted after the implementation of ASFA. Nevertheless, one strength of most reunification research is the use of multivariate statistical techniques, these techniques isolate the unique effect of a factor on maltreatment recurrence, while simultaneously accounting for the influence of other variables. This allows for a greater degree of confidence in linking certain factors to reunification outcomes. Unless otherwise noted, all studies in this section and the adoption section use multivariate techniques.
Child Factors: A number of child factors have been found to be associated with the likelihood of reunification, including age, race/ethnicity, and health and behavioral problems. In general, research suggests that younger children are less likely than older children to reunify.66 Using a large administrative database in California, another study found that children under age one and children over age 12 had a decreased likelihood of reunification when compared to other age groups.67 Other research suggests that type of placement may affect likelihood of reunification for children of varying ages. One study found that children under age one placed with non-kin had a lower reunification rate than children ages 4-12, however for children placed with kin, there was no association between age and reunification.68
There is also some evidence to suggest that children of color reunify more slowly than white children, even after statistically controlling for the influence of other factors. One study found that African American children had a decreased likelihood of reunification when compared to White children.69 Similarly, another study found that found that African American children reunified nearly 40% more slowly than White children. Further analysis indicated that race/ethnicity interacted with age to predict reunification among African American children. Specifically, African American children under age 13 reunified more slowly than their White
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counterparts, however rates of reunification did not differ by race/ethnicity among children over age 13.70
Other research has examined whether type of placement affects reunification rates among racial/ethnic groups. One study found that African Americans in both kin and non-kin placements were less likely than whites to be reunified, while Latino children placed with kin (but not non-kin) were less likely than whites placed with kin to be reunified. Additionally, further analysis revealed that age and race/ethnicity interacted to affect reunification rates. Specifically, among African American children placed with non-kin, those who were under age one or over age 12 reunified slower than their White counterparts, however those who were between one and 12 actually reunified more quickly than their White counterparts. Among Latino children placed with kin, the likelihood of reunification was lower among Latino children under age one. Region also may interact with race/ethnicity to affect reunification rates. Among Latino children and children categorized as “other” (mostly Asian Pacifica Islanders in this sample), those placed with either kin or non-kin, were reunified more quickly if they were from Los Angeles when compared to urban/suburban areas or rural areas.71
Additionally, research also suggests that birth family composition may interact with race/ethnicity to affect reunification. Specifically, one study found that African American children from single-mother homes had a decreased likelihood of reunification when compared to white children from both one parent and two parent homes, whereas Hispanic children from two-parent families were more likely than white children from two-parent families to be reunified.72
Health and emotional/behavioral problems among children may also affect reunification. One study found that children placed with non-kin who had health problems reunified more slowly than children without problems, however this association was not found among children placed with kin.73 Using interview data on a large sample from San Diego California, another study found that children in non-kin placements with behavioral/emotional problems or externalizing behavior problems were approximately one-half as likely as children without these problems to be reunified.74
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Family Factors: A variety of family factors have been linked to likelihood of reunification, including poverty, family composition, and caretaker risk factors. For instance, research suggests AFDC eligible families are less likely to reunify than those not AFDC eligible.75 Similarly, another study using interview data found that families experiencing poverty returned home approximately 50 percent more slowly than non-poor families. These findings are particularly significant because certain variables not available in administrative databases were included in the multivariate analysis including whether the primary caretaker used drugs or alcohol, and treatment compliance of the family.76
Another study found that although children who came from AFDC eligible families reunified more slowly than those from non-AFDC eligible families, those placed with kin who were AFDC eligible had a slower rate of reunification than AFDC eligible children placed with nonkin.77 Moreover, using survey, interview and administrative data, another study examined a sample from Milwaukee County and found that families who had ever been homeless in the past 12 months reunified more slowly than other families.78
Other studies suggest that moving from welfare to employment may actually have a negative effect on the likelihood of reunification. One study used administrative data from Cuyahoga County, Ohio and found that children whose mothers lost income from AFDC, but gained income from employment had a slower reunification rate than mothers who never received AFDC and those who remained on AFDC. Specifically, mothers who never received AFDC reunified with their children nearly three times faster than mothers who went from AFDC to employment, while mothers who remained on AFDC reunified with their children over ten times faster than mothers who moved from welfare to work.79 In a follow-up study to determine the impact of welfare reform on time to reunification, it was found that reunification rates differed before and after welfare reform was implemented. Specifically, children in the sample before welfare reform was implemented reunified 46 percent faster than children after welfare reform was implemented. Moreover, results also indicated that family income had a larger impact on time to reunification after welfare reform was implemented; that is, increases in income after
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welfare reform increased speed to reunification to a greater extent after welfare reform than before.80
In addition to poverty, other research suggests family composition may affect reunification. One study found that children from two-parent homes were more likely to be reunified than children from one-parent homes.81 Likewise, other research indicates that children removed from motheronly families reunify more slowly than those from families with both parents.82
Not surprisingly, caretaker risk factors also affect reunification rates. Interestingly, research suggests that cases involving mothers who used drugs prenatally and gave birth to a substanceexposed infant removed from them actually reunified more quickly than cases not involving these characteristics.83 Another study found that the presence of maternal mental health problems decreased the likelihood of reunification.84
Case Factors: Case factors, such as type of maltreatment, type of placement, service provision and service participation have also been linked to reunification rates. Research suggests that children initially placed out of the home as a result of neglect are generally less likely to reunify than children placed for other reasons.85 Other research suggests that type of placement may interact with type of maltreatment to affect reunification. One study found that children placed with non-kin due to neglect had a decreased likelihood of reunification than children removed for sexual abuse, however no differences in reunification rates based on type of maltreatment were found among children placed with kin.86
In general, research also suggests that children placed with kin reunify more slowly than children placed with non-kin. For instance, one study found that children placed in foster homes were more likely than children placed in group homes, with a guardian or in kinship care, to be reunified. The authors speculate that children placed in group homes may have more behavioral problems than other children that prevent reunification, while children placed with a guardian or with kin may have more stable placements.87 Similarly, other research indicates that children placed in kinship care or in foster family agencies reunify more slowly than children placed in
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foster family homes.88 However, other research has found that children whose first placement was a hospital reunify approximately 33% more slowly than children first placed in kin-care.89
Service provision and participation may also affect reunification rates. One study found that families receiving pre-placement preventive services were more likely to reunify than those not receiving these services, however the authors note that it is difficult to conclude that these services result in reunification, as selection effects might create a situation in which higherfunctioning families are the ones who receive services.90 Another study found that drug dependent parents who completed drug treatment were reunified approximately six times faster than children with parents who were not drug dependent. Among children whose parents reported continuing to use drugs while their children were in out-of-home care, the reunification rate was 57% slower than among children whose parents were not using drugs.91
Contextual Factors: There is also some evidence to suggest contextual factors affect reunification rates. One study found that children placed in rural areas had an increased likelihood of family reunification than children placed in urban or suburban regions.92 Neighborhood context may also affect reunification. One study found that caregivers who reported higher ratings of the quality of their neighborhoods were more likely to reunify than those with lower ratings.93 Adoption In cases where reunification does not occur, adoption has often been considered the next best alternative. National data indicate that adoption is the case goal for 22 percent of children in outof-home care and that among children exiting care in 2001, 18 percent were adopted. National data also suggest that a sizable portion of children wait long periods in out of home care before adoption. Among children waiting to be adopted, 24 percent have been in out-of-home care for five years or more. Among children who are adopted, 19 percent wait two years or more after parental rights are terminated, and before adoption is finalized. Research using longitudinal data on rates of adoption has generally found lower adoption rates than those reported in federal point-in-time data. As was the case with reunification research, adoption rates vary depending on the time periods under investigation. Additionally, some
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studies do not report adoption as its own outcome, but rather include adoption among several different types of outcomes, such as aging out of care or having a guardianship established. Studies using a 6 year time period have found adoption rates to vary from 9.3 percent to 20 percent.94 One study using a 3.5 year time period found that 1.5 percent of children were adopted.95 Another study using a 12-month time period found that 5.1 percent of children were adopted or had a guardianship established; other research using a 12-month time period has found 18.5 percent to 25.3 percent of children to have a guardianship established.96 One study using an 18-month time period found that 32.5 percent of children had a guardianship established.97 Other research using a sample of children whose parental rights had been terminated found that during a 12-month time period, 32.2 percent had been adopted and 2.1 percent had a guardianship established.98
In general, less research has been conducted on adoption in comparison to reunification, however the same caveats regarding reunification research holds true for adoption research as well; differing methodologies makes comparisons between studies difficult and changes as a result of ASFA may make research conducted prior to ASFA less valid. Again, the studies discussed in this section use multivariate techniques unless otherwise noted.
