United States General Accounting Office

GAO Report to Congressional Committees

September 1995 CHILD WELFARE

Complex Needs Strain

Capacity to Provide

Services

GAO/HEHS-95-208

GAO United States

General Accounting Office

Washington, D.C. 20548

Health, Education, and

Human Services Division

B-261055 

September 26, 1995

The Honorable William V. Roth, Jr.

Chairman

Committee on Finance

United States Senate

The Honorable Nancy Landon Kassebaum

Chairman

Committee on Labor and Human Resources

United States Senate

The Honorable Bill Archer

Chairman

Committee on Ways and Means

House of Representatives

The Honorable Bill Goodling

Chairman

Committee on Economic and Educational

 Opportunities

House of Representatives

In 1993, more than 1 million American children suffered some abuse or

neglect.1

 One in six of these children were removed from home for their

protection and temporarily placed in foster care. Both the children

remaining home and those placed in foster care were eligible for services

to help them deal with their family situation, obtain medical treatment, or

meet other critical needs. By the end of 1993, an estimated 450,000

children were in foster care, more than in any other year since the

mid-1970s.

States provide the majority of funds for foster care and child welfare

services. Even so, the federal share of expenditures reached $4.1 billion in

1995. These federal funds come primarily from two sources, one an

open-ended entitlement and the other limited to annual appropriations.

Under title IV-E of the Social Security Act, open-ended funds are available

to states for the maintenance (food, shelter, and incidentals) of all foster

children meeting certain income and other criteria. Title IV-B of the act

provides separate funds to states for child welfare services for abused and

neglected children who remain in their homes or are placed in foster care.

1

The most recent year for which data are available is 1993.

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B-261055 

These services include helping families to resolve their problems and

referring families for specialized help, such as substance abuse treatment.

The Congress is currently considering sweeping changes to programs

designed to support children and families. Among these changes is a

proposal to replace many child welfare programs, including foster care,

with a block grant. To assist the Congress in its deliberations, this report

presents an overview of the foster care system and related child welfare

services. Specifically, we address the following questions:

• What are recent trends in the characteristics of the foster care population?

• Have resources for foster care and child welfare services kept pace with

changing needs?

• How are states responding to current foster care and other service needs?

To develop this information, we drew upon our past reports on foster care

and related child welfare issues (see list of Related GAO Products in app. V)

and reviewed reports by government and other organizations as well as

position papers and written testimony from witnesses at congressional

hearings. In addition, we interviewed national experts and researchers in

the child welfare area, child welfare advocates, representatives of public

interest groups, government officials in selected states and localities, and

federal officials (see app. I). Our work was performed between March and

July 1995.

Results in Brief Between 1983 and 1993, sharp increases in the number of foster children

combined with unprecedented service needs led to a crisis in foster care.

Reports of child abuse and neglect nearly doubled, and foster care

caseloads grew by two-thirds. Demands for child welfare services grew

not only because the number of foster children increased but also because

families and children were more troubled and had more complex needs

than in the past. In Los Angeles County, New York City, and Philadelphia

County, for example, 29 percent of preschool-age foster children in 1986

were at risk of health problems due to prenatal drug exposure; this rose to

62 percent in 1991.

Meanwhile, resources for child welfare services failed to keep pace with

the needs of troubled children and their families. While foster care funding

has increased dramatically at all levels of government, federal funding for

child welfare services has lagged. States and localities have found it

difficult to meet the demand, although they have more than tripled

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expenditures in some cases. Federal foster care funds generally cannot be

transferred to support child welfare services, and available state funds are

increasingly being spent on child abuse and neglect investigations. The

effect has been to further constrain resources for preventive and

rehabilitative child welfare services that offer some promise of containing

growth in foster care caseloads.

Faced with increasing demands and limited resources, states have adopted

various measures to meet the needs of troubled children and their families

while maintaining children’s safety. Many states now offer family

preservation services or place children with relatives to maintain family

ties and save money. States are also increasingly considering the use of

specialized foster homes for children with unique problems, including

emotionally disturbed and medically fragile children, to provide more

family-like care at lower costs than institutions, where such children are

typically placed. If states can save foster care costs, they may be able to

transfer state funds to support child welfare services.

Background Foster care is an integral part of a child welfare system designed to ensure

the safety and well-being of children whose families are not providing

adequate care for them. Foster care provides primarily food and housing

to meet the physical needs of children who are removed from their homes.

Child welfare services are designed to address the complex family

problems associated with children’s abuse, neglect, exploitation, or

delinquency. In providing child welfare services, caseworkers may also

refer children and their families to mental health agencies, medical

facilities, or elsewhere for specialized treatment and services.

Child welfare services are critical in helping prevent the need for foster

care as well as in achieving appropriate and stable permanent living

arrangements for children placed in foster care. Most states and counties

provide some child welfare services directly and purchase others from

private agencies. Available services vary considerably from one area to

another in number, type, intensity, and duration, although calls and visits

with caseworkers are considered essential in most areas.

Children generally enter foster care for their own protection because their

parents will not or cannot take care of them.2

 When problems such as

abuse or neglect are identified, the child welfare system may intervene

2

Other children enter care because they represent a danger to themselves, their families, or their

communities.

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B-261055 

with services designed to improve the situation and avoid removing

children from their homes. If such services cannot ensure children’s safety

and well-being in their homes, the child welfare system petitions the court

to place children in foster care, either in the homes of relatives or

nonfamily foster parents, group homes, or institutions.

Foster care provided by relatives, who are often grandmothers, is known

as kinship care. States may choose whether to license relatives as foster

parents and provide foster care payments. On the other hand, states

require nonfamily foster parents to be licensed and pay them an average of

$8 to $15 a day per child for food, housing, and incidental expenses. States

also license group homes and institutions to provide care by paid staff.

These homes receive an average of $100 a day per child for food, housing,

and overhead expenses.3

 Foster care is a temporary solution until children

can be returned safely to their parents, adopted, or placed in some other

permanent living arrangement; however, some children remain in foster

care until their eligibility for foster care assistance expires, generally at

age 18.

Under federal law, states must provide foster care if they participate in Aid

to Families With Dependent Children (AFDC), the largest federal welfare

program providing cash assistance to poor families. States receive federal

matching funds for about half of all foster children because these children

would have qualified for AFDC had they remained in their homes. For the

other half, states and localities are the sole source of government support.

In addition, states and localities supply the majority of government funds

for child welfare services. Many states directly administer foster care and

child welfare, but nearly one-third delegate this authority to their counties,

including several states with the largest caseloads—California,

Pennsylvania, and New York.

Two titles under the Social Security Act provide federal funding targeted

specifically to foster care and related child welfare services.4

 (See app. II.)

Title IV-E provides an open-ended individual entitlement for foster care

maintenance payments to cover a portion of the food, housing, and

incidental expenses of children from AFDC-eligible families. Title IV-E also

provides payments to adoptive parents of eligible minority foster children

3

Cost estimates are for 1990 as reported in Overview of Entitlement Programs: 1994 Green Book,

Committee on Ways and Means, U.S. House of Representatives (Washington, D.C.: 1994).

4

Title XX provides funds under the social services block grant that may be used for many purposes,

including child welfare. See Foster Care: Services to Prevent Out-of-Home Placements Are Limited by

Funding Barriers (GAO/HRD-93-76, June 29, 1993).

Page 4 GAO/HEHS-95-208 Foster Care Overview
B-261055 

or others with special needs, such as health problems, that may make

adoptive homes more difficult to find. Title IV-B provides limited or

“capped” funding for child welfare services to foster children as well as

children remaining in their homes.

In 1995, total IV-E funding was $3.6 billion and total IV-B funding was

$453 million, representing about 97 percent of all federal funding targeted

to child welfare and protection, including foster care. Another nine

programs provided an additional $136 million in federal funds to states for

activities designed to protect the safety and well-being of children.

