Tag: residential treatment

A Home for Every Child: an inadequate framework for assessing state child welfare programs

On December 19, 2025, the Administration for Children and Families (ACF) released CFSR Technical Bulletin No. 14, the first step in its plan to replace the the existing process by which it reviews state child welfare performance with one that is less burdensome and more useful. The replacement is long overdue. But ACF’s attempt to reorganize all outcomes under one slogan–A Home for Every Child–is highly problematic. It disregards the need for larger homes for sibling groups and residential treatment for some young people. And it devalues and disincentivizes the central function of child welfare–protecting children from harm.

In an article in The Imprint called Why We Are Putting the PIP on a PIP, Alex Adams, the Assistant Secretary for ACF, explains the shortcomings of the Child and Family Services Reviews (CFSR’s), which are the periodic federal reviews of state child welfare systems to assess their performance and ensure they are in compliance with federal requirements. In 25 years, no state has been in substantial compliance with all the outcomes and systemic factors that are evaluated, and every state has been placed on a Performance Improvement Plan (PIP). Meanwhile, the administrative burden is heavy. Adams rightly states that “this is busywork–expensive, repetitive, punitive busywork–and it has not improved child or family outcomes.” I don’t think many child welfare stakeholders would disagree. It is time for the CFSR’s to be put out of their misery.

But what will replace the CFSR’s? As a first step to a solution, ACF has announced a pilot PIP process that states can opt to follow instead of the standard PIP procedure. As described in the Technical Bulletin, “this Administration is creating a pilot opportunity for states….to center their program improvement efforts around the A Home for Every Child goal.” Interestingly, the goal is not defined in the Technical Bulletin;1 the definition is found in several other places including a press release stating that “A Home for Every Child sets an ambitious goal of achieving a foster home-to-child ratio greater than 1:1 in every state. The initiative will focus on both sides of the equation — increasing the availability of safe homes through diligent recruitment, prioritizing kin, and improving retention of existing caregivers while reducing entries into foster care through effective prevention and faster pathways to permanency.” This sounds reasonable at first, but there are problems with centering program improvement planning around this goal–problems with the concept itself and with the implications of using it as an organizing principle in the assessment and improvement of child welfare performance.

A Flawed Concept

A Home for Every Child as a goal of child welfare seems to make sense on its face. To take a child into foster care when there is no place to put that child seems like folly, and a state that cannot equalize the supply and demand for foster care might need to rethink its rules about when to remove a child. But ACFs definition of that goal–one licensed home per foster child– makes no sense. Many foster homes can accommodate more than one child, and we need more larger homes to welcome sibling groups. And some young people in foster care need residential treatment before they can flourish in a foster home. For these reasons, child welfare administrators tend to use the concept of “beds” rather than “homes” when counting available placements for foster youth. What matters is not how many homes there are, but how many children can be accommodated in a placement that meets their needs. The two issues of multi-child homes and placements that are not foster homes are discussed below.

Foster homes with more than one child

As mentioned above, many if not most foster homes can accommodate more than one child. Many children come into care as part of sibling groups, and child welfare agencies hope to place as many of them together as possible. Despite their efforts, siblings are often separated in foster care for lack of homes that can accommodate them. We need more programs like Together California, a new community of 12 homes each built to house up to six siblings with full-time, professionally trained foster parents. Similar programs exist in Illinois, Florida and other states. Such homes could also be offered to relatives who are do not have room to take in larger sibling groups. The requirement of one home per child encourages states to focus on assembling as many foster homes as possible, rather than developing programs to keep sibling groups together.

Placements that are not foster homes

Secondly, A Home for Every Child should not include just foster homes. Most experts acknowledge that some children and youth need residential treatment before they can thrive in a foster home. Secretary Adams wrote in The Imprint that when the number of foster homes exceeds the number of children needing them, “[c]hildren avoid sleeping in offices or cycling through short-term rentals.” But most of the children sleeping in hotels, offices, short-term rentals, and other inappropriate placements have complex behavioral health needs and have been through many foster homes already. Media reports from California, Colorado, Hawaii, Illinois, Kentucky, Maryland, Massachusetts, Michigan, Missouri, New Mexico, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Washington, West Virginia, and Wisconsin document the preponderance of high-needs children among those in unlicensed, inappropriate placements.2 In Adams’ own state of Idaho, the child welfare agency under his leadership reported that short-term rentals were until recently used to “temporarily house children with complex needs.” Many of these high-needs young people need residential treatment, maybe for six months or a year, before they can live in a foster home. Otherwise, they will simply be bounced from home to home until they end up in another inappropriate placement or worse.

