The continued decline in foster care placements: What, if anything, are children and families getting instead?

On May 9, 2025, the US Administration for Children and Families (ACF) announced that the number of children entering foster care had continued to decrease in FFY 2023. Entries to foster care dropped from an estimated 264,000 in FFY 2018 to 175,282 in FFY 2023–a drop of 33.6 percent. But foster care is not the only service provided by child welfare agencies after an investigation or assessment finds that a child needs protection. Instead of being placed in foster care, some children and their families receive “in-home services,” which aim to ameliorate the risks to their safety without removing them from their homes. With the large drop in child removals, it is natural to ask whether home-based services are being provided to more families as fewer children are placed in foster care. Unfortunately, the data to answer to that question is not available on a national basis or for most states.

Clearly we cannot determine what is happening to the children who “would have been placed in foster care” under previous policies and practices. But at least we can ask if declining foster care placements are being offset by the opening of more cases for in-home services–which some states call Intact Family Services, Family Maintenance, or Family Preservation Services, among other terms. These are the services that are provided to children and their parents after an investigation or assessment determines that the situation does not meet the criteria for foster care placement (usually imminent danger to the child) but that the family does need services and monitoring to reduce risks to the children. In a major investigation, Texas Public Radio (TPR) found that a 40 percent drop in child removals by the state’s Department of Family and Protective Services (DFPS) over a six-year period was not accompanied by an increase in family preservation services (as they are called in Texas) but instead by a “radical curtailment” of such services. Children were left in dangerous homes with no services or monitoring.

For many years, many powerful groups like Casey Family Programs blamed the alleged lack of federal reimbursement for services to families, like drug treatment, mental health care, and parenting support, for the removal of many children who could have been helped at home. As I have pointed out, this argument was largely spurious because states were already providing these services using Medicaid and other sources. In any case, the passage in 2018 of the Family First Prevention Services Act (FFPSA) was supported by advocates as a means to alleviate this alleged problem by making funds available for these in-home services. Given the repeated use of that narrative by proponents of FFPSA, it would have been logical to mandate that states report on the numbers of children receiving such in-home services, the characteristics of these children and the services they receive. But such a mandate was not included in the Act.

States are currently required to provide child welfare data to the Children’s Bureau via two separate systems. They must submit foster care and adoption data through the Adoption and Foster Care Analysis and Reporting System (AFCARS). A separate system, the National Child Abuse and Neglect Data System (NCANDS), includes data on abuse, neglect, and child protective services. NCANDS includes numbers of children receiving “postresponse services,” or services provided as a result of needs discovered during an investigation or assessment. But these numbers are provided in a form that is neither meaningful nor comparable to the AFCARS data, and therefore does not allow the comparison of foster care and in-home numbers for each state and the nation.¹

Not only does the federal government not ask the states for meaningful data on in-home cases; most states do not provide such data on public-facing platforms. A review of reviewed publicly available data for the 12 states with the largest number of children in foster care yielded only two (California and Texas) that provided enough data on in-home services to answer the question of whether declines in foster care removals have been offset by the opening of in-home cases. The results are discussed below.

California

California has far more children in foster care than any other state, 43,095 children at the end of Federal Fiscal Year 2023, which was 12.6 percent of the national total, according to AFCARS data. Fortunately, California Child Welfare Indicators Project (CCWIP), a collaboration between University of California at Berkeley and the California Department of Social Services, provides excellent data on all child welfare services provided in California. The CCWIP dashboards include data on the number of entries into foster care and the opening of Family Maintenance cases, as in-home cases are called in California. According to CCWIP, entries into foster care declined from 26,766 in Federal Fiscal Year (FFY) 2019 to to 17,071 in FFY 2024. Rather than increasing to make up for the drop in children entering foster care, the number of children with Family Maintenance case openings as the first service component declined from 25,887 to 18,441 over the same period. The total number of children with cases opened for child welfare services dropped from 44,747 to 29,936 over the five-year period–a drop of 33.1 percent.² Rather than a shift from foster care to in-home services, there has been an reduction in the number of children reached by child welfare services.