Under the Child Protection Block Grant passed by the House in 1995,

foster care and the other child welfare programs would be replaced by a

single block grant to states with capped funding. (See apps. III and IV.) In

addition, proposals for an AFDC block grant would cap federal funding and

repeal AFDC eligibility rules that currently enable states to claim IV-E foster

care funds. Further, the AFDC block could affect the amount of federal

funds states would receive for IV-E foster care if it makes certain

categories of children ineligible for AFDC and all children ineligible for AFDC

after 5 years of assistance.

Recent Trends Have

Led to a Foster Care

Crisis

Current trends in the number and needs of foster children have led to a

crisis in the child welfare system. The number of reports of abuse and

neglect and the number of children removed from home and placed in

foster care for their protection have grown alarmingly. Also, compared

with the foster children of 10 years ago, today’s foster children have

characteristics associated with longer stays in foster care and greater

service needs. Although stays in foster care for most children are less than

1 year, permanent placements following foster care are delayed or

unstable for a significant minority of children.

Reports of Child Abuse

and Neglect Have

Increased

An estimated 2.3 million children were reported possible victims of abuse

or neglect in 1993.5

 Although the number of reports has nearly doubled

since 1983, the rate of increase has shown signs of leveling off since 1990.

The increased reporting has been due, in part, to heightened public

awareness and state laws mandating reports from professionals who see

5

Child Maltreatment 1993: Reports From the States to the National Center on Child Abuse and Neglect,

Department of Health and Human Services (Washington, D.C.: 1995).

Page 5 GAO/HEHS-95-208 Foster Care Overview
B-261055 

children on a daily basis.6 Meanwhile, the incidence of poverty and

substance abuse, factors associated with abuse and neglect, were also at

relatively high levels during this period.

Upon investigation, child welfare workers confirmed abuse or neglect of

1 million children in 1993.7

 Although child abuse and neglect are more

likely to be reported today than 10 years ago, whether children are as

likely to be removed from their homes is not clear. Experts believe that as

a result of increased demands, strained resources, and efforts to

strengthen families, child welfare agencies are currently reevaluating

conditions in the family and neighborhood that formerly might have been

grounds for the child’s removal. Most of the 1 million abused or neglected

children remained in their homes. However, about 15 percent were

considered in imminent danger and placed in foster care. Most children

who enter foster care do so because of abuse; neglect; inadequate care due

to parental absence; or conditions, such as illness or financial difficulty, as

shown in figure 1.

6

Teachers most often reported the abuse or neglect that was most often perpetrated by parents or

other relatives.

7

Nearly half of the confirmed cases involved neglect; a quarter, physical abuse; one-seventh, sexual

abuse; and the remainder, unspecified maltreatment. About half of the children were under 8 years of

age, a quarter under 4. Neglect was more common among younger children; physical abuse, among

boys under 12 or girls over 12; and sexual abuse, among girls. (See footnote 5.)

Page 6 GAO/HEHS-95-208 Foster Care Overview
B-261055 

Figure 1: Reasons Children Entered

Foster Care, 1990

50% • Protective Service

21%•

Parent Condition or Absence

•11%

Status Offense/Delinquent

•15%

Other

•

3%

Unknown

Notes: “Protective service” includes children who entered care because of abuse or neglect

reported to child protective services.

“Parent condition or absence” includes children who entered care because of absence, illness,

death, handicap, financial hardship, or other condition of the parent(s).

“Status offense/delinquent” includes children who entered care because of (1) status offenses,

such as running away or truancy, or (2) delinquent behavior.

“Other” includes children who entered care for such reasons as parent-child relationship

problems, child’s handicap, a plan for adoption, deinstitutionalization, and unwed motherhood.

Source: American Public Welfare Association (APWA) Voluntary Cooperative Information System

(VCIS).

Foster Care Caseloads

Have Reached Record

Levels

By 1993, an estimated 450,000 U.S. children—more than at any other time

in two decades—were in foster care. This represents a two-thirds increase

in the foster care caseload since 1983, as shown in figure 2. The growth in

foster care caseloads occurred because more children entered than left

care in each year between 1983 and 1993. This trend was especially

noticeable between 1987 and 1990, when the number of children entering

Page 7 GAO/HEHS-95-208 Foster Care Overview
B-261055 

care increased the most. Since peaking in 1990, the number of children

entering care has leveled off.

Figure 2: Foster Care Caseloads,

1983-1993 Number of Children (in thousands)

90

140

190

240

290

340

390

440

83 84 85 86 87 88 89 90 91 92 93

Fiscal Year

Total Foster Care Population

Entries

Exits

Source: APWA VCIS.

Meanwhile, the number of foster children who were eligible for federal

matching funds, by virtue of their family’s eligibility for AFDC, grew by a

larger percentage than the number of foster children in general. In 1993,

about half of all children in foster care were eligible for federal matching

funds under title IV-E. California and New York, the two states with the

largest foster care caseloads, accounted for one-third of all foster children

and much of the increase in title IV-E eligible children.

More Minority and Young

Children Are in Care

Although trends in the characteristics of foster children vary by state,

since 1983, foster children increasingly have come from minority groups

Page 8 GAO/HEHS-95-208 Foster Care Overview
B-261055 

and have been younger. The 1990 foster care population consisted of

40 percent African Americans and 11 percent Hispanics compared with

39 percent whites.8

 Not only are more minorities entering, but, once placed

in foster care, African American and Hispanic children remain longer and

leave at slower rates than whites.9

 African American children, in

particular, are disproportionately represented in foster care, as shown in

figure 3, and, if the trend continues, caseloads may increasingly consist of

minority children removed from their homes for prolonged stays in foster

care.

Figure 3: Proportion of White and

African American Children in General

Population and Foster Care, 1990

Percentage of Children in 1990

0

10

20

30

40

50

60

70

80

White African

American

Race

General Population 18 Years and Younger

Foster Care Population

Sources: For the general population, U.S. Census Bureau, Statistical Abstracts; for the foster care

population, APWA VCIS data from 31 states.

8

1990 is the most recent year for which nationwide data on characteristics are available from the

American Public Welfare Association’s (APWA) Voluntary Cooperative Information System (VCIS), the

major source of nationwide information on foster care.

9

Toshio Tatara, A Comparison of Child Substitute Care Exit Rates Among Three Different

Racial/Ethnic Groups in 12 States, FY 84 to FY 90, APWA, Research Note #10 (Washington, D.C.:

June 1994).

Page 9 GAO/HEHS-95-208 Foster Care Overview
B-261055 

Also by 1990, the average median age of children in foster care had

dropped from 12.6 to 8.6 years of age,10 as the percentage of preschoolers

increased by 50 percent and the percentage of teens declined (see fig. 4).

The increase in infants entering the system is particularly striking.

Although the majority of foster children entered the system between the

ages of 1 and 12, the percentage of children entering care who were under

1 year increased by two-thirds from 1983 to 1990, leading to a foster care

“baby boom.” Further, infants are staying in foster care longer than any

other age group, and as their time in care increases, their chance of being

adopted decreases.11

10APWA VCIS.

11R.M. Goerge, F.H. Wulczyn, and A.W. Harden, Foster Care Dynamics 1983-1993: An Update from the

Multistate Foster Care Data Archive, The Chapin Hall Center for Children, University of Chicago

(Chicago: 1995).

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B-261055 

Figure 4: Foster Children by Age,

1983-1990 Percentage of Children in Foster Care

0

5

10

15

20

25

30

35

40

45

50

83 84 85 86 87 88 89 90

Fiscal Year

Under 6 Years

6 to 12 Years

Over 12 Years

Source: APWA VCIS. Number of states responding in each year is 30 (fiscal year 1983), 33 (fiscal

year 1984), 32 (fiscal year 1985), 33 (fiscal year 1986), 26 (fiscal year 1987), 26 (fiscal year 1988),

27 (fiscal year 1989), 23 (fiscal year 1990). Nine states gave data in all 8 years.