Unfortunately Adams gives short shrift to the need for residential treatment. He writes in The Imprint that “I saw firsthand the power of this ratio [of licensed homes to children] when I ran Idaho’s child welfare system. In just one year, Idaho increased from 74 to 104 foster homes per 100 children—eliminating emergency short-term placements, expanding kinship care, augmenting prevention services, improving licensing timeliness, reducing congregate care, lowering costs, and restoring public trust.” But the press release announcing the end of Idaho foster youth being placed in short-term rentals also credited the opening of a new 16-bed assessment center which “immediately reduced the department’s reliance on temporary housing.” The center is “designed to serve as a homelike setting for foster youth until an ideal placement in a foster home or residential treatment facility [my italics] is located.” Another such center is planned. So reducing the child-to-home ratio may have helped in closing the short-term rentals, but it certainly was not the only factor that allowed these rentals to be closed.

Moreover, Idaho is still struggling to find treatment for the youth with the most complex needs, the Idaho Press reported in October 2024, shortly before the last short-term rental closed. The article concluded that “Many of the youth require residential care for mental health, substance abuse disorder or other behavioral health issues, and there still isn’t enough of this treatment available in the state.” As of December 30, 2025, DHW reports having 173 children in “congregate care,”3 of which 32 were out of state.4 If Idaho is like most states, it is the lack of high-quality, trauma-informed residential treatment facilities, rather than foster homes, that is the main cause of the stays in inappropriate placements. The Family First Prevention Services Act defined a new option for providing such care–a Qualified Residential Treatment Program (QRTP). But based on a recent listing of residential facilities, Idaho appears to have only two QRTP’s. Having a goal like “A Home for Every Child” provides no incentive to develop the needed therapeutic placements for youth with complex needs.5

Equalizing the number of licensed homes with the number of children in foster care is an arbitrary goal that does not encourage the development of needed resources, like larger foster homes and residential treatment programs. But replacing it with a one-to-one ratio of available placement slots to youth is not a good idea either. A well-functioning system needs a sizable excess capacity, because existing vacancies may not be in the right geographical area or in the right type of placement for a child who comes into care. Moreover, many existing homes and residential treatment programs are probably substandard and should be closed.6 A Home for Every Child encourages states to maximize the number of homes, regardless of quality, capacity, or the need for residential treatment.

What about safety?

The ratio of homes to children can be improved in two ways, as ACF has stated: increasing the number of foster homes or decreasing the number of children in foster care. But the latter means taking fewer children into foster care. An easy way to do this is to redefine “safety” to make it harder to find a child unsafe. It appears that states have been doing this already, driving foster care numbers down to their lowest level in years and raising concerns about children being left in unsafe conditions in states as diverse as Washington, Texas, Indiana and New Jersey. As Naomi Schaefer Riley puts it, “foster care numbers are close to record lows and there are plenty of reasons to think that states are pushing them lower and sacrificing child safety in the process. If the federal government provides them with an excuse to double down on their plans to reduce the number of kids in care, many states will jump at the chance.”

The Technical Bulletin states that A Home for Every Child “provides a unifying construct that reflects the full continuum of good practice in child welfare—from prevention and family strengthening to permanency and post-permanency support—offering a cohesive framework for aligning state efforts with what works.” “From prevention to permanency” conveniently leaves out the screening and investigation of child maltreatment reports. With A Home for Every Child as the metric, the incentive is clearly to reduce entries into foster care regardless of trends in child abuse and neglect.

Some language in the Technical Bulletin suggests that other factors can be considered outside of the child-to-home ratio. States participating in the pilot must also include in their PIP’s “wraparound measures related to safety, permanency, and child and family well-being, such as adverse placement scores.” But the next sentence is “Wraparound measures should be chosen such that they will show performance improvement in areas that are expected to lead to improvements in the ratio of homes to child.” But, again, the only way child protective services can do that is reducing foster care removals. Clearly, A Home for Every Child does not center child safety.