Texas

Texas has the third largest state foster care caseload, behind California and Florida. The number of Texas children entering foster care dropped from 16,028 in 2021 to 9,623 in 2022, an incredible 40 percent, and then stayed about the same for the following two years. Confirming the conclusions of TPR, the number of children entering family preservation services dropped from 51,806 in FY 2020 to 39,655 in FY2021 and then to 26,132 in 2022–half of the 2020 total. The drops in foster care and in-home case openings were presumably related to a new Texas law that changed the definition of neglect and put restrictions on child removals. In addition, a 2020 policy change restricted eligibility for Family Preservation Services in Texas, according to the TPR investigation. TPR found that the number of families that DFPS rejected for family preservation services jumped from 300 to about 2,800 in the first year the policy took effect. Perhaps in an effort to rectify the extreme curtailment of services, the number of children with in-home case openings increased in 2023 and 2024, while the number of children entering foster care remained stable. Nevertheless, the overall trend over time was a decrease in foster care entries, and in children with new family preservation cases.³

A look at the two figures above shows a major difference between the California and Texas. In California, substantially more children entered foster care (17,071) than entered family maintenance services (13,473) in FFY 2024. But in Texas, the number of children entering family preservation services (42,855) was more than four times the number of children entering foster care (9,220) in FY 2024. This vast difference makes clear that nationally we have no idea whether more investigations result in foster care or in in-home services. And we don’t know whether the number of children with new in-home cases has increased as the number being placed in foster care has gone down. Moreover, we don’t know what kind of in-home services parents and children are getting. Are children in California’s Family Maintenance Services getting a similar package of services as those in Texas’ Family Preservation Services? We just don’t know. That is not an acceptable state of affairs, especially given the use of federal funds for these services.

In order to make the needed information available, new legislation might be required. Section 479 of the Social Security Act required the establishment of a system to collect data on foster care and adoption in the United States. AFCARS was created based on general guidelines laid out in the law and more detailed regulations promulgated by HHS. But now it is time to expand AFCARS to include data on child welfare services delivered in children’s homes when a case is opened for the provision of such services. The same sorts of data on entries, exits, caseloads, demographics, and reasons for the initiation of services as is required for foster care should be included for in-home servcies. Required variables should also include the types of services provided to each family and whether they are voluntary or mandatory with court involvement.

While data from Texas and California suggest that child welfare has been reducing its footprint since 2018, we cannot assume that this is happening nationwide without data. That is why ACF should request that Congress act to require that states submit data on in-home cases. Even with this information we will not know how effective in-home services are in protecting children andhelping their parents ameliorate the conditions that put their children at risk; there is very little research that addresses this question. More and better research on that issue is needed. But not even knowing whether children who would have once been placed in foster care are now being protected at home while their parents are helped to make them safe is simply not an acceptable situation.

Notes

The numbers provided include foster care as well as in-home services. The number of children provided is a duplicated count. And the number of children receiving each type of services is not provided. ↩︎
These totals are lower than the sum of the children with foster care entries and in-home case openings, presumably because some children entered in-home services and were placed in foster care in the same year. ↩︎
Texas does not provide the total number of children entering services of any type as does California. Adding those entering foster care to those entering in-home services would produce an inflated estimate since we do not know the number of children who may have entered both types of services during the year ↩︎

As foster care removals plummet, where’s the promised help for families?

Year after year, states and the federal government continue to release annual data showing a decline in the number of children in foster care, congratulating themselves on keeping families together. They seem to have forgotten that reductions in foster care were supposed to be accompanied by increased services so that children could be safely maintained at home. Unfortunately, there seems to be little to no interest on the part of the federal Children’s Bureau, Members of Congress, advocates, or the media in whether such services are actually being provided.

