The Title IV-E Prevention Services Clearinghouse: Fatally flawed like the law that created it

by Marie Cohen

In Home Visiting: More Hype than Hope, I wrote about the failure of decades of studies to prove that home visiting programs have real-life outcomes for children and families. In this post, I explain how the federal government promotes these and other programs as interventions to prevent foster care despite the lack of meaningful evidence for their success. A “Prevention Services Clearinghouse” established by federal legislation approves programs for reimbursement based on the results of outcome studies, with virtually no attention to the quality of the measures used, the lack of corroboration, the total weight of the evidence, or the logic and size of the impacts. There is little evidence to support the effectiveness of these programs in making it possible for children who are maltreated (or at risk of foster care for another reason) to remain safely in their homes. Congress should consider eliminating the Clearinghouse and changing the type of services services eligible for federal funding.

The stated purpose of the Family FIrst Prevention Services Act (FFPSA),¹ which was signed by President Trump in 2018, was to “provide enhanced support to children and families and prevent foster care placements through the provision of mental health and substance abuse prevention and treatment services, in-home parent skill-based programs, and kinship navigator services.” To achieve this purpose, FFPSA expanded the use of Title IV-E funds from foster care and adoption to what it called “foster care prevention services and programs” designed to prevent the removal of children from their homes.² These programs were nothing new; at the state level, they are often called in-home services, family preservation services, or intact family services. Under FFPSA, these services are available to children who are “candidates for foster care” [meaning the child is at imminent risk of entering foster care but can safely remain at home or with a relative with the provision of services provided under the Act³] and to pregnant or parenting foster youth and the parents or kin caregivers of these children.⁴

Under FFPSA, these “foster care prevention services” must be provided “in accordance with practices that meet the requirements for being promising, supported, or well-supported practices.” Among the requirements, the components of the practice must be described in a book or manual, there must be no evidence suggesting the program does more harm than good, and when there are multiple studies of one program, the “overall weight of the evidence” must support the benefits of the practice. Each practice must be found to be “superior to an appropriate comparison practice using conventional standards of statistical significance in terms of demonstrated meaningful improvements in validated measures of important child and parent outcomes, such as mental health, substance abuse, and child safety and well-being.”

To receive the highest rating of “well-supported,” a practice must have data from at least two randomized controlled trials (RCT’s), or quasi-experimental research designs if RCT’s are not available. At least one of the studies must demonstrate that the practice has a sustained effect lasting at least a year. The requirements are somewhat lower to be a “supported” practice and lower still to be a “promising” practice. In order for a program to be rated as “supported” or “well-supported,” the supporting studies must have been conducted in a “usual care or practice” setting, which is defined as an existing service provider that delivers substance abuse, mental health, parenting or kinship navigator services as part of its typical operations.

At least 50 percent of a state’s foster care prevention services funding must be for “well-supported” programs in order to claim federal support under Title IV-E. Thus it is not surprising that states have chosen to include mostly “well-supported practices” in their Title IV-E Prevention Plans.

In order to further define the requirements and apply them to existing programs, FFPSA created the Title IV-E Prevention Services Clearinghouse (“the Clearinghouse” from now on), which is run under contract by Abt Global, formerly Abt Associates. The Clearinghouse has published a Handbook of Standards and Procedures describing the methodology it has developed to evaluate whether a program meets the requirements established by FFPSA.⁵ Program ratings are based on what the handbook calls “contrasts.” A contrast is defined as “a comparison of an eligible intervention condition to an eligible comparison condition on a specific outcome for a specific posttest measurement.” A “contrast” might be a comparison of the number of substantiated child abuse reports for the experimental vs the control group in one study, for example. A contrast must be statistically significant based on conventional standards in order to be considered favorable.⁶

The Clearinghouse staff has interpreted the requirements written by Congress in a way that sets a very low bar for a program to be judged “well-supported,” “supported,” or “promising.” To be “well-supported,” the Clearinghouse requires no more than two contrasts from different studies that show favorable effects.” At least one of the contrasts must demonstrate a “sustained favorable effect” of at least 12 months. This is a low standard for many reasons.

