Tag: Family First Act

The power of wishful thinking: The continued promotion of Healthy Families America as a child abuse prevention program

by Marie Cohen

The original version of this post was published on April 4, 2022. I decided to update and re-publish it after reading a press release from Prevent Child Abuse America stating that “PCAA’s signature home visiting program, Healthy Families America, has been proven to reduce child abuse and intimate partner violence while improving long-term health and educational outcomes.” While I cannot evaluate the claim about domestic violence, the post below show that Healthy Families America has not been “proven” to reduce child abuse.

I have written before about the power of wishful thinking and how it causes people to disregard research and real-life results. A program called Healthy Families America (HFA) offers a good example of the power of wishful thinking. The nation’s oldest and largest charity (now called Prevent Child Abuse America or PCAA) dedicated to the prevention of child abuse launched HFA based on weak evidence that a program in Hawaii could prevent child maltreatment. The first experimental study of the Hawaii program found no impact on child maltreatment but did nothing to derail the launch of HFA, which grew into the centerpiece of PCAA. Studies of HFA programs around the country have found little evidence of reductions in child maltreatment, but the program has continued to grow. The story of HFA is a lesson in the power of wishful thinking and the failure of evidence (or lack thereof) to counteract it.

As told in a helpful history of home visiting, all modern programs can trace their origins to Henry Kempe, whose book, The Battered Child, brought about the recognition of child maltreatment as a national problem. To address child abuse, Kempe called for universal prevention through a network of home health visitors. Inspired by Kempe, modern home visiting began with Hawaii’s implementation of the Healthy Start Project (HSP) in 1975. HSP was developed on the island of Oahu. It had two components: early identification (at the birthing hospital) of families with newborns at risk of child abuse and neglect and home visiting by trained paraprofessionals for those families classified as at-risk who agreed to participate. This initial program was never evaluated, but anecdotal information suggested it was successful in promoting effective parenting, and six similar programs were established on neighboring islands.

The Hawaii Legislature authorized a three-year pilot program focusing on one neighborhood in Oahu, which began in 1985. There was no control group in the pilot study, and the researchers used CPS reports and changes in family stress in participating families to measure program effectiveness. During the three-year pilot, there were few reports of physical abuse, neglect or imminent harm for program participants. Because evaluations of other home visiting programs had found much higher rates of reported maltreatment in comparison group families, these results were viewed as evidence that the program had a positive impact. According to the authors of the first rigorous evaluation of HSP, “The pilot study results might have been given too much weight, given the lack of a control group and the short period of follow-up for most families.” Nevertheless, the results of this unpublished study were enough evidence for the Legislature to expand HSP throughout Hawaii starting in 1989.

Home visiting in general was gathering steam in the 1980s and early 1990’s. In 1990, the U.S. General Accounting Office (GAO) issued a report promoting home visitation as a “promising early intervention strategy for at-risk families.” In its summary of research evidence, GAO focused mostly on health and developmental benefits for children, rather than maltreatment prevention. In 1991, the U.S. Advisory Board on Child Abuse and Neglect issued a report recommending a pilot of universal voluntary neonatal home visitation, stating that the efficacy of home visiting as a preventive measure was “already well-established.” The Board cited the results of a federally-funded demonstration begun 17 years earlier as well as the the nurse home visitation program started by David Olds in 1977. But HSP was not mentioned.

Despite the lack of a rigorous evaluation, the National Committee to Prevent Child Abuse (NCPCA, now called Prevent Child Abuse America), which bills itself as the nation’s “oldest and largest organization committed to preventing child abuse and neglect before it happens,” had become interested in using HSP as the nucleus of a national home visiting program. But first, NCPCA conducted a one-year randomized trial of HSP. The trial suffered from severe methodological limitations, including “less than ideal followup,” differential dropout rates in the program and control groups, the failure to blind interviewers to experimental or control status, and reliance on program staff rather than researchers to measure some outcomes. Nevertheless, the trial concluded that HSP reduced child maltreatment, and this apparently gave NCPCA the assurance it needed to invest in the model.

NCPCA launched Healthy Families America in 1992, with financial support from Ronald MacDonald House Charities. Rather than impose a single service model, HFA was based on a set of principles or critical elements, which included initiation of services prenatally or at birth, assessment of the needs of all new parents in the target area, voluntary nature of services, at least weekly services for families with the highest needs, availability of services for three to five years, comprehensive nature of services, and cultural competence, among others. The typical HFA program included an assessment of all new or first-time parents in a given community at the time their babies are born or prenatally.”

In the meantime, the Hawaii Department of Health recognized the limitations of both the pilot study and the NCPCA study and initiated a more rigorous evaluation of HSP in 1994. This was a randomized controlled trial, with at-risk families identified at the hospital and randomly assigned to the experimental and control groups. In 1999 the results of the Evaluation of Hawaii’s Healthy Start Program were released as part of an issue of the Future of Children journal containing evaluations of six different home visiting models.  No overall positive program impact emerged after two years of service in terms of child maltreatment (according to maternal reports and child protective services reports). Early HFA evaluation results, published in the same issue, also failed to find effects on abuse and neglect in three randomized trials, which included the HSP evaluation discussed above and another Hawaii HSP study.

David Olds had had begun testing his Nurse Home Visiting Program in 1977 and already had long-term results on the program in Elmira, NY, as well as shorter-term results for a replication in Memphis, Tenn. That program, now known as Nurse Family Partnership, was very different from HFA. It was restricted to first-time teenage mothers and the home visitors were nurses rather than paraprofessionals. The nurses followed detailed protocols for each visit. The researchers found that among low-income unmarried women (but not other participants), the program reduced the rate of childhood injuries and ingestions of hazardous substances that could be associated with child abuse or neglect. Follow-up of the Elmira group when the children were 15 found that the nurse-visited mothers were significantly less likely to have at least one substantiated report of maltreatment. These results are particularly impressive because they overrode a tendency for nurse-visited families to be reported for maltreatment by their nurse visitors. The researchers concluded that the use of nurses, rather than paraprofessionals, was key to the success of the program.

In their analysis of all six studies published in the Future of Children volume on home visiting, Deanna Gomby et al. concluded that while the HFA and HSP evaluations showed some change in maternal attitudes and self-reported behaviors related to abuse and neglect, only the Nurse Home Visiting Program showed impacts on abuse and neglect other than from self-reports. Gomby and her co-authors also concluded that the results of all six home visiting evaluations were discouraging for those who had high hopes for home visiting for solving an array of problems. All the programs “struggled to enroll, engage and retain families.” Program benefits generally accrued to only a subset of enrolled families and were often quite modest. The authors explained the disappointing results by concluding that human behavior is hard to change, particularly when problems are community-wide. They recommended that “any new expansion of home visiting programs be reassessed in light of the findings presented in this journal issue” and stated that home visiting services are “best funded as part of a broad set of services for families and children.”

But the home visiting juggernaut was already in motion nationwide. And NCPCA, renamed Prevent Child Abuse America in 1999, had already made HFA its centerpiece program. Home visiting grew, and HFA grew with it. In 2010, Congress created the Maternal, Infant and Early Childhood Home Visiting Program (MIECHV), which was re-authorized in 2018 with funding of $400 million per year through FY 2022. HFA is one of the models that are most frequently implemented with MIECHV dollars. Home visiting programs can also receive funding through Medicaid, Title IV-B and IV-E of the Social Security Act, and many other funding sources. HFA now serves over 70,000 families per year at an average cost of over $3,000 for a family in its first year of home visiting.

The infusion of funding for HFA research resulted in a multitude of research projects (both randomized trials and less rigorous studies) and resulting publications. Nevertheless, research has yet to find solid evidence that these programs have an impact on child maltreatment: The California Evidence-Based Clearinghouse for Child Welfare (CEBC), the pre-eminent child welfare program clearinghouse, reviewed 19 research reports on HFA. Its website as of April 2022 gave the program a rating of “4” on a scale of 1 to 5 for prevention of child abuse and neglect, meaning the evidence fails to demonstrate that HFA has an effect on abuse and neglect. Interestingly, that rating no longer appears on the CEBC website, but the earlier version is preserved by the Wayback Machine. As of April 2025, HFA is no longer listed at all in the CEBC’s document titled Home Visiting Programs for Prevention of Child Abuse and Neglect. When I emailed the CEBC to ask about the missing rating, I received an email stating that Healthy Families America “is still currently under review in the Prevention of Child Abuse and Neglect topic area. The rating for this topic area was pulled from the website during the rereview process. Some programs take longer to review due to the amount of research and other factors.”

HFA was not designed to work with families that have already been found to abuse or neglect their children but that did not stop child welfare agencies from spending federal and state funds delivering HFSA to families under the Family First Prevention Services Act (FFPSA). Despite the lack of evidence of its impact on maltreatment, HFA received a rating of “Well Supported” from the clearinghouse established by FFPSA to determine whether a program can receive federal funding under Title IV-E of the Social Security Act. To get such a rating, the program must show improved outcomes based on at least two randomized trials or rigorous quasi-experimental studies. But these outcomes could be any sort of “important child and parent outcome,” (not just reduction of child abuse or neglect) and there is no standard for how to measure each outcome. Based on its review of all HFA studies that met their criteria for inclusion, the Clearinghouse found 23 favorable effects, 212 findings of no effect, and four unfavorable effects across 16 outcomes. This included five favorable effects on child safety based on parents’ self-reports of maltreatment, with no favorable effects on other measures of child safety. Self-report is generally frowned upon as a measure of child maltreatment, for obvious reasons. A positive impact of HFA might reflect that participants in HFA were more eager than control group members to provide the “right answer” to questions about maltreatment.

The “well-supported” rating from the Title IV-E clearinghouse allowed states to spend Title IV-E funds on services to families with a child welfare in-home case. To take advantage of this new market, HFA announced in September 2018 that families referred by the child welfare system were now able to enroll as long as the child in question was 24 months of age or younger, as opposed to the original requirement that services start at or before birth. To serve these families, HFA introduced special child welfare protocols. HFA advertises these protocols on its website, stating that “HFA’s evidence and the flexibility of enrollment make HFA a great prevention choice for states and child welfare organizations seeking to strengthen families and reduce the number of children placed in foster care.” (Note that there is no mention of reducing abuse and neglect!)

Today, the diversity of HFA programs makes evaluation of the program as a whole impossible. According to the website, “HFA puts communities in the driver’s seat. Local HFA programs are able to choose their eligibility criteria, parenting materials, and hire the staff they deem best to do the job. With the amount of flexibility offered, HFA has been able to be successfully implemented in a wide variety of communities.” It is hard to imagine what the evaluation of one HFA program means about the effectiveness of other programs under the same name.

Critical examination of the HFA website shows that the organization skews its portrayal of available research to present it in the most favorable light and avoids direct statements that the program prevents child abuse and neglect. On its Evidence page, HFA claims the “highest rating possible from CEBC in the category “Home Visiting Programs for Child Well-Being,” without mentioning that in the category “Home Visiting Programs for the Prevention of Child Abuse and Neglect,” HFA is currently unrated after the statement that it was unable to demonstrate an effect was removed. The page goes on to group the effects of HFA into three categories, stating that participants “build nurturing relationships with their children,” “champion their children’s health and development,” and “cultivate a flourishing future for their family.” Reductions in abuse and neglect are not mentioned in the description of how parents “build nurturing relationships with their children.”

It is disappointing that an organization that defines its mission as child abuse prevention, decided to fund HFA before it was proven to prevent child maltreatment and continued with this commitment even after the disappointing evaluations of 1999 might have led them to diversify their investment. That PCAA continues to use charitable contributions made for the prevention of child abuse and neglect to fund a program that has not been proven to accomplish this goal, raises serious ethical questions. Twenty-three members of the 45-person staff (which has grown by five staff in three years !) listed on the Prevent Child Abuse website have duties linked to Healthy Families America.

The story of HFA is not an unusual one. I have written about the similar disregard for evidence in the promotion of models such as Homebuilders and blind foster care removals. Such stories are all too frequent. They show us how wishful thinking can drive leaders to disregard research, especially after they have made a premature decision to commit to one program or course of action.

