CHILD WELFARE

States Use Flexible 

Federal Funds, But 

Struggle to Meet 

Service Needs

Report to Congressional Committees

January 2013

GAO-13-170

United States Government Accountability Office

GAO
 United States Government Accountability Office 

Highlights of GAO-13-170, a report to 

Congressional Committees 

January 2013 

CHILD WELFARE

States Use Flexible Federal Funds, But Struggle to 

Meet Service Needs 

Why GAO Did This Study 

In fiscal year 2011, over 675,000 

children were found to be victims of 

abuse or neglect. To help ensure that 

such children have safe and 

permanent homes, state and local child 

welfare agencies secure child welfare 

services, such as parenting classes 

and substance abuse treatment. Title 

IV-B of the Social Security Act is the 

primary source of federal funding 

designated for child welfare services 

that is available to states. In fiscal year 

2012, Congress appropriated $730 

million under Title IV-B. Although 

states augment these funds with state, 

local, and other federal funds, some 

children and families may not receive 

the services they need. Congress 

mandated that GAO provide 

information about the funding and 

provision of child welfare services. This 

report addresses: (1) how selected 

states use funds provided under Title 

IV-B, (2) what alternative sources of 

federal funding states use to fund child 

welfare services and other activities 

covered under Title IV-B, and (3) what 

services, if any, child welfare agencies 

have difficulty securing for children and 

their families. To answer these 

questions, GAO reviewed relevant 

laws, regulations, guidance, and 

reports; analyzed HHS expenditure 

data and program evaluations; and 

interviewed HHS officials, child welfare 

experts, and state and local child 

welfare officials in 4 states and 13 

localities selected to illustrate a variety 

of approaches to financing and 

delivering services. GAO also reviewed 

state fiscal year 2011 expenditure data 

from selected states and administered 

a data collection instrument to selected 

localities. 

What GAO Found 

The four states GAO selected used funds provided under Title IV-B of the Social 

Security Act for a variety of child welfare services and other activities, and had 

different strategies for spending these funds. For instance, in fiscal year 2011 

Virginia provided funding to all local child welfare agencies to spend on their own 

priorities, such as parenting classes. New Mexico targeted certain counties for 

services, such as intensive in-home services for families at risk of foster care. 

States nationwide also use other federal funds, such as Temporary Assistance 

for Needy Families (TANF) and Social Services Block Grant (SSBG) funds, as 

well as Medicaid, for purposes covered under Title IV-B. In the spring of 2011, 31 

states reported spending TANF funds, and in fiscal year 2010, 44 states reported 

spending SSBG funds on these purposes. Some states also claim federal 

Medicaid reimbursement for activities covered under Title IV-B. One selected 

state, Minnesota, claimed reimbursement for case management for children at 

risk of foster care placement in 2011. Funds authorized under Title IV-E of the 

Social Security Act make up the large majority of federal child welfare funds, but 

are designated for purposes such as providing room and board payments for 

children in foster care and subsidies to adoptive parents, and generally cannot be 

used for child welfare services. However, 14 states have waivers allowing them 

to use these funds more flexibly to improve child and family outcomes. Among 

GAO’s selected states, Florida had a waiver allowing it to use some Title IV-E 

funds for in-home services designed to prevent foster care placement. 

Many services, including substance abuse treatment and assistance with 

material needs, such as housing, are difficult for child welfare agencies to secure 

due to a variety of challenges. A 2008-2009 U.S. Department of Health and 

Human Services (HHS) survey that sampled children and families in the child 

welfare system found that many did not receive needed services. For example, 

an estimated 58 percent of children age 10 and under at risk of emotional, 

behavioral, or substance abuse problems had not received related services in the 

past year. Local child welfare officials in four selected states reported service 

gaps in multiple areas, as seen in Figure I. Service gaps may harm child wellbeing and make it more difficult to preserve or reunite families. For example, 

officials from one locality noted 2- to 3-month wait times for substance abuse 

services. Due to the chronic nature of the disease, delays in receiving services 

may make it more difficult to reunify families within mandated deadlines. Officials 

cited factors contributing to service gaps that included provider shortages and 

lack of transportation. Additionally, officials noted difficulty securing services from 

partner agencies, such as housing authorities. State fiscal constraints, which 

affect both child welfare and partner agencies, contribute to such difficulties. 