Foster Children Have

Greater Service Needs

Than in the Past

Children are also entering care from families more troubled than in the

past and with greater emotional, behavioral, and medical needs. Such

families today more often face economic hardship, substance abuse,

homelessness, mental or physical illness, or the imprisonment of a family

member. In Los Angeles County, New York City, and Philadelphia County

in 1991, over half of the preschool-age foster children were estimated to

have serious health-related problems, including developmental delays, low

birth weight, heart problems, and human immunodeficiency virus (HIV)

infection. An estimated 62 percent of the preschool-age foster children

were at risk of serious health problems due to prenatal drug exposure,

more than double the 29 percent at risk of such problems in 1986.12

12See Foster Care: Parental Drug Abuse Has Alarming Impact on Young Children (GAO/HEHS-94-89,

Apr. 4, 1994).

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B-261055 

Children with these complex needs require a variety of community-based

services and a level of care not required in the past. A California study

found that foster children were 10 times more likely to use mental health

services than other children on Medicaid and that they were hospitalized

for mental conditions almost twice as long.13 For this reason, while foster

children constituted only 4 percent of California children on Medicaid they

accounted for 40 percent of all Medicaid mental health expenditures.

Permanent Living

Arrangements Following

Foster Care May Be

Delayed or Unstable

Children who leave foster care are increasingly returned home when

caseworkers consider it safe. About 67 percent of children leaving care in

1990 returned to their families (see fig. 5), up from 56 percent in 1983.

Meanwhile, the percentage of children adopted declined from 12 to

8 percent.

13N. Halfon, G. Berlowitz, L. Klee, “Children in Foster Care in California: An Examination of

Medicaid-Reimbursed Health Services Utilization,” Vol. 89 Pediatrics (1992), pp. 1230-37.

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B-261055 

Figure 5: Disposition of Children

Leaving Foster Care, 1990

67% • Reunited With Parent or Relative

•

8%

Adopted

•

7%

Reached Age 18

•16%

Other

•

3%

Unknown

Note: “Other” includes such reasons as placement with a legal guardian, marriage, running away,

incarceration, death, or discharge to another public agency.

Source: APWA VCIS data from 24 states.

Although foster care is a relatively short-term experience for many

children, some children remain in care for extended periods. Of the

children leaving care in 1990, for example, 50 percent had been in foster

care for 8 months or less. However, of those remaining in care, over

25 percent had been in foster placements for at least 3 years. (See fig. 6.)

Foster children for whom adoption is ultimately planned spend an average

of 4 to 6 years in foster care, according to a 1991 report on adoptions in 20

states.14

14See J.K. McKenzie, “Adoption of Children With Special Needs,” The Future of Children: Adoption,

Vol. 3, The Center for the Future of Children (Los Altos, Cal.: Spring 1993).

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Figure 6: Length of Stay in Foster Care

at the End of 1990

33% • 1 Year or Less

40%•

1 to 3 Years

•17%

3 to 5 Years

•10%

More Than 5 Years

Source: APWA VCIS data from 22 states.

The shorter the initial stay in foster care, the more likely it appears that

children who are reunited with their parents will reenter care.15 In Los

Angeles County and New York City, for example, 32 percent of children

whose initial stay in foster care was less than 1 year later returned to care,

compared with 16 percent of children whose initial stay was 1 year or

longer.

Youths who leave foster care at age 18 because they are no longer eligible

may experience unstable and troubled lives. A study conducted 2.5 to 4

years after youths left foster care found that 46 percent had not completed

high school, 38 percent had not held a job for more than 1 year, 25 percent

had been homeless for at least one night, and 60 percent of young women

15Foster Care: Children’s Experiences Linked to Various Factors; Better Data Needed

(GAO/HRD-91-64, Sept. 11, 1991).

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had given birth to a child.16 Forty percent had been on public assistance,

incarcerated, or a cost to the community in some other way.

Resources Have Not

Kept Pace With

Service Needs

The child welfare system has been under great pressure to meet increased

demands. States and localities provide the majority of funding for foster

care and child welfare services. From 1983 to 1993, rising caseloads have

increased federal, state, and local expenditures for foster care

dramatically, leaving proportionately less for child welfare services.

Federal foster care funds cannot be used to pay for most child welfare

services, and available state funds are increasingly required for

investigations of abuse and neglect reports. As a result, states have found

it difficult to ensure that child welfare services are sufficiently funded to

meet needs. Other resource constraints have included problems recruiting

and retaining caseworkers, shortages of available foster parents, and

difficulties obtaining needed services from systems outside the control of

child welfare.

Foster Care Expenditures

Have Increased

Dramatically at All Levels

of Government

With increasing foster care caseloads, expenditures for the basic needs of

foster children and program administration have risen dramatically at all

levels of government. Federal expenditures grew faster than state

expenditures in three of the largest states from 1983 to 1993. Nevertheless,

as of 1990, states and localities continued to fund about 65 percent of all

foster care.

Federal costs of foster care maintenance increased by over 350 percent

(see table 1) from 1983 to 1993 in California and New York, which

approaches the nationwide increase of nearly 400 percent for this period.

(See fig. 7.)

16A National Evaluation of Title IV-E Foster Care Independent Living Program for Youth: Phase II Final

Report, Vols. I and II, Westat, Inc. (Rockville, Md.: 1991).

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Figure 7: Expenditures for Title IV-E

Foster Care Maintenance and Title IV-B

Child Welfare Services, 1983-1993

Dollars (in millions)

100

200

300

400

500

600

700

800

900

1000

1100

1200

1300

1400

83 84 85 86 87 88 89 90 91 92 93

Fiscal Year

Title IV-E Foster Care Maintenance

Title IV-B Child Welfare Services

Source: Overview of Entitlement Programs; 1994 Green Book, Committee on Ways and Means,

U.S. House of Representatives.

The rapid rise in federal foster care expenditures has been linked to

several simultaneous developments: States have increased efforts to

determine children’s eligibility for federal funds; more children have

become eligible under AFDC rules for IV-E assistance; and payments to

providers have increased in most states. Further, federal administrative

costs17 have increased over the same period as states have increasingly

emphasized the case management and placement activities required by

federal law (see app. IV) and sought full reimbursement for these

activities. By 1993, nearly $1.1 billion in IV-E reimbursement went to states

for foster care administrative activities, almost as much as the $1.3 billion

that went for foster care maintenance in that year.18

17Expenditures for administrative activities include costs required to recruit and license foster homes,

determine children’s title IV-E eligibility, and manage cases (see app. II).

18Overview of Entitlement Programs: 1994 Green Book.

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At the state level, foster care expenditures also rose between 1983 and

1993. For example, California and New York increased expenditures for

foster care maintenance payments by about 200 percent, while Michigan’s

expenditures doubled, as shown in table 1.19

Table 1: Changes in Foster Care

Caseloads and Related Expenditures

in Three States, 1983-1993

State

California Michigan New York

Foster care caseload growth 119% 50% 108%

Foster care maintenance expenditures

State and local 258 112 183

Federal IV-E 381 146 356

Child welfare services expenditures

State and local 309a 213 239

Federal IV-B 131 80 –14b

aPercent change from 1985 to 1992. Data for other years are not available.

bThe allocation formula under IV-B reduced New York’s grant from $18 million to $15.5 million.

Because of fiscal difficulties states experienced in the early 1990s,20 they

looked to localities and the federal government to assume greater shares

of foster care costs. California, Michigan, and New York, for example, are

among the states that increased the portion of foster care maintenance

payments supported by local funds. Faced with a $14 billion budget deficit

in 1992, California increased counties’ portion of foster care maintenance

payments by 1,100 percent.