A program can be rated “well-supported” with as few as two positive contrasts, even if they are wildly outnumbered by contrasts that fail to show an impact. Even within a specific category (such as parental drug abuse, for example), one favorable contrast is enough, no matter how many other related indicators from the same or other studies show no effect.
Any positive contrast is counted, regardless of whether it is based on objective indicators or subjective ones like self-reports. Improvements on subjective measures are counted even if objective measures fail to find impacts.
Any pattern of impacts (or contrasts) is accepted, regardless of whether it is predicted by the program’s theory or logic model. If a program is supposed to work by changing parental behavior, but it instead changes children’s behavior directly, the outcome is counted. There is no requirement that a program impact be explained by its logic model or theory.
There is no requirement that a specific contrast reported by one study be corroborated by another study. Many of the individual impacts that are reported are supported by only one study, with each study cited providing evidence of a different impact.
Any contrast that is statistically significant is accepted, regardless of whether it is of practical significance. The American Statistical Association has stated that “[S]tatistical significance is not equivalent to scientific, human, or economic significance.” A tiny effect can be statistically significant if the sample size or measurement precision is large enough.
Studies are counted even when the specific populations studied are very different from those eligible for Title IV-E Prevention services.

Examining the Clearinghouse evidence on some of the most popular programs clearly reveals the flaws of its methodology, providing multiple examples of the problems noted above.

Parents as Teachers is the most popular program rated by the Clearinghouse, having been included by 31 states in their Title IV-E Prevention plans as of August 2024. PAT is a home visiting program that describes its mission as “To promote the optimal early development, learning and health of children by supporting and engaging their parents and caregivers.” The rating of “well-supported” was based on only three studies, one of which was not conducted in a “usual care and practice setting” and another of which was conducted in Switzerland–with a very different population from that of the U.S. The Clearinghouse found three favorable contrasts (out of six total contrasts) on child social functioning, all from one study, along with one unfavorable contrast and two showing no effect. They found two favorable contrasts on child cognitive abilities (one from the Swiss study) compared to 10 findings of no effect). And they found two small favorable contrasts on child welfare administrative reports (with two showing no effect) from a comparison group study that was not done in a “usual care or practice setting,” Only one study reviewed looked at the quality of parenting or the home environment, and it found no favorable effects. The authors of that study said that the results “raised questions about the underlying premise of PAT that focusing services on parents to improve parenting knowledge, attitudes, and behaviors is an effective way to benefit children.” They also concluded that their results (including the three positive contrasts on child social functioning and one on child cognitive functioning) “are consistent with the overall research base for family-focused early childhood programs, which have produced ‘modest and inconsistent effects.'” (ee Appendix A for more detail on all the contrasts discussed here).

Functional Family Therapy (FFT) is second in popularity only to Parents as Teachers, being included in the plans of 25 states as of August, 2024. As described by the Clearinghouse, FFT “aims to address risk and protective factors that impact the adaptive development of 11 to 18 year old youth who have been referred for behavioral or emotional problems.” The Clearinghouse rated FFT as “well-supported” based on the results of six studies. The Clearinghouse reported two favorable contrasts, 23 contrasts showing no effect, and one unfavorable contrast on Child Behavioral and Emotional Functioning–the core goal of the program. It showed two favorable contrasts, two unfavorable contrasts, and 16 contrasts showing no effect on child delinquent behavior. No contrasts showed an effect on positive parenting practices and only two out of 13 contrasts showed an favorable effect on family functioning. Ten contrasts showed a favorable impact on children’s substance abuse, compared to eight findings of no effect. But all of these favorable contrasts came from one study of alcohol-abusing youths who resided in a shelter after running away–a very specific population that may not be generalizable to children abusing other substances or those who are living at home.

Like FFT, Motivational Interviewing (MI) is included by 25 states in their Family First plans. MI, according to the Clearinghouse, is a” method of counseling clients designed to promote behavior change and improve physiological, psychological, and lifestyle outcomes.” The Clearinghouse reviewed studies of MI focused on illicit substance and alcohol use or abuse among youth and adults, and nicotine or tobacco use among youth under the age of 18. These programs are typically delivered in one to three sessions with each session lasting about 30 to 50 minutes. The Clearinghouse rated MI as “well-supported” based on results from 21 studies. The contrasts reviewed showed no effects on child substance use, caregiver mental health, caregiver criminal behavior, family functioning, parent/caregiver physical health, or economic and housing stability. The only favorable effects were on parent/caregiver substance abuse, for which there were sixteen favorable contrasts, two unfavorable contrasts, and 91 showing no effect. Eleven of the favorable contrasts came from one study of heavy-drinking college students–a very different population from parents of children at risk of foster care placement; presumably few if any were parents at all. It was also not conducted in a “usual care or practic setting.” It is no surprise that a program of one to three sessions would not lead to major changes in parents’ and children’s lives, but it is strange that serious analysts would accept these results as proof that such a minimal program would change lives.