The child placement crisis: It’s time to lose the slogans and find real solutions

By Judith Schagrin

A note from Child Welfare Monitor: It is a privilege to publish this important essay by Judith Schagrin. Judith earned an undergraduate degree from the University of Pennsylvania and a master’s degree in social work (MSW) from the University of Maryland School of Social Work.  She unexpectedly found her passion in public child welfare, and more specifically, foster care after helping start an independent living preparation program for young people in care. After a decade as a foster care social worker specializing in adolescence in a large Maryland county department of social services, she supervised two different units before becoming the county’s director of foster care and adoptions, serving in this position for twenty years.  She also worked part-time for the Agency’s after-hours crisis response for a decade.  For almost 10 years, she served as a respite foster parent for a private foster care agency, and since 2008, has mentored a young person who aged out of care in California and came east for college.  In  2001, with a little help from her friends, Judith founded Camp Connect, a weeklong sleepaway camp to reunify brothers and sisters living apart in foster care and provide memorable experiences siblings can share for a lifetime.  For the past 23 years – one year virtual – she has spent the week at Camp Connect immersed in the care of Maryland’s foster children and youth.

The closing of children’s mental hospitals in the 1980s, the subsequent closure of detention centers leaving foster care to take up the slack, the movement to shutter all group homes and residential treatment programs and the prohibition of out-of-state placements have created a slow-motion train wreck whose results could have been predicted easily at every new chain in the sequence. Those results include children and youth staying in psychiatric hospitals long after being ready for discharge, “boarding” in emergency rooms and “placed” in hotels at a cost of $30,000 to $60,000 per child per month. From my 35-year vantage point as a caseworker, supervisor, and then running foster care and adoptions in a large Maryland county, I’ve had a front row seat to the evolution of this crisis and the failure to come up with real solutions. 

Deinstitutionalization

The first in a series of events that created this crisis occurred in the 1980s, when the deinstitutionalization that began for adults in the 1960’s with the civil rights movement expanded to include children.  Until then, youth remained in state hospital facilities for as long as a year or even more.  The closure of those state facilities led to the expansion of Medicaid-funded residential treatment centers (RTC’s), that stepped in to provide the longer term care once provided in the state hospitals.  In turn, group homes proliferated to meet the needs of youth discharged from RTC’s.  The advent of Medicaid was instrumental in expanding prIvate psychiatric treatment options, including hospitals.  But over time, Medicaid stopped funding even 30 days of treatment, limiting payment to only  a few days of crisis intervention. 

Today, many youth, especially older youth, are entering foster care not because of what we traditionally think of as maltreatment, but due to parental incapacity or unwillingness to care for them due to acutely problematic behavior, and behavioral health and/or developmental needs.  Services to meet these needs are often missing or inadequate, and parents of children with high-intensity needs cannot find residential treatment except through the child welfare system.  Medicaid doesn’t pay for treatment and care in a group home of any kind; access in Maryland requires the child welfare system’s physical or legal custody.

New approach to juvenile justice

In the early 2000’s, a series of Supreme Court decisions brought welcome changes to juvenile justice and shifted the country from the ‘get tough’ approach of the ‘80’s and 90’s to the ‘kids are different’ era.  Moving from punishment to rehabilitation and minimizing detention in favor of community services makes sense on both humanitarian and neuroscience grounds.  But it meant that youth who once fell under the purview of Juvenile Services now required child welfare intervention when parents or other caregivers were unwilling or unable to continue to provide care. The mother evicted from four apartments because of her son’s property damage; the grandmother who stepped in years ago and is no longer able to cope with her granddaughter after the third vehicular misuse charge and chronic episodes of running away; or a parent with younger children afraid that an older sibling known to have rages and episodes of violence will harm his siblings, are examples of desperate caregivers I have come across.

In Maryland, the first alarm that child welfare was ill-equipped to care for these youth was sounded in 2002 by local department directors in a memo to the head of the Department of Human Services.   Closing detention centers was a good thing, but alternatives weren’t developed for those youth unable to live at home, and no resources were provided to help child welfare accommodate its new clients. As the closure of state psychiatric facilities and detention beds was widely celebrated, the belief that every youth had a family eager and able to provide a home was more than a touch naive, as would soon become clear. 

Group home closures

Another domino fell in the early 2000’s, when group homes, many poorly administered with little oversight, became a scandal in Maryland.  A series of articles in the Baltimore Sun exposed the flaws of many group care programs, and some were forced to close.  With the scandals around bad group homes, the timing was perfect for state leadership, encouraged by a national advocacy group with deep pockets and the laudable dream of a family for every child, to lead a movement to shutter congregate care placements.  Funding constraints, too, forced some providers out of business.  Reimbursement rates did not keep up with costs, and some programs closed their doors due to inadequate reimbursement.   The state lost roughly 450  beds in five or six years, including entire residential treatment center programs.  Rate-setting ‘reform’, which began in October of 2021, will not be completed until July of 2026 if it stays on schedule.

At the same time group homes were being closed in Maryland, state agency leadership began to frown on out-of-state placements for youth with highly specialized needs when no placement in Maryland to meet those needs was available.  Public officials with little understanding of placement resources pronounced these out-of-state placements to be evil incarnate, and an overwhelming number of bureaucratic obstacles made them nearly impossible.  

With the loss of group homes as an option, we were urged to ‘re-imagine’ care for children, yet discouraged from developing individualized plans of care because insufficient flexible funding was allowed to make that happen.  We’re fond of slogans in child welfare, as if words will change outcomes, but too many initiatives are about clever slogans and not about substance.  If only we would review every child in group care, we were told, we would realize how many had other options.  With consultation from the national advocacy group, we spent hours seriously poring over the needs of our children in congregate care and attempting to find matches with kin or foster families.  Not at all surprising to our staff, “low hanging fruit” didn’t exist.   

We also initiated a rigorous “Family Finding” practice, in hopes of finding kin willing to become providers with services and supports.  What we learned is that youth in congregate care had  already exhausted family and “kin of the heart” resources.  Today it’s not clear that public officials and child welfare leaders grasp that children and youth wouldn’t be in hotels if there were any kin – fictive or otherwise – willing and able to provide care, or if parents could and would be a safe resource.

Youth with intensive, complex needs

As other doors closed, the child welfare system became increasingly tasked with providing residential behavioral health care for children and youth with high-intensity and complex needs for supervision and treatment.  The differences between those involved with the juvenile justice system (and may have gone to detention centers in the past) and those who are not are often hard to discern.  Both groups tend to engage in behaviors that pose a serious safety hazard  to themselves or others.  These  behaviors may include physical violence; property damage; compulsive self-harm such as cutting or swallowing objects; chronic truancy; frequent runaway episodes; sexual victimization of siblings; aberrant sexual behaviors such as public masturbation; molesting younger siblings; participating in petty crimes; harming family pets; and generally oppositional and dysregulated behavior.  

Contrary to the popular notion that the public child welfare system is tearing families apart, these are children whose families are typically frustrated, exhausted, and often eager to place their child.  Some even view foster care as a much-needed punishment, imagining that when the youth is ready to “behave,” they can return home.  Of course these young people have many strengths to be nurtured, but they need intensive supervision and therapeutic intervention by professionals trained to evaluate and address their special needs and work with families.

The gist of the matter is that we are serving two different out-of-home placement populations with very different needs.  One is a younger population in foster care primarily due to maltreatment stemming largely from parental substance abuse and/or untreated mental illness. The other is older youth with complicated behaviors, and behavioral health needs and/or developmental disabilities.  The parents and kin of the older group are asking for placement, not objecting to it, and are typically worn out and adamantly opposed to more in-home services.  In spite of the stark differences in these two populations, our policymakers and those upon whom they rely have failed to recognize their needs are not the same.

In Maryland and other states, treatment, or ‘therapeutic,’ foster care stepped in to accommodate this new population of older, harder to serve foster youth. To some extent this approach has been effective as an alternative to congregate care, but it’s not the panacea some would like to believe.  The desperate need for foster families willing to care for these youth means there’s a certain amount of pressure to lower expectations and even turn a blind eye to foster parents that do a less than stellar job.  Tales of locked refrigerators and youth left sitting on the stoop at the end of the school day until the caregiver came home soon proliferated.  However, we were told by representatives of a national advocacy group that, “Youth are better off moving from shabby foster home to shabby foster home than in the very best congregate care.”   In my own experience, instability begets instability and there’s little more soul-sucking than being rejected from family after family.

Setting aside the question of quality, foster care, whether treatment or not, has great challenges recruiting homes for youth with weapons charges, those with a history of drug dealing, or whose parents have refused to pick them up from the police after another runaway episode. “Cutters” and “swallowers” need 24/7 supervision to keep them safe and in general, kin have already tried to provide care long before the child’s entry into state custody.  With the closure of group homes and residential treatment centers in Maryland and the prohibition on out-of-state placements, finding placements willing to accept youth with high-intensity needs became literally impossible.  As a result, for years now children have been left in psychiatric hospitals (sometimes for months) after “ready” for discharge, and others are ‘boarding’ in emergency rooms for weeks or months.  

A failure to recognize reality

Instead of recognizing the lack of capacity to serve those youth with nowhere to go after being hospitalized, hospital representatives, public officials, and legislators blamed caseworkers for not ‘picking children up’, as though they were simply lazy and incompetent.   “Advocates” proposed legislation imposing more caseworker accountability as the solution, as though if caseworkers worked harder and filled out more forms, placements that didn’t exist would magically appear.  Fortunately, none of the legislation passed, but being a lonely voice trying to explain the source of the problem wasn’t lazy caseworkers or enough forms was painful.  Public officials, leaders and advocates also clamored for more “prevention” services, not recognizing the acute needs of older youth developed over many years and that new services authorized today are not going to keep them safely at home.

During my 20 years as the director for my county’s foster care and adoptions program, I can’t count the nail-biting times we came close to not finding a placement for a child – but we were always able to pull something together.  The state made funding available for a 1:1 staff person (or sometimes 2:1) we could offer existing providers, allowing us to use that as a bargaining chip. Of course, increasing reimbursement rates and staff salaries would have been far less expensive than millions for extra staff to support ill-equipped placements, but that change in fiscal allocation has yet to happen. 

Five years have now passed since I retired, and hotel placements have become not a rarity but a regular necessity.  At the rate of $30,000 to $60,000 per child each month (not including damages to hotels) to warehouse children in hotel rooms supervised by an untrained aide – one can only imagine what that kind of money could be doing productively for children.  Caseworkers are overseeing the most precarious and risky “placements,” and being ‘hotel reservation clerks’ isn’t the reason competent social workers choose to do the work.  We’ve all heard the tales of youth stealing their 1:1’s car; or youth locking themselves in their rooms doing what we don’t know; a youth who overdosed on his medication; parties taking place with the acquiescence of the 1:1; youth harassing guests; and the youth who leaped over the reservation desk to try to steal cash.

Over the years there have been many, many meetings among high ranking state officials and others; ironically, these meetings didn’t include the experienced and knowledgeable child welfare staff responsible for the children.  Lots of strategies, goals, and plans too – a personal favorite was the goal of instructing local department staff on hospital discharge planning, as if they weren’t already experts.  Despite all the meetings and all the hand-wringing, progress meeting the needs of the children in our care, or soon to be in our care when parents abandon them at the hospital or elsewhere, has been negligible. Years that could have been spent on developing and promoting new model programs have been wasted. In the meantime, Congress saw fit based on testimony from well-heeled advocacy groups to pass the Family First Prevention Services Act,  which limited congregate care even more by restricting funding to approvable options based on criteria seemingly pulled out of a hat.   

Today, the deepening and pervasive placement crisis is affecting nearly every state and attracting media attention around the country.  Given the financial resources dedicated to keeping children in hotels, finances clearly aren’t the issue.  And it certainly isn’t about quality of care, since hotel rooms, overstays in hospitals, and boarding in emergency rooms rank far below a quality congregate care program as a suitable home for a child.  

What is to be done?

In the short run, Maryland and other states need respite programs for young people awaiting placements in hospitals, emergency rooms, and hotels.  In the long run, we must acknowledge child welfare’s responsibility not only for maltreated children, but also those with high-intensity needs for supervision and treatment once served by other child-serving organizations.  We need to bring the finest minds together to reimagine how residential care is provided, and its role in the continuum of child welfare resources to meet the needs of older youth entering foster care because of needs related to behavioral health and/or developmental disabilities. That process should include some of the scholars who have been studying the use of congregate care in other countries where it is more highly valued as a treatment and a professional field.  Exploring the development of real alternatives to congregate care is also a worthy investment.  Finally,  the unintended consequences of the Family First Prevention Services Act that disincentivized needed placements without a credible replacement must be remedied.