Child Factors: Certain child factors have been linked to the likelihood of adoption, including gender, age, race/ethnicity and health problems. Although not all studies have found gender to be a significant predictor of adoption, one study used administrative data from Washington state, and found that among children who were legally freed for adoption, boys were less likely to be adopted or to be placed with a legal guardian than were girls.99 Similar results were found using a sample of children initially placed as infants.100
Studies have consistently found that younger children are more likely to be adopted than older children.101 In an effort to understand factors related to having a case plan of adoption versus long term foster care, one study used case record review data of children whose parental rights had been terminated from a mid-Western state and found that older children were more likely that younger children to have a case plan of long term foster care, rather than adoption. The
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authors note that age not only influences adoption outcomes, but also appears to influence the kinds of case plans that workers create for children.102
There is also evidence to suggest that African American children are less likely than white children to be adopted.103 With respect to Latinos, some research has found no differences between whites and Latinos in adoption rates,104 while other research has found Latinos to be less likely than white children to be adopted.105 Other research suggests that non-White children are more likely than White children to have a case plan of long term foster care, rather than adoption.106 Another study found that compared to white children, African American and Asian/Pacific Islander children are less likely to be adopted or to have a legal guardianship established.107 Another study found that African Americans freed for adoption were less likely to exit foster care within one year than any other racial/ethnic group.108
Some research suggests that child health problems may negatively affect the likelihood of adoption. One study found that children with health problems are less likely than those without health problems to be adopted.109 Another study found that children with disabilities were less likely than other children to exit care within one year after termination of parental rights, however this difference was only marginally significant after controlling for other factors such as age, ethnicity, number of placements and placement type.110
Family Factors: Few studies have addressed the association between family factors and likelihood of adoption, however, one study found that children who were AFDC eligible were less likely to be adopted than those who were not eligible for AFDC.111
Case Factors: Case factors such as type of maltreatment, type of placement, and service provision may also affect likelihood of adoption. One study found that children experiencing physical abuse were less likely to be adopted than children who were neglected, while children placed for “other reasons” were more likely to be adopted.112 The authors note that the majority of children placed for “other reasons” were voluntarily placed and may have been freed for adoption more quickly than other children.
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There is also evidence to suggest that children placed with kin are less likely to be adopted. Research has found that children placed in a foster home were more likely to be adopted than children placed in group homes, with guardians or in kinship care.113 Another study found that compared to children in pre-adoptive homes, those that were in kinship placements were 72 percent less likely to exit care within one year, those in non-relative placements were 52 percent less likely, and those in institutional placements were 59 percent less likely to exit care.114 In an effort to understand how permanency planning activities may affect likelihood of adoption, one study employed qualitative methods to explore permanency planning activities for youth in group homes or in residential treatment centers. Interview results with child welfare professionals indicated three overall barriers to achieving permanency for youth in group homes or residential treatment programs. Specifically, professionals reported that case workers’ negative stereotypes about youth resulted in decreased efforts to find permanent homes. Additionally, professionals reported that social workers felt that it was not the responsibility of group home or treatment center staff to work with them on finding permanent homes for youth. Such a lack of collaboration was reported to interfere with permanency outcomes. Last, professionals also noted difficulties in working with birth parents and other relatives due to transportation issues.115
Other research suggests that pre-placement prevention services are associated with a decreased likelihood of adoption; children receiving these services have been found to be less likely to be adopted than children not receiving these services.116
Contextual Factors: Some research suggests contextual factors may impact adoption likelihood. One study found that children placed in a rural area or in Los Angeles county were less likely to be adopted when compared to children placed in urban or suburban regions.117 Using a national database, another study found state-level differences in the rate at which children whose parental rights had been terminated exited care, even after the influence of possible demographic differences in case characteristics had been accounted for. Specifically, compared to a Midwestern state, children from a Western state and a Northeastern state exited care more quickly, while children from a Southern state exited care more slowly.118
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Some research has examined the preferences of adoptive parents in understanding factors related to adoption. One study used survey data of adoptive parents to understand the preferences of these parents. Overall, 82 percent of the sample indicated a willingness to adopt a foster child. Descriptive statistics suggested racial/ethnic preferences; 98 percent were willing to adopt a white child, 88 percent biracial, 83 percent Latino, 81 percent Native American, 81 percent Asian and 64 percent were willing to adopt a Black child. Adoptive parents were also more willing to adopt younger children than older children; whereas 94 percent indicated a willingness to adopt children under age one, only 25 percent indicated a willingness to adopt children over age 13. Seventy three percent of adoptive parents indicated some willingness to adopt a drugexposed child, and nearly 82 percent indicated some willingness to adopt a sibling group.119 In a separate analysis focusing on adoptive parents’ willingness to adopt Black children, it was found that adoptive parents who were willing to adopt Black children were also more willing to adopt older children and children with special needs and their motivation for adoption was generally focused on religious or humanitarian reasons. Additionally, among the parents who indicated they were not willing to adopt a Black child, 50 percent also reported that adoption workers discouraged them from adopting Black children. Only 11 percent of adoptive parents who were willing to adopt a Black child indicated that adoption workers encouraged them to adopt a Black child.120
Placement Stability Accurate measures of the overall rate of placement disruption among children in out-of-home care are difficult to ascertain due to methodological differences between studies. While some studies consider any move a placement change, others do not include stays of only a few days (e.g. temporary shelters). Additionally, the amount of time used to capture the number of placement changes varies between studies; some use as little as eight months, while others use time periods up to eight years. In general, research does suggest that the more time a child spends in out-of-home care, the more placements they have, and that the period of time of greatest placement disruption occurs in the first six months a child spends in out-of-home care.121 Using an 18-month time period, one study found that 54 percent of children had one placement, 27 percent had two, 14 percent had three, and five percent had four or more placements.122 Another study using an 18-month time period reported the average number of placements for
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children was 4.4.123 Using a 2 ½ year time period, another study found 22 percent of children had three or more placements.124 Using a time period of three years, another study found that among children who remained in care for the entire three-year period, 21 percent had three placements, 15.7 percent has 4 placements and 14.6 percent had five or more placements.125 Using a fouryear time period, another study found that 66.7 percent of children had experienced more than one placement and of those with more than one placement, 26.9 percent had two placements, 24.9 percent had three to four placements and 14.9 percent had five to ten placements.126 Thus, it appears a sizable minority of children experience multiple placement disruptions.
Research has identified a number of factors associated with placement disruptions, including child factors such as gender, age, ethnicity and behavior problems, as well as case factors such as initial reason for removal and placement types. Again, unless otherwise noted, the research presented uses multivariate techniques, allowing for the influence of possibly confounding factors to be statistically controlled.
Child Factors: Child factors that have been linked to placement instability include gender, age, race/ethnicity, sibling groups, and behavioral problems. Using a large administrative database in California, one study tracked children in out-of-home care for eight years and found that males were more likely to experience placement instability than females.127 However, another study of children referred to a treatment foster care agency found that age and gender may interact to increase the likelihood of placement disruption. Findings indicated that girls over age 13 had the highest likelihood of placement disruption when compared to boys and girls under age 12 and boys over age 13.128 Another study using administrative data in New York City found that girls in group care settings had more placement moves than boys in group care settings; however this relationship was not true among children placed in foster family care.129 With respect to race/ethnicity, one study found that African Americans experienced more placement stability than white children.130
In general, age tends to be one of the most consistent predictors of placement disruptions with older children tending to have more placement instability than younger children. One study found that compared to children under one year of age, those who were between 1 year and 5
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years were more likely to experience placement disruptions.131 Similarly, another study found that every four-year increase in child’s age resulted in a 66 percent increased likelihood of an unstable pattern of placements.132 Using a sample of children referred to a treatment foster care agency, those who were older were found to be more likely to experience placement disruption in the first six months than those who were younger.133 Another study using administrative data from New York City found that among children in foster family placements those between the ages of 11 and 13 had the highest number of placements.134 However, other research has found age, gender and ethnicity to be unrelated to placement stability.135
There is also some evidence to suggest that non-sibling groups have greater placement stability than children in care with siblings. One study found that children placed in foster family care who do not have a sibling currently in out-of-home care move less frequently than children with siblings currently in care; however among children placed in group care, those with a sibling currently in care actually move less frequently.136
A fairly consistent finding in the research is that child behavior problems tend to be associated with placement disruptions. For instance, one study using administrative data from San Diego found that children with externalizing behavior problems that fell in to a “problem range” on the Child Behavior Checklist were over 3 ½ times more likely than other children to have an unstable pattern of placement, characterized by several brief placements with no placement lasting longer than 9 months. Using a sample from Canada, another study surveyed workers about children on their caseloads and found that the difficulty of the child’s behavior as rated by their caseworker was related to a higher number of placements.137 Using a sample of children from Australia, one study used case record review data and survey data from foster parents and case workers and found that children with mental health problems (as determined by case records) were 7.75 times more likely to experience placement instability than children without these problems. Conversely, those children with higher scores on a social adjustment scales were more likely to experience placement stability. Further analysis of children experiencing placement instability indicated that 32 percent of these children had at least one placement move as a result of their disruptive behavior; this group of children experienced an average of 5.7
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placement moves in just 4 months and nearly 88 percent of them were 10 years of age or older.138
Much of the research on behavioral problems and placement instability is cross-sectional (e.g point-in-time) in nature, which can make drawing conclusions about what factors cause placement disruptions and what factors are a consequence of placement disruptions difficult to determine. One study addressed this issue by using a longitudinal design with data gathered from caretaker interviews at two points in time. Results revealed that behavior problems, as measured by the Child Behavior Checklist were both a cause and a consequence of placement instability. Overall, children with more behavior problems experienced more placements, and using advanced statistical techniques, the authors found that behavior problems (particularly externalizing behavior problems) at Time 1 significantly predicted number of placements, while number of placement changes significantly predicted behavior problems at Time 2. Further analysis revealed that among children who initially showed no behavioral problems, those who experienced a high number of placements were more likely to have problem behaviors at the second measurement time.139