Available Funding and

Competing Demands

Constrain Child Welfare

Services

Available funding and competing demands from other activities have

constrained resources available for child welfare services. Despite

increasing appropriations, the federal government spent about $.12 on

child welfare services in 1993 for every $1 it spent on foster care, as

compared with about $.40 in 1983. While states and localities have

continued to provide the majority of funds for child welfare services, they

have found it increasingly difficult to maintain sufficient funding levels to

ensure that needs are met.

19State and local expenditure data are not routinely reported. We obtained this information directly

from the three states shown. These states include the two with the nation’s largest

caseloads—California and New York.

20This is according to fiscal surveys of states conducted by the National Association of State Budget

Officers and the National Governors’ Association.

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At the national level, title IV-B appropriations increased 88 percent from

1983 through 1993, lagging behind increases in federal foster care

maintenance costs, as shown in figure 7.21 Increases in federal

expenditures for child welfare services also lagged behind state and local

expenditure growth during this period.

State and local expenditures for services rose dramatically from the early

1980s to the early 1990s and represented over half of all funding as of 1990.

In California, Michigan, and New York, state and local expenditures for

child welfare services increased by over 200 percent (see table 1).

Meanwhile, federal IV-B funding for California and Michigan increased at

half these rates and in New York actually decreased by 14 percent.

Although federal law requires the provision of direct child welfare services

to children and families, these services generally cannot be supported with

federal funds designated for foster care.22 Available state funds,

meanwhile, have been stretched to the limit to cover increasing demands

from other activities. Most notably, rising reports of abuse and neglect

have led states to devote more resources to investigating reports, leaving

less for providing services.

Because of constrained resources and competing demands, states have not

been able to ensure that child welfare services are sufficient to meet

needs. For example, an APWA survey of agencies in every state found that

services were limited and generally involved managing, rather than

treating, families and their abused or neglected children. Since 1987,

children’s advocates have successfully filed class action lawsuits on behalf

of children against eight states, obtaining court orders to improve child

welfare services, and similar cases are pending in other states.23

Shortages of Caseworkers

and Foster Parents Further

Strain Service Delivery

Next to funding, states report that staffing is the most serious issue facing

their child welfare systems. In response to an APWA survey, 90 percent of

states reported difficulty recruiting and retaining caseworkers.

Caseworkers are at the heart of the foster care system, visiting children

21The Congress authorized a new IV-B program for family preservation and support services designed

to prevent the need for foster care and appropriated $60 million for start-up activities in 1994.

22AFDC funds for emergency assistance to families have been used for services, particularly since

1993. See Review of Rising Costs in the Emergency Assistance Program, Department of Health and

Human Services, Office of the Inspector General (Washington, D.C.: 1995).

23The eight states are Alabama, Arkansas, Connecticut, District of Columbia, Illinois, Indiana, Kansas,

and Utah.

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and families in their homes and arranging services to help prevent the

need to remove children from their homes, or, in case of their removal, to

find permanent living arrangements for foster children. Caseworkers also

coordinate contacts among families and children with health, mental

health, and other service systems.

State officials attributed difficulties in recruiting and retaining

caseworkers to several factors, including hiring freezes, low pay, and poor

working conditions. These factors, in turn, led to staff shortages, high

caseloads, and high burnout and turnover rates among caseworkers. In

some jurisdictions, caseloads have reached 100 cases per caseworker, well

above the 25 per caseworker recommended by the National Association of

Social Workers. In New York City, annual turnover rates for caseworkers

have been as high as 75 percent, so that each year most foster children,

who have suffered from unstable families, get a new caseworker.

Foster parents are the other essential component of an effective service

delivery system, but the supply of foster parents has lagged behind the

growth in the foster care caseload. While the number of children in foster

care has increased, the number of foster homes has decreased.24 Child

welfare experts attribute this growing shortage of foster homes to several

factors, including the poor public image of foster care, low reimbursement

rates, inadequate support services, greater difficulties caring for today’s

more troubled foster children, and increased employment opportunities

for women. In some states, the shortage of foster homes is so great that

children are placed in temporary shelters or shuttled from one place to

another until a proper home can be found, according to the National

Foster Parent Association.

Fragmented Service

Delivery System

Exacerbates Problem

Difficulties providing families and children with services also arise

because many needs must be met by services, such as medical care and

drug treatment, that are outside the control of the child welfare system.

Rarely does a single state or local agency have control over the full array

of services required to address the needs of increasingly troubled children

and families who have many problems. Rather, a complex set of service

delivery systems must be tapped; these are usually linked to separate

categorical funding sources and different eligibility criteria.

24See Foster Parents: Recruiting and Preservice Training Practices Need Evaluation (GAO/HRD-89-86,

Aug. 3, 1989).

Page 19 GAO/HEHS-95-208 Foster Care Overview
B-261055 

Because caseworkers may be overworked and families may often lack the

sophistication and resources necessary to arrange services on their own

behalf, some children and families may experience delays or gaps in

service. For example, when we visited metropolitan areas in three states,

we found that many foster children under age 3 lacked routine health

examinations and immunizations.25

The goals of the child welfare system and those of various programs may

also be inconsistent. For example, caseworkers report that more parents

of abused and neglected children are addicted to drugs than in the past.

Although one of the primary goals of the current child welfare system is to

keep families together, residential drug treatment programs are rarely able

to accommodate the children of parents undergoing treatment. For

parents to receive treatment, therefore, some children must be placed in

some kind of foster care.

States Struggle to

Meet Caseload and

Resource Challenges

In response to the escalating pressure on the foster care system, states

have adopted various measures to meet changing foster care needs. Many

states provide family preservation services to avoid the need for foster

care or facilitate the return of foster children to their families. When

children must be removed from their homes, many states give preference

to placing them in kinship care with relatives to maintain family ties, and,

in some cases, save on costs. In addition, some states are considering the

use of specialized foster parents for children with health or other unique

needs because these parents provide more family-like care than

institutions, and at the same time, save costs. To find permanent homes

for foster children who cannot return to their families, states have also

participated in a federal adoptions assistance program, although

significant barriers to adoption still exist.

States Seek to Preserve

Families and Minimize the

Need for Foster Care

States have acted to strengthen families to lessen the likelihood of

continued abuse and neglect and minimize the need for foster care. To

prevent the need for foster care, states and localities are experimenting

with providing family preservation services. Families with children at risk

of abuse or neglect receive a combination of services over several weeks

or months arranged by caseworkers who generally make frequent home

visits and concentrate on helping a few families. Services can include

25See Foster Care: Health Needs of Many Young Children Are Often Unknown and Unmet

(GAO/HEHS-95-114, May 26, 1995).

Page 20 GAO/HEHS-95-208 Foster Care Overview
B-261055 

training in parenting and housekeeping, transportation, and mental health

and family counseling.

Studies show that family preservation services can preclude the need for

foster care at least up to 1 year, although little is known about long-term

results.26 Because costs for family preservation services are a fraction of

foster care costs, these findings offer some promise of cost savings. In

1993, 48 states offered some family preservation services. Despite

promising early results, resources are still sufficiently limited so that most

states cannot offer family preservation services to all clients in need of

services.27 However, such services should expand as a result of recent

federal funding earmarked for this purpose.

States Increase Use of

Kinship Care

When foster care is necessary, states have increasingly placed children

with relatives in what is called kinship care. The proportion of foster

children placed with relatives grew from 18 percent to 31 percent between

1986 and 1990 in 25 states, including California and New York.28 The

proportions were even higher in some metropolitan areas, such as New

York City, where about half of foster children were in kinship care in the

early 1990s. African American children are especially likely to be placed in

kinship care. About 29 states give preference to kinship care when

appropriate.