How many more years until we wake up?  And how many children will have to be harmed?  A colleague had a quote in her office that stays with me always, “when we are doing something with somebody else’s child we wouldn’t do with our own, we need to stop and ask ourselves why.”  Who among us would consent to our own children boarding in emergency rooms, on overstay at hospitals, or ‘placed’ in hotel rooms?  If that’s not okay for our own children, it shouldn’t be okay for the children in our state’s custody either.


Residential care in child welfare: An international perspective

In my last post, Family First at five: Not much to celebrate, I discussed how the Family First Prevention Services Act (FFPSA) made it more difficult to provide residential care (often pejoratively called “congregate care” by the Act’s supporters) for the most troubled foster youth while doing little to ensure the development of alternatives. The result has not been surprising–an exacerbated placement crisis, with foster youth around the nation sleeping in hotels, offices, jails and other inappropriate settings. An important new book provides an international perspective on residential care. It shows that the U.S. ranks very low in the percentage of foster youth that are in residential care, casting doubt on the advisability of trying to further reduce residential placements. The obvious conclusion is that we would do better to increase the quality of residential care by raising standards for staff.

The new book, Revitalizing Residential Care for Children and Youth, is a compilation of research on residential care in 16 high and middle-income countries, edited by James K. Whittaker, Lisa Holmes, Jorge F. Del Valle, and Sigrid James, who are professors at universities in the US, England, Spain, and Germany, respectively.1 The editors define “residential care” as “any group setting where children spend the night,” encompassing settings that vary in size and function and that operate under the auspices of child welfare, juvenile corrections, or mental health. The 16 countries are viewed through a common template, making comparisons possible. However, there are problems with such comparisons. As explained in the second chapter, countries differ in the terms they use for different types of care and how they define these terms, among other things. The editors’ definition of “residential care” does not ensure that the same facilities are being counted across nations. A small group home with paid staff might be classed as “foster care” in some countries, and some facilities (like those for youth offenders) might be counted in the residential totals for some countries and not others.

Keeping in mind the impossibility of obtaining data that is totally comparable across countries, there appears to be a striking variation between nations in the utilization of residential care for youths who are in out-of-home placements. The editors defined the residential care utilization rate as the proportion of out-of-home care dedicated to residential care rather than family foster care or other types of out-of-home placements. This percentage ranged from seven percent in Ireland and Australia to 97 percent in Portugal, as shown in Figure 29.1, which is reproduced below. The United States had the third lowest residential care utilization rate, with ten percent of children in out-of-home placements being in residential settings. Moreover, the number of children in U.S. residential care fell by about 25 percent between 2015 and 2019. According to the editors, it appears that countries in the low-utilization category have made legislative changes (like FFPSA and California’s Continuum of Care Reform in the US) that have led to drastic reductions in residential care. But the countries with medium utilization rates (between 30 and 55 percent) seem to be focused on improving residential care by strengthening the elements believed to be associated with quality care rather than reducing the utilization of residential care.2

Source: James Whittaker et al, Revitalizing Residential Care for Children and Youth, page 430.

The authors also found great variability in the education and training requirements for residential care staff. These range from no minimum qualification in the United States, Canada and Australia, to high school level (Israel, Argentina and Portugal), to rigorous multiyear vocational training and/or university education in the other countries. A number of countries use both vocationally trained and university educated staff. For example, in Germany, about 70 percent of residential care staff hold a 3.5 to five-year vocational degree as educators (or in fewer cases two years as assistants) and 30 percent have Bachelors’ degrees in social work or “social pedagogy.”3

The editors found that it is countries with lower educational requirements for staff that have turned against residential care and have sought a drastic reduction of its use. Among those countries was, no surprise, the United States, along with Australia and England. In contrast, countries with a high qualification requirement have higher utilization of residential care. This correlation is not surprising. There is no doubt, say the volume’s editors, that “the quality of the services is directly related, in any field, to the qualifications, training and experience of the professionals who provide them.” In child welfare, they argue, “[I]t is difficult to carry out the work without a qualification based on the learning of very diverse theories related to child development, the clinical expressions of trauma, listening and helping techniques, the framework of family relationships, and ecological theories.” The editors suggest the existence of a vicious cycle, where low staff qualifications may led to poor quality and outcomes, which in turn lead to reduced funding, making it harder to recruit well-qualified staff.

Unfortunately, available data do not tell us what proportion of children and youth in residential care in each country are there for time-limited treatment for behavioral issues with a plan to “step down” to a family setting. Available data suggest that a majority or large minority of children and youth in residential care in the middle-utilization countries have a mental health diagnosis, which does necessarily mean that they are in a time-limited therapeutic setting. Most likely, the residential care population in the middle-utilization countries is a combination of youths with issues that require treatment in residential care and those who could be in family foster care if available As one of the editors notes in the introductory chapter, “residential care across the globe …does not seem to be limited to the narrow treatment-oriented and time-limited setting it is generally reduced to in several Anglo-American nations. In fact, in many countries,…., children and youth still spend years in residential care programs.”

The assumption that family foster care is always the better choice unless a child cannot function in such a setting may be unique to the English-speaking countries. Small, family style group homes, whether freestanding or part of a campus of such homes, may be difficult to distinguish from foster homes, especially if they use a house-parent model. In fact, the authors say, some countries classify “a small “family group” home, staffed by paid staff” as a foster home. I have argued in the past that high-quality family-like group homes may be better for children than mediocre or poor-quality foster homes and are especially appropriate for siblings. Indeed, as discussed in the book, France has 28 children’s villages, which are family-like units especially for siblings.

The evidence shared by Whittaker et al. has important implications for the United States. Given our low position on the scale of residential care utilization, one might logically conclude that further lowering the number of children in residential care would be unrealistic. In the two countries with lower residential utilization rates than the United States, Ireland and Australia, news accounts document an urgent need for more foster parents, with young people being separated from siblings, moving from one emergency placement to another for lack of a suitable home, and spending nights at hotels. Instead of trying to bring the residential share of foster care even lower, the U.S. might be better advised to follow the example of countries like Germany and Finland, which are focusing on improving residential care programs rather than eliminating them.

Cross-national comparisons are valuable in many policy areas, and the absence of such comparisons in child welfare debates is particularly unfortunate. Reading this book brings home the lack of international comparisons informing Congress when it passed the FFPSA. As far as I know, the supporters of FFPSA’s drastic restrictions on residential care never referred to other countries’ use of residential options; that’s not surprising as such comparisons may have led to uncomfortable questions about the premise that too many foster children and youth were in residential care.

Some members of Congress who supported the residential restrictions in FFPSA may have been more concerned about budgets than ideological objections to residential care. Improving residential care costs money, while cutting it may appear to help balance budgets. FFPSA was designed to be budget-neutral, so that restrictions for funding of residential care were required in order to offset the increase in spending for services to families. And it apparently did not matter to Congress if those costs were by necessity picked up by states that had no other options: the federal government would see the savings.

Perhaps the federal coffers have benefited from the restrictions on federal funding for residential care, especially because federal spending for the “prevention services” side of Family First has been negligible. But it is hard to believe that states have gained financially from the new law. Spending as much as $2,000 a night for a hotel room complete with staffing and security for foster youth, as Washington State is reportedly doing, cannot possibly be a better use of funds than improving and expanding residential care. And the effects on children and youth are disastrous. One can only hope that state leaders will be brave and smart enough to take the first steps in the direction of revitalizing residential care to be a nurturing and therapeutic environment for children and youth and a field that is a source of pride for its practitioners.

Revitalizing Residential Care for Children and Youth should be required reading for anyone involved in making policy or drafting legislation regarding foster care. But it is probably too much to hope that the anti-residential crusaders will choose to read this important book. They find it more comfortable to continue believing that cutting funds for these programs without providing an alternative will save money and help children at the same time.

Notes

  1. The countries studied include Argentina, Australia, Canada, Denmark, England, Finland, France, Germany, Ireland, Israel, Italy, the Netherlands, Portugal, Scotlad, Spain, and the United States.
  2. Portugal, with 97 percent of its out-of-home youth in residential care, is in violation of its own law establishing residential care as the last option for out-of-home care. It appears that the country has not developed the supply of foster parents needed to shift the system toward home-based care. Argentina, with 86 percent of children separated from their families living in residential care, is only in the early stages of developing family-based foster care. In Israel, a system of residential facilities or “youth villages” developed as a means of social integration of immigrant groups, starting with survivors of the Holocaust. This system of residential care operates under the MInistry of Education. A separate child welfare system developed later under the Ministry of Labor, Social Affairs and Social Services, to serve the needs of maltreated children, and 63 percent of the children in this system are also in youth villages.
  3. According to the editors, “[s]ocial pedagogy is grounded in a holistic understanding of the person and espouses participation, democratic processes, self-determination, and social and moral education within the context of everyday life as guiding values and principles for practice. Individualization (n contrast to standardization) and professional decision-making are further hallmarks of this approach.”

Family First at five: Not much to celebrate

Photo by Ivan Samkov on Pexels.com

When the Family First Prevention Services Act (FFPSA) passed as part of the Bipartisan Budget Act of 2018, it was hailed by many as a revolutionary step in the history of U.S. child welfare. Five years after the Act took effect, child welfare leaders have been weighing in with statements like this one from Rebecca Jones Gaston, Commissioner of the Administration on Children, Youth and Families: “Following its passage five years ago, the Family First Prevention Services Act has transformed our approach to child welfare and benefited families across the many states that have used it to provide concrete support and services.”1 But for those closer to ground-level and less invested in demonstrating the act’s success, there’s not much to celebrate.

FFPSA had two major goals: to keep children out of foster care altogether through services to families and to keep more of those who do have to enter care in family homes. In terms of the first goal, the law’s impacts on services to families have been almost negligible. And in its effort to keep foster children in families, FFPSA has exacerbated the critical shortage of appropriate placements for our most troubled youth, many of whom may need placements in larger settings. In this post, I examine these two goals and their outcomes in greater detail.

FFPSA’s Part I made it possible to allocate funds under Title IV-E of the Social Security Act, previously directed mainly to foster care, to services aimed at keeping children out of care. The law allowed spending on mental health, substance abuse prevention and treatment, and in-home parenting services, “when the need of the child, such a parent, or such a caregiver for the services or programs are directly related to the safety, permanency, or well-being of the child or to preventing the child from entering foster care.”

As I explained in my 2019 post, Family First Act: a False Narrative, a Lack of Review, a Bad Law, Part I was based largely on the false premise that current law, by allowing TItle IV-E funds to pay for foster care and not for services to prevent it, incentivized states to remove children rather than keep families together. While it is true that IV-E funds were not available to pay for services to children and families in their homes, that does not mean that no money was available to help keep families together or that states had an incentive to place children in foster care. In fact, states had long been using Medicaid and other funds for services to prevent placement of children in foster care. In Federal Fiscal Year 2017, according to federal data, out of the children who received services after a CPS investigation or alternative response, only 201,680 were placed in foster care, while 1,332,254 (or more than five times as many children) received in-home services such as case management, family support, and family preservation services.2

Disregarding the role that other funding already played in child welfare, the framers of FFPSA required that Title IV-E would be the “payer of last resort,” so that any services already paid for by Medicaid could not be paid for by Family First. By doing this, they ensured that states with a generous Medicaid programs would be hard-pressed to find any service already existing in the state on which to spend their TItle IV-E money. If not for this provision, such states might have chosen to supplement Medicaid funding for some of these services. Perhaps some states would have allowed Title IV-E funds to be used to pay high-quality providers who do not accept Medicaid funding due to the program’s low reimbursement rates and high paperwork burden. (During my time as a foster care social worker in the District of Columbia, we had contracts with high-quality providers who did not accept Medicaid in order to provide therapy for our most complex clients).