Another longitudinal study that tracked children from preschool to early adulthood found that instability in living situations was significantly related to problem behaviors later in life, after controlling for the influence of socioeconomic status and the effects of maltreatment. Results revealed that the more caretaker transitions a child had, the more likely they were to be involved in criminal acts, to use alcohol or drugs, to be involved in school truancy, underage driving, running away from home, or school drop-out.140
However, not all research supports the finding that placement instability results in negative effects on children. One study used a sample of children from Australia and found that children who had unstable placements actually displayed improvements in behavior problems including conduct, hyperactivity and emotionality, perhaps suggesting that multiple placements may be needed and justified in order to find an appropriate placement for a child. However, one limitation of this study is that it tracked children for only 8 months, and the negative effects of placement instability may require longer periods of time to become evident.141
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Case Factors: Other research indicates that type of maltreatment and type of placement are related to placement instability. Overall, research suggests that children placed as a result of neglect have greater placement stability. One study found that compared to neglect, children removed due to all other types of abuse were more likely to experience placement disruptions.142 Other research has found that children who had been neglected were 3.39 times more likely to have stable placements.143
Research consistently suggests that children placed with kin have more placement stability than children placed with non-kin. One study found that children placed with non-kin were nearly 2 times as likely to experience placement disruptions as those placed with kin.144 Other research has found that children first placed with kin are significantly less likely to experience placement disruptions than children first placed in family foster homes.145
System-Related Factors: Research also suggests that placement disruption may be related to a lack of support from the child welfare system. Although more research is needed in this area, one qualitative study that used interview data from 19 foster parents who ended placements with an adolescent in their care suggested several possible system-related factors that may have contributed to the placement failure. The majority of foster parents reported that they had not been given enough information about the child before the child was placed in their care. Many respondents felt that caseworkers withheld information about children’s behavior problems in order to ensure that the child would be placed and that this lack of information compromised their abilities to provide appropriate care. Other respondents noted that requests for assistance or additional services often were not adequately fulfilled; some requests resulted in no response, while others resulted in only a phone call. Respondents also discussed interventions that may have prevented the child from being removed from their care. More foster parent respite services, immediate crisis response services, mentors for children, counseling and more education on managing an adolescent were all identified as factors that may have prevented the placement failure.146
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Well-Being Indicators Enhancing child and family well-being is a third goal of the child welfare system. Physical health, mental health and educational problems among children in the child welfare system have been fairly well documented in the research literature, although differing research methodologies present some challenges in interpreting findings. Many studies use data collected at one point in time, which may over-sample children who have been in the child welfare system for long periods, thus possibly inflating rates of mental, physical and educational problems. Some studies suggest that children come into the child welfare system with numerous problems and it is often difficult to determine if problems are improved or exacerbated by experiences in out-of-home care. The research findings related to well-being indicators are described below.
Physical Health There is evidence to suggest that children entering the child welfare system have a number of physical health problems. One study conducted in Cook County Illinois performed medical and developmental evaluations on a sample of children entering the system and found these children suffered from numerous physical and developmental problems. Overall just 13 percent of the children were determined to be physically and developmentally normal. Forty percent had at least one chronic condition, 19 percent had growth problems, 19 percent had neuromuscular problems, and 19 percent had cardiovascular abnormalities. Overall, 24 percent were below the 5th percentile for height and 16 percent were below the 5th percentile for weight. Developmental delay was suspected in 38 percent of the children five years of age or under.147 Similarly, another study of the physical health of children entering foster care (ages 3 days to 18.8 years) found that 92 percent of the children had at least one abnormality, 25 percent failed a vision screen and 16 percent failed the hearing test and 35 percent had a chronic illness. Developmental assessments performed on children ages zero to five indicated that 23 percent of the children had abnormal or questionable results.148
Other studies have found even higher rates of developmental delay among children in the child welfare system. One study of young children (ages 3 –36 months) entering the child welfare system in San Diego found that 62 percent of children received a “suspect” score on standardized developmental assessment tool. Further analysis indicated that suspect scores were more
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common among males, and children from Hispanic, Spanish-speaking backgrounds, as well as among children placed in non-relative foster care (as compared to all other out-of-home placement settings).
Mental Health Children involved with the child welfare system have been found to have relatively high rates of mental illness, and emotional and behavioral problems. One study used the Child Behavior Checklist (CBCL) administered to foster parents to determine the prevalence of psychological disorders among foster children (ages 4 to 18) in one city located in Tennessee. Results indicated that 48.7 percent of the sample had some sort of clinical psychological disorder. Of these children, 61 percent were rated as having “disordered status” on two or more scales on the CBCL, and the remaining 39 percent had disordered status on one scale. Comparisons between foster youth and a sample of children from the general population indicated that foster children scored significantly higher on 45.7 percent of internalizing symptoms and 53.8 percent of externalizing symptoms.149 Similar rates of emotional and behavioral problems were found in a multi-site study of foster children in non-relative care (ages 0 to 17) in three counties in California (San Diego, Santa Cruz, and Monterey). Overall, no differences in rates of emotional and behavioral problems were found between the three sites and among the three sites approximately 40 percent of children ages 4 to 16 scored in the clinical range of the CBCL on total behavior problems and approximately 50 percent of school age children had social competence deficiencies.150 Another study examined CBCL scores among children in kinship care in Baltimore and found similar levels of emotional and behavioral problems. Overall, 42 percent of boys and 28 percent of girls had CBCL scores in the clinical range. Multivariate analyses indicated that boys were at greater risk for behavior problems, as were children placed for abuse compared to other reasons for placement. Additionally, African American children were more likely to have behavior problems than white children, as were children whose caregivers had four or more contacts with caseworkers; and children with college educated caregivers were less likely to have behavior problems.151
Another study used a sample from a nationally representative survey of households in the U.S. and compared children in the child welfare system to children in parent care and children in
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high-risk parent care, defined as children living in single, low-income families. Results indicated children in the child welfare system had significantly more behavioral and emotional problems, they were more likely to have received mental health services in the past year, and they were more likely to have a limiting physical, learning or mental health condition than either children in parent care or children in high-risk parent care.152 Additionally, other research has found that among children entering foster care, 75 percent had a family history of mental illness and/or substance abuse. Mental status exams of children over age three indicated that 15 percent admitted to, or were suspect for, suicidal ideation and 7 percent admitted to, or were suspect for, homicidal ideation.153
Analysis of mental health service utilization by children in foster care in California in 1988 revealed that foster children made up a sizable proportion of Medi-Cal claims. Overall, children in foster care represented just 4 percent of Medi-Cal eligible users, yet they made up 41 percent of all users of Medi-Cal reimbursed mental health services. Foster children made up 53 percent of all psychologist visits, 47 percent of all psychiatry visits, 43 percent of all Short Doyle/MediCal inpatient hospitalizations in public hospitals, 27 percent of all inpatient psychiatric hospitalizations in community hospitals, and 27 percent of all community-based Short-Doyle Medi-Cal services. Foster care children had an age-adjusted utilization rate of 160 per 1,000 children, compared to 11 per 1,000 children among the reference population of non-foster children. The most frequently reported diagnoses for foster children included adjustment disorders (28.6%), conduct disorders (20.5%), anxiety disorders (13.8%), and emotional disorders (11.9%).154
Similarly, another study compared mental health care utilization and expenditures among foster children and children in the AFDC program in Southwestern Pennsylvania in 1995 and found that foster children were more likely to suffer from a variety of mental health problems and to use mental health services more frequently. After statistically controlling for demographic factors, 34.6 percent of children in foster care, compared to 8.7 percent of AFDC children had a mental health service. The most commonly occurring mental health diagnosis among foster children was ADHD (14.7% compared to 3.9% among AFDC children), followed by oppositional defiance (9.4% vs. 1.9%), and depression (5.9% vs. 1.1%).155
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Using administrative data from Los Angeles County, another study focused on identifying children who are most at risk of having emotional or behavioral problems. Multivariate analysis indicated that children most at risk for behavior problems were more likely to be living in therapeutic foster care than kinship care, girls were more likely than boys to be rated by teachers as having at least one behavioral problem, and whites were more likely than Latinos to be rated as having a classroom behavior problem.156
Other research suggests that the type of maltreatment that brings children into the child welfare system is related to whether or not they receive mental health services. One study examined children (ages 0-17) in the foster care system in San Diego, California and multivariate analysis indicated that children in foster care as a result of sexual abuse were 4.47 times more likely to receive mental health services, and those referred for physical abuse were 2.43 times more likely to receive mental health services than those in out-of-home care for other reasons, controlling for the effects of behavioral or emotional problems, gender and age, whereas those referred for neglect were less likely to receive mental health services. Additionally, those children with higher scores on the CBCL were more likely to receive services, and older children were more likely than younger children to receive services.157 Another study using a nationally representative sample of children used multivariate techniques to identify predictors of mental health service use during the first year children were in the child welfare system. Results revealed that older children in were more likely to receive mental health services than younger children, African American and Hispanic children were less likely to receive services than White children, and children referred for physical abuse, emotional abuse or sexual abuse were more likely to receive services than children referred for other reasons, even after controlling for the need for services (as measured by the CBCL).158
There is also some evidence to suggest that children who are reunified have worse mental health outcomes than those who are not reunified. One study used a sample of children between the ages of 7 and 12 entering the foster care system in San Diego California; children and their current caregivers were interviewed 6 months after entering out-of-home care and again six years after entering out-of-home care. Multivariate comparisons between children who were reunified and those who were not (the majority of whom were still in the child welfare system), indicated
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that children who were reunified were more likely to display destructive behaviors, substance use, and higher scores on a risk behavior problem scale. They were also more likely to have received a ticket or been arrested, to have dropped out of school, and to have academic problems.159 The authors suggest that there may be a need for more services for children before and after reunification. Additionally, some research suggests that children’s quality of life may be improved when they are removed from the home. One study conducted in Israel found that among children ages 3 to 13, children assessed four months after the initial investigation of maltreatment were rated as having a higher quality of life on all four domains assessed by the instrument, including psychological, physical, social and cultural quality of life.160 Similarly, another study conducted in Connecticut tracked foster children’s (ages 11-74 months) functioning with an adaptive behavior scale for one year, beginning from the point of entry into out-of-home care. Results indicated that, on average, at entry into care, children scored in the below average range, yet adaptive functioning continuously improved while children were in care so that at the 12 month point, on average children’s scores were within the normal range.161 Taken together, these studies suggest that children in the foster care system may fare better than those who were reunified or those who were never removed from the home.