Figure I: Most Common Service Gaps Reported by 13 Selected Localities 

View GAO-13-170. For more information, 

contact Kay Brown at (202) 512-7215 or 

brownke@gao.gov. 
Page i GAO-13-170 Child Welfare 

Letter 1 

Background 4

Selected States Used Title IV-B Funds to Support a Wide Array of 

Services, and Strategies for Using These Funds Varied 12

Most States Rely on Flexible Federal Funding to Provide 

Additional Support for Child Welfare Services 14

Child Welfare Agencies Have Difficulty Securing Many Services 

Due to a Variety of Challenges 25

Concluding Observations 37

Agency Comments and Our Evaluation 38

Appendix I Comments from the Department of Health and 

Human Services 40

Appendix II GAO Contact and Staff Acknowledgments 44

Tables

Table 1: Common Types of Child Welfare Services 6

Table 2: Purposes and Selected Requirements of Title IV-B Subpart 

I Child Welfare Services and Subpart II Promoting Safe 

and Stable Families Programs 9

Table 3: Percent of Caregivers and Children with Selected Service 

Needs Who Reported They Had Not Received Related 

Services in the Past 12 Months: 2008-2009 26

Figures

Figure 1: Example of Types of Services and Providers a Child 

Welfare Agency May Secure to Meet the Needs of a 

Hypothetical Family 7

Figure 2: Federal Funding Used to Finance Services and Other 

Activities Covered under Title IV-B for Selected States, 

State Fiscal Year 2011 15

Figure 3: Active and Approved Title IV-E Waiver Demonstration 

Projects 22

Figure 4: Top Child Welfare Service Gaps Reported by 13 Selected 

Localities (3 Selections per Locality) 27

Contents 
Page ii GAO-13-170 Child Welfare 

Abbreviations

ACF Administration for Children and Families

CAPTA Child Abuse Prevention and Treatment Act

CBCAP Community-Based Child Abuse Prevention

CHIP Children’s Health Insurance Program

CMS Centers for Medicare and Medicaid Services

CWS Stephanie Tubbs Jones Child Welfare Services

HHS Department of Health and Human Services

HUD Department of Housing and Urban Development

NSCAW National Survey of Child and Adolescent Well-Being

PSSF Promoting Safe and Stable Families 

SAMHSA Substance Abuse and Mental Health Services 

Administration

SSBG Social Services Block Grant

TANF Temporary Assistance for Needy Families

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Page 1 GAO-13-170 Child Welfare 

United States Government Accountability Office 

Washington, DC 20548

January 30, 2013

The Honorable Max Baucus

Chairman

Committee on Finance

United States Senate

The Honorable Orrin G. Hatch

Ranking Member

Committee on Finance

United States Senate

The Honorable Dave Camp

Chairman

Committee on Ways and Means

House of Representatives

The Honorable Sander M. Levin

Ranking Member

Committee on Ways and Means

House of Representatives

In fiscal year 2011, states reported that over 675,000 children were 

victims of maltreatment, often abused or neglected by their parents. To 

help ensure that children affected by abuse and neglect have safe and 

permanent homes, the federal government provides states with funding to 

assist them in carrying out state and local child welfare programs.1

Funds provided under Title IV-B of the Social Security Act (Title IV-B) are 

the chief source of federal support explicitly targeted at child welfare 

Services designed to ensure that children live in safe and permanent 

homes, either with their parents or with other caregivers, are commonly 

referred to as child welfare services. Such services may include parenting 

classes, mental health counseling, and substance abuse treatment. In 

many cases, services aim to improve how a family functions so that 

children can remain safely at home or return home from foster care.

 

1

Federal funding is also provided to assist territories and tribes in carrying out their child 

welfare programs.

 
 

Page 2 GAO-13-170 Child Welfare 

services. In fiscal year 2012, Congress appropriated $730 million under 

Title IV-B. The Administration for Children and Families (ACF) within the 

U.S. Department of Health and Human Services (HHS) distributes Title 

IV-B funding to state child welfare agencies. In addition to Title IV-B 

funds, states may also use state, local, and other federal funds to support 

services to children and families. Some of these other federal funds are 

not specifically designated for child welfare, but states are allowed to use 

them to fund some services to children and families in the child welfare 

system. For instance, Social Services Block Grant (SSBG) goals include 

preventing or remedying child abuse; a wide variety of services, including 

parent education and training, may be supported with these funds. While 

other federal funding sources like SSBG may be used for purposes 

similar to those of Title IV-B, the service needs of children and families 

are complex, and agencies may face difficulty meeting them.

Congress mandated in the Child and Family Services Improvement and 

Innovation Act of 2011 (which extended funding authorization for Title IVB) that GAO explore issues related to federal funding sources for child 

welfare services and family service needs.2

To answer our research objectives, we reviewed relevant federal laws, 

regulations, and guidance, as well as past GAO reports related to child 

welfare funding and services. We used a survey of states funded by the 

Annie E. Casey Foundation and Casey Family Programs to identify 

sources of federal funding commonly used by child welfare agencies.

This report addresses: (1) 

how selected states use funds provided under Title IV-B, (2) what 

alternative sources of federal funding states use to fund child welfare 

services and other activities covered under Title IV-B, and (3) what 

services, if any, child welfare agencies have difficulty securing for children 

and their families.