States have increased their use of kinship care for a variety of reasons: to

maintain children’s ties to their families; encourage long-term placements;

meet federal standards of care (see app. IV); offset shortages of traditional

foster homes; and, in some cases, save on costs by offering lower

payments. Kinship care is less costly than traditional foster homes in those

states where relatives are ineligible for state foster care payments.

Although relatives might be eligible for assistance from AFDC, AFDC levels

are significantly lower than state foster care maintenance payments.

Kinship care, however, poses several challenges. First, children’s access to

needed services may be more limited because kinship foster parents are

more likely to live in impoverished communities and lack experience

accessing needed services than other foster parents. Second, children may

26See Foster Care: Services to Prevent Out-of-Home Placements Are Limited by Funding Barriers.

27See Child Welfare: Opportunities to Further Enhance Family Preservation and Support Activities

(GAO/HEHS-95-112, June 15, 1995).

28Using Relatives for Foster Care, HHS, Office of the Inspector General (Washington, D.C.: July 1992).

Page 21 GAO/HEHS-95-208 Foster Care Overview
B-261055 

be more vulnerable to repeated neglect or abuse because they are more at

risk of unsupervised visits with parents or other relatives from whose care

they were removed. Third, child welfare agencies do not always monitor

or supervise kinship care placements as much as traditional foster care

placements. Finally, children in kinship care tend to stay in foster care

longer than other foster children because, for various reasons, child

welfare agencies are less likely to arrange alternative placements, such as

guardianship or adoption. In those states where relatives receive AFDC

rather than foster care payments, AFDC costs may offset savings that might

have resulted from lower reimbursement rates when children remain in

kinship care for prolonged periods.

Specialized Family Foster

Care Addresses Needs in

Less Institutional Setting

Increasingly, states are using specialized foster parents rather than

institutional care to provide more nurturing and family-like care at

reduced costs for children and adolescents with special needs. These

children include those who are severely emotionally disturbed, medically

complex or fragile, HIV positive, or delinquent. Specialized care typically

involves therapy or treatment provided in the foster home.

To meet the unique needs of foster children they serve, specialized foster

parents are generally carefully selected and trained. In addition, they are

paid at higher rates, provided more agency support and supervision, and

given access to more comprehensive referral services than traditional

foster parents. Although generally more expensive than traditional foster

family care, specialized care is less expensive and considered more

nurturing than institutional care in group homes, residential facilities, or

psychiatric institutions.

States Participate in

Adoption Initiative for

Hard-to-Place Foster

Children

States also participate in the federal adoptions assistance program, which

is designed to obtain stable, permanent homes for certain foster children.

This program encourages the adoption of federally eligible foster children

who cannot return to their biological families and have special needs that

make them difficult to place. Title IV-E provides an open-ended individual

entitlement that helps cover one-time adoption expenses and offers

monthly payments to adoptive families of children who might otherwise

languish in foster care because of their age; minority status; disabilities;

emotional, behavioral, or learning problems; or other special needs.

Studies have indicated that such assistance increases the likelihood of

adoption of older and minority children and is cost effective. Regarding

costs, a Westat study found that adoption assistance saved the government

Page 22 GAO/HEHS-95-208 Foster Care Overview
B-261055 

$1.6 billion from 1983 to 1987 over what costs would have been if children

had remained in foster care.29

The success of the adoption assistance program in reducing foster care

caseloads and costs, however, appears to be limited by barriers to timely

adoptions.30 Many states view federal standards (see app. IV) as requiring

a sequential approach to the permanent placement of foster children and

therefore plan for family reunification before considering adoptions.31

Further, once adoption is planned, delays often occur in terminating

parental rights, a required step before adoptions can be arranged. This

occurs, in part, because the courts lack a clear consensus on the proper

balance among the needs of biological parents, adoptive parents, and the

child. Attempts to ensure racial or ethnic matches between children and

adoptive parents are also believed to add delays.32

The Congress

Considering Changes

to Child Welfare

Programs

The Congress is currently debating proposals to replace foster care and

other child welfare programs with a block grant. The Child Protection

Block Grant (CPBG)—title II of H.R. 4—passed by the House of

Representatives on March 24, 1995, would consolidate foster care and at

least 18 related child welfare programs into a single block grant to states.

(See app. III.) CPBG would eliminate restrictions on states’ use of various

funding sources under the current programs, place annual limits on

funding, and allocate funds to states on the basis of past rather than

current expenditures. Federal eligibility criteria and oversight largely

would be eliminated, and standards and planning and reporting

requirements would be streamlined to allow states more flexibility in

designing and administering their programs.33

Federal, state, and local officials and child welfare experts we consulted

(see app. I) noted possible benefits of CPBG. First, officials agreed that

29A.J. Sedlak and D.D. Broadhurst, Study of Adoption Assistance Impacts and Outcomes: Final Report,

Vol. I, Westat, Inc. (Rockville, Md.: 1993).

30See also Barriers to Freeing Children for Adoption, HHS, Office of the Inspector General

(Washington, D.C.: 1991).

31Washington state is experimenting with concurrent reunification and adoption efforts to decrease the

time needed to place children for adoption.

32The Howard M. Metzenbaum Multi-Ethnic Placement Act of 1994 (P.L. 103-382) bars these practices.

Although the block grant proposal repeals this act, it substitutes similar language prohibiting racial or

ethnic barriers to adoption.

33See Karen Spar’s Welfare Reform: Implications of H.R. 4 for Child Welfare Services (CRS 95-566

EPW), Congressional Research Service (Washington, D.C.: May 1995).

Page 23 GAO/HEHS-95-208 Foster Care Overview
B-261055 

capping the block grant would control federal foster care expenditures

and might result in savings at that level. Second, officials generally agreed

that CPBG would provide increased program flexibility so that states could

respond more quickly and creatively to changing caseload needs. For

example, states would be able to use funds, formerly restricted to foster

care, for preventive and rehabilitative services—a move that some states

believe holds promise for controlling caseload growth. Further, increased

flexibility resulting from simplified planning, reporting, and eligibility

criteria would streamline administration and could cut costs. As a result,

states could more easily shift resources to areas of greater need.

On the other hand, many experts expressed concern that the block grant

would shift much of the financing burden to the states, which might be

unable to support increased caseloads without reducing services.34 They

were also concerned that, due to reduced federal funding and oversight,

the quality of foster care could be adversely affected.

Our work on block grants suggests that three lessons can be drawn from

the experience with the 1981 block grants35 that would have value to the

Congress as it considers creating new ones. First, a clear need exists to

focus on accountability for results to provide the Congress with

information on program performance. Second, funding allocations to

states should be studied carefully and reflect need, ability to pay, and

variations in the cost of providing services. Finally, because the programs

in the current proposal are much larger and essentially different from

those programs included in the 1981 block grants, states are likely to face

greater challenges than they did in the early 1980s.

34Advocates expect foster care caseloads to grow to accommodate children ineligible for AFDC under

the proposed welfare block grant. Growing caseloads, in turn, would shift funds from services to

payments to foster care providers.

35Under the Omnibus Reconciliation Act of 1981, the administration of federal domestic assistance

programs was substantially changed by consolidating more than 50 categorical grant programs into

nine block grants and shifting primary administrative responsibility for these programs to the states.

Page 24 GAO/HEHS-95-208 Foster Care Overview
B-261055 

In addition to Members of the Congress, we are providing copies of this

report to the Secretary of Health and Human Services, state child welfare

directors, and other interested parties. Should you have any questions or

wish to discuss the information provided, please call me at (202) 512-7230.

Other GAO contacts and staff acknowledgments appear in appendix VI.