However, other research suggests that the well-being of children discharged from the foster care system depends in part on type of permanent placement. In a comparison of well-being indicators among children discharged to their biological parents, adoptive parents, relatives or other permanent foster home, results indicated that at three points in time after discharge (4 months, 6 to 10 months and 12 to 16 months), children in adoptive homes scored higher on a measure of family adjustment. Moreover, at time 1, children in relative placement appeared to have better emotional and developmental functioning that children in other types of permanent placements and at time 2, children in adoptive homes and relative homes appeared to have better overall behavior than children in other types of permanent placements. Additionally, at time 1, children in relative placements appeared to have the best school functioning that children in other types of permanent placements.162 These results suggest that children discharged to adoptive or relative homes may fare better than children discharged to their biological parents.
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Educational Status As with other well-being indicators, research consistently finds educational deficits among children in foster care. One study found that children in the child welfare system were more likely than children in parent care or children in high-risk parent care (defined as children living in low-income single parent homes) to have low levels of engagement in school, and they were more likely than children in parent care to be in special education, to not be involved in extracurricular activities and to have been suspended or expelled in the past school year.163 Similarly, a study that compared children in foster care in Canada to those not in foster care found that 41 percent of foster children had repeated a grade, compared to 9 percent of nonfoster children, and 43 percent of foster children (versus 7 percent) were currently receiving special education. Moreover, the foster children had changed schools nearly twice as often as non-foster children.164 Another study used multivariate techniques to compare children in the child welfare system to those not in the system in a small city in New York. Results revealed that even after controlling for demographic factors, children in the system scored significantly below the comparison group on reading and math assessments, their grades were lower, they were more likely to have repeated a grade, and older foster children were more likely to have more discipline referrals.165 Similar results were found in a study comparing school-age children and adolescents in the child welfare system to non-maltreated children in Georgia; neglected children scored significantly below non-maltreated children in language and reading assessments and both physically abused and neglected children scored below non-maltreated children on math assessments.166 Another study of children entering foster care found that 40 percent had repeated a grade and 21 percent were receiving special education services.167
Other research has investigated the types of factors that may be related to educational deficits among foster children. Using multivariate techniques on a sample of foster children from Los Angeles County, one study found that African American children were three times more likely to have academic skill delays than Latino children, and that for every additional placement change a child experienced, the odds of academic skills delay increased by 1.18. Additionally, on an index of school failure, children living in group homes were more likely of repeating at least one grade than children in kinship care or family foster care, older children were more likely to have a history of suspension or expulsion from school, boys were more likely than girls to have been
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suspended or expelled, and children in foster care for longer periods of time were also more likely to have been suspended or expelled.168
Some research has focused on determining whether placement in out-of-home care improves or hinders academic achievement. One study tracked reading, vocabulary, and math test scores over three years among a group of foster children in England who had been in out-of-home care for a minimum of six months. Results indicated no improvement in scores over the three years regardless of whether children remained in care, or were discharged to parents or other permanent placements.169 Another study assessed IQ and achievement test scores among a sample of foster children who reentered care in Arkansas in order to determine if children reentering foster care showed declines or gains in academic development compared to when they initially entered care and compared to a control group of children who entered the system only once. Results indicated that at reentry into out-of-home care, there were no changes in IQ or achievement except on one scale measuring written expression, however the control group also demonstrated this improvement and the author suggests that this finding may be related to age or test-related changes. Moreover, compared to the control group, children reentering care demonstrated no improvements in IQ or achievement. The author concludes that foster care placement neither helps, nor hinders the educational achievement of children.170 Similar findings were reported in an analysis of educational attainment of foster youth in Washington state. Results indicated that foster youth fell significantly behind non-foster youth on a number of educational outcomes. Further analysis indicated that a number of system-related factors had no impact on educational outcomes for foster youth, including total time in foster care, number of placements, age first entered foster care, whether or not the child recently entered foster care, average number of placements per year, average number of caseworkers per year, or whether special services were provided.171
Preparation for Independent Living Annually, approximately 20,000 youth are discharged from the foster care system to “independent living.”172 The plight of older adolescent foster you who are “aging out” of the child welfare system has received an increasing amount of attention in recent years. In 1999, the federal Foster Care Independence Act (FCIA) was passed which expanded Independent Living
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Programs (ILP) for adolescents in the foster care system. This legislation allows states and counties to continue to provide services up until age 21 and places increased attention on identifying youth likely to be in care until the age of 18; increased employment training and education; increased preparation for post-secondary education; and increased attention on providing emotional support to youth leaving care at age 18.173
Most research on outcomes for foster youth who have emancipated from the child welfare system is limited to studies conducted prior to the implementation of the FCIA, so it is difficult to determine if this legislation has improved outcomes for this group of foster youth. However, the research that is available suggests that many foster youth who age out of the system face serious challenges in successfully transitioning out of foster care. Major areas that have been researched include: health, mental health and substance abuse, criminal activity, employment and financial circumstances, living situation, education and overall preparation for independent living.
Health, Mental health and Substance Abuse: There is evidence to suggest that after leaving care at age 18, many former foster youth have difficulties with health, mental health and substance abuse. One study focusing on youth who emancipated from care in Nevada found that six months after leaving care, 30 percent of the sample had had a serious health problem and only 54 percent rated their health as very good or excellent. Access to health care was also a major issue; 55 percent had no health insurance, and 32 percent needed health care and could not obtain it.174 Similar results were found in a study of former foster youth in Wisconsin 12 to 18 months after leaving care; 44 percent had difficulties obtaining needed medical care most or all of the time; 51 percent had no health insurance; 38 percent reported that medical care was too expensive; and 28 percent could not get needed dental care.175 Similarly, another study with youth who were interviewed approximately one year after emancipating from the system found that 44 percent had a serious health problem since leaving care; only 53 percent reported that their health was very good or excellent; 40 percent reported that they sometimes or often have problems or worries about medical bills; and 38 percent indicated that they had a current untreated health problem.176 Another study on former foster youth who aged out of the system and were currently attending a four-year university in California found that even among this group of relatively
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successful former foster youth, health outcomes and access to health care was still a problem; 33 percent rated their current health status as fair or poor and 46 percent of the sample had no health insurance.177
Other research suggests that many youth who age out of foster care have difficulty accessing mental health services. Courtney et al. (2001) found that during interviews while youth were still in care, mental health assessments indicated that foster youth experienced more mental health problems than is typical for other youth their age, and while still in care 47 percent of the sample indicated they had received some form of mental health services. However, 12 to 18 months after leaving care, mental health assessments indicated no significant improvement in the overall mental health of the sample; yet only 21 percent reported receiving some form of mental health services. These results suggest that although these youth continued to need mental health care; after leaving foster care, they were much less likely to receive this needed care.