The Clearinghouse rated the Healthy Families America (HFA) home visiting program (included by 22 states in their Title IV-E Prevention Plans) to be “well-supported” based on the results of six studies. Healthy Families America was developed as an intervention to prevent child maltreatment and is now the signature program of an organization called Prevent Child Abuse America, as I discussed in an earlier post. Yet, HFA’s effects on child maltreatment are decidedly underwhelming. The Clearinghouse found five positive contrasts on self-reported measures of maltreatment and no favorable contrasts on 99 more objective measures like CPS reports, hospitalizations and injuries. Of the 16 remaining favorable contrasts for the entire program, five come from improvements in parental reports of child behavioral and emotional functioning (a self-reported item with possible bias), another was on the child’s self reports about skipping school “often,” and none were corroborated by another study.

Some readers might observe that the standard critiques of the clearinghouse focus on the difficulty, not the ease, of meeting its standards. Critics like The Child Welfare League of America have stated that the “high evidentiary standards for the clearinghouse require rigorous, costly research that many states, Tribes and programs are unable to fund. This barrier is particularly onerous for programs that focus on underserved populations, such as Black and Native families, children of more than one race, and rural communities.” This assertion is not inconsistent with my conclusions about the Clearinghouse. That is because there are two types of standards. The standards for the rigor of the studies themselves may be too high for many programs to meet. But once a study meets the requirements to be reviewed, the requirements for being “well-supported” are almost laughable.

Another problem with the Clearinghouse is that many of the programs included are generally paid for by Medicaid, private insurance, or other state and federal programs, such as the federal home visiting program. And Title IV-E is required to be the payer of last resort for these services so it cannot pay if another source is available. The idea was apparently that Family First could be used to supplement these sources for families without private health insurance or where these funds are not available, but this does not seem to be occurring on a large scale, as I explain below.⁷

Finally, the Clearinghouse does not include what may be the most important foster care prevention service of all–case management. All of the services in the clearinghouse depend on relationships, but it is the relationship with the social worker managing the in-home case that may be the most important intervention for a maltreating parent. It is the case manager who refers the client to the parenting, substance abuse and mental health programs prescribed by the Act and who maintains contact with the programs to monitor the parent’s participation and progress. The case manager is responsible, through home visits, for monitoring the safety of the child or children who have not been placed in foster care. Without such monitoring, there can be no foster care prevention services.

Currently, case management is treated as an administrative cost under Title IV-E, which means it cannot be paid for unless the client is receiving other services that are supported by the Clearinghouse. At least one agency, the District of Columbia’s Child and Family Services Agency, has found a way to adapt one of the “well-supported practices” listed in the Clearinghouse as a case management model, allowing it to claim Title IV-E funding for case management for all children receiving foster care prevention services. CFSA adapted the practice of Motivational Interviewing (MI, discussed above), which is in the Clearinghouse as a substance abuse intervention, as a model for case management for all in-home services. As one account puts it, the approval of this use for MI was “particularly notable because while [MI] was approved by the Title IV-E Clearinghouse for Family First reimbursement only as a substance abuse service, DC received approval to implement and claim for it as an integral component of CFSA’s case management practice for all families.” But it should not be necessary for states to go through this type of charade in order to obtain Title IV-E funding for their case management services.

All of the problems mentioned above may explain why states are not drawing down large amounts of Title IV-E funding for foster care prevention programs. The federal government spent only $182 million reimbursing states for Title IV-E prevention services in FY2024, serving only about 18,300 children per month. A recent federal report showed that reported reimbursement claims on Title IV-E prevention services constituted less than two percent of overall Title IV-E program reimbursement claims in FY 2023, serving about two percent of the children receiving Title IV-E funded services.

What can be done?

Raising the standards for “promising,” “supported,” ‘well-supported” to be meaningful is simply not a viable option. Adjusting the three ratings to incorporate the quality of the measures, the need for corroboration, the weight of the evidence and the logic and size of the impacts, would probably mean that few if any programs would be classified in the top tier. So there is not really a way to classify programs based on evidence that will work well for the purpose of funding foster care prevention programs in Title IV-E.