The newest report from the Adoption and Foster Care Analysis and Reporting System (AFCARS) showed that the number of children in foster care dropped to 368,530 on September in 2022–a drop of 5.8 percent over the previous year 15.6 percent since 2018. “We are encouraged by the continued decrease in the number of children entering foster care and staying in foster care and we will continue working with our state, tribal and territorial partners to ensure an emphasis on family well-being and safe family reunification,” said Jeff Hild, the Principal Deputy Assistant Secretary of the Administration on Children and Families (ACF) in a press release heralding the new numbers. ACF gave credit to the Family First Prevention Services Act (FFPSA), which “helped change the conversation to be about prevention of foster care placements and preservation of families.”

It seems premature to celebrate the shrinkage of the foster care rolls as a triumph without knowing what is happening to the children remaining at home who would have been removed in a different year. How many of these children are living with abuse or neglect that will leave lasting scars or impair their development, if not endanger their lives? Supporters of the Family First Prevention Services Act (FFPSA), which passed in 2018, said that declining foster care counts would result from providing support to parents who needed help to address the problems (like substance abuse, mental illness and poor parenting skills) that led to their maltreatment of their children.

After an allegation of abuse or neglect is substantiated, an agency can place a child in foster care or open a case for in-home services, among other options.¹ FFPSA made it possible to use the same federal funds for foster care and in-home services, allowing children to stay at home safely while their parents addressed the issues that put them at risk. A major purpose of FFPSA was to enable states to use federal funds that were formerly available only for foster care to pay for parenting support, mental health, and drug treatment that would enable children to stay safely with their families. The rationale for this change was that allowing foster care funds to be used for such services was necessary to enable states to keep kids out of foster care.

However, FFPSA has not made massive federal resources available for such services. ACF estimates that only 18,400 children in the entire country were served by Title IV-E prevention services programs in FY 2023, at a cost of $167 million. But perhaps states are using their own funds to pay for these services? After all, foster care is more expensive than services provided to families in their homes. Both require case management, but instead of the cost of room and board for foster youth, providing in-home services usually involve referring parents to mental health and drug treatment services often funded by Medicaid or paying for parenting support programs that cost less than foster care. (Of course the supporters of FFPSA ignored this basic fact and claimed the legislation would revolutionize child welfare!). States were already providing these services before FFPSA and they could have increased them without the promised federal funding.

But believe it or not, nobody knows if more children and their families are receiving in-home services as the foster care rolls decline, since the federal government doesn’t ask states for this information. While states were already required to report the number of children entering foster care, leaving it, and in care at a point in time, FFPSA did not add a requirement to provide the same data on services provided to children and families in their homes, now that they were also covered by federal Title IV-E funds.² Hoping some states might track this data of their own accord, I searched the data publications and dashboards on the websites of the ten states with the largest number of children in foster care according to the most recent AFCARS report,³ but I was able to obtain this data for only California and Texas.

California has by far more children in foster care than any other state, 45,924 children at the end of September, 2022, which was 12.4 percent of the national total. Fortunately, there is extraordinarily good data from the California Child Welfare Indicators Project (CCWIP), a collaboration between University of California at Berkeley and the California Department of Social Services. The CCWIP dashboards include data on the number of entries into foster care and the opening of Family Maintenance cases, as in-home cases are called in California. Entries into foster care declined precipitously from April 2019 to March 2020 and continued declining, though more slowly, through March 2024. Family Maintenance case openings also declined continuously throughout the period. Thus, there was no increase in Family Maintenance case openings to compensate for the decline in removals. Or put in a different way, the total number of cases opened for child welfare services dropped from 46,264 at the beginning of the period to 29,969 at the end–a drop of 35 percent. Rather than a shift from foster care to in-home services, there has been a shrinkage of children reached by child welfare services overall.

Source: California Child Welfare Indicators Project, Entries, https://ccwip.berkeley.edu/childwelfare/reports/Entries/MTSG/r/ab636/l and Case Openings, https://ccwip.berkeley.edu/childwelfare/reports/CaseOpenings/MTSG/r/ab636/l.