The choice to fund only parenting, mental health and drug treatment services by the framers was another design flaw of FFPSA. The absence of a domestic violence service among the funded services is striking. It is universally acknowledged that drug abuse, mental illness and domestic violence are the “big three” factors that result in foster care placement. But for some reason, the words “domestic violence” are nowhere to be found in FFPSA. Perhaps even more striking is the failure to include one of the most promising services to prevent foster care–high-quality child care. As I have written, not only does quality early care and education prevent foster care placement through multiple pathways, but it also provides an extra set of eyes on the child in case of continued abuse or neglect–greatly needed if FFPSA is to achieve its goal of keeping children both safe and out of foster care. Think of what a difference Congress could have made by providing matching funds to provide quality child care to all families with in-home cases!

Perhaps the most unfortunate feature of FFPSA’s Part I is the requirement that all funds must be spent on “promising, supported or well-supported practices,” with 50 percent of the total spent spent on “well-supported practices” — a percentage that increases after 2026. The law imposes strict requirements for designating a program as promising, supported or well-supported. It set up a clearinghouse to assess the data on existing programs and approve those that met the criteria. As Dee Wilson points out in one of his essential commentaries, the law gets it exactly backwards. We have very little evidence about what works to prevent foster care placement. What we need is to invest in innovative approaches to doing this safely. But FFPSA prevents the use of TItle IV-E funds for this purpose.

Thanks to the various restrictions imposed by FFPSA, the clearinghouse is woefully incomplete. For example, Cognitive Behavioral Therapy (CBT), the therapy of choice for depression and anxiety, which has not been approved nor is it on the list of programs to be examined by the clearinghouse. (“Trauma-Focused CBT,” a newer and much narrower and short-term model, has been approved.) No residential drug treatment program has been approved or is even slated to be considered. The requirement that the practice have a manual may be at fault for the failure to include CBT and residential drug treatment programs, but I’d like to hear from readers who may be better-informed. Buphenorphine therapy for opioid use disorder, which is often preferred to methadone therapy (which is approved by the clearinghouse)because it does not require daily clinic visits, has not been approved and is not slated for consideration, according to the Clearinghouse.. Of course, these popular programs are often funded by Medicaid anyway, so they would be ruled out by the last resort provision as well.

With all these restrictions on Title IV-E spending, it is not surprising that states have been hard-put to find useful ways to spend Title IV-E funds to keep families together. In an important article, Sean Hughes and Naomi Schaefer Riley cited the latest available federal data showing that just 6,200 children across the entire country received an FFPSA-funded service in FFY 2021, costing a grand total of $29 million. That is truly underwhelming given that about 600,000 children were found to be victims of maltreatment in FFY 2021.

The other major purpose of FFPSA was outlined in Part IV, entitled “Ensuring the Necessity of a Placement that is not in a Foster Family Home.” The purpose of this part was to keep more children out of “congregate care,” a term used to designate settings other than foster homes, such as group homes and residential treatment centers. FFPSA made it more difficult to place a child in a congregate placement by imposing conditions on Title IV-E reimbusement for such placements, and by limiting reimbursement after two weeks to facilities that qualify as “Quality Residential Treatment Programs (QRTP’s), a new category defined by the act. QRTP’s must meet strict criteria that many facilities that were caring for foster youth at the time of FFPSA’s passage could not meet without major changes. The act also (perhaps inadvertently) further restricted the number of congregate care beds available to foster youth by creating a conflict with a Medicaid provision called the “Institutions for Mental Diseases (IMD) exclusion” that prevents Medicaid paying the cost of care for children who are placed in facilities with more than 16 beds.“

Like Part I, Part IV of FFPSA was in large part based on a false narrative. The myth this time was that every child does better in a family rather than in a more institutional setting. But as I described here, there are many foster youths who cannot function in an ordinary foster home, at least until after a stay in a high-quality residential treatment program or group home. These are the same young people who bounce from home to home and end up in hotels, offices, jails, and other inappropriate settings, but FFPSA made no provision for them.

Even if too many children had been placed in residential care without sufficient clinical justification (which is probably the case in at least some states), it would not be responsible to shut down congregate care placements before ensuring that appropriate foster homes were available for all the children being displaced. But just as the deinstitution movement of the 1960s closed mental hospitals before putting alternatives in place, FFPSA disregarded the question of where children would go when congregate settings disappeared.

As I described here, FFPSA exacerbated trends that were already underway. Group homes and residential treatment centers were already shutting down due to growing publicity about abusive incidents at some facilities, failure of reimbursement rates to keep up with costs, and resignation of staff due to poor pay and working conditions. Tragically, this reduction in residential capacity coincided with increased demand for care due to the youth mental health crisis and increasing levels of need in the foster care population due at least in part to delays in removing children from abusive and neglectful homes. The restrictions put in place by FFPSA added to the problem. As Hughes and Schaefer Riley put it, “If you want to understand why foster children across the country are being housed in a range of inappropriate temporary settings, including county and state offices, hospitals, hotels and shelters, FFPSA is a significant factor.” 

The trends just mentioned have contributed to a foster care placement crisis that has if anything worsened since I described it last October. In Illinois, the Department of Children and Family Services (DCFS) is being sued by the Cook County Public Guardian for allowing foster children to remain locked up in juvenile detention even after they’ve been ordered released. In Maryland, a disability rights group has just filed suit against the Department of Human Services and other agencies for keeping foster children in hospitals and restrictive institutions beyond medical necessity for weeks, months, or even as long as a year. In a must-read article, Dee Wilson documents a 370 percent increase in hotel/office stays in his state of Washington since 2018 despite a federal court order to stop the practice. At an average cost of up $2,000 per night (including the cost of paying two social workers and a security guard), overnight hotel placements cannot possibly be cheaper than group homes or residential treatment centers. Similar problems are reported around the country, differing only in which inappropriate settings each state is relying on.

As is often the case, California paved the way for FFPSA by passing its Continuum of Care Reform, designed to curb the use of congregate placements, in 2015. A new article in the Los Angeles Times recounts the results. The number of children living in congregate care has dropped from 3,655 to 1,727 since implementation of the law, but the state has failed to find the foster homes to replace the congregate care settings. As a result, Los Angeles County has placed more than 200 foster youths in hotels, sometimes for months. County officials report that two social workers have been assaulted by foster youths in separate incidents this year at hotels. Moreover, it appears that care at the existing congregate facilities has grown worse as larger numbers of troubled youths are placed together in fewer facilities. The results of California’s reform and of FFPSA were predictable and indeed predicted by some commentators (including this writer), but these predictions were ignored.

As Dee Wilson puts it, “The implementation of Family First legislation has accelerated the demise of residential care, which has decreased 25% nationally during the past five years. It has been the goal of the federal Children’s Bureau and influential foundations to reduce the use of residential care (which has a bad reputation among advocates and most scholars) and they have succeeded; but without developing — or sometimes even proposing – viable alternatives.”

Anyone who chooses to celebrate the “revolution” wrought by FFPSA is living in a dream world. It’s time for Congress to recognize and correct the many errors it made in passing the law. At a minimum, Congress should add funding for early care and education and domestic violence programs to the models that can receive funding under Title IV-E, loosen the standards for evidence-based practices, modify the last-resort provision to allow payment for services to providers who do not accept Medicaid, eliminate some of the restrictions on congregate care, and provide incentives for states to boost their capacity of quality residential programs. Until such changes are made, there will be nothing to celebrate.

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  1. Alexia Suarez (asuarez@wearerally.com), [YOU’RE INVITED] Expert panel on the Family First Prevention Services Act. Email message, May 15, 2023.
  2. These are duplicated counts as children are counted again each time they are the subject of an investigation and receive post-response services.

The power of wishful thinking revisited: the improbable growth of Healthy Families America

I have written before about the power of wishful thinking and how it causes people to disregard research and real-life results. In that earlier commentary, I discussed the successful promotion of a practice called race-blind removals based on data from an article by a scholar who now denies knowledge of their provenance, and which have been shown to be inaccurate. A program called Healthy Families America (HFA), which currently serves over 70,000 families per year according to its website, offers another example of the power of wishful thinking. This program has become the centerpiece of the nation’s oldest and largest charity dedicated to the prevention of child abuse, even though the program has failed to demonstrate its utility in preventing child maltreatment. This organization, now called Prevent Child Abuse America, launched HFA based on weak evidence that a program in Hawaii called Healthy Start Program (HSP) could prevent child maltreatment. The first experimental study of HSP found no impact on child maltreatment but did nothing to derail the launch of HFA. Studies of HFA programs around the country have found little evidence of reductions in child maltreatment, but the program has continued to grow and now serves more families than any other home visiting program. The story of HFA is a lesson in the power of wishful thinking and the failure of evidence (or lack thereof) to counteract it.

As told in a helpful history of home visiting, all modern programs can trace their origins to Henry Kempe, whose book, The Battered Child, brought about the recognition of child maltreatment as a national problem. To address child abuse, Kempe called for universal prevention through a network of home health visitors. Inspired by Kempe, modern home visiting began with Hawaii’s implementation of the Healthy Start Project (HSP) in 1975. As described in the 1999 evaluation by Duggan and colleagues, HSP was developed by the Hawaii Family Stress Center (HFSC) on the island of Oahu. It had two components: early identification (at the birthing hospital) of families with newborns at risk of child abuse and neglect and home visiting by trained paraprofessionals for those families classified as at-risk who agreed to participate. This initial program was never evaluated, but anecdotal information suggested it was successful in promoting effective parenting, and six similar programs were established on neighboring islands.

As described by Duggan et al., the Hawaii Legislature authorized a three-year pilot program focusing on one neighborhood in Oahu, which began in 1985. There was no control group in the pilot study, and the researchers used CPS reports and changes in family stress in participating families to measure program effectiveness. During the three-year pilot, there were few reports of physical abuse, neglect or imminent harm for program participants. Because evaluations of other home visiting programs had found much higher rates of reported maltreatment in comparison group families, these results were viewed as evidence that the program had a positive impact. According to Duggan and her co-authors, “The pilot study results might have been given too much weight, given the lack of a control group and the short period of follow-up for most families.” Nevertheless, the results of this unpublished study were enough evidence for the Legislature to expand HSP throughout Hawaii starting in 1989.

Home visiting in general was gathering steam in the 1980s and early 1990’s. In 1990, the U.S. General Accounting Office (GAO) issued a report promoting home visitation as a “promising early intervention strategy for at-risk families.” In its summary of research evidence, GAO focused mostly on health and developmental benefits for children, rather than maltreatment prevention. In 1991, the U.S. Advisory Board on Child Abuse and Neglect issued a report recommending a pilot of universal voluntary neonatal home visitation, stating that the efficacy of home visiting as a preventive measure was “already well-established.” The Board cited the results of a federally-funded demonstration begun 17 years earlier as well as the the nurse home visitation program started by David Olds in 1977. But HSP was not mentioned.

Despite the lack of a rigorous evaluation, the National Committee to Prevent Child Abuse (NCPCA, now called Prevent Child Abuse America) the nation’s “oldest and largest organization committed to preventing child abuse and neglect before it happens,” had become interested in using HSP as the nucleus of a national home visiting program. But first, NCPCA conducted a one-year randomized trial of HSP, as described by Duggan et al. The trial suffered from severe methodological limitations, including “less than ideal followup,” differential dropout rates in the program and control groups, the failure to blind interviewers to experimental or control status, and reliance on program staff rather than researchers to measure some outcomes. Nevertheless, the trial concluded that HSP reduced child maltreatment, and this apparently gave NCPCA the assurance it needed to invest in the model.

NCPCA launched Healthy Families America in 1992, with financial support from Ronald MacDonald House Charities, arranging visits to 22 states by Hawaii Family Stress Center Staff. The “theory of change,” or theoretical basis for the program, as quoted by Duggan et al, started with the targeting to all newborns and their parents, which allows for diversified service options determined by individual need. Also part of the theory was a commitment to change at the individual and community levels. Rather than impose a single service model, HFA contained a set of critical elements, which included the prenatal initiation of services and the assessment of all new parents. A network was launched to bring together researchers doing experimental and quasi-experimental studies of HFA programs.

Unlike NCPCA, The Hawaii Department of Health recognized the limitations of both the pilot study and the NCPCA study and initiated a more rigorous evaluation of HSP in 1994. This was a randomized controlled trial, with at-risk families identified at the hospital and randomly assigned to the experimental and control groups. In 1999 the results of the Evaluation of Hawaii’s Healthy Start Program were released as part of an issue of the Future of Children journal containing evaluations of six different home visiting models.  No overall positive program impact emerged after two years of service in terms of child maltreatment (according to maternal reports and child protective services reports). Early HFA evaluation results, published in the same issue, also failed to find effects on abuse and neglect in three randomized trials, which included the HSP evaluation discussed above and another Hawaii HSP study.