The leadership of ACF is to be commended for seeking to reduce the burden imposed by the Child and Family Services Reviews. But the attempt to build a new quality review around a simplistic slogan like A Home for Every Child is not adequate for such a complex and serious problem as child abuse and neglect. It ignores the needs for larger foster homes to keep siblings together and for high-quality residential placements. It also creates an incentive to reduce foster care entries regardless of safety. One hopes that the current pilot will be succeeded by a more comprehensive approach that keeps safety in the forefront and recognizes the diverse needs of foster youth.

Note: After this post was published, Dr. Sarah Font of Washington University in St. Louis reminded me of another problem with A Home for Every Child. Many states rely heavily on unlicensed relatives to care for children who need placements. These states can greatly increase their count of licensed homes simply by licensing these relatives, without actually increasing the number of available placements.

Notes

  1. It does appear in the technical bulletin as an adverbial phrase in the following sentence: “In furthering efforts to achieve the 1:1 ratio of licensed foster homes to children in foster care, states will not be required to address every item or practice area identified in the CFSR Final Report.” ↩︎
  2. In New York, these young people are often sent to residential programs that are not equipped to provide the level of care that they need. ↩︎
  3. “Congregate care” is a term used, often pejoratively, to describe placements that are not foster homes. ↩︎
  4. Email from A.J. AJ McWhorter, Public Information Officer, Office of the Director |Idaho Department of Health and Welfare, December 30, 2025. ↩︎
  5. The Technical Bulletin does say that “The 1:1 ratio does not preclude states from pursuing placements outside of foster homes or from placing multiple children, for example, siblings, in one home but rather is intended to serve as an indicator spanning the full child welfare spectrum.” But the meaning of “intended to serve as an indicator spanning the full child welfare spectrum” is unclear. Placements outside of foster homes, or of more than one children in one home, do not count toward the goal of A Home for Every Child as defined by ACF. ↩︎
  6. This statement is based on my own personal experience in the District of Columbia and Maryland as well as personal accounts from youth around the country and media reports of abuse and neglect in foster care. ↩︎

A disappointing report from the Senate Finance Committee

A new report by the Senate Finance Committee concludes that children in residential treatment facilities routinely suffer harms like sexual and physical abuse, unsafe and unsanitary conditions, and lack of needed therapy. Further, it concludes that these harms are endemic to residential care itself. While the fact that some residential care facilities are substandard and cause harm to children is undisputed, the SFC’s study is poorly designed and should not be used as the basis of policy. It is based on facilities run by only four companies and cannot be used to make generalizations about residential care as a whole. Both the study design and the findings of the SFC report appear to stem from a preconceived conclusion and not on a desire to describe the actual landscape of residential care for America’s youth who need intensive behavioral health care.

On June 12, 2024, the Senate Finance Committee (SFC) released a report called Warehouses of Neglect: How Taxpayers are Funding Systemic Abuse in Youth Residential Treatment Centers. The report was based on an investigation of what it calls residential treatment facilities (RTF’s) operated by four large companies, “each owning facilities with a history of public abuse and neglect allegations and a substantial facility footprint.” It does not define RTF’s, but the term clearly refers to facilities that provide behavioral health services in a residential context to children with funding from programs under SFC jurisdiction, mainly Medicaid and foster care funds under Title IV-E of the Social Security Act. The four companies include three profit making corporations (United Health Services, Acadia Healthcare, and Vivant Behavioral Healthcare), and one nonprofit, Devereux Advanced Behavioral Health.

The report describes a pattern of poor conditions and abusive practices that the SFC staff observed by reviewing media articles and company documents, supplemented by interviews with senior leaders in the four companies and visits to several facilities not operated by these companies.1 These conditions and practices include sexual and physical abuse by staff; the inappropriate and often abusive use of restraints and seclusion; staff who are unqualified and inadequately trained staff or who routinely fail to discharge their duties, leading sometimes to tragic results; “non-homelike,” unsanitary and unsafe conditions; failure to provide the treatment that children need and that states are paying for; failure to maintain connections between children and their communities and to make adequate discharge plans; use of technology to monitor children that is more appropriate to detention facilities than therapeutic settings; and the absence of adequate oversight by state and federal authorities.