Jane L. Ross

Director, Income Security Issues

Page 25 GAO/HEHS-95-208 Foster Care Overview
Contents

Letter 1

Appendix I 

Organizations and

Experts Contacted

Regarding Foster Care

and Block Grant

Proposed Under Title

II of H.R. 4

28

Appendix II 

Funding to States

Under Social Security

Act Titles IV-B and

IV-E

29

Appendix III 

Child Welfare

Programs Proposed

for Consolidation

Under Title II of H.R. 4

and Fiscal Year 1995

Appropriations

30

Appendix IV 

Federal Foster Care

Standards in Current

Law and Title II of

H.R. 4

31

Page 26 GAO/HEHS-95-208 Foster Care Overview
Contents

Appendix V 

Recent GAO Reports

and Testimonies on

Child Protection,

Foster Care,

Adoption, and Related

Topics

32

Child Abuse and Neglect Prevention 32

Foster Care 33

Other 36

Appendix VI 

GAO Contacts and

Staff

Acknowledgments

38

Table Table 1: Changes in Foster Care Caseloads and Related

Expenditures in Three States, 1983-1993

17

Figures Figure 1: Reasons Children Entered Foster Care, 1990 7

Figure 2: Foster Care Caseloads, 1983-1993 8

Figure 3: Proportion of White and African American Children in

General Population and Foster Care, 1990

9

Figure 4: Foster Children by Age, 1983-1990 11

Figure 5: Disposition of Children Leaving Foster Care, 1990 13

Figure 6: Length of Stay in Foster Care at the End of 1990 14

Figure 7: Expenditures for Title IV-E Foster Care Maintenance

and Title IV-B Child Welfare Services, 1983-1993

16

Abbreviations

AFDC Aid to Families With Dependent Children

APWA American Public Welfare Association

CAPTA Child Abuse Prevention and Treatment Act

CPBG Child Protection Block Grant

HHS Department of Health and Human Services

HIV human immunodeficiency virus

SSI Supplemental Security Income

VCIS Voluntary Cooperative Information System

Page 27 GAO/HEHS-95-208 Foster Care Overview
Appendix I 

Organizations and Experts Contacted

Regarding Foster Care and Block Grant

Proposed Under Title II of H.R. 4

Organization Expert

American Enterprise Institute Douglas Besharov

American Public Welfare Association Jan Cooper, Betsy

Rosenbaum, Pat Shapiro,

Toshio Tatara

California Department of Social Services Wes Beers, Marilyn Lewis

Center on Effective Services for Children Jule Sugarman

Center for Law and Social Policy Jodie Levin-Epstein

Center for the Study of Social Policy Mark Friedman, Charles

Gershenson, Judy Meltzer

Child Welfare League of America Mike Petit

Congressional Budget Office Sheila Dacey, John Topogna

Congressional Research Service Dale Robinson, Karen Spar

Congressional Quarterly Jeffrey Katz

County Welfare Directors’ Association of California Frank Mecca

Los Angeles County Department of Children’s Services Peter Digre

Massachusetts Department of Social Services Linda Carlisle

Michigan Department of Social Services Stephanie Comai-Page

National Conference of State Legislatures Shelly Smith, Jack Tweedie

New York State Department of Social Services Fred Wulczyn

North Dakota Department of Social Services Don Schmid

U.S. Department of Health and Human Services

Children’s Bureau Michael Ambrose, Dan

Lewis, Penny Maza

National Center on Child Abuse and Neglect David Lloyd

Office of Human Services Policy, Division of Children

and Youth

Laura Feig, Matthew Stagner

University of California Berkeley Child Welfare Research

Center

Richard Barth, Jill Duerr

Berrick, Barbara Needell

University of Chicago Chapin Hall Center for Children Robert Goerge

University of Washington School of Social Work James Whittaker

Westat Diane Broadhurst, Ronna

Cook, Andrea Sedlak

Washoe County, Nevada, Department of Social Services May Shelton

Wisconsin Division of Community Services Linda Hisgen

Page 28 GAO/HEHS-95-208 Foster Care Overview
Appendix II 

Funding to States Under Social Security Act

Titles IV-B and IV-E

Program Federal support Eligibility Allowable costs

Title IV-B Child Welfare

Services

Nonentitlement for 75 percent

match with 1995 appropriations

cap at $292 million

No eligibility criteria Child welfare services to prevent abuse, neglect;

foster care; reunited families; arrange adoptions;

ensure adequate foster care

Title IV-B Family

Preservation and

Support

Title IV-E Foster Care

Maintenance

Administration

State entitlement for 75 percent

match with 1995 cap at $150 million

Individual entitlement with

open-ended funding; state claims

in 1995 for reimbursement of

$3.1 billion

Match at Medicaid rate

(50 to 83 percent)

Match of 50 percent

AFDC-eligible

children 

Services to support families and prevent need

for foster care

Payments to foster care providers; may not be

used for direct services

Basic maintenance, including children’s food

and sheltera plus parental visits

Case management, eligibility determinations,

licensing, and other administrative costs

Training Match of 75 percent Training of agency staff and foster parents

Title IV-E Adoption

Assistance

Maintenance

Administration

Training

Nonrecurring Expenses

Individual entitlement with

open-ended funding; state claims

in 1995 for reimbursement of

$426 million

Match at Medicaid rate

Match of 50 percent

Match of 75 percent

Match of 50 percent up to $2,000

per placement

Special needs

childrena eligible for

AFDC or SSIb

Special needs

children

Payments to adoptive parents not to exceed

comparable foster care amounts; nonrecurring

adoption expenses

Basic maintenancec

Child placement and other administrative

activities

Training of agency staff and adoptive parents

Reasonable and necessary adoption fees, court

costs, attorney fees, and related expenses

Title IV-E Independent

Living

State entitlement for 50 percent

match of first $45 million of

$70 million of 1995 cap

Foster children at

least 16 years old

Services to assist in transition from foster care to

independent living, including basic living skills

training and education and employment initiatives

aA special needs child is defined in the statute as a child for whom the state determines that a

specific condition or situation, such as age; membership in a minority or sibling group; or a

mental, emotional, or physical handicap prevents placement without special assistance.

bThe Supplemental Security Income (SSI) program provides cash benefits to disabled children.

cBasic maintenance includes expenditures for food, shelter, daily supervision, school supplies,

incidentals, liability insurance for the child, reasonable travel to the child’s home for visits, and, for

group homes and institutions, some overhead.

Page 29 GAO/HEHS-95-208 Foster Care Overview
Appendix III 

Child Welfare Programs Proposed for

Consolidation Under Title II of H.R. 4 and

Fiscal Year 1995 Appropriations

Dollars in millions

Programs Funding

Mandatory entitlements authorized under the Social Security Act

Family Preservation and Support $150.0

Adoption Assistance 399.3a

Foster Care 3,128.0a

Independent Living 70.0

Total entitlement spending $3,747.3

Discretionary programs authorized under the Social Security Act

Child Welfare Services $292.0

Research and Demonstration 6.4

Training 4.4

Discretionary programs authorized under the Child Abuse Prevention

and Treatment Act (CAPTA)

HHS administered

Child Abuse Research and Demonstration Grants 15.4

Child Abuse State Grants 22.9

Community-Based Family Resource Grants 31.4

Other discretionary programs

HHS administered

Abandoned Infants Assistance 14.4

Adoption Opportunities 13.0

Temporary Child Care for Children With Disabilities and Crisis Nurseries 11.8b

Family Support Centers 7.4

Department of Justice administered

Children’s Advocacy Centers 3.0

Grants to Improve the Investigation and Prosecution of Child Abuse

Cases 2.0

Missing and Exploited Children 7.0

Department of Housing and Urban Development administered

Family Unification Program 7.6

Total discretionary spending $438.7

Note: We list 18 programs proposed for consolidation in the Child Protection Block Grant, title II of

H.R. 4 passed by the House of Representatives in 1995. Other congressional sources list 22

programs as being consolidated. We list four fewer programs because we treat title IV-E Foster

Care and title IV-E Adoption Assistance as one program each, whereas other sources break out

both programs into their three parts: maintenance payments, administration, and training.

aEstimated in February 1995.