David Olds had had begun testing his Nurse Home Visiting Program in 1977 and already had long-term results on the program in Elmira, NY, as well as shorter-term results for a replication in Memphis, Tenn. That program, now known as Nurse Family Partnership, was very different from HFA. It was restricted to first-time teenage mothers and the home visitors were nurses rather than paraprofessionals. The nurses followed detailed protocols for each visit. The researchers found that among low-income unmarried women (but not other participants), the program reduced the rate of childhood injuries and ingestions of hazardous substances that could be associated with child abuse or neglect. Follow-up of the Elmira group when the children were 15 found that the nurse-visited mothers were significantly less likely to have at least one substantiated report of maltreatment. These results are particularly impressive because they overrode a tendency for nurse-visited families to be reported for maltreatment by their nurse visitors. The researchers concluded that the use of nurses, rather than paraprofessionals, was key to the success of the program. In their analysis of all six studies published in the volume, Deanna Gomby et al. concluded that while the HFA and HSP evaluations showed some change in maternal attitudes and self-reported behaviors related to abuse and neglect, only the Nurse Home Visiting Program showed impacts on abuse and neglect other than from self-reports.

Gomby and her co-authors also concluded that the results of the six home visiting evaluations were discouraging for those who had high hopes for home visiting for solving an array of problems. All the programs “struggled to enroll, engage and retain families.” Program benefits generally accrued to only a subset of enrolled families and were often quite modest. The authors explained the disappointing results by concluding that human behavior is hard to change, particularly when problems are community-wide. They recommended that “any new expansion of home visiting programs be reassessed in light of the findings presented in this journal issue” and stated that home visiting services are “best funded as part of a broad set of services for families and children.”

But the home visiting juggernaut was already in motion nationwide. And NCPCA had already made HFA its centerpiece program. Home visiting grew, and HFA grew with it. In 2010, Congress created the Maternal, Infant and Early Childhood Home Visiting Program (MIECHV), which was re-authorized in 2018 with funding of $400 million per year through FY 2022. According to the HFA website, HFA is the model most frequently implemented with MIECHV dollars. Home visiting programs can also receive funding through Medicaid, Title IVB and IVE of the Social Security Act, and many other funding sources.

The infusion of funding for HFA research by NCPCA initiative set in motion a multitude of research projects (both randomized trials and less rigorous studies) that continues to result in publications. Nevertheless, HFA research has yet to find solid evidence that these programs have an impact on child maltreatment: The California Evidence-Based Clearinghouse for Child Welfare (CEBC), the pre-eminent child welfare program clearinghouse, reviewed 19 research reports on HFA. It gave the program a rating of “4” on a scale of 1 to 5 for prevention of child abuse and neglect, meaning the evidence fails to demonstrate that the HFA has an effect on abuse and neglect. HFA did receive a rating of 1 for “child well-being,” based on its impacts on outcomes like physical health, child development, and school readiness. In contrast, Nurse Family Partnership was rated as “1,” “well-supported by the research evidence, for the prevention of child abuse and neglect, as well as for child well-being.

Despite the lack of evidence of its impact on maltreatment, HFA received a rating of “Well Supported” from the new clearinghouse established by the Family First Prevention Services Act (“Family First”) to determine whether a program can receive federal funding under Title IV-E of the Social Security Act. To get such a rating, the program must show improved outcomes based on at least two randomized trials or rigorous quasi-experimental studies. But these outcomes could be any sort of “important child and parent outcome,” (not just child abuse or neglect) and there is no standard for how to measure each outcome. Based on its review of all HFA studies that met their criteria for inclusion, the Clearinghouse found 23 favorable effects, 212 findings of no effect, and four unfavorable effects across 16 outcomes. This included five favorable effects on child safety based on parents’ self-reports of maltreatment, with no favorable effects on other measures of child safety. Self-report is generally frowned upon as a measure of child maltreatment, for obvious reasons. A positive impact of HFA might reflect that participants in HFA were more eager than control group members to provide the “right answer” to questions about maltreatment.

The “well-supported” rating from the Title IV-E clearinghouse opened up a new source of funding for HFA. Passage of Family First as Title VII of the Bipartisan Budget Act of 2018, allowed states to spend Title IV-E funds on programs on services to families with a child welfare in-home case. To take advantage of this new demand, HFA announced in September 2018 that families referred by the child welfare system were now able to enroll until 24 months of age. To serve these families, HFA introduced special child welfare protocols, with limited evidence that that the program was effective for parents who had already abused or neglected their children.* The program had already departed from its initial mission of screening all families with newborns in a geographic area. Even without the child welfare protocols, each program can choose its own admission criteria and there is no universal screening; potential participants are generally referred by health or child welfare agencies, who often can choose between several home visiting programs when referring a client.

Another part of HFA’s original theory of change was a “dual commitment to change at the individual and community levels.” As described by Daro and Harding in their 1999 evaluation of HSA, this meant that HFA “must move beyond direct efforts to help families and begin to serve as a catalyst for reshaping existing child welfare and health care efforts and improving coordination among other prevention and family support initiatives.” This vision has clearly gone by the wayside as HFA has become one choice in a menu of home visiting programs offered by local jurisdictions. Far from trying to enhance and coordinate available community offerings, HFA is busy trying to maximize its share of the pie through its public relations effort, exemplified by the self-promotional statements on its website.

It is disappointing that Prevent Child Abuse America (“Prevent Child Abuse,” formerly NCPCA), an organization that defines its mission as child abuse prevention, decided to fund HFA before it was proven to prevent child maltreatment and without apparently considering other approaches also being tested at the time. And it is concerning that the organization continued with this commitment even after the disappointing evaluations of 1999 might have led them to diversify their investment beyond HFA or even beyond home visiting or to focus more on advocacy rather than services. And finally, that Prevent Child Abuse continues to use charitable contributions made for the prevention of child abuse and neglect to fund a program that has not been proven after 40 years to accomplish this goal, raises serious ethical questions. Twenty-two of the 40 staff listed on the Prevent Child Abuse website have positions with Healthy Families America. Perhaps the charity has backed itself into a corner; it would be difficult to escape this commitment without serious repercussions.

Some federal administrators do not seem to be much more interested in evaluation results than Prevent Child Abuse. The legislation authorizing MCHIEV required a randomized controlled trial (RCT), which may provide useful information on the relative merits of these programs in addressing different outcomes. But strangely, HHS indicated in a response to a critique from the Straight Talk on Evidence Blog that it is not interested in a “horse race” between the models but rather is interested in assessing home visiting in general. This odd statement is an indicator of the kind of thinking that allowed Prevent Child Abuse to invest in HFA for 40 years despite the lack of evidence that it does “Prevent Child Abuse.”

The story of Healthy Families America is not an unusual one. My discussion of the Homebuilders program could also be called “the power of wishful thinking.” Such stories are all too frequent. They show us how wishful thinking can drive leaders to disregard research, especially after they have made a premature decision to commit to one program or course of action.

*One study of Healthy Families New York, published in 2018, looked at a subgroup of 104 mothers who already had a substantiated CPS report, and found a decrease in abuse and neglect among the mothers who were in the experimental group. However, the sample was small and was not planned in advance, so the authors recommend further testing home visiting programs as prevention of repeat maltreatment for child welfare-involved mothers.

Homebuilders program, never proven effective for family preservation, approved regardless by Title IV-E Clearinghouse

Screen Shot 2020-04-06 at 5.48.54 PMThe federal Title IV-E Prevention Services Clearinghouse recently approved Homebuilders, a well-known family preservation program, for Title IV-E funding, giving it the highest rating of “well-supported.” This decision is sure to be lauded by many child welfare administrators looking for more program choices, including those in the fourteen states where it is currently being used as of 2018. Unfortunately, the Clearinghouse decision does not appear to be justified by the research it cites. Of the two studies cited as the basis of the rating, one worked to reunify rather than preserve families; the other study concluded that Homebuilders was not effective in preserving families.

As many readers know, the Family First Prevention Services Act expanded the use of Title IV-E funds, which were formerly used only for foster care, to pay for evidence-based practices to prevent the placement of children in foster care. “In-Home Parent Skill-based” services were one of the three groups of services authorized, and Homebuilders has been frequently cited as a likely member of this category. To be approved for funding, each practice must be approved by the Prevention Services Clearinghouse, which was also created by the Act, with a rating of “promising,” “supported” or “well-supported.” The Act establishes criteria for meeting each of these standards.

In order to be rated as “well-supported,” a practice must be shown to be superior to an “appropriate comparison practice using conventional standards of statistical significance” as demonstrated by improvements in “important child and parent outcomes, such as mental health, substance abuse and child safety and well-being.” This must be established by at least two studies that were determined by an independent review to be “well-designed and well-executed,” used random assignment or a quasi-experimental design, and “were carried out in a usual care or practice setting,” and at least one of which established a sustained effect lasting at least a year.

Homebuilders is the best-known family preservation program. Developed in 1974 by the Institute for Family Development, it provides “intensive, in-home crisis intervention, counseling, and life-skills education for families who have children at imminent risk of placement in state-funded care.” Its goal is to “prevent…unnecessary out-of-home placement … through intensive, on-site intervention, and to teach families new problem-solving skills to prevent future crises.”

In the 1980s and early 1990s, a movement in support of Homebuilders and other Intensive Family Preservation Services (IFPS) spread throughout the child welfare world, spearheaded by wealthy foundations and advocacy groups, as described by Richard Gelles in his influential text, The Book of David: How Preserving Families Can Cost Children’s Lives. This movement resulted in a rapid expansion of these programs around the country, culminating in federal legislation allocating $1 billion to these programs nationwide. However, a major study authorized by Congress and conducted between 1994 and 2002 cast doubt on the effectiveness of these programs at keeping children safe and reducing foster care placements. In recent years, that study seems to have been forgotten. Indeed it is common for supporters to express the belief that “research shows Homebuilders has been well-supported for decades,” as one advocate told the Chronicle of Social Change.

Therefore there were no expressions of surprise or consternation that the clearinghouse gave Homebuilders its highest rating as a “well-supported practice.” In its narrative, the Clearinghouse explains that Homebuilders meets the criteria laid out in the Family First Act for that rating. Specifically, “at least two studies with non-overlapping samples carried out in usual care or practice settings achieved a rating of moderate or high on design and execution and demonstrated favorable effects in a target outcome domain. At least one of the studies demonstrated a sustained favorable effect of at least 12 months beyond the end of treatment on at least one target outcome.”

The clearinghouse reviewed 17 studies for possible relevance to  the Homebuilders program. Of these studies, only three were determined eligible for inclusion as evidence of Homebuilders’ effectiveness. The others were ruled out because they were done before 1990, were not relevant, or did not meet basic quality standards. Of those three studies, two were determined to meet the clearinghouse design for “moderate” or “high” support of the causal evidence, and both met the “moderate” rather than the “high” standard. So  the Clearinghouse based its recommendation on two studies only–the minimum required for Clearinghouse approval–both of which the lowest acceptable standard for support of the evidence.

For each of these two studies, the Clearinghouse separated out each individual effect found at each site and date, resulting in separate listings for the same effect at different follow-up times and sites if the project had multiple sites. At the end of this process, the Clearinghouse cited 10 instances of “no effect” on child safety across the two programs, confirming what was already well-known. For child permanency, there were seven favorable outcomes, two unfavorable outcomes, and 13 findings of no effect. For adult well-being, they found one favorable effect, 14 instances of no effect, and no unfavorable effects. Despite the preponderance of findings that Homebuilders had no effect, the eight  favorable outcomes were enough to give Homebuilders the coveted rating of well-supported.”

The aggregate data is already underwhelming but it becomes worse when considering that seven of the eight favorable effects came from one study, which should not have been included at all in the review. That study, described by Elaine Walton and others in reports published between 1993 and 1998, assessed an intensive family reunification program provided in Utah. The study involved 110 families divided between the program and control groups. There were many things that made this program a strange prototype for Homebuilders. First, the program was aimed at reunification of children in foster care with their families, not the prevention of foster care placement. While Homebuilders can be used for reunification as well as for family preservation, it is known predominantly as a family preservation program.  Similarly, while Title IV-E funds can be used for family reunification programs as well as family preservation (if a state chooses to define children existing foster care as “foster care candidates”) Family First has been described by its supporters almost exclusively as an initiative to prevent the placement of children in foster care.