Perhaps this is not surprising. The concept of evidence-based practice was adapted from medicine. When applied to social services, the concept has many limitations. Research conducted under controlled, small-scale, well-funded conditions, even if conducted in a “usual care and practice” setting is often not applicable to the messy, underfunded world of social services practice. It is well-known that effect sizes often shrink when a small pilot program is expanded to cover a larger population. Moreover, a study conducted on one population may not be generalizable to other groups. The population of parents at risk of losing their children to foster care is distinct from many other populations included in the studies mentioned above. The antecedents of child maltreatment, substance abuse and mental illness are extremely complex and may go back for generations. The idea that a three-session, three-month or even a three-year program can eliminate these problems may be unrealistic.

Finally, in relationship-intensive services like all of those included in the Clearinghouse, the characteristics of the practitioner probably matter more more than the specific model. In psychotherapy, multiple studies have concluded that “who your therapist is matters more than the model they use.” Ordinary people dealing with mental illness or addiction do not usually look for an “evidence-based practice.” They look for the best provider they can find–the one they have heard by word-of-mouth, or by scanning the internet for ratings. As mentioned above, the quality of the therapist matters more than the model, and the same applies to program staff. When I was a foster care social worker, and we had a child who had complex mental health needs, we used available funds to reimburse a top-notch provider who did not accept Medicaid. I don’t think we ever talked about what “model” they offered, and they met with clients for much longer than than program manuals prescribe. Medicaid itself does not require proof that a program is evidence-based.

In light of these issues, Congress should consider eliminating the Title IV-E Clearinghouse, as proposed by the Bipartisan Policy Center’s child welfare working group in its recent Blueprint for Child Welfare Financing and Accountability Reform.” The group of 15 child welfare experts representing different professional experiences and perspectives agreed that the clearinghouse process for approving programs as evidence-based “is cumbersome, is idiosyncratic, and impedes states from meeting the needs of families….” The group recommended replacing the clearinghouse with an expert panel convened by the U.S. Department of Health and Human Services that would consider proposals from the states for programs they want to provide using Title IV-E funds. States would be required to submit “evidence to support the efficacy of the interventions, and data that demonstrates the why states believe that proposed interventions would reduce child welfare involvement or improve outcomes of child welfare-involved children and families.”

Congress should also change the definition of the “prevention” services that can receive federal reimbursement under Title IV-E. Instead of continuing to pay for programs that belong to the field of mental health and substance abuse or are generally funded by Medicaid or private insurance, Title IV-E funds should be used for the critical service provided either directly or under contract by child welfare agencies–case management. Agencies should not have to go through the contortions that DC’s Child and Family Services Agency went through to adapt a three-session substance abuse cessation program into a case management model only to receive reimbursement from Title IV-E. This is the main service that they provide directly and it should be funded. Congress could also add a provision for states to be reimbursed to provide services mental health or drug treatment for the small number of parents who do not have public or private coverage for such services–in other words, where a payer of last resort is needed.

In drafting and passing FFPSA, Congress hoped to make new funds available to programs that would ameliorate the problems that were putting children at risk of being removed from their homes. In its effort to ensure that effective programs were funded, Congress instead created a process that awards ratings to programs based on the mindless and mechanical application of standards that mean little–and that fails to unlock the hoped-for source of funding for foster care prevention. The law must be changed in order to fulfill the intent of its framers.

Notes

See Title VII of Public Law 115–123. ↩︎
There is something odd about the concept of services to prevent foster care. Prevention usually refers to a social problem like child maltreatment or teen pregnancy, not a government policy, which is itself a response to the problem of child maltreatment. It is like talking about preventing hospitalization rather than preventing illness. It would be more natural to think of services to prevent the underlying problem that result in foster care, which is usually child abuse or neglect, but can also be children’s behavioral health problems that are so severe that parents feel compelled to relinquish their care to the state. But this is the term used by FFPSA and I will use it here. ↩︎
A note about foster care candidacy is in order here. In general, children are placed in foster care because they are abused or neglected or are at imminent risk of abuse or neglect. However , there is another group of children entering foster care who have drawn increasing attention. These are children whose parents voluntarily relinquish them because they are unable to care for them at home or obtain needed services–usually care for severe behavioral issues. ↩︎
Federal research has estimated that as many as five percent of all children entering foster care between 2017 and 2019 may have entered care primarily to receive behavioral health
or disability services, not because of maltreatment. ↩︎
The Handbook has already been revised once, but the language on this specific issue has not been revised. ↩︎
See pages 83-84 for more on statistical significance. This author did not find a statement of the required p-level. ↩︎
Also problematic is the failure to include domestic violence services in the clearinghouse. This was always puzzling. Child welfare social workers and academics often speak of the “Big Three” factors that result in child welfare involvement– drug abuse, mental illness and domestic violence. So the omission of domestic violence was strange–especially because domestic violence programs are greatly underfunded and not chargeable to an another program like Medicaid. ↩︎