The report raises valid concerns about private businesses being involved in services to the most fragile young people. Several details stand out, all of them involving the company called Vivant and its CEO, John “Jay” Ripley. Ripley is the former CEO of Precision Tune Auto Care and and cofounder of BGR the Burger Joint. Ripley previously founded Sequel Youth and Family Services, which became known for the death of 16-year-old Cornelius Frederick while being restrained at a Michigan facility in 2020 and allegations of abuse and neglect at other Sequel facilities. In 2021, according to the report, Sequel closed half of its facilities and sold the other half, including 13 facilities that it sold to Vivant, Ripley’s new company. VIvant in turn hired many former Sequel executives and staff. In a video made by the University of Baltimore’s Merrick School of Business, Ripley explained that “you can make money in this business if you control staffing.” Ripley does not seem like the kind of person who should be running facilities dedicated to healing the most vulnerable young people.

The SFC report might have been a valuable document had it not tried to apply its findings to residential care in general. “Children suffer routine harm inside RTF’s,” the authors write. “These harms include sexual, physical, and emotional abuse, unsafe and unsanitary conditions, and inadequate provision of behavioral health treatment.” Leaving aside the ambiguity of the word “routine” (does that mean every resident or the majority of residents are harmed in such a way?), such a conclusion cannot be drawn from an investigation of treatment centers operated by four large companies. We have no idea what proportion of young people receiving publicly funded RTF care are in facilities operated by these four companies. Around the country, there are residential treatment facilities operated by many providers, including many freestanding facilities that are not part of large chains. Even within the companies reviewed, the report provides no data to document whether the problems exist only at certain facilities or throughout the chains. A facility’s functioning to a large extent reflects its leadership, and there may be well-run facilities among those operated by these companies.

Going even further, the SFC concludes that “the risk of harm to children in RTF’s is endemic to the operating model. The harms children in RTFs experienced are the direct, causal result of an operating model that incentivizes providers to optimize revenues and operating and profit margin. RTF providers offer minimal therapeutic treatment in deficient physical settings with lean staff composed of non-professionals, which maximizes per diem margins…” The report goes on to say that “[a]t its core, the RTF model typically optimizes profit over the wellbeing and safety of children.” But there is no “RTF operating model.” The understaffing and lack of professionals that are common among publicly funded residential providers more likely stem from the low reimbursement rates that that these programs receive, which in turn means that staff receive low pay as well, forcing the facilities to rely on poorly educated and trained staff.

Even more extremely, the report states that “In the best of circumstances, children at RTFs receive care from under-trained and overburdened staff, are given infrequent therapy, sometimes by non-professionals, and are exposed to unsanitary, unsafe, and non-homelike environments.” It is hard to understand how the SFC is capable of describing the best residential programs when its entire methodology consisted of seeking abuses in an extremely limited universe of residential programs.

In suggesting that residential treatment is a flawed model that should not exist, the SFC report ignores the important role of residential treatment facilities in the continuum of care for young people with mental illness. The Committee’s own invited witness, Elizabeth Manley of the University of Connecticut School of Social Work, testified about the need for these programs.

Residential treatment facilities have an important role in the provision of care for young people with complex behavioral health care needs when they have a clinical or behavioral health treatment need that cannot be met in a family and community setting due to the intensity of their treatment and supervision needs. In those instances, we need the care to be delivered in trauma-responsive environments that embrace parent and caregiver engagement throughout the treatment intervention and continually focus on best practice. These residential treatment facilities can have a significant benefit to the young person and their family.

The Child Welfare League (CWLA), in written testimony submitted to the SFC, added that residential services are “a small but important part of the full array of services” that must be available to meet children’s mental health needs.” CWLA went on to explain that there “are many providers and programs providing or striving to provide trauma-responsive, time-limited, effective residential care. They are informed by the emerging literature highlighting promising practices in residential interventions..” CWLA cited the Building Bridges Initiative, which is a national initiative working to identify and promote best practice and policy in residential interventions for youth. The initiative has produced a guide called Building Effective Short-Term Residential Interventions. According to this report, a new literature has developed in the last ten years or so which documents promising practices in residential intervention which are associated with positive benefits. These include “actively engaging youth and families, ensuring active school and community connection, and keeping residential intervention as short as possible.” The authors explain that “[c]utting-edge effective residential intervention now means providers are creatively working with youth and families in the home, in the community, and as briefly as possible – often for three months or less.” The guide was developed to help organizations make the transition to the new approach, with case histories of 12 programs that are making or have made this transition.