3 As 

a result of this survey’s findings, we analyzed data from a federal 

Temporary Assistance for Needy Families (TANF) expenditure report and 

reviewed data from an SSBG expenditure report.4

 

2

Pub. L. No. 112-34, §102(f), 125 Stat. 369, 372 (2011).

We also reviewed data 

3

DeVooght et al., Federal, State, and Local Spending to Address Child Abuse and Neglect 

in SFYs 2008 and 2010 (Washington, D.C.: Annie E. Casey Foundation and Casey Family 

Programs, June 2012).

4

National data on child welfare agency expenditures of Medicaid funds—the other key 

source of federal funding cited in this report—were not available.
 

Page 3 GAO-13-170 Child Welfare 

on service needs and service receipt from ACF’s National Survey of Child 

and Adolescent Well-Being (NSCAW) and analyzed findings on the 

availability of services from an aggregate ACF report on its Child and 

Family Services Reviews.5

To complement information available from national data sources, we also 

conducted site visits to four states—Florida, Minnesota, New Mexico, and 

Virginia—and three to four localities within each state. We visited state 

and local agencies in Florida, New Mexico, and Virginia, and interviewed 

officials in Minnesota by phone. We chose our four states to reflect 

diversity in poverty levels and child welfare agency characteristics of 

interest, including state vs. local administration,

Further, we used data from a survey funded

by Casey Family Programs to describe waiting lists for various types of 

child welfare prevention services reported by states. We determined 

through interviews with knowledgeable officials and reviewing existing 

information about the data that the data sources cited above were 

sufficiently reliable for our purposes. Lastly, in response to our 

Congressional mandate, we reviewed academic studies that explored the 

impact of substance abuse treatment on family reunification outcomes.

6 use of differential 

response models,7

 

5

We used standard errors provided by HHS to calculate 95-percent confidence intervals 

for NSCAW statistics cited in this report.

and experimental child welfare funding and service 

delivery practices. Within each state, we selected localities based on 

criteria including urban/rural mix; tenure of local child welfare leadership; 

and community challenges, such as high substance abuse rates. Our 

selected state and local child welfare agencies serve as illustrations of 

state and local experiences; they are not representative of child welfare 

agencies nationwide. We reviewed select state and local needs 

assessments and other relevant documentation, and administered a data 

collection instrument to local officials about service needs and gaps. We 

also analyzed state fiscal year 2011 expenditure data for our four 

selected states. We interviewed knowledgeable officials about these data 

and compared the data with other relevant information, and determined 

6

States vary in how they fund and organize their child welfare programs. The majority of 

states administer their child welfare programs centrally, but some supervise child welfare 

programs that are administered by localities.

7

Differential response is a child protective service practice that generally involves two 

“tracks” or paths of response to reports of child abuse and neglect: traditional investigation 

for higher-risk cases and assessments or alternative responses for low- to moderate-risk 

cases. 
 

Page 4 GAO-13-170 Child Welfare 

them to be sufficiently reliable for our purposes. We used these data to 

identify expenditures of federal funds that appeared to be for purposes 

covered under Title IV-B. We excluded foster care maintenance 

payments and adoption subsidies from the scope of our review, because 

they are typically not covered under Title IV-B. Due to their similarity to 

foster care maintenance payments and adoption subsidies, we also 

excluded maintenance payments made to relative caregivers of children 

in foster care and subsidies to relatives who become legal guardians of 

children leaving foster care. We interviewed ACF officials and various 

child welfare experts who had published reports on topics relevant to our 

research questions. We also conducted a discussion group with officials 

from seven state child welfare agencies at ACF’s 18th National 

Conference on Child Abuse and Neglect. We assembled officials for the 

discussion group with the help of the American Public Human Services 

Association and the National Association of Social Workers.

We conducted this performance audit from January 2012 through January 

2013 in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a reasonable basis for 

our findings and conclusions based on our audit objectives. We believe 

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives.

In 2011, an estimated 6.2 million children were referred to child welfare 

agencies by sources including educators, law enforcement officials, and 

relatives because they were allegedly maltreated. After an initial 

screening process, agencies conducted abuse or neglect investigations 

and assessments on behalf of more than half of these children.8

 

8

In an assessment, otherwise known as an alternative response, the caseworker does not 

generally make a determination regarding whether the abuse or neglect allegation was 

founded. Instead, the caseworker assesses what the family’s needs are, and may offer 

services to address those needs.