A program that is successful in family reunification may not be successful for family preservation. A family facing the possible removal of a child is in a very different situation from a family with a child already in foster care. Children in the Walton study had been in out-of-home placements from one to 88 months, with an average of one year. Most of the parents had presumably already participated in court-ordered services such as therapy, drug treatment and parenting classes.

Further undermining the relevance of the Walton study is that it was not a study of the Homebuilders program. The model described by Walton et al, called Family Reunification Services (FRS) by the authors,  departed from Homebuilders in many respects. Services were less intensive and longer in duration. Workers spent an average of about three hours per week in direct contact with the families, and this contact could last up to 90 days. This is a very different model from Homebuilders, which typically provides at least 40 hours of face-to-face services or about seven to ten hours a week, over a period of only four to six weeks.  It is hard to understand how the Clearinghouse could use this study of a non-Homebuilders reunification program to affirm the success of Homebuilders in general.  Yet, the Clearinghouse drew six or seven of its eight or nine favorable results from this study.[^1]

The second study cited by the Clearinghouse was conducted by three well-known research firms, Westat, Chapin Hall, and James Bell & Associates. This was a congressionally mandated evaluation that was intended to overcome shortcomings of previous studies. It included three family preservation program sites using the Homebuilders model, although the Clearinghouse cites only the studies from New Jersey (343 families) and Kentucky (442 families).  The researchers studied one family reunification program in New York, but the Clearinghouse did not review that portion of the study.

In reviewing the Homebuilders family preservation program sites in the three states,  the Westat researchers found no impact on child safety or foster care placement. The researchers concluded that their results were consistent with other studies that “have failed to produce evidence that family preservation programs with varying approaches to service have placement prevention effects or have more than minimal benefits in improved family or child functioning.”

Not surprisingly, the Clearinghouse found only one “favorable effect” from the Westat study. That effect was not on child safety or permanency but on adult well-being. They found a favorable impact on adult (not child) receipt of WIC program benefits at the Kentucky site immediately after program participation–not surprisingly as one would hope the Homebuilders caseworker helped families sign up for WIC. This is a very weak hook upon which to hang a “well-supported” rating.

The authors of the Westat study suggest that “The extent to which the intensive, short-term, crisis approach fits the needs of child welfare clients should be reexamined. The lives of these families are often full of difficulties—externally imposed and internally generated—such that their problems are better characterized as chronic, rather than 24 crisis. Short-term, intensive services may be useful for families with chronic difficulties, but those services are unlikely to solve, or make much of a dent in the underlying problems. Of course, the hope is family preservation programs will be able to connect families with on-going services to treat more chronic problems. But, that appears to happen far less than needed.”

In sum, the Clearinghouse based its rating on Homebuilders on two studies of two different programs. One of the programs did not follow the Homebuilders model and worked only to reunify families already separated by foster care. The second was a study of Homebuilders family preservation programs and according to its authors failed to demonstrate any favorable program impacts. The clearinghouse found only one favorable effect from this study, and it pertained to adult well-being. It is hard to believe that any reasonable person would conclude that these two studies together provide “strong support” that Homebuilders is effective in meeting the goals of Family First.

The flaws in the Clearinghouse approach to Homebuilders raise issues that are broader than the effectiveness of this one program. While the Act’s criteria for approval of a program are often described as “rigorous,” the Homebuilders result show that they are anything but that. Requiring only two studies to show favorable results regardless of the number of studies that show no impact; reporting that two studies have found favorable effects even though the one relevant study had only one minor favorable effect that its authors did not mention in their conclusion; allowing the use of data from an evaluation of one program to support the effectiveness of another program; rating a program as “well-supported” without specifying the specific outcomes that it has been shown to achieve — all of these connote a lack of rigor. Regarding the last point in particular, if a program is found to work for only one goal (such as family reunification and not family preservation) the Clearinghouse should approve it only for that goal.

The initial wave of Homebuilders expansion was spurred by an onslaught of non-scientific “evaluations” funded by foundations intent on demonstrating its effectiveness, as Richard Gelles describes in his book cited above. Sadly, the same type of advocacy-based analysis was used to support the passage of Family First.  Supporters of the Act repeatedly stated that we know what works to preserve families and we just need to fund it.  Yet Child Welfare Monitor has found few or no programs with strong evidence of large favorable effects. It is likely that other practices approved by the Clearinghouse have equally skimpy support.

This post was updated on April 16, 2020 after the Clearinghouse responded to Child Welfare Monitor’s question, submitted on April 2, requesting an explanation on apparent internal inconsistencies in its table about favorable program effects for Homebuilders.

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Washington Post on foster care: old tropes and false narratives

The Donald R. Kuhn Juvenile Center in Julian, W.Va., where Geard Mitchell, now 17, spent part of his childhood. A lawsuit says 10 states’ agencies tasked with caring for children failed, “jeopardizing their most basic needs.” (Sarah L. Voisin/The Washington Post)
Image: Washington Post

Foster care has finally made it to the front page of the Washington Post, and a sad story it is. The story highlights the growing crisis in many states due to the increase in drug addiction bringing in its wake a cascade of child removals into foster care, outstripping the supply of  foster homes and other placement. The problems outlined in the article are real and urgent, but the analysis and prescriptions offered in the article and subsequent editorial reveal the authors’ lack of understanding of the issues, which results in the repetition of false narratives and common misleading tropes.

The Post‘s front-page article focused on a growing crisis caused by increased drug addiction among parents, especially the opioid crisis. The author, Emily Wax Thibodeaux, zeroed in on West Virginia, one of the epicenters of the crisis. She introduced us to Arther Yoho, a young man who spent more than two years in a detention center because there was no foster parent available to take him in. Locked up with 27 juveniles with criminal convictions, Arther was failed by the system that was supposed to protect him.

Thibodeaux reports that other desperate states are using emergency shelters, hotels and out-of-state institutions to house youth for whom there is no foster family home available. This is tragic and true, and I wrote about it in a recent post, although the placement of foster youth in detention centers along with criminally charged youth may be unique to West Virginia with its cataclysmic foster care crisis. Thibodeaux reports Oregon’s use of refurbished detention centers to house foster youth, which is certainly not ideal but is quite different from housing them with juvenile offenders. In any case, Thibodeaux is right to point out that many young people in foster care are being placed in inappropriate (and often harmful) placements because appropriate ones are not available.

However, Thibodeaux takes an unwarranted conceptual leap by linking the placement of children in inappropriate facilities to states’ use of congregate care, a term used to connote placements that are not families. These include what are generally known as group homes, as well as residential treatment centers, which are part of the accepted continuum of care for foster youth. While detention centers are never appropriate for foster youth who have not been charged with a crime, group homes and residential treatment centers may be the appropriate placement, often for a limited time, for some youths in foster care. These are the young people who cannot be maintained in a regular foster home because of their defiant, violent, or self-destructive behavior. Many of these children might be able to “step down” to foster care after spending time at a therapeutic residential facility.  It is possible that some of these young people could be helped in a professional therapeutic foster home staffed by salaried and trained foster parents, an approach that is gaining increasing interest, but programs so far are few and small and not likely to meet the need for therapeutic placements.

Thibodeaux cites the common trope that “Compared with foster children living with families, those housed in congregate care settings are more likely to drop out of high school, commit crimes and develop mental health problems.” That is very true. But it is a matter of correlation, not causation. It is the younger and less damaged children who end up in foster homes in the first place. Not surprisingly, they are likely to have better outcomes. Concluding that congregate care causes the negative outcomes may well be akin to concluding that fire trucks cause fire damage since buildings that have been visited by fire trucks are far more likely than typical buildings to have sustained fire damage. We don’t have a body of research on what happens to children with similar risk factors who spend time in foster homes compared to those who spend the same amount of time in group homes.

Thibodeaux appears to be unaware that some of the states with the lowest proportions of children in congregate care are those that are struggling the most with inappropriate placements. Washington and Oregon are among the states with the highest proportions of foster children placed in families as opposed to congregate care facilities, according to federal data cited in a recent report from the Annie E. Casey Foundation. Both states have been the subject of disturbing media reports that foster youth are staying in hotels, offices and substandard and abusive out-of-state facilities. That’s not surprising, since appropriate options are not available.  In Washington, ten years of group home closures led to the current crisis. The director of Washington’s child welfare agency has requested funding to expand the capacity of therapeutic group home beds to accommodate the children who are now staying in hotels and offices. The director of Oregon’s agency has cited a reduced number of treatment beds as a cause of children being sent to substandard and abusive out-of-state facilities.

By implying that all congregate care placements are inappropriate, Thibodeaux lays the groundwork for false conclusions about policy. Rather than saying that states need to beef up their therapeutic options, whether they are professionally-trained therapeutic foster parents or therapeutic group homes or residential treatment centers, Thibodeaux suggests that the new Family First Prevention Services Act, which makes it more difficult to obtain federal reimbursement for congregate care stays, may solve the problem.

Actually, the Family First Act may well make things worse. By making it harder to license therapeutic group homes, there is reason to fear that Family First will exacerbate the placement crisis. This has already happened when group homes closed in in jurisdictions like Oregon, Washington, New York City, and Baltimore. In California, the closure of group homes due to their Continuum of Care “reform” (a predecessor of the Family First Act) has resulted in, according to one veteran service provider, “fewer kids in group homes, but only because there are fewer group homes and counties have inappropriately been pushing challenging, difficult-to-manage youth into lower levels of care.”

The Washington Post followed Thibodeaux’ article with an editorial, “The Crisis in Foster Care,” which repeated and further distorted some of Thibodeaux’s questionable statements. Where Thibodeaux reported that 71% of foster children aged 12 to 17 are in congregate care placements in West Virginia (a high number to be sure), the editorial page erroneously stated that seven in ten of all foster children are in such foster care placements. That is a huge difference as older children are much more likely to be in such placements.

The opinion writers go on to repeat Thibodeaux’ misleading statement from the Casey Foundation about children in group homes doing worse than those in foster homes. However, they also cite discouraging outcome data about children growing up with foster parents. Because both options seem bad, the opinion writers suggest that “the least-bad option for many children” may be staying or reuniting with their parents, “unless there is abuse in the home. “They go on to cite one of the most persistent tropes of all that child protective services workers “often remove minors from neglectful parents who, while a far cry from being good caregivers, may still be better than group homes.”

The trope that child neglect is “less than ideal parenting” is belied by some of the stories that have come out of West Virginia and other states in the throes of the opioid crisis. We’ve all heard the stories: infants born addicted to drugs to mothers unable to care for them,  children who lost their parents and even their extended families due to opioid overdoses, children abandoned at home without food while parents seek drugs, children strapped in cars while their parents get high, babies and toddlers who ingest heroin, alcohol or meth; children whose parents are incarcerated due to substance abuse or dealing; and more. This is not “imperfect parenting” but something much worse. Living with an addicted parent is has a host of negative consequences that may be lifelong and is in itself considered an Adverse Childhood Experience (ACE).

One article from the Seattle Times documents the impact of the drastic increase in infants born addicted to drugs when they reach school age. “[The lives of children who grow up with drug-abusing parents are marked frequently by the presence of police, the constant fear of a mother or father’s incarceration and the likelihood of sudden death by overdose — all traumas shown to impede brain development and learning.”

To add insult to injury, the Post did not even seek to find out what is happening in its own back yard. Only two weeks before Thibodeaux’s article, a hearing was held in the 30-year-old LaShawn class action case to discuss the current placement crisis in the District of Columbia. The Judge referred to a letter from the court monitor that 31 children, including seven children between eight and ten years old, experienced a total of 60 overnight stays at the Child and Family Services Agency between April and November of 2019. All of these children had challenging behaviors that excluded them from existing placements. The agency director acknowledged that the District needs more therapeutic placements (either in family or group settings) for these children. The District is in the process of developing  a new group home and “a couple of” professional foster parents. The District is a small jurisdiction and its crisis is dwarfed by that of West Virginia, but its 60 office stays deserved a mention in our hometown paper.