Texas has the third largest state foster care caseload, after Florida. The Texas data are a bit more confusing. The number of children entering foster care dropped from 16,028 in 2021 to 9,623 in 2022, an incredible 40 percent, while the number of children entering in-home services declined steeply as well, resulting in a 35.7 percent drop in all case openings. Both drops may well have been related to a new Texas law that took effect on September 1, 2021 and changed the definition of neglect to an action or lack of action that puts a child in “immediate danger” of harm, rather than “substantial risk” of harm as the previous language read. The bill also put restrictions on child removals, requiring that children can be removed only from parents who display “blatant disregard” for their actions, or whose inaction “results in harm to the child or creates an immediate danger to the child’s physical health or safety.” Interestingly, in 2022, foster care entries actually rose slightly in Texas, while family preservation entries sprung back to where they were in FY2021, resulting a substantial increase in total case openings that year. Nevertheless, the overall trend over time was a decrease in foster care entries, family preservation case openings and the total number of children receiving help through open in-home or out-of home cases. That total dropped from 72,181 to 48,619 over five years–a drop of 32.6 percent–almost the same as the drop in California’s child welfare case openings.

Source: Texas Department of Family and Protective Services, CPS Conservatorship, Removals, https://www.dfps.texas.gov/About_DFPS/Data_Book/Child_Protective_Services/Conservatorship/Removals.asp, and CPS Family Preservation, Children Entering Services, https://www.dfps.texas.gov/About_DFPS/Data_Book/Child_Protective_Services/Family_Preservation/Children_Entering_Services.asp

Florida, the state with the second largest number of children in foster care, reports on the numbers of children entering foster care but not on the number entering in-home cases. One can, however, compare the number of children in foster care at a point in time with the number of children and young adults receiving in-home services. Both numbers have been decreasing and the number of children receiving in-home services has been consistently about half of the number of children in foster care. But these numbers don’t tell us whether declining entries to foster care have been offset by increasing entries to in-home services. In general, foster care cases last longer than in-home cases. Not knowing the average length of stays in foster care and in-home cases, and how they have changed over time, one cannot tell whether in-home case openings have made up for the reduced number of entries into foster care.

The Florida data show why point-in-time data cannot be used to answer the question of whether the decline in foster care entries has been accompanied by a rise in in-home case openings. Unfortunately, none of the other eight states with the highest caseloads provide this data on their websites. Illinois and Indiana provide point-in-time data on foster care and in-home participants. The other five states with the largest caseloads–Ohio, New York, Pennsylvania, Arizona, and North Carolina–display no data on in-home case participants at all.

If California and Texas are typical, states have not been increasing their provision of in-home services to make up for declines in foster care. Instead, the total number of abused and neglected children being helped by in-home or out-of-home services (or foster care) has declined by as much as a third in five years. But we cannot assume that California and Texas represent the entire nation. It is unfortunate that the writers of FFPSA did not requiring states to include data on in-home case openings and total caseloads, given that the legislation allowed federal funds to be used for this purpose. States have not begun tracking and reporting on this data on their own, and are triumphantly proclaiming the drop in foster care without even reporting on whether in-home services are being provided instead. When Congress considers desperately-needed fixes to FFPSA, a requirement that states report in-home case data analogous to the foster care data in the AFCARS system should be included in the new legislation.

Notes

Other options include referring a family to a community provider or even doing nothing nothing if the abuse or neglect was assumed to be a one-time event unlikely to occur. The family may also refuse in-home services, and the agency would then have to decide whether to file a court petition to require such services ↩︎
States must provide to National Child Abuse and Neglect Data System (NCANDS) information on how many children receive “postresponse services,” meaning services after a child protection investigation. But unfortunately, “postresponse services” includes foster care and provides a duplicated count, counting children every time they are the subject of an investigation, so it is not useful in telling us how many children receive in-home services. ↩︎
State foster care data can be accessed from https://www.acf.hhs.gov/cb/report/trends-foster-care-adoption. According to the latest information, the ten states with the largest number of children in foster care on September 30, 2022 were California, Florida, Texas, Illinois, Ohio, New York, Missouri, Pennsyhlvania, Arizona, and Indiana. ↩︎

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

PuttingfamiliesfirstDC On 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 Act Passage 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.