Appendix

Parents as Teachers Contrasts Cited by Clearinghouse

Two small favorable contrasts from the matched comparison group study, which was not carried out in a usual care or practice setting and two contrasts showing no effect on child welfare administrative reports;
One contrast showing no effect on out-of-home placement;
Three favorable contrasts, two contrasts showing no effect and one unfavorable contrast on child social functioning;
Two small favorable contrasts and ten contrasts showing no effect on child cognitive functions and abilities;
Three contrasts showing no effect on child physical development and health;
One contrast showing no effect on adult parenting practices;
Eight contrasts showing no effect and one showing an unfavorable effect on family functioning;
Nine contrasts showing no effect and one showing an unfavorable effect on adult economic and housing stability.

Functional Family Therapy (FFT) Contrasts Cited by Clearinghouse

Two favorable contrasts, 23 contrasts showing no effect, and one unfavorable contrast on Child Behavioral and Emotional Functioning–the core goal of the program. One of the two favorable contrasts is on “Strengths and Needs Assessment: Child Behavioral/Emotional Needs” immediately after completing the program. But another study shows no impact on the same outcome.
Two favorable contrasts, two unfavorable contrasts, and 16 contrasts showing no effect on chid delinquent behavior;
Nine contrasts showing no effect on positive parenting practices;
Two favorable contrasts and 13 contrasts showing no effect on family functioning.
Ten contrasts showing a favorable impact compared to only eight showing no effect on children’s substance abuse. But all of these effects came from one study of alcohol-abusing youths who resided in a shelter after running away–a very specific population that may not be generalizable to children who are living at home.

Motivational Interviewing (MI) Contrasts Cited by Clearinghouse

Thirteen contrasts showing no effects on child substance use;
Five contrasts showing no effect on caregiver mental health;
Sixteen contrasts showing a favorable effect, 91 showing no effect, and two showing an unfavorable effect on parent/caregiver substance use. Among the favorable contrasts, one study shows a favorable effect on the number of drinks per week while there is no effect on the number of drinks per day but the Clearinghouse did not apparently take account of such contradictions.
Seven contrasts showing no effect on parent/caregiver criminal behavior;
One contrast showing no effect on family functioning;
Ten contrasts showing no effect on parent-caregiver physical health;
One contrast showing no effect on economic and housing stability.

Healthy Families America (HFA) Contrasts Cited by Clearinghouse

Forty-three contrasts showing no effect on child safety as measured by child welfare administrative reports, medical indicators of maltreatment risk, or “maltreatment risk assessment” measures.
Five favorable contrasts, 38 contrasts showing no impact, and one showing a negative impact on child safety based on parental self-reports of maltreatment. Clearly these self-reports are less valid than more objective measures, since parents clearly know what answers are expected after having been through the program. A parent’s negative answer to the question of whether she ever used physical abuse in the past year (one of the actual indicators used) cannot be trusted to be accurate.
Seven contrasts showing no effect on child safety as measured by “medical indicators of maltreatment risk,” a strange heading for a group of questions from the Adolescent-Adult Parenting Inventory including “Inappropriate Expectations, Lack of Empathy, and “Belief in Corporal Punishment.”
Eleven contrasts showing no effect on “Maltreatment Risk Assessment” measures such as hospitalizations and injuries needing medical care.
Five favorable contrasts and two showing no effect on parent reports of child behavioral and emotional functioning, also a self-reported item;
Two favorable contrasts, six showing no effect, and one unfavorable contrast on child cognitive functions and abilities.
One favorable contrast on “child delinquent behavior;” The measure was actually “child skips school often,” self-reported by children in first or second grade, according to the study.
One favorable contrast and two showing no effect on child educational achievement and attainment. This was a positive contrast on the percentage of children retained in first grade. However, the percentage of children who performed above or below grad level did not change.
Three favorable contrasts and 24 showing no effect on positive parenting practices. The three favorable contrasts came from observations of “Positive Parenting” from researchers’ observations of parents during a puzzle task, a “delay of gratification” task, and a cleanup task. However observations of harsh parenting during those same tasks did not show a statistically significant change.
Three contrasts showing a favorable impact and 16 contrasts showing no effect on parent/caregiver mental or emotional health;
Fifteen contrasts showing no effect on parent/caregiver substance use;
Three contrasts showing a favorable effect and 28 contrasts showing no effect on family functioning. Twenty-two of the contrasts were measures of intimate partner violence (IPV) or family violencefrom one study only and not corroborated. The positive impacts were on three specific measures based on the perpetrator, the type of violence and the age of the child. Only three of those 30 contrasts showed a positive impact and no effect sizes were provided.
Five contrasts showing no effect on economic and housing stability.