There is also some evidence to suggest that youth who age out of foster care may use drugs and alcohol more frequently than other youth their ages. In a study that compared former foster youth attending college to low-income students attending college, results indicated that former foster youth were significantly more likely than the comparison group to have used alcohol or illegal drugs.178 However, other studies have not found differences between former foster youth and the general population in drug and alcohol use.179
Criminal Activity: Some research suggests that youth who age out of foster care are at risk for engaging in criminal activities. Courtney et al. (2001) found that 18 percent of former foster youth had been arrested, and 18 percent had been incarcerated. Hines and Lemon (in press) found that former foster youth were more likely than a comparison group of low-income college students to have done something illegal to get money and to have had a problem with the law. Moreover, another study found that among youth who had aged out of foster care, 45 percent had trouble with the law since leaving care; 41 percent had spent time in jail; 26 percent had formal charges against them; 24 percent had supported themselves by selling drugs at some point since leaving care; and 11 percent had exchanged sex for money.180
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Employment and Financial Circumstances: Being able to support oneself financially is often considered a marker of successful transition to adulthood; yet many foster youth aging out of care struggle with employment and finances. One study found that 26 percent of former foster youth had not had steady employment since leaving care; 60 percent had an annual income of $10,000 or less; 41 percent indicated that they did not have enough money to cover basic expenses. Courtney et al. (2001) found similar results; 57 percent of the sample currently held a job, and the median wage was just $4.60/hour; 54 percent reported that they did not have at least $250 in savings when they left care; and 32 percent reported that they had received some form of public assistance since leaving care. Another study of youth who aged out of care found that one year after leaving care, 53 percent reported that they had had difficulty meeting basic needs.181 Other research comparing employment outcomes of former foster youth with those of the general population have found that former foster youth generally have worse employment outcomes than the general population. One study found that 49 percent of former foster youth were employed 2.5 to 4 years after leaving care, compared to a 60 percent employment rate among the general population of 16-24 year olds. Further analysis indicated that 32 percent of youth who were working were also dependent on others for economic support.182
Living Situation: Foster youth who age out of the child welfare system face an increased risk of housing instability and homelessness. One study measuring outcomes 2.5 to 4 years after youth left care found that approximately one-third of youth had lived in five or more different places, and 25 percent had been homeless for at least one night.183 Courtney et al. (2001) found that 12 to 18 months after discharge from foster care, 22 percent of youth had lived in four or more different places. Additionally, 14 percent of males and 10 percent of females reported being homeless at least once since leaving care. Other studies report higher levels of homelessness among former foster youth. Reilly (2003) found that 36 percent of youth who left care were homeless at least once 6 months after leaving care. Another study found that 29 percent of youth had no place to live at least once in the 12 months since leaving care and that youth had an average of 6 living situations.184 Additionally, one study examined public shelter admissions by type of child welfare service and child welfare discharge among adults admitted to homeless shelters in New York City. Results indicated that nearly 26 percent of youth who were discharged to independent living had been in a homeless shelter at least once 10 years after
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leaving care, compared to 19 percent of youth who were reunified; and 12 percent of youth who received preventive services.185 Another study found that former foster youth were significantly more likely than low-income college students to have been homeless.186
Education: Former foster youth who age out of foster care are also at risk for educational difficulties. Research suggests that high school completion/GED rates among youth who age out of care are significantly below those of the general population in the same age group. Studies have found high school completion/GED rates among former foster youth to range from 39 percent to 77 percent,187 this is in comparison to rates of high school/GED completion in the general population of 25-29 year olds that range from 85 percent to 88 percent.188 Rates of college attendance among former foster youth have been found to range from 9 percent to 57 percent.189
Preparation for Independent Living: Overall, former foster youth aging out of the foster care system have varying levels of preparedness for independent living. Merdinger et al. (in press) found that among a sample of former foster youth attending college, 35 percent reported that the child welfare system did not prepare them well for independent living. In a study of youth 16 years or older who were currently in care, multivariate techniques were used to determine the types of characteristics most predictive of readiness for independent living. Results indicated that youth without mental health problems, those who had fewer out-of-home placements, those who performed well in school, those with an employment history, those who had contact with their fathers and those whose caretaker perceived them as ready for independent living performed better on measures of readiness for independent living.190
In general, there is evidence to suggest that you who participate in ILP services are better prepared for independent living that youth who do not participate in these services. For instance, Reilly (2003) found that the more services former foster youth received in preparation for independent living, the more likely the were to be more satisfied with their current living situation and to have less trouble with the law. Another study of former foster youth in college found that those who participated in ILP while in care reported being taught a greater number of independent living skills while in care.191 Additionally, Cook (1994) found that participation in
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ILP was related to better outcomes among former foster youth; those who participated in ILP were more likely than those who did not participate in ILP to be self-sufficient, very satisfied with life, and were more likely to access healthcare. ILP participation is also associated with an increased likelihood of having a stable living situation;192 as well as an increased likelihood of college attendance193 and participation in vocational programs.194
The Federal Outcomes Review Process Overview While previous federal review and accountability processes focused almost entirely on the accuracy and completeness of case files and other records, the new “Children’s and Family Services Reviews” (CFSR) process focuses on the effectiveness of services to children and families by measuring client outcomes. The CFSR process was launched in 2001; all 50 states, plus the District of Columbia and Puerto Rico, have now completed their CSFR reviews.
The review process has three phases. First, administrative data are summarized to assess certain quantitative indicators for each state. Second, an on-site review is conducted of a sample of 50 cases (half are foster care cases, and half in-home services cases) from three sites.195 Reviewers spend one week reviewing cases and interviewing agency stakeholders (such as judges or advocates) and case-specific stakeholders (such as parents, workers, and children)196 in order to determine whether each case is in “substantial conformity” with seven overall outcomes.197 If the state is found to be out of compliance on any of the outcomes based on both the administrative data and the on-site review process, the third phase involves the development of a program improvement plan. After a two-year implementation period, changes in the outcomes are assessed. If agreed upon targets have not been met by that time, financial penalties are assessed.198
Seven outcomes are assessed in this review process. These fall into three broad domains: safety, permanency, and well-being. In the safety domain, outcomes assess whether children are protected from abuse and neglect, and whether they are safely maintained in their homes. In the permanency domain, federal outcomes intend to assess whether children in out-of-home care have permanency and stability in their living situations, and whether continuity of family
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relationships are preserved. In addition to safety and permanency, the child welfare system must also ensure the well-being of children in its care. A total of 26 different indicators are used to assess the seven outcomes. Of these indicators, 3 rely on the administrative data only, 20 rely on the on-site data only, and 3 rely on both the onsite review and administrative data sources. Figure 1 provides a summary of the federal CSFR outcomes, the indicators used to measure each outcome, and the sources of information for evaluating the indicator. Figure 1: Federal outcomes, indicators, and data source Domain Outcome Indicator SAFETY
PERMANENCY
Children are protected from abuse and neglect Children are safely maintained in their homes Children have permanency and stability in their living arrangements
Continuity of family relationship is preserved
WELL-BEING
Families have enhanced capacity to provide for children’s needs
Children receive appropriate services to meet educational needs Children receive adequate services to meet their physical and mental health needs
Case Reviews x x
1. Timeliness of investigations of reports 2. Recurrence of maltreatment 3. Incidence of abuse or neglect in foster care 4. Services to family to protect children/ prevent removal 5. Current risk of harm to child 6. Foster care re-entries 7. Stability of foster care placement 8. Permanency goal for child 9. ILS (2001); reunification, guardianship or permanent placement with relative (2002-2004) 10. Achievement of adoption 11. Permanency goal of “other planned living arrangement” 12. Time to reunification 13. Time to adoption 14. Proximity of current placement 15. Placement with siblings 16. Visiting with parents and siblings 17. Relative placement 18. Current relation of child in care with parents 19. Preserving connections 20. Needs and services of child, parents, foster parents 21. Child and family involvement in case planning 22. Worker visits with child 23. Worker visits with parents 24. Educational needs of child
x x x
25. Physical health of child 26. Mental health of child
x x
Admin Data x x
x x x x x x
x x
x x x x x x x x x x x x
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The federal government has established the minimum performance level that a state must attain in order to be in “substantial conformity” with the outcomes. For outcomes based solely upon administrative data, a state must meet or exceed the standard established by the federal government. Standards are set at the point at which approximately 25% of states had performed better and 75% had performed worse in AFCARS and NCANDS submissions.199 Figure 2 displays the measures for the six administrative data indicators as well as the national standards. For outcomes based solely upon on-site case review data, 90% of cases reviewed in the state must be found to be in “substantial conformity.” For those outcomes based on both on-site reviews and administrative data, both requirements must be met. No state has achieved substantial conformity on all the outcomes. Figure 3 shows the number and proportion of jurisdictions achieving substantial conformity on the seven outcomes. California did not meet any of the national standards for the administrative data indicators, and was not in substantial conformity with any of the seven outcomes. As of January 2004 no penalties had been applied, but potential penalties range from $91,492 for North Dakota to $18,244,430 for California.200 Figure 2: Administrative data indicator measures and national standards Indicator Measurement Recurrence of maltreatment Incidence of abuse or neglect in foster care Foster care re-entries Stability of foster care placement Time to reunification
Time to adoption
Of all victims of substantiated child abuse or neglect during the first six months of the period under review, what % had another substantiated or indicated report within 6 months. For all children in foster care during the period under review, what % were the subject of substantiated or indicated maltreatment by a foster parent or facility staff For all children who entered foster care during the year under review, what % of them re-entered care within 12 months of a prior episode. Of all children who have been in foster care less than 12 months from the time of the latest removal, what % had no more than 2 placement settings. Of all children reunified with their parents at time of discharge from foster care, what % were reunified in less than 12 months from the time of the latest removal from home. Of all children who exited foster care during the year under review to a finalized adoption, what % did so in less than 24 months from the time of the latest removal from home.