Page 30 GAO/HEHS-95-208 Foster Care Overview
Appendix IV 

Federal Foster Care Standards in Current

Law and Title II of H.R. 4

Standard

Current

law

Block

grant

Applicable to all children

Abuse and neglect

reports

Enact laws to mandate reporting and

investigate promptly

x x

Child’s safety Protect children x x

Applicable to federally eligible children at risk of foster care

Services to family Make reasonable efforts to improve family

conditions so child need not be removed

from home

x

Applicable to all foster children

Child’s safety Ensure proper care x

Services to family Provide services to improve family

conditions so foster child can return to

family

x

Services to foster family Provide services to assist in permanent

placement

x

Parent’s rights Procedurally safeguard parent’s rights

when child is removed from home, the

foster placement is changed, or visitation

is at issue

x

Family’s rights Protect family’s rights x

Foster care placement Place child in most family-like, least

restrictive setting available that meets

child’s needs and best interests

x

Place child in close proximity to parents’

home consistent with child’s needs and

best interests

x

Case plan Have written plan for foster child with goal

for permanent home

x

Include placement type, appropriateness,

health and education records

x

Include information on children collected

regularly

x

Case review Ensure that foster placement is needed,

appropriate, and in compliance with plan

x

Hold every 6 months x x

Court hearing Decide disposition or future of child within

18 months of placement

x

Decide disposition or future of child within

3 months of fact-finding hearing

x

Page 31 GAO/HEHS-95-208 Foster Care Overview
Appendix V 

Recent GAO Reports and Testimonies on

Child Protection, Foster Care, Adoption, and

Related Topics

Child Abuse and

Neglect Prevention

Child Abuse: Prevention

Programs Need Greater

Emphasis

(GAO/HRD-92-99, Aug. 3,

1992)

Child abuse prevention programs have been shown to be effective and

may pay for themselves by lowering the social costs resulting from child

abuse. However, federal child abuse prevention funding appears relatively

low compared with federal expenditures for assistance to abuse victims.

Prevention programs have difficulty meeting their funding needs because

grants are short term and come from multiple sources, which increases

programs’ administrative costs.

Child Abuse and Neglect:

Progress of the National

Center Since May 1991

(GAO/T-HRD-92-14, Mar. 6,

1992)

Since May 1991, the National Center on Child Abuse and Neglect has made

some progress in monitoring grant programs, managing the clearinghouse

and resource centers on child abuse data, and obtaining more staff and

expertise. Despite these encouraging signs, administrative effectiveness

may not improve because of the Center’s growing workload. The Center

continues to fall short in providing timely on-site monitoring, assessing its

technical assistance, and submitting required reports to the Congress. The

Center’s limited resources continue to hinder its goal of providing

leadership in preventing and treating child abuse and neglect.

Child Abuse and Neglect:

NCCAN’s Implementation

of CAPTA of 1988

(GAO/T-HRD-91-29, May 9,

1991)

Although the National Center on Child Abuse and Neglect addressed the

requirements of the Child Abuse Prevention and Treatment Act of 1988 to

varying degrees, staff and resource shortages hindered its grant

administration. Further, the Center’s implementation of the act does not

satisfy all of the requirements.

Child Abuse Prevention:

Status of the Challenge

Grant Program

(GAO/HRD-91-95, May 9,

1991)

By fiscal year 1989, 42 states had established child abuse prevention trust

funds with a median trust fund revenue of about $240,000. Although more

than $94 million in state funds were available for child abuse prevention

activities, only $40 million were considered for federal matching funds.

The total amount of federal funds spent on child abuse prevention was

unknown.

Page 32 GAO/HEHS-95-208 Foster Care Overview
Appendix V 

Recent GAO Reports and Testimonies on

Child Protection, Foster Care, Adoption, and

Related Topics

Foster Care

Child Welfare:

Opportunities to Further

Enhance Family

Preservation and Support

Activities

(GAO/HEHS-95-112,

June 15, 1995)

A crisis in the child welfare system has constrained states’ ability to meet

the service needs of our nation’s most vulnerable children and their

families. The family preservation and support provisions of the Omnibus

Budget Reconciliation Act of 1993 were enacted to help states provide

services designed to preserve families, especially those at risk of abusing

and neglecting their children, and prevent unnecessary foster care

placements. While activities implementing the law during its first 18

months appear to be on target, opportunities exist for HHS to further

enhance state efforts to develop a viable plan and monitor results.

Foster Care: Health Needs

of Many Young Children

Unknown and Unmet

(GAO/HEHS-95-114,

May 26, 1995)

Important health-related needs, including routine medical examinations

and various specialized services, remained unmet for nearly one-third of

the young foster children in Los Angeles County, New York City, and

Philadelphia County. Additionally, most young foster children in the

locations reviewed were at high risk for the human immunodeficiency

virus (HIV) as a result of parental drug abuse. Yet, foster care agencies have

been slow to respond to one critical health need—HIV risk

assessment—which is the first step in identifying infected children so that

they can receive appropriate and timely health care. Few children in the

locations reviewed were tested for the virus. Furthermore, young children

in kinship care were less likely than those placed in traditional foster care

to receive needed health-related services.

Foster Care: Parental Drug

Abuse Has Alarming

Impact on Young Children

(GAO/HEHS-94-89, Apr. 4,

1994)

Compared with the 1986 population, the 1991 population of young foster

children in Los Angeles County, New York City, and Philadelphia County

were more likely to have drug-abusing parents and to be at risk for health

problems related to prenatal drug exposure. Seventy-eight percent of the

foster children in 1991 had at least one drug- or alcohol-abusing parent,

compared with 52 percent in 1986. Further, 62 percent of the foster

children had a higher risk for future health-related problems because of

prenatal drug exposure compared with 29 percent in 1986.

Page 33 GAO/HEHS-95-208 Foster Care Overview
Appendix V 

Recent GAO Reports and Testimonies on

Child Protection, Foster Care, Adoption, and

Related Topics

Residential Care: Some

High-Risk Youth Benefit,

But More Study Needed

(GAO/HEHS-94-56, Jan. 28,

1994)

Residential care appears to be a viable treatment option for some high-risk

youths. Residential care programs report benefits in school attendance

and in avoiding drug abuse and criminal activity. However, these programs

seldom conduct controlled or comparison studies to determine how

outcomes are linked to their treatment efforts, and few programs have

conducted studies to show what happened to participants more than 12

months after they left the programs.

Foster Care: Federal Policy

on Title IV-E Share of

Training (GAO/HRD-94-7,

Nov. 3, 1993)

Federal funds for foster care and foster care training are made available to

the states under title IV-E of the Social Security Act. Under current

procedures, states allocate foster care training costs between the IV-E

foster care program and other programs so that each program is charged

its proportionate share of training costs on the basis of benefits received.

Some state officials oppose the current HHS cost-sharing policy because it

limits IV-E reimbursement and the amount of foster care training they can

provide.

Foster Care: Services to

Prevent Out-of-Home

Placements Are Limited by

Funding Barriers

(GAO/HRD-93-76, June 29,

1993)

The existing federal system for financing child welfare programs offers

little incentive for states to provide services designed to keep families

together and avert the need for foster care; instead, states find it easier to

house a growing population in federally subsidized foster care. Various

funding barriers limit states’ ability to provide welfare services. Federal

funding for foster care is open ended, but funding for direct child welfare

services is limited. Further, state fiscal crises have limited funding for

preventing foster care placements and family reunification services.