Family First at five: Not much to celebrate

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.

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

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.

Title IV-E as Payer of Last Resort: The Achilles Heel of the Family First Act?

Family First Act The Family First Prevention Services Act Act was widely hailed as allowing for the first time the use of federal Title IV-E child welfare funds for services to prevent a child’s placement in foster care. Unfortunately, the law has been interpreted in a way that has almost negated this central purpose of Family First. Thanks to a technical-sounding determination about Title IV-E’s place in the hierarchy of programs as payers for services, Title IV-E funds are now unavailable to beef up services that are eligible for funding from other programs.

Before implementation of Family First on October 1, 2019, federal matching funds under Title IV-E of the Social Security Act could be used only to match state spending on foster care. Advocates of Family First and its predecessors argued that providing Title IV-E funds for foster care and not services to prevent it encouraged jurisdictions to place children in foster care rather than helping their parents address their problems and keep their children at home. As I argued in an earlier post, this was a false narrative that disregarded the fact states were already working with families in their homes using other funds, such as Medicaid, maternal and child health programs, and others.

But the advocates won and Family First was passed. It allowed federal Title IV-E matching funds to be used for evidence-based practices (EBP’s) in the categories of “in home parent skill-based programs,” mental health, and drug treatment programs that meet criteria for being “evidence-based” as defined by the Act. These are all considered to be “prevention services” because they are aimed at preventing placement of children in foster care. (Funds can also be spent on kinship navigator programs to help kin who agree to take custody of children temporarily while their parents pursue services.) The Act also created a clearinghouse of programs from which states can choose. The clearinghouse has so far approved nine programs for inclusion and is in the process of considering 21 more.

But the contents of the clearinghouse have much less impact in light of decisions made by Congress and the Children’s Bureau, as explained in a useful webinar from the Chronicle of Social Change. As a result of these decisions, Title IV-E became in effect the “payer of last resort” for the foster care prevention services authorized under the Act .

It would be difficult to overestimate the magnitude of this decision to make Title IV-E the payer of last resort for foster care prevention services. Many of the services that are already included in the clearinghouse or being reviewed now are covered by Medicaid or paid for by other programs in many states. This means that states with more generous Medicaid plans (those covering more people and/or more services) and more participation in other federal programs have less opportunity to use Title IV-E funds for foster care prevention services.

Consider the District of Columbia, which has a generous Medicaid program in terms of whom and what it covers. In my five years as a child welfare social worker in the District, I don’t remember a parent who was not eligible for Medicaid. The District was the first jurisdiction to submit a Family First plan and the first to have its plan approved, but it’s hard to understand the District’s eagerness to make the transition. In its plan, the District’s Child and Family Services Agency (CFSA) indicates that of the seven services in its plan that are currently deemed allowable by Title IV-E, six are funded through other federal sources–Medicaid and the Maternal, Infant, and Early Childhood Home Visiting Program. Therefore, CFSA will be claiming Title IV-E funds for only one allowable evidence-based program–Parents as Teachers (PAT).

So here is the irony. Family First was supposed to revolutionize child welfare by allowing federal foster care funds to be used for family preservation or foster care prevention, whatever one chooses to call it. Never mind that states have been using Medicaid and other funds for this purpose for many years. And now it turns out that with Title IV-E as a payer of last resort, many states will continue to provide these services with other funds. Family First will make little difference except adding a new layer of bureaucracy: states will now have to include these services in their prevention plans even if they are not funded by Title IV-E!

Things are actually worse under Family First for the 27 states that had waivers under Title IV-E. Under the waivers, states were able to use Title IV-E funds in combination with other funds to expand and improve services–an option not available to them now.