National Standard 6.1%
0.57% 8.6% 86.7% 76.2%
32.0%
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Figure 3: Number and Proportion of States Achieving Substantial Conformity on Outcomes Domain Outcome # Safety Children are protected from abuse and neglect 6 Children are safely maintained in their homes 6 Permanency Children have permanency and stability in their living arrangements 0 Continuity of family relationship is preserved 7 Well-Being Families have enhanced capacity to provide for children’s needs 0 Children receive appropriate services to meet educational needs 16 Children receive adequate services to meet their physical and mental 1 health needs
% 12% 12% 0% 14% 0% 31% 2%
Measurement Issues The federal government and many state officials report that the CSFR process is valuable. In the 2004 GAO survey, 26 of 36 responding states either generally or completely agreed with results of their final CSFR report, even though none of the states achieved substantial conformity with all the outcomes. As a result of the process, some states report improved relationships with community stakeholders, as well as increased public and legislative attention being given to important child welfare issues.201
However, a number of measurement issues regarding the federal outcomes have been raised. State officials in all five states visited by the GAO office in 2004 expressed concerns that AFCARS and NCANDS data, upon which administrative data indicators are based, were not reliable. In addition, researchers have argued that administrative and case review data indicators may not be good measures of the phenomena of interest.
Administrative Data Indicators The administrative data indicators have a number of measurement problems. First, these indicators do not capture important aspects of child welfare processes, such as the rate of reunification and adoption. None of the six indicators relate to family and child well-being or to emancipated youth. Similarly, some do not capture the experience of important subsets of children. For example, placement stability is a far greater problem for youth who have been in care for longer periods, yet the related indicator captures the phenomenon only for children in care for 12 months or less.
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Second, the indicators do not take into account the dynamic nature of the child welfare system. Changes in one outcome can affect other outcomes.202 For example, decreasing the time to reunification is problematic if the re-entry rate increases as a result. Outcomes need to be considered in the context of other outcomes.
Third, the indicators do not take into account differences between states. According to Goerge, “…states exhibit a rather stunning degree of diversity…”203 These differences can include caseload dynamics (caseload population counts), use of kin placements, rate of entry, racial/ethnic populations, poverty, ethnicity, age and other variables that are likely to influence the outcomes. However, all states are required to meet the national standards, regardless of these differences.
Fourth, the indicators are limited by the format of the datasets from which they are drawn, and do not capture longitudinal caseload dynamics. As a result, indicators that require a longitudinal view, such as re-entry, cannot be adequately captured. Currently, the re-entry indicator represents the portion of current entries to care that are re-entries, a statistic that does not convey information about the rate at which cases re-enter care.
Fifth, several indicators rely upon exit cohorts to describe case phenomena. Exit cohorts are likely to be biased in important ways, since they exclude all youth who do not leave care. As a result, indicators derived from exit cohorts will tend to misrepresent the proportion of cases achieving permanency outcomes within the time frames.204 Exit cohorts are also heavily influenced by population dynamics, such as the number of children entering or exiting care per year. When these dynamics shift, length of stay estimates based on exit cohorts will change as well, even if nothing in the system has occurred that would affect them.205
These problems are intensified when indicators based upon exit cohorts are used to measure change over time. Research studies have demonstrated that performance trends differ markedly according to whether an entry or an exit cohort is used to assess change, even occasionally heading in opposite directions.206 The exit cohort perspective “distorts patterns of change over
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time making it difficult if not impossible to understand whether program and policy innovations are having their intended effect.”207
Lastly, there are concerns regarding the amount of improvement the federal government will be requiring states to make on the administrative indicators in order to avoid financial penalties. To determine how much states should be required to improve on each administrative indicator, the federal government treated the data submissions of the 52 jurisdictions as a sample, then derived the “sampling error.” This sampling error is the amount by which states must improve. However, the variability within the 52 jurisdiction sample is likely to be substantially greater than the variability of an individual state’s performance over time, particularly if the state is large. Applying the sampling error derived from the 52 sample to every individual state is inappropriate and places a much greater burden upon larger states. Researchers at the Center for Social Services Research at U.C. Berkeley calculated an improvement amount for the federal administrative indicators based upon the variability within the state of California, rather than the variability in the 52-jurisdiction sample. This amount is considerably lower than the current federal requirement, demonstrating the disadvantage large states experience in addressing federal mandates.
On-site Review Indicators A primary concern regarding the case file reviews is the small sample size, consisting of a total of 50 cases, half of which are in-home services cases and half foster care cases. While small samples can sometimes adequately reflect patterns that exist in a population, this is likely only when the sample is randomly selected. Moreover, because not every one of the cases in the sample has relevance for each indicator assessed in the on-site review, sometimes as few as one or two cases are used to evaluate the performance of a state.208 For example, in Wyoming only 2 cases were relevant to assess the on-site indicator of time to adoption. In one of these cases, reviewers determined that appropriate efforts had not been made to achieve the outcome. As a result, the state was assessed as “needing improvement” in this area.209 In California, 49 cases from three sites -- Los Angeles, San Mateo, and Stanislaus -- 210 represented over 100,000 children receiving services in California.
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A second concern is that in spite of the small sample, data from the on-site record reviews and interviews are heavily weighted in the CSFR process: 23 of the 26 indicators are based upon data from on-site reviews. Additionally, impressions arising from interviews and focus groups may be distorted when some participants are more vocal, even if the experiences they describe are not common. According to a state official in Arizona, one vocal participant in a focus group or interview can have an unreasonably large effect. “Those single comments too often become part of the case (review) report.”211
California’s Accountability Efforts California passed AB 636 in 2001 in response to both the federal outcomes reporting requirements, and the limitations of the indicators as performance measures. The “Child Welfare System Improvement and Accountability Act” of 2001 introduces an accountability system intended to facilitate continuous improvements in each county. Beginning in January 2004, “California Child and Family Service Reviews” were initiated in each of California’s 58 counties. These include a set of administrative performance indicators (see Figure 4). While a subset of these parallel the federal CFSR administrative data indicators, another subset goes beyond the federal effort by using California’s own database, the Child Welfare Services Case Management System (CWS/CMS). CWS/CMS data are shared with the Center for Social Services Research at the University of California at Berkeley, where analysts reconfigure the data so that they can be analyzed and considered longitudinally. This longitudinal database is able to generate outcomes that can better reflect the performance of the system and change in that performance over time.212
The California accountability effort differs from the federal one in several important respects. First, it is more comprehensive, utilizing more administrative data indicators including measures of well-being and measures related to emancipating youth. Secondly, these measures are more carefully constructed. For example, the federal indicator assessing maltreatment recurrence includes all children who experienced an initial referral. However, children who were removed at the time of the initial referral are much less likely to experience a subsequent referral, as they are now in state custody; therefore, one California indicator related to this area excludes these children from consideration. Third, California’s data are configured longitudinally, allowing
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accurate estimates of outcomes like re-entry to foster care. And fourth, indicators assessing the proportion of cases attaining permanency outcomes within certain time frames are based upon entry cohorts. Entry cohorts provide better estimates than do exit cohorts both of the phenomenon of interest, and of change over time. Figure 4: California 636 Administrative Indicators Area Safety Of all children with substantiated allegation within first 6 months of study period, what % had another substantiated allegation within 6 months? (Federal indicator #2) Of all children with a substantiated allegation during the 12 month study period, what % had a subsequent substantiated allegation within 12 months? Of all children with a first substantiated allegation during the 12 month study period, what % had a subsequent substantiated allegation within 12 months? Of all children with an inconclusive or substantiated allegation during the 12 month period who were not removed, what % had a subsequent substantiated allegation within 12 months? Of all children in foster care, what % had substantiated allegation by a foster parent? (Federal indicator #3) What % of child abuse and neglect referrals in the study quarter have resulted in an in-person investigation [stratified by immediate and 10 day]? Of all children who required a monthly social worker visit, how many received them? Permanency For all children who entered foster care during the year under review, what % of them re-entered care within 12 months of a prior episode? (Federal indicator #6) For all children entering foster care for the first time and staying in care for 5 or more days during the 12 month period, and reunified within 12 months of entry, what % re-entered care within 12 months? Of all children who have been in foster care less than 12 months from the time of the latest removal, what % had no more than 2 placement settings? (Federal indicator #7) For all children entering foster care for the first time and staying in care for 5 or more days during the 12 month period, and were in care for 12 months, what % had no more than 2 placements? Of all children reunified with their parents at time of discharge from foster care, what % were reunified in less than 12 months from the time of the latest removal from home? (Federal indicator #12) Of all children entering foster care for the first time and staying in care for 5 or more days during the 12 month study period, what % were reunified within 12 months? Of all children who exited foster care during the year under review to a finalized adoption, what % did so in less than 24 months from the time of the latest removal from home? (Federal indicator #13) Of all children entering foster care for the first time and staying in care for 5 or more days, what % were adopted within 24 months? Well-being For all children in care at the point-in-time of interest, of those with siblings in care, what % were places with some or all siblings [stratified by all/some]? For all children entering foster care for the first time (5 days+) during the 12 month study period, what % were in each placement type? [stratified by first placement, predominant placement, point-in-time]? Of those children identified as American Indian, what % were placed with relatives, non-relative Indian, and non-relative Indian families?