Foster Care: State

Agencies Other Than Child

Welfare Can Access Title

IV-E Funds

(GAO/HRD-93-6, Feb. 9,

1993)

HHS has issued several policy statements clarifying eligibility requirements

for reimbursement for foster care placements. The Department has

reimbursed states for placements made by juvenile justice agencies since

1984. Of the states that responded to a 1991 survey, 21 claimed

reimbursement for placements by juvenile justice agencies, and 13 claimed

reimbursement for placements by mental health agencies.

Page 34 GAO/HEHS-95-208 Foster Care Overview
Appendix V 

Recent GAO Reports and Testimonies on

Child Protection, Foster Care, Adoption, and

Related Topics

Foster Care: Children’s

Experiences Linked to

Various Factors; Better

Data Needed

(GAO/HRD-91-64, Sept. 11,

1991)

We analyze data on length of stay in foster care and reentry for children

who entered or left foster care in six states and two localities. Of children

reunited with their families in 1986, up to 27 percent subsequently

reentered foster care. The median length of stay for children entering or

leaving care in 1986 in the states and localities reviewed varied from 8 to

19 months. Children whose initial stay in foster care was under a year,

however, were more likely to reenter foster care than those whose initial

stays were longer. Moreover, children placed in institutions in the states

reviewed generally stayed in foster care longer than those placed in foster

family homes.

Child Welfare: Monitoring

Out-of-State Placements

(GAO/HRD-91-107BR, Sept.

3, 1991)

Our review of 42 children from 15 states showed that placement agencies

complied with federal law regarding the frequency of case reviews.

Despite budgetary constraints, most placement agencies visit the children

to assess the children’s well-being and progress in the treatment program.

Respite Care: An Overview

of Federal, Selected State,

and Private Programs

(GAO/HRD-90-125, Sept. 6,

1990)

Respite care provides temporary child care relief to family members and

other caretakers of disabled children to prevent child abuse and neglect

and support family unity. Respite care services are funded through state

and local agencies, national organizations, and federal departments.

Funding patterns differ among states. The demand for respite care

services exceeds the available supply.

Foster Parents: Recruiting

and Preservice Training

Practices Need Evaluation

(GAO/HRD-89-86, Aug. 3,

1989)

The most effective recruiting strategies realistically portrayed foster care

difficulties, emphasized foster care’s temporary nature, and defined the

positive role of foster parents. Effective preservice training focused on

enabling foster parents to make informed decisions about foster children’s

needs, enabling social service agencies to assess foster parents’ suitability

for caring for foster children, and facilitated teamwork between social

service agencies and foster parents. States have performed limited formal

evaluations of their recruiting and preservice training practices, and few

have comprehensively evaluated the effectiveness of various

demonstration activities.

Page 35 GAO/HEHS-95-208 Foster Care Overview
Appendix V 

Recent GAO Reports and Testimonies on

Child Protection, Foster Care, Adoption, and

Related Topics

Other

Adoption: Assistance

Provided by Selected

Employers to Adopting

Parents

(GAO/HRD-90-47FS,

Dec. 19, 1989)

Fifty-six of 77 employers in our review financially assisted employees

adopting children and commonly imposed a dollar limit on the amount of

assistance. All 77 employers allowed adopting parents to use some form of

unpaid or paid leave, but few employers provided adoption or parental

leave benefits.

Child Welfare: HHS Begins

to Assume Leadership to

Implement National and

State Systems

(GAO/AIMD-94-37, June 8,

1994)

HHS’ initiatives to address information system implementation problems

include issuing final regulations and functional system requirements,

working with the states to develop a draft system model for other states to

follow in developing their systems, and hiring a contractor to help states

develop their systems.

Families on Welfare: Sharp

Rise in Never-Married

Women Reflects Societal

Trend (GAO/HEHS-94-92,

May 31, 1994)

From 1976 to 1992, the proportion of single women receiving Aid to

Families With Dependent Children (AFDC) who had never been married

more than doubled, increasing from about 21 percent to about 52 percent.

This change paralleled a broader societal trend among all single mothers.

Single women receiving AFDC in 1992 were better educated, had fewer

children, and worked as much as their counterparts in 1976, but were

twice as likely to have incomes below the poverty level.

Families on Welfare:

Teenage Mothers Least

Likely to Become

Self-Sufficient

(GAO/HEHS-94-115,

May 31, 1994)

Women who gave birth as teenagers make up nearly half of the AFDC

caseload—a sizeable group. Women who had their first child when they

were teenagers may have the most difficulty earning their way off welfare

and becoming self-sufficient.

Page 36 GAO/HEHS-95-208 Foster Care Overview
Appendix V 

Recent GAO Reports and Testimonies on

Child Protection, Foster Care, Adoption, and

Related Topics

Integrating Human

Services: Linking At-Risk

Families With Services

More Successful Than

System Reform Efforts

(GAO/HRD-92-108, Sept. 24,

1992)

Broad-based and ambitious system-oriented efforts have faced many

obstacles and met with limited success. For example, programs and

initiatives we visited were unable to create new organizational structures

or develop multiagency service plans and budgets. In contrast,

service-oriented efforts were able to link at-risk families to human services

and provide a combination of health and other supportive services.

ADMS Block Grant:

Women’s Set-Aside Does

Not Assure Drug

Treatment for Pregnant

Women (GAO/HRD-91-80,

May 6, 1991)

The Alcohol, Drug Abuse, and Mental Health Services women’s set-aside

increased almost 500 percent between fiscal years 1988 and 1990. Despite

that increase, the Congress lacked adequate information to determine

whether the set-aside effectively reduced treatment barriers and addressed

treatment needs since HHS did not clearly specify reporting requirements to

states. The women’s set-aside did not ensure that states provided

appropriate treatment services to women since the set-aside encouraged,

but did not require, states to fund specifically designed treatment.

Drug Abuse: The Crack

Cocaine Epidemic—Health

Consequences and

Treatment

(GAO/HRD-91-55FS,

Jan. 30, 1991)

Cocaine abusers had high rates of such mental disorders as depression,

schizophrenia, and antisocial personality disorder. Health professionals

associated crack use with the spread of acquired immunodeficiency

syndrome and other sexually transmitted diseases. No state-of-the-art

treatment method for crack abusers existed.

Drug-Exposed Infants: A

Generation at Risk

(GAO/HRD-90-138, June 28,

1990)

Estimates of the number of infants exposed to cocaine annually ranged

from 100,000 to 375,000. Drug-exposed infants were more likely than

unexposed infants to suffer from medical problems and, in some cases,

required costly medical care. Twelve hundred of the 4,000 drug-exposed

infants at 10 hospitals were placed in foster care, and the cost of 1 year of

foster care for those infants was about $7.2 million.

Children’s Issues: A

Decade of GAO Reports

and Recent Activities

(GAO/HRD-90-162, Sept. 21,

1990)

Pursuant to a congressional request, we provided an annotated

bibliography of our studies on children’s issues. We provided (1) an

annotated bibliography of 58 reports and testimonies published between

October 1988 and March 1990; (2) titles of reports issued between fiscal

years 1980 and 1988; (3) information on current assignments relating to

children and families, as of March 31, 1990; and (4) information on other

publications by our staff on child-related issues.

Page 37 GAO/HEHS-95-208 Foster Care Overview
Appendix VI 

GAO Contacts and Staff Acknowledgments

GAO Contacts Robert L. MacLafferty, Assistant Director, (415) 904-2123

Patricia L. Elston, Evaluator-in-Charge, (916) 974-3341

Susan E. Arnold, Senior Evaluator

Staff

Acknowledgments

In addition to those named above, the following individuals made

important contributions to this report. Inez Azcona, Kerry Dunn, Karen

Lyons, and Elizabeth Olivarez provided information in their areas of

expertise. Jon Silverman assisted in writing the report.

(105823) Page 38 GAO/HEHS-95-208 Foster Care Overview
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