It gets even worse. Under Family First, states must spend at least 50% of their Title IV-E prevention funds on practices defined as “well supported” as defined by the Act. It looks like payments made by Medicaid won’t count toward the 50%, so states will need to find enough “well-supported” practices that are not covered by Medicaid in order to meet this requirement, which may cause great difficulty.

Title IV-E’s status as payer of last resort also appears to prevent Title IV-E from paying a provider who does not accept Medicaid for an EBP that is allowed under Medicaid. It is widely known that low Medicaid reimbursement rates restrict the quality and quantity of mental health services available to Medicaid participants. Both jurisdictions where I have served as a foster care social worker, Maryland and the District of Columbia, use their own funds to pay for top-notch providers who don’t accept Medicaid. In both jurisdictions and I suspect many others, children with the most complex mental health needs are enrolled with one of these high-quality providers rather than left to the mercy of the Medicaid-funded agencies, with their long waits for service and high turnover. We rarely or never paid for mental health services to parents but isn’t that just what Family First should allow jurisdictions to do? Where, otherwise, is the revolution in child welfare that Family First was supposed to bring about?

Title IV-E as payer of last resort means that very little will change, except perhaps in some states with very narrow Medicaid programs and little categorical federal funding. To have any hope of fulfilling its promise to keep families together, Family First should be amended to allow Title IV-E to supplement Medicaid and other funding to provide critically needed services to parents.

Early Care and Education: A Missing Piece of the Child Welfare Puzzle

early-childhood-education-texas-tech-teaching-2 — Photo: Texas Tech University

Over the past two decades, the emphasis in child welfare policy has been on keeping children at home with their families instead of placing them in foster care. Starting in the 1990’s, states began obtaining federal waivers to use Title IV-E foster care funds for services designed to prevent children being placed in foster care. The use of these funds to prevent foster care placement has now entered permanent law through the Family First and Prevention Services Act (FFPSA), which became law as part of the Continuing Resolution signed by Donald Trump on February 9, 2018. FFPSA allows states to use Title IV-E funds to pay for mental health services, drug treatment, and parenting training for parents whose children would otherwise be placed in foster care.

But there is something missing in this list of allowed services, and that is services to the children themselves. Most notably, quality early care and education (ECE) holds great promise as a way both to keep at-risk children safe at home and to compensate for the developmental effects of past and ongoing neglect.

Providing ECE for infants, toddlers and preschool aged children involved with child welfare was supported in an excellent issue brief by the U.S. Department of Health and Human Services, which received too little attention when it was published in November 2016. This brief explained how high-quality ECE can help promote both the safety and the well-being of children involved with the child welfare system.

Promoting Safety: For a parent to receive services under Title IV-E under FFPSA, the child must be a “candidate for foster care,” which means that the child is at imminent risk of being placed in foster care but who can remain safely at home provided that the parents receive the parenting, mental health, or drug treatment services. Obviously, there is always an element of guesswork in deciding if children can indeed remain safely at home. Many children have been injured or killed after a social worker decides they are safe at home with services.¹ Others end up being placed in foster care later because the abuse or neglect continues.

As described in the HHS issue brief, enrolling young children who are candidates for foster care in high-quality ECE provides an extra layer of protection against further abuse or neglect. There are several pathways that link ECE and child safety.

Participation in an ECE program with staff trained in detection of abuse and neglect ensures that more adults will be seeing the child and able to report on any warning signs of maltreatment.
Taking young children away from home for the day provides respite to the parent, gives them time to engage in services, and may reduce their stress, which contributes to child maltreatment.
Attending quality ECE all day improves child safety by reducing the amount of time the children spend with the parents.
Quality ECE programs that involve the parents can also improve child safety by teaching parents about child development, appropriate expectations, and good disciplinary practices. They may also connect parents with needed resources in the community and help them feel less isolated.

As documented in the HHS issue brief, multiple studies link ECE to reduced child maltreatment. The most striking findings were from Chicago’s Parent Child Centers: participants were half as likely as a similar population to be confirmed as a victim of maltreatment by age 18.

Promoting Emotional and Cognitive Development: Enrollment in high quality ECE would promote healthy brain development for children involved with child welfare. A large body of research demonstrates that ECE has positive effects on the early cognitive and socio-emotional development, school readiness and early academic success of children in the general population. And these effects are greater and long-lasting for children who are socioeconomically “at risk,” like most children involved in child welfare.