The Washington Post‘s treatment of foster care illustrates the consequences of letting reporting and editorial staff without subject matter expertise tackle a complex subject like foster care. Repeating false narratives and tropes from alleged authorities is easy and saves time. But it does not help readers to understand what is wrong and what is needed and on the contrary leads them to look for “solutions” that may make things worse.

 

 

First “Family First” Plan to be approved shows limits of new law

PuttingfamiliesfirstDCOn October 29, 2019, the Administration on Children and Families (ACF) announced its first approval of a Title IV-E Prevention Plan to be submitted under the Family First Prevention Services Act (“Family First”). This plan, called Putting Families First in DC, was submitted by the District of Columbia’s Child and Family Services Agency (CFSA). While it is encouraging that the District was successful in gaining federal support for its plan, it is disheartening that there will be very little expansion of services under this new legislation, and that Family First will have no impact on the shortage of critically needed mental health services for parents.

Family First widened the population of children and families that can be served under Title IV-E of the Social Security Act from children in foster care to children who are “candidates for foster care” and their families.  A “candidate for foster care” is defined as a child who is identified in the jurisdiction’s prevention plan is being at “imminent risk of entering foster care” but who can remain safely at home or in a kinship placement if services are provided.  Each state sets its own definition of a candidate for foster care in its Title IV-E plan. CFSA has chosen a fairly broad definition, which includes many types of families that have been investigated by CFSA after an allegation of child abuse or neglect

Most interestingly, CFSA has chosen to include as “candidates for foster care” children of pregnant or parenting youth who are in foster care or have left foster care within five years. The inclusion of these families is particularly significant because it allows services to families in which abuse or neglect has not taken place. Rather than preventing the recurrence of abuse or neglect (known as “tertiary prevention”) this extends  the use of Title IV-E funds to preventing the first occurrence to a high-risk population (known as “secondary prevention”).  This  represents a more “upstream” approach, which many experts and child welfare leaders have long been arguing deserves more support.

However, the effects of this expansion of the eligible population are drastically constrained by the severe limitation on what services can be provided under Family First. The Family First Act extends the use of Title IV-E funds to services designed to prevent placement of children in foster care. Three categories of services are allowed: “in-home parent skill-based services,” mental health services, and drug treatment. (“Navigation” services to kin who are caring for children are also covered). So far, so good. But when specific services are considered, things become complicated.

As I described in earlier posts, the decision of Congress to make Medicaid the payer of last resort rules out using Title IV-E to fund many mental health and drug treatment programs that are crucial to keeping families together safely. And Congress’ decision to limit reimbursement to programs that are included in a Title IV-E Prevention Services Clearinghouse rule out support for many promising and supported programs that jurisdictions are already using or might want to use to support their struggling families.

Through a Program Instruction, ACF recently gave states an option to claim “transitional payments” for services that have not yet been approved by the clearinghouse, by conducting an “independent systematic review” of such services. But the funding will be cut off if the Clearinghouse decides not to approve the service, and it is not clear if any states will use this option. The District of Columbia has elected not to do so. As a result, after all the hoopla, the District is claiming only one evidence-based prevention service for funding under Family First! That is the Parents as Teachers (PAT) home visiting program, which is already being provided by the DC Department of Health using federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) funds. CFSA will be using local dollars, matched by federal Title IV-E funds, to add slots to this program to meet the needs of its foster care candidates and their parents.

It is worth noting that the evidence on PAT’s potential to prevent child maltreatment or its recurrence not very compelling.  The California Clearinghouse for Evidence Based Practices in Child Welfare (CEBC the leading organization of its kind) rates it as only “promising” (not “supported” or “well supported”) on primary prevention and does not even rate it on prevention of maltreatment reduction. Since the CEBC rated the program, a new study was released testing the potential of PAT to reduce maltreatment among parents who already have been found neglectful or abusive. The study found no overall effect, though they did find that there was a reduction in maltreatment reports for parents who were not depressed and did not have a significant history with Child Protective Services–in other words, the easiest-to -treat minority of the population of parents involved with CPS.

It is likely that CFSA will eventually receive Title IV-E support for a second service. Motivational Interviewing (MI) was approved by the Title IVE Prevention Services Clearinghouse after CFSA had already submitted its plan. MI is a method of counseling to facilitate behavior change, especially regarding substance abuse. It is typically delivered over one to three sessions.  However, CFSA has included Motivational Interviewing in its plan as a “cross-cutting” program rather than a program addressing substance abuse. The agency states that it intends to use MI as a “core component” of its case management model, rather than a two-or-three-session freestanding program. Brenda Donald, CFSA’s director, told the Chronicle of Social Change that she expected to be able to claim IV-E reimbursement for case management once it was added to the clearinghouse. Other jurisdictions are moving in the same direction, according to the Chronicle.

CFSA included in its Family First Plan other programs eligible for Title IV-E funding but is not planning to claim federal funds for these programs because they are already supported by federal funds. Also included are several services that have not yet been approved for Family First funding and are supported by Medicaid or local dollars. It’s a large array of programs, none of which will be supported by Title IV-E funds except PAT and perhaps MI.

So under Family First, Title IV-E dollars are being used to expand one home visiting program in the District and perhaps can be used to match funds spent on case management if CFSA succeeds in making the case that the use of the MI approach makes case management reimbursable. In the meantime, District parents with children at risk of foster care placement are desperately seeking needed services, especially mental health services to treat their mental disorders, such as depression and Post Traumatic Stress Syndrome (PTSD) that contribute to child abuse and neglect.  As recently reported by the District of Columbia’s Citizen Review Panel (CRP), there is such a shortage of basic  mental health services for parents that social workers are doing therapy themselves and also trying to substitute alternative services that may not be as effective, such as telemedicine or yoga. Lack of appropriate mental health services and long waiting lists were major themes of CFSA’s 2019 Quality Service Review, as reported by the CRP.  Poor quality of Medicaid-funded services and rapid turnover of providers are also problems that plague CFSA-involved parents and their social workers.

What a difference Family First could have made if its funds could be used to augment the supply of Medicaid-funded basic mental health services such as medication management, individual and group therapy! How many families could be strengthened if the Clearinghouse had included, or was considering, newer and exciting evidence-based mental health services like EMDR and Mindfulness Based Stress Reduction that may not be covered by Medicaid! Without federal help through Family First, parents involved with CFSA continue to wait for services they need to parent their children safely.

Another problem for CFSA lurks down the road. As CFSA describes in its plan, the law requires that 50% of IV-E spending be for practices that are “well-supported” as defined by the Act. But most of the “well-supported” practices that CFSA is using are funded by Medicaid in the District. If the Medicaid-funded programs cannot be counted as part of CFSA’s total Family First expenditures (which ACF has suggested will be the case), CFSA will not be able to show that it is spending 50% on “well-supported” practices. Congress has already passed the Family First Transition Act, which delays implementation of this requirement to 2024, with a requirement that by 2022 states have to show 50% of practices as “supported” or “well supported.” But what will happen then? The Chronicle voices the hope that more practices would have made it to the well-supported list by that time. We shall see.

With all the fanfare around Family First and CFSA’s large investment of time in developing this plan, it seems clear that the agency is gaining few resources in return for the large  burden of showing compliance with Family First.  It’s ironic that CFSA must provide extensive documentation to ACF regarding services that are getting no funds under the act. CFSA and other jurisdictions should press for amendments that make Family First more likely to achieve its objective of supporting parents to improve their parenting and keep their children safely at home.

Family First Act: no funding for important drug treatment and mental health services

Family First ActPassage of the Family First Prevention Services Act as part of the Bipartisan Budget Act early in 2018 was hailed as a game changer in child welfare.  For the first time, according to the celebrants, Title IV-E funds could be used to pay for services to keep families intact rather than place children in foster care. But the more we learn about Family First and how it is being implemented, the less cause for celebration there seems to be. In my last post, I discussed the problems caused by the decision to make Title IV-E the payer of last resort for foster care prevention services. In this post, I discuss the surprising omission of important mental health and drug treatment programs from the list of programs that have been approved or proposed to be paid for under Family First. The paucity of useful programs in the clearinghouse certainly will detract from the utility of Family First in preventing foster care placements.

In expanding the use of federal IV-matching funds beyond foster care through Family First, Congress wanted “to provide enhanced support to children and families and prevent foster care placements through the provisions of mental health and substance abuse prevention and treatment services, in-home parent skill-based programs, and kinship navigator services.” Family First allowed federal Title IV-E matching funds to be used for programs in these categories that meet criteria for being “evidence-based” as defined by the Act.

The categories  of mental health, drug treatment and parenting programs make sense in light of what we know about why children come into foster care. Anyone who has worked in foster care knows that parental drug abuse and mental illness are two of the major circumstances behind child removals, while a third major factor, domestic violence, was inexplicably left out of the Act. The inclusion of parenting programs makes sense because abuse in particular is often related to parents’ lack of knowledge about child development and appropriate disciplinary practices.

Family First established a Title IV-E Prevention Services Clearinghouse, which is being developed under contract by Abt Associates, to review and approve programs for reimbursement using Title IV-E foster care prevention funds. So far, the clearinghouse has approved nine programs for inclusion and is in the process of considering 21 more. A careful look at the programs that are included, under review, and not on either list raises some questions.

Take substance abuse treatment, the most common single factor behind child removals according to federal AFCARS data, which indicates that drug abuse was a factor in 36% of the child removals that took place in Fiscal Year 2018. The opioid crisis, often cited as a reason to pass Family First, seems to have peaked in most areas but is still wreaking havoc in many states and their foster care systems. Medication-assisted treatment is often called the “gold standard” for treating opioid addiction and is vastly underutilized. But strangely that Abt Associates chose to include in the clearinghouse only Methadone Maintenance Therapy and not the newer buprenorphine treatment, which is not even on the list of programs to be considered for clearinghouse listing.  According to the National Institute on Drug abuse, “Methadone and buprenorphine are equally effective at reducing opioid use.” And there are reasons to prefer the newer medication. As the federal Substance Abuse and Mental Health Administration (SAMHSA) states, unlike methadone treatment, “which must be performed in a highly structured clinic, buprenorphine is the first medication to treat opioid dependency that is permitted to be prescribed or dispensed in physician offices, significantly increasing treatment access.”

Let’s turn to mental health. It is clear that mental illness is the major factor behind many removals into foster care. AFCARS data indicate that 14% of child removals are associated with a “caregiver’s inability to cope,” but that percentage sounds small to this former social worker. It is likely that many more removals where other factors (like child abuse and substance abuse) are cited are also related to parental mental illness. Parents suffering from untreated depression, bipolar disorder, post-traumatic stress disorder (PTSD), and other mental health disorders often have difficulty providing appropriate care to their children. So it is not surprising that mental health was included as a category of services to prevent foster care under Family First.

What is surprising is the nature of the services that have been chosen so far. The clearinghouse has approved four mental health programs: Functional Family Therapy, Multisystemic Therapy, Parent Child Interaction Therapy, and Trauma-Focused Cognitive Behavior Therapy. All of these programs are geared at addressing the issues of children–not their parents. It is very odd that the clearinghouse did not include any services to address common mental disorders, such as depression and PTSD, that afflict many parents who come to the attention of child welfare agencies. After all. the California Evidence-Based Clearinghouse for Child Welfare (CEBC), the leading repository of evidence practices in child welfare, lists nine programs meeting Family First criteria as well supported, supported or promising  for treating depression and 11 programs meeting those criteria for trauma treatment for adults. Even odder, among the six mental health programs being considered for inclusion in the Title IV-E clearinghouse, only one (Interpersonal psychotherapy) could be used to treat adults although there is also a version for adolescents and the clearinghouse does not specify which one is under review.

Among the evidence based practices included in the CEBC and not included or under review by the Title IV-E clearinghouse are some well-established programs known to be effective, such as Cognitive Behavioral Therapy for adult depression and  Mindfulness Based Cognitive Therapy.  Both of these have the top rating of “well-supported” from CEBC for treatment of depression in adults. Another mindfulness-based treatment called Mindfulness Based Stress Reduction is becoming increasingly popular and supported by research for treatment of depression and anxiety. Because it is not generally covered by insurance, using Family First funds could make this treatment available to parents who could not otherwise get it. Eye Movement Desensitization and Reprocessing (EMDR), a popular trauma treatment, is also given the top rating from the California clearinghouse and not included or being reviewed by its Title IV-E counterpart.