Lastly, the state did not establish any particular standards and counties are not expected to meet a particular performance goal. (There is a single exception: for the measure regarding monthly
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worker visits with children, there is a required level of compliance of 90%). Rather, based on their performance on the measures, counties identify areas for improvement. To enhance their understanding of problem areas, counties conduct “peer quality reviews.” Relevant cases are randomly selected and interviews with involved social workers, clients, and other personnel are conducted. This process generates qualitative information that “provides an in-depth analysis of case results and promotes information sharing that helps build the capacity of social workers and other staff.”213 This strategy eliminates direct comparisons of outcomes between counties that may have very different population, economic, and demographic characteristics.
Implications The child welfare research literature was reviewed to provide a context for assessing federal and state measurement and accountability efforts. However, researchers and federal administrators have framed outcomes differently: while federal reports and outcomes consider exit cohorts to determine what proportion of cases reunify or are adopted, and how quickly, researchers have not used this sampling strategy due to the biases involved. This makes it difficult to assess whether the national standards are reasonable in the context of the historical achievements of the system. However, a number of conclusions could be drawn from the research literature on child welfare outcomes.
First, there is clearly plenty of room for improvement, and the government’s effort to assess outcomes is an important step in the right direction. Second, some of the outcomes that researchers have been studying over the last few decades (such as the proportion of cases that reunify or are adopted, or placement stability for children in long-term care) are not captured by current administrative data indicators. Third, a myriad of factors appear to influence each outcome, suggesting that comparisons between states could be misleading if these differences are not taken into account. And fourth, while the outcomes of youth in care and emancipating from the system related to well-being are generally poor, this area is not emphasized in the federal review process.
Additionally, the measurement problems in the federal review process have several implications. The distortion from using estimates based upon exit cohorts, combined with the questionable
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reliability of the data from the on-site reviews due to the small sample size, suggest that conclusions about state performance drawn from these data sources could very well be erroneous. As a result, heavy fines could be levied inappropriately. The potential consequences for California are substantial; the state stands to lose more than 18 million dollars, more than any other state.214 And because the understanding gained from these data could be inaccurate, “corrective action” taken by a state to improve outcomes could negatively affect the true outcomes being sought.215 Because financial penalties will be imposed if targets are not met, states have a strong incentive to achieve the targets even if the efforts necessary to do so do not serve children and families well.216 For example, in order to reach the re-entry target, an agency might reunify fewer families, since fewer reunified families means fewer re-entries. Similarly, current practices that benefit children might negatively affect the outcomes.217 For example, successful efforts to move children currently in long-term foster care into adoptive homes would negatively affect a state’s performance on the adoptions indicator as currently defined; any child adopted after having been in care over 24 months will reduce the proportion of those adoptions that are completed within 24 months.
The good news is that California’s proactive efforts to articulate meaningful outcomes and utilize longitudinal data may serve the state well. If the federal government attempts to levy the fines as threatened, California will be in a good position to argue such fines are not appropriate, based upon better and more comprehensive data, more carefully conceptualized indicators, and more sensibly calculated improvement rates.
Recommendations With the CSFR review process, the federal government has chosen to hold states accountable for what can be counted, even though these measures do not always capture meaningful outcomes. To correct the situation, the following changes are recommended.
Three changes related to administrative indicators are needed. First, administrative indicators should be redefined based upon entry cohorts and longitudinal data, rather than exit cohorts and point-in-time samples, so that a more accurate depiction of case processes can be obtained. Second, additional administrative data indicators (based upon longitudinal entry cohorts) should
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be incorporated into the review process in order to capture important aspects of child welfare case processes (such as the proportion of cases reunified, adopted, and still in care at certain time points). Third, national standards for administrative indicators should be eliminated. States should only be compared against themselves because of their many differences. If this is not possible, estimates could be risk-adjusted. For example, while incorporating an understanding of all relevant risk factors would be impossible, it would not be difficult to use some basic demographics like age and race to adjust performance estimates.218
Additionally, states should ensure their data systems allow for a longitudinal view of children’s experiences. Changes to SACWIS systems that would be necessary to facilitate this could involve some costs to states, but would not be difficult to undertake.219 States would also be well-advised to develop their own accountability systems based upon longitudinal data, both so that they can better understand their own performance and make corresponding program and policy adjustments, but also so they will be prepared to defend their performance as appropriate and necessary should conclusions from the federal CSFR process differ from their own assessments.
The measurement concerns regarding the administrative indicators arise from the limitations of AFCARS and NCANDS data. These databases do not link files for children from year to year, a structure that does not allow a longitudinal consideration of children’s experiences.220 Ultimately, AFCARS and NCANDS datasets need to be overhauled221 so that the federal government can gain more accurate understanding of state processes and achievements. Until AFCARS and NCANDS are reconstituted, states should be allowed to utilize other data sources in their CFSR assessments and these should be considered before final CFSR determinations are made.222
On-site case review and interview data should not be used to assess state performance, unless a true random sample of a reasonable size can be drawn. If this is not possible, a small, nonrandom sample might be useful as a way to explore possible explanations for outcomes seen in administrative data.
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Lastly, federal and state legislatures must devote resources to helping public child welfare agencies carry out their responsibilities for accountability.223 States need the ability to configure data so that it conveys meaningful information for management and accountability efforts, as well as the resources to hire personnel with the capacity to conceptualize and calculate appropriate measures of systems improvements. Only with these resources can states evaluate and improve services to children and families. Endnotes 1
Courtney, Needell & Wulczyn (2004) Kautz, Netting, Huber, Borders & Davis (1997) 3 Administration for Children and Families (b) 4 U.S. General Accounting Office (2004) 5 English, Marshall, Brummel & Orme (1999); Fuller & Wells (2003) 6 DePanfilis & Zuravin (2002), (1999); English et al. (1999); Lipien & Forthofer (2004); Terling (1999) 7 DePanfilis & Zuravin (1999); Lipien & Forthofer (2004); Terling (1999) 8 Drake, Johnson-Reid, Way & Chung (2003) 9 Lipien & Forthofer (2004); Marshall & English (1999) 10 Fuller, Wells & Cotton (2001) 11 Courtney et al. (1997); Terling (1999) 12 Terling (1999) 13 Fluke et al. (1999) 14 Fuller &Wells (2003) 15 Depanfilis & Zuravin (2002) 16 Marshall & English (1999) 17 Jones (1998) 18 Fuller & Wells (2003) 19 Marshall & English (1999) 20 Depanfilis & Zuravin (2002) 21 Depanfilis & Zuravin (2002) 22 Marhall & English (1999) 23 Fuller et al. (2001) 24 Depanfilis & Zuravin (2002) 25 Fluke et al. (1999); Fuller et al. (2001); Terling (1999) 26 Lipien & Forthofer (2004) 27 Depanfilis & Zuravin (2002) 28 Fluke et al. (1999) 29 Fuller et al. (2001); Marshall & English (1999) 30 Terling (1999) 31 Fluke et al. (1999) 32 Lipien & Forthofer (2004) 33 DePanfilis & Zuravin (1999) 34 Marshall & English (1999) 35 Inkelas & Halfon (1997) 36 Fuller et al. (2001) 37 Depanfilis & Zuravin (2002) 38 Groze (1990) 39 U. S. DHHS (2005) 40 Annie E. Casey (2005) 41 Rosenthal, Motz, Edmonson, & Groze (1991) 42 Spencer & Knudsen (1992) 43 Blatt (1992) 2