Many children involved with child welfare are victims of “chronic neglect,” which has been defined as “a parent or caregiver’s ongoing, serious pattern of deprivation of a child’s basic physical, developmental and/or emotional needs for healthy growth and development.” There is increasing evidence that chronic neglect has adverse impacts on children’s brain development, which may lead to lifetime cognitive, academic and emotional deficits.

High-quality ECE can be viewed as a “compensatory” service to make up for emotional and developmental neglect, as Doug Besharov, the first Director of the National Center on Child Abuse and Neglect, suggested back in 1988.

Unfortunately, there is already a national shortage of high quality ECE, and children involved with child welfare cannot simply be inserted into existing slots without displacing other children who may be equally at risk. The lack of high quality ECE is a problem that is far broader than the child welfare system.

The federal spending bill recently passed by Congress and signed by President Trump provides some new money for child care subsidies for low-income parents, but it is only $29 billion for a two-year-period. Child welfare advocates should ally with advocates of expanded ECE to support voter initiatives, such as those that have passed in various Colorado jurisdictions, to use public money to expand the number and quality of ECE slots. All at-risk children can benefit from quality ECE. And maltreated children need it perhaps most of all.

The Associated Press found 768 children who died of abuse or neglect over a six-year period while their families were being investigated or receiving services to prevent further maltreatment. According to the latest federal data compiled from 35 states, nearly 30% of the children who died had at least one prior contact with CPS in the previous three years. ↩

Family First: A “Reform” that Isn’t

By now most readers will know that Congress passed the Family First Prevention Services Act (FFPSA) as part of the continuing resolution to fund the government until March 23. The passage of this major legislation as part of a continuing resolution marks the final victory of an ideological agenda that has taken over the child welfare advocacy community.

FFPSA was drafted in secret without feedback from stakeholders such as state and county child welfare administrators, many of whom expressed opposition to the bill or at least concern about its consequences. After several failed attempts to pass the bill over a two-year period, it was finally passed as part of a continuing resolution that was urgently needed to fund the entire government and avert a shutdown.

If we had a more pluralistic intellectual landscape in child welfare, FFPSA might have looked very different. Any bill calling itself “child welfare finance reform” should have started by addressing the most egregious flaw in child welfare financing–the linkage between Title IV-E eligibility and eligibility for the long-defunct AFDC program, which was terminated in 1996.

As a result of this linkage, fewer children are eligible for Title IV-E assistance every year, and states spend millions of dollars on the useless exercise of verifying eligibility for every child entering the system, as described by Sean Hughes in the Chronicle of Social Change. Yet, the advocacy community, in its single-minded quest to reduce the foster care rolls, gave up the fight to de-link foster care from AFDC.

Instead, the goal of “finance reform” became expanding the use of Title IV-E funds to included what the Act calls “prevention services.” These are not services to prevent abuse and neglect, but rather to prevent a child’s entry into foster care once that abuse or neglect has already occurred. FFPSA allows the use of these funds to fund parenting education, drug treatment and mental health services for parents.

Most of these “prevention” services logically belong to other systems, such as drug treatment and mental health, and are also funded by Medicaid. But prevailing ideology favors diverting foster care funds to other purposes, ostensibly to encourage prevention. In the most recent display of this ideology, the President and CEO of Casey Family Programs testified last week that “for every $7 the Federal government spends on foster care, only $1 is spent on prevention.”

No footnote was provided, but it appears that Bell was restating a common refrain that compares Title IV-E foster care expenditures with spending under Title IV-B, that is used mostly for in-home services. This comparison fails to take into account all the services provided by other programs, such as Temporary Assistance for Needy Families, Social Services Block Grant, the Child Abuse Prevention and Treatment Act, Medicaid, the Maternal Infant and Early Childhood Home Visiting Program and the Comprehensive Addiction and Recovery Act. Most of these programs are insufficiently funded, but it makes sense to increase their funding rather than divert funds that were designed to help good Samaritans meet the needs of the children they have volunteered to care for temporarily.

This view that a foster home is always better than a congregate (non-family) placement is another part of the prevailing ideology in child welfare. Congregate placements also happen to be more expensive, making restrictions on congregate care a perfect offset to FFPSA’s increased costs. It’s very convenient when ideological correctness coincides with saving money! Unfortunately, restrictions on congregate care may be harmful to children when there is a foster home shortage and so many of today’s foster homes are inadequate, as I described in my last column.

The lack of robust conversation and debate in the child welfare advocacy community has resulted in a “reform” that will create more problems than it solves. Our most vulnerable children deserved a better outcome.