On the other hand, the inclusion of two out of three “in-home parent skill based” programs in the Title IV-E Clearinghouse is somewhat surprising. The inclusion of Healthy Families America (HFA) raises questions because it has not yet been able to demonstrate an impact on the prevention of child abuse and neglect. There is one study with a promising result but this study was criticized by CEBC due to a very small sample size, limitation to one region, reliance on parent self-report and other factors. CEBC gave HFA as a rating of “4” (“evidence fails to demonstrate effect”) for the prevention of child abuse and neglect.

Another home visiting program, Nurse Family Partnership (NFP), has limited potential to prevent foster care among the Title IV-E eligible population. NFP is the only home visiting program given the top rating for prevention of child abuse and neglect by the CEBC; however it is approved only for first-time teenage mothers. It cannot by definition be used to prevent a recurrence of abuse or neglect. NFP can be provided under Family First in jurisdictions, like the District of Columbia, that have defined all children of teens in foster care as foster care candidates. But it is not applicable to most families eligible for prevention services under Title IV-E.

In sum, the list of programs that have been cleared by the Title IV-E clearinghouse as well as those that are being reviewed contains some disconcerting omissions and surprising entries. While some of the most exciting and promising mental health and drug treatment programs are not included, some home visiting programs with very limited applicability to the purposes of the Act have been included. When added to the decision to make Medicaid the payer of last resort, these decisions by the clearinghouse make the utility of Family First as a vehicle of foster care prevention even more dubious. Those who agree should join me in requesting that the Title IV-E Clearinghouse review and approve some of the effective practices mentioned in this post.

 

 

Family First Act: a False Narrative, a Lack of Review, a Bad Law

Family First ActThe passage of the Family First Prevention Services Act (FFPSA) was greeted with joy and celebration when it passed as part of the Bipartisan Budget Act of 2018. “The Family First Prevention Services Act will change the lives of children in foster care,” crowed the Annie E. Casey Foundation.  The new law “will change foster care as we know it,” raved the Pew Charitable Trusts. But the Act took effect on October 1 to little fanfare. Based on contacts with all the states, the Chronicle of Social Change expects only 14 states and the District of Columbia to implement the Act and 36 to delay implementation for up to two years as allowed by the law. But as of two weeks before implementation, only four states had submitted the plan required in order to implement the Act.

An Act with Many Flaws

FFPSA has been revealed (as some knew all along) as a messy and poorly written piece of legislation. It starts with a misnomer. What the Act calls “prevention services” (“in-home parent skill-based,” mental health, and drug treatment programs for parents who have already been found to have abused or neglected their children) are aimed at prevention of foster care, not of child abuse and neglect before they occur. To most experts, these would be considered to be “intervention” and not “prevention” services. But beyond this misnomer, the legislation has multiple flaws which means it may create more problems than it solves.  Among these issues, covered in detail in a recent webinar from California’s Alliance for Children’s Rights and an article in Governing, are the following:

  1. Lack of new funding: FFPSA was designed to be budget neutral, redirecting funds toward foster care prevention services from congregate care and a delay of an expansion in adoption assistance. The Congressional Budget Office has estimated that FFPSA will actually result in a $66 million reduction in federal spending over a ten-year-period. This comes on the heels of 20 years of federal disinvestment in foster care, leaving jurisdictions struggling to maintain reasonable caseloads and services.  Some states are anticipating crippling losses of of funds due to the loss of their Title IV-E waiver programs, which expire at the end of the year and were far more generous and less restrictive than FFPSA. For example, California anticipates the loss of $320 million in federal funding when the waiver ends, forcing service reductions in some of its largest counties. New York will lose support for a program that hired more social workers and supervisors and has been credited with allowing youth to leave foster care earlier.
  2. Requirement that 50% of funding be spent on “well-supported” programs. FFPSA requires that 50% of funding be spent on programs that meet a rigorous set of criteria to be defined as “well-supported.” But so far, the clearinghouse created for the purpose of this provision has designated only six programs as “well-supported”: three mental health programs, three home visiting programs, and no drug treatment programs. Some states may prefer to adopt or expand in other similar programs that are not on the list. Therefore there has been a chorus of proposals that this provision be eliminated or delayed.
  3. Interaction with Medicaid: Each state’s Medicaid program covers a different set of services, but many of the services meeting FFPSA criteria, especially mental health and substance abuse treatment, are already funded by Medicaid in most cases. Allowing Title IV-E to supplement Medicaid funds might have helped improve the quantity and quality of services available. But in its guidance on implementing the legislation, the Children’s Bureau specified Title IV-E as the payer of last resort for these services. That means that Medicaid must pay first before Title IV-E can be billed. Thus, in states with more generous Medicaid programs, the law will not greatly expand the services available to families. Moreover, it appears, based on the federal government’s answer to one state’s question, that programs paid for by Medicaid may not count toward the 50% of programs that must be “well-supported,” leaving states that use Medicaid to fund these programs in a difficult situation. 
  4. Restrictions on congregate care: One of the two main purposes of FFPSA was to restrict congregate care, which is basically any placement that is not a foster home. To do so, FFPSA cuts off funding after two weeks for any placement that is not a foster home, with four exceptions. Three of these are programs for special populations and the fourth is a new category called a Quality Residential Treatment Programs (QRTP)–a new category created by FFPSA. QRTP’s must meet numerous requirements, such as accreditation, 24-hour nurse coverage, and a “trauma-informed” approach. Moreover, a child must be assessed by a “qualified individual” as needing placement in a QRTP and that decision must be approved by the family court. Furthermore, a youth may not remain in a QRTP for more than 12 consecutive months without written approval from the head of the agency. As Child Welfare Monitor has discussed elsewhere, there is concern that some group homes will have trouble meeting the FFPSA criteria. Group homes are closing around the country due to insufficient funding and state-level policy changes. Many states have desperate shortages of foster homes, and closing group homes at the same time will worsen their placement crises. Furthermore many young people, especially those with more issues, may need more than 12 months in a group home and may lose all their gains if transferred prematurely to a foster home.  There is also a problem with Medicaid and QRTP’s, as it appears they will fall into a category of “Institutions for Mental Diseases” that are not payable by Medicaid.
  5. Kinship Diversion: FFPSA creates an avenue for prevention of foster care by placing a child with relatives (often called kinship diversion) while the parents receive prevention services for up to 12 months. If reunification with the parents never happens, there is no requirement that the children be placed formally with the relatives, or that the relatives receive any assistance either financially or with services. They would be forced to rely on Temporary Assistance for Needy Families (TANF), which is much less generous than foster care payments, and to make do with any services they can find in the community. There is concern that FFPSA may encourage states and counties to use kinship diversion rather than licensing relatives as foster parents, thus entitling them to more services and assistance and ensuring that the agency does not lose track of the children.

How a bad bill was born

The passage of FFPSA was the outcome of many years of advocacy, under the mantra of “child welfare finance reform.” So how did such a flawed bill pass after so many years of proposals and discussions? The answer includes a truncated legislative process, an insistence on budget neutrality,  and a false narrative promoted by a wealthy group of organizations.

False Narrative

This call for finance reform was based on the idea that, as expressed by one of its primary proponents, Casey Family Programs, in a “White Paper” published in 2010:

 …the major federal funding source for foster care, Title IV-E, primarily pays for maintaining eligible children in licensed foster care, rather than providing services for families before and after contact with the child welfare system. The fact that no IV-E funding can be used for prevention or post-reunification services has created a significant challenge to achieving better safety and permanency outcomes for children.

This statement was literally true. Before implementation of FFPSA, Title IV-E funds were not available for services provided to families to help them avoid placement of their children in foster care. But plenty of other funds were available to cover these services. We’ve already mentioned that Medicaid currently pays for many or most of the services that will be provided under FFPSA, with the specifics depending on the state. Other funding sources  included Title IV-B, TANF, Social Services Block Grant, and CAPTA funds.

Moreover, Title IV-E does not cover all foster care costs. The federal government reimburses states for 50 to 75% of the cost of foster care payments, depending on the state. But only 38% of foster children were eligible for federal reimbursement under Title IV-E in 2016, down from an estimated 54% in 1999. The reason for this decline is an antiquated provision (often called the “Title IV-E lookback”) that links Title IV-E eligibility to eligibility for Aid to Families with Dependent Children, a welfare program that ended in 1996. Anything calling itself finance reform should have addressed this senseless linkage, but the framers did not.

So, between the availability of other funds and the fact that states had to pay a large share of foster care costs themselves,  it is hard to accept the narrative that states had an incentive to place children in care rather than provide services to their families to keep them at home. And indeed states have for years been providing in-home services to help families avoid foster care. According to federal data, 1,332,254 children received in-home or family preservation services in FY 2017 compared to only 201,680 children who received foster care services. So the argument for “finance reform” is simply a red herring.

The idea that a foster home is almost always better than a group home or residential placement is behind the other major part of FFPSA, the strict restrictions on funding for congregate care. But this narrative ignores the fact that there are not enough foster parents, especially those who are willing, loving and gifted enough to care for older and more troubled young people. Perhaps some supporters think that these foster parents will suddenly appear once group homes disappear. But this kind of wishful thinking failed when the mental hospitals closed in the 1960’s and the promised community mental health services did not appear, and there is no reason to think it will be more accurate this time around.

So how did a false narrative gain such a large following and become accepted as the truth? This idea has been supported by a powerful coalition of organizations led by Casey Family Programs, author of the white paper quoted above. Casey’s assets totaled $2.2 billion at the end of 2018 and it spent $111 million that year in pursuit of its goals, which include “safely reducing the need for foster care by 50 percent by the year 2020.” Casey has relentlessly promoted this narrative through publications, testimony, and assistance to jurisdictions that agree to implement its agenda.

Budget Neutrality

As mentioned above, FFPSA does not add resources to the system but instead redirects them from congregate care and adoption assistance to services designed to keep families together. Much of the savings will come from states taking on the full cost of group home placements that they cannot avoid. The Congressional Budget Office estimates that about 70% of the children residing in group home placements (other than residential treatment programs) would become ineligible for Title IV-E funding in 2020. So the cost of funding this placements will be shifted to states and counties that are often already struggling to fund these necessary placements. Moreover, the continuation of the TItle IV-E “lookback” means that the federal share of foster care funding will continue to decrease.

Much of the blame for the Act’s budget neutrality goes to Casey and its fellow advocates, who have been uninterested in increasing resources for foster care. As longtime Hill staffer Sean Hughes points out, “…Congressional staffers will tell you that child welfare advocates are perhaps the only group of federal advocates that consistently decline to even ask for new resources.” According to Hughes, these advocates have been unwilling to increase resources for foster care because of their bias toward family preservation. (Remember Casey’s goal of reducing foster care by 50% by 2020). They apparently hope that “starving the foster care beast” might result in fewer foster care placements, whether or not children might be left in unsafe situations. The framers wanted a budget neutral bill, and the advocates were happy to accept it in order to reallocate resources away from foster care (through the continuation of the “lookback” and the restrictions on group homes) toward family preservation.

Lack of review

Aside from a pair of hearings that were orchestrated by the bill’s sponsors to support their vision for the legislation, there were no hearings or floor debate on the Family First Act after it was introduced in 2016. In 2017, it passed the House by voice vote, and its Senate sponsors failed to get it passed. In 2018, after failing twice to attach it to larger bills without hearings of debate, the sponsors succeeded at the eleventh hour in getting it attached to the budget act. Young people whose lives were saved by group homes were never able to tell their stories. The technical problems with Medicaid eligibility were never discussed and may not have even been noticed until long after passage.

A bill called the Family First Transition Act has been introduced to ease the transition to the new legislation. It would delay for two years the implementation of the 50% “well-supported” requirement for services reimbursement,  provide a small amount of transition funding to help states implement the Act, and provide temporary grants to jurisdictions with expiring waivers to make up for a portion of their loss under FFFPSA. However, none of these temporary fixes would cure this fundamentally flawed bill, the inevitable result of a false narrative, inadequate funding, and a truncated legislative process.

This post was updated on November 7, 2019, to specify that the Children’s Bureau made the determination that Title IV-E would be the payer of last resort for prevention services to foster care candidates. This designation of Title IV-E as payer of last resort was not made in the Act itself.