Ignoring this new literature, the SFC claims that “studies show that home and community-based approaches produce better treatment outcomes than placing children in RTFs, and are more cost-effective than RTF placements.” In the footnote to that sentence, the writers list only one study, which concerns only one type of facility, Psychiatric Residential Treatment Facilities, a particular model the provides the equivalent of in-patient psychiatric services outside a hospital setting to young people under 21 through an agreement with a State Medicaid agency. Moreover, that study does not conclude that community-based approaches produce better treatment programs. Instead, it concludes that “evidence is insufficient to assess which interventions are effective.” It is almost impossible to conduct a meaningful study comparing residential treatment to community-based approaches, since the children who are sent to RTF’s are generally much more troubled or impaired than the children who are not, and it would be hard to control for such differences without doing a randomized controlled trial. That’s why there are few if any studies that shed light on this issue.

It is hard to avoid the conclusion that both the study design and the findings of the SFC reflect the Committee’s desire to show that residential care is harmful to young people. The SFC’s anti-residential bias is displayed in numerous passages throughout the report. One particularly inaccurate statement claims that “In some cases….., child welfare agencies place children in state custody without diagnoses in RTFs because they have nowhere else to place them.” As evidence, the report cites a 2013 report that showed 28.8 percent of children in “congregate care” had no clinical diagnoses. But congregate care (a term used to designate any placement that is not a foster home) is a more general term than RTF’s. The earlier report included many other types of facilities including cottage-style homes (often on the site of former orphanages and often providing high-quality family-style care) that are not intended for children with serious behavioral health needs, as well as emergency shelters that some states operate to house children before they are placed in a foster home. Given the relatively high cost of RTF’s, it would be very strange if states placed children in them for lack of another option.

Much more common is the opposite scenario: agencies placing children in foster homes unprepared to care for them, resulting in placement instability, or even letting them sleep in hotels or offices, for lack of residential treatment facilities. Articles about this problem appear frequently, including a recent report from the Midwest Newsroom (a collaboration between NPR and Midwest member stations) on the insufficient capacity of residential care for girls in Missouri and Iowa. The article starts with the story of a young woman who was placed in a residential treatment program called Missouri Girls Town after a traumatic childhood, placement in foster care and a disrupted adoption by a parent who could not handle her rebellious adolescence. This young woman credits Missouri Girls Town with completely changing the trajectory of her life. Sadly, this nonprofit program, which relies on private donations to supplement what it gets from government agencies, was designed to accommodate up to 50 girls but can only take 12 because of “staffing and funding challenges.” Stories like this have been appearing from around the country for years. There is not enough residential treatment for the young people in foster care who need it. Facilities have been shutting down due to failure of state reimbursement rates to keep up with operating costs, as well as the increasing unpopularity of residential care among state officials and legislators.

Despite the major flaws in the SFC’s analysis, there is little to object to in its recommendations. It’s hard to argue against recommendations that Congress act to improve conditions in congregate care facilities, that the companies reviewed raise their standards, and that states invest in community-based services for children with behavioral health needs and improve oversight over RTF’s. The need to invest in community-based services is particularly important because it might enable some children to be helped before their problems become so severe that they need residential care. It might even prevent some placements in foster care that occur when parents can no longer care for behaviorally challenging their children at home. But the findings of the report remain dangerous even if the recommendations are benign; they can be used to support attempts to defund residential care entirely, which would be disastrous for our most vulnerable young people and their families.

The SFC report confounds a group of residential treatment facilities poorly run by four large corporations with the entire field of residential treatment for youth with serious behavioral health care needs. The report presents a distorted picture of a field that already contains excellent, life-changing programs and where passionate and dedicated leaders are already providing or working toward trauma-informed, short-term, and effective residential services for these most vulnerable young people.

  1. Visits to five facilities that were not operated by the four providers being investigated were used to document physical conditions in the facilities, as well as their efforts to provide education to the residents. The finding of “non-homelike,” unsanitary and unsafe conditions was based on the visited facilities rather than on the four companies that were investigated. ↩︎