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Groze (1990) Rosenthal et al. (1991) 46 Spencer & Knudsen (1992) 47 Courtney (1995); Courtney, Piliavin & Wright (1997); Festinger (1996); Jones (1998); Wulcyzn (1991) 48 Frame, Berrick, & Brodowski (2000) 49 Courtney (1995) 50 Wells & Guo (1999) 51 Courtney, Piliavin, & Wright (1997) 52 Courtney (1995); Courtney, Piliavin & Wright (1997); Jones (1998); Wells & Guo (1999) 53 Courtney (1995) 54 Jones (1998) 55 Courtney (1995) 56 Frame et al. (2000) 57 Festinger (1996) 58 Festinger (1996) 59 Wells & Guo (1999) 60 Wells & Guo (1999) 61 Courtney (1995); Courtney et al. (1997); Frame et al. (2000) 62 Courtney (1995); Courtney et al. (1997); Wells & Guo (1999) 63 Barth (1997); McMurty & Lie (1992) 64 Courtney (1994), Harris & Courtney (2003); Wells & Guo (1999) 65 Courtney, McMurty & Zinn (2004); Wells & Guo (2004); Wells & Guo (2003) 66 Courtney & Wong (1996); Smith (2003) 67 Harris and Courtney (2003) 68 Courtney (1994) 69 Courtney & Wong, (1996) 70 Wells & Guo (1999) 71 Courtney (1994) 72 Harris & Courtney (2003) 73 Courtney (1994) 74 Landsverk, Davis, Ganger, Newton & Johnson (1996) 75 Courtney & Wong (1996) 76 Smith (2003a) 77 Courtney (1994) 78 Courtney, McMurty, et al. (2004) 79 Wells & Guo (2003) 80 Wells & Guo (2004) 81 Harris & Courtney (2003) 82 Wells & Guo (1999) 83 Smith (2003a) 84 Wells & Guo (2004) 85 Courtney & Wong (1996); Harris & Courtney (2003); Wells & Guo (2003), (1999) 86 Courtney (1994) 87 Courtney & Wong (1996) 88 Harris & Courtney (2003) 89 Wells & Guo (1999) 90 Courtney & Wong (1996) 91 Smith (2003a) 92 Courtney & Wong (1996) 93 Courtney, McMurty & Zinn (2004) 94 Barth (1997); McMurty & Lie (1992) 95 Courtney (1994) 96 Wells & Guo (2004) 97 Wells & Guo (2003) 98 Kemp & Bodonyi (2002) 45
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Kemp & Bodonyi (2002) Kemp & Bodonyi (2000) 101 Barth (1997); Courtney & Wong (1996); Kemp & Bodonyi (2002); Smith (2003b) 102 Schmidt-Tieszen & McDonald (1998) 103 Barth (1997); Courtney & Wong (1996) 104 Barth (1997) 105 Courtney & Wong (1996) 106 Schmidt -Tieszen & McDonald (1998) 107 Kemp & Bodonyi (2002) 108 Smith (2003b) 109 Courtney & Wong (1996) 110 Smith (2003b) 111 Courtney & Wong (1996) 112 Courtney & Wong (1996) 113 Courtney & Wong (1996) 114 Smith (2003b) 115 Freundlich & Avery (2004) 116 Courtney & Wong (1996) 117 Courtney & Wong (1996) 118 Smith (2003b) 119 Brooks, James & Barth (2002) 120 Brooks & James (2003) 121 Smith et al. (2001); Webster, Barth & Needell (2000); Wulczyn, Kogan & Harden (2003) 122 Palmer (1996) 123 James, Landsverk, & Slymen (2004) 124 Pardeck (1984) 125 Usher, Randolph & Gogan (1999) 126 Fernandez, (1999) 127 Webster et al. (2000) 128 Smith et al. (2001) 129 Wulczyn et al. (2003) 130 Webster et al. (2000) 131 Webster et al. (2000) 132 James et al. (2004) 133 Smith et al. (2001) 134 Wulczyn et al. (2003) 135 Newton, Litrownik & Landsverk (2000) 136 Wulczyn et al. (2003) 137 Palmer (1996) 138 Barber, Delfabbro & Cooper (2001) 139 Newton et al. (2000) 140 Herrenkohl, Herronkohl & Egolf (2003) 141 Barber & Delfabbro (2003) 142 Webster et al. (2000) 143 Barber et al. (2001) 144 Webster et al. (2000) 145 Wulczyn et al. (2003) 146 Gilbertson & Barber (2003) 147 Hochstadt, Jaudes, Zimo & Schachter (1987) 148 Chernoff, Combs-Orme, Risley-Curtiss & Heisler (1994) 149 McIntyre & Keesler (1986) 150 Clausen, Landsverk, Ganger, Chadwick & Litrownik (1998) 151 Dubowitz, Zuravin, Starr, Feigelman & Harrington (1993) 152 Kortenkamp & Ehrle (2002) 153 Chernoff et al. (1994) 100
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Halfon, Berkowitz & Klee (1992) Harman, Childs & Kelleher (2000) 156 Zima, Bussing, Freeman, Yang, Belin & Forness (2000) 157 Garland, Landsverk, Hough & Ellis-Macleod (1996) 158 Hurlburt, Leslie, Landsverk, Barth, Burns, Gibbons, Slymen & Zhang (2004) 159 Taussig, Clyman & Landsverk (2001) 160 Davidson-Arad, Englechin-Segal & Wozner (2003) 161 Horowitz, Balestracci & Simms (2001) 162 Fein, Maluccio, Hamilton & Ward (1983) 163 Kortenkamp & Ehrle (2002) 164 Flynn & Biro (1998) 165 Eckenrode, Laird & Doris (1993) 166 Wodarski, Kurtz, Gaudin & Howing (1990) 167 Chernoff et al. (1994) 168 Zima et al. (2000) 169 Colton, Health & Aldgate (1995) 170 Evans (2004) 171 Burley & Halpern (2001) 172 U. S. GAO (1999) 173 National Foster Care Awareness Project (2000) 174 Reilly (2003) 175 Courtney, Piliavin, Grogan-Kaylor & Nesmith (2001) 176 Barth (1990) 177 Merdinger, Hines, Lemon & Wyatt (in press) 178 Hines & Lemon (in press) 179 Cook (1994) 180 Reilly (2003) 181 Barth (1990) 182 Cook (1994) 183 Cook (1994) 184 Barth (1990) 185 Park, Metraux, Brodbar & Culhane (2004) 186 Hines & Lemon (in press) 187 Barth (1990); Blome (1997); Cook (1994); Courtney et al. (2001); Festinger (1983); Mech (1994); Reilly 2003; Zimmerman (1982) 188 Merdinger et al. (in press) 189 Barth (1990); Cook (1994); Courtney et al. (2001); Festinger (1983); Wedeven, Pecrora, Hurwitz, Howell & Newell (1997) 190 Iglehart (1994) 191 Lemon, Hines & Merdinger (2005) 192 Harding & Luft (1994) 193 Lindsey & Ahmed (1999) 194 Harding & Luft (1994); Lindsey & Ahmed (1999) 195 Administration for Children and Families (May, 2002) 196 U.S. General Accounting Office (2004) 197 U.S. Department of Health and Human Services (2003) 198 Administration for Children and Families (August, 2001) 199 Administration for Children and Families (a); Courtney, Needell & Wulczyn (2004). 200 U.S. General Accounting Office (2004, April) 201 U.S. General Accounting Office (2004, April) 202 Courtney, Needell & Wulczyn (2004); Goerge, Wulczyn & Harden (1996); Tilbury (2004); Usher, Wildfire & Gibbs (1999); Wells & Johnson (2001) 203 Goerge et al. (1996) 204 Courtney, Needell & Wulczyn (2004) 205 Wulcyzn, Kogan & Dilts (2001) 155
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Courtney, Needell & Wulczyn (2004) Courtney, Needell & Wulczyn (2004) 208 U.S. General Accounting Office (2004, April) 209 U.S. General Accounting Office (2004, April) 210 Administration of Children and Families (c) 211 Stack (2005) 212 California Department of Social Services 213 California Department of Social Services 214 U.S. General Accounting Office (2004, April) 215 Courtney, Needell & Wulczyn (2004) 216 Courtney, Needell & Wulczyn (2004) 217 U.S. General Accounting Office (2004, April) 218 Courtney, Needell & Wulczyn (2004) 219 Courtney, Needell & Wulczyn (2004) 220 Courtney, Needell & Wulczyn (2004) 221 Courtney, Needell & Wulczyn (2004) 222 U.S. General Accounting Office (2004, April) 223 Courtney, Needell & Wulczyn (2004) 207
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APPENDIX: BASSC SEARCH PROTOCOL Search Terms 1. Child welfare OR foster care AND reunification 2. Child welfare OR foster care AND recidivism 3. Child welfare OR foster care AND reentry 4. Child welfare OR foster care AND permanency 5. Child welfare OR foster care AND health AND outcomes 6. Child welfare OR foster care AND well-being AND outcomes 7. Child welfare OR foster care AND educational AND outcomes 8. Child welfare OR foster care AND safety AND outcomes 9. Child welfare OR foster care AND performance OR outcome AND measures 10. Child abuse OR child neglect OR child maltreatment AND foster home OR out-of-home 11. Child welfare OR foster care AND adoption 12. Child welfare OR foster care AND emancipation OR transition OR adulthood 13. Child welfare OR foster care AND placement stability OR placement instability OR placement disruption. Academic databases for books and articles Pathfinder or Melvyl ArticlesFirst Current Contents Database ERIC Expanded Academic ASAP Family and Society Studies Worldwide PAIS International PsychInfo Social Science Citation Index Social Services Abstracts Social Work Abstracts Sociological Abstracts Systematic Reviews Campbell Collaboration Cochrane Library Reference lists from primary & review articles Research Institutes Brookings Institute CASRC (San Diego) Chapin Hall GAO Manpower Demonstration Research Corporation Mathmatica Policy Research, Inc.
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National Academy of Sciences RAND Urban Institute Conference proceedings PapersFirst (UCB Database) Proceedings (UCB Database) Dissertation Abstracts DigitalDissertations (UCB database) Professional Listserves EVALTALK GOVTEVAL ChildMaltreatmentListserve Internet Google / Google Scholar Dogpile
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