Over 

675,000 children were found to be the victims of abuse or neglect. Many 

of the children (both victims and non-victims) who were referred to child 

welfare agencies, as well as their caregivers and families, received some 

child welfare services, such as in-home services and counseling or other 

Background
 

Page 5 GAO-13-170 Child Welfare 

mental health services.9 Child welfare agencies also conduct activities 

referred to in the report as non-service related. These non-service-related 

activities include investigating allegations of abuse or neglect (known as 

child protective investigations), providing case management for children 

at home or in foster care, training staff, and administering programs.10

Further, child welfare agencies make payments to caregivers of children 

in foster care (maintenance payments) and to adoptive parents of former 

foster children and other eligible children with special needs (adoption 

subsidies).11

Children referred to child welfare agencies as well as their families may 

need a variety of services. Families may need services to prevent child 

abuse or neglect, or to help stabilize the family if abuse or neglect has 

occurred so that the child can safely remain at home. If it is not in a child’s 

best interest to remain at home, the child may be placed in foster care. In 

these cases, services may be offered to help the family reunite. If 

reunification is not possible, services may be needed to encourage 

adoption and support adoptive families. Some common types of child 

welfare services are listed in table 1, below.

 

9

Child welfare services are generally defined in HHS regulations as public social services 

directed toward protecting and promoting the welfare of all children, preventing or 

remedying child neglect or abuse, and preventing the unnecessary separation of children 

from their families. Services also help ensure that children are adequately cared for away 

from their homes, safely restored to their families, and placed in suitable adoptive homes 

when returning them to their families is not possible. 45 C.F.R. § 1357.10(c).

10Case management involves assessing the needs of a client and client’s family, and 

arranging, monitoring, evaluating, and advocating for a package of services to meet those 

needs. 

11These payments may also be made on behalf of children with special needs who are 

eligible to receive Supplemental Security Income benefits.

Child Welfare Services
 

Page 6 GAO-13-170 Child Welfare 

Table 1: Common Types of Child Welfare Services

Service type Service description

Home visiting programs Typically involve trained personnel visiting parents and 

children in their homes to provide support and education in 

order to prevent child maltreatment.

In-home services May include intensive family preservation services when a 

child is at immediate risk of being removed from home, and 

longer-term family support services. These services may 

include teaching parents to prevent accidents and injuries by 

making the home environment safer and hazard free.

Parent education and 

training

Usually center-based and delivered in groups, aiming to 

prevent child maltreatment by improving child-rearing skills, 

increasing parental knowledge of child development, and 

encouraging positive child management strategies.

Respite care or crisis 

nurseries

For caregivers in stressful situations, respite care services 

provide temporary relief from the ongoing responsibilities of 

caring for children in the home. These services provide shortterm care to children who have disabilities or chronic or 

terminal illnesses, who are in danger of abuse or neglect, or 

who have experienced abuse or neglect.

Parent support May include parent mentor programs with stable, non-abusive 

families acting as “role models” and providing support to 

families in crisis, or parent support groups that help parents 

transform negative practices and beliefs into positive 

parenting behaviors and attitudes.

Material supports 

(including housing)

May include vouchers, subsidies, or other assistance to help 

families obtain child care, clothing, transportation, housing, 

employment or meet other material needs.

Counseling/ mental 

health services

Includes mental health services for children and families 

affected by maltreatment to improve family communication 

and functioning.

Substance abuse 

assessment and 

treatment

May include screening for substance abuse, Family 

Treatment Drug Courts, services for substance-exposed 

infants, and referrals or direct provision of substance abuse 

services. 

Domestic violence 

services 

May include assessment, safety planning or analysis of safety 

threats, legal or therapeutic interventions for perpetrators, 

and referrals to a domestic violence advocate or other 

needed services.

Source: Information provided to GAO by Child Trends.

Child welfare agencies secure services in a variety of ways. Child welfare 

agency staff may provide some services directly in addition to carrying out 

typical case management duties. Child welfare agencies may also rely on 

contractors, also called purchased service providers. Another way child 

welfare agencies secure services is by relying on partner agencies, such 

as behavioral health agencies and public housing authorities. These 
 

Page 7 GAO-13-170 Child Welfare 

agencies serve families in the child welfare system in addition to clients 

who are not in the child welfare system. Child welfare agencies also refer 

individuals for medical services. Medical services may be supported in a 

variety of ways, including through Medicaid or private health insurance.12

Figure 1: Example of Types of Services and Providers a Child Welfare Agency May Secure to Meet the Needs of a 

Hypothetical Family

Figure 1, below, is an example of how a child welfare agency might 

meet—using various providers and funding sources—a hypothetical 

family’s diverse service needs.

 

12Medicaid is a joint federal-state program that finances health care services for certain 

low-income individuals, nearly half of whom are children. 
 

Page 8 GAO-13-170 Child Welfare 

States are chiefly responsible for funding and administering child welfare 

programs. Most states administer their child welfare programs centrally. 

However, in some states, local agencies administer their own child 

welfare programs, with supervision from the state. To varying degrees, 

these agencies use a combination of state, local, and federal funds to 

support their programs. According to a survey of states funded by the 

Annie E. Casey Foundation and Casey Family Programs, in state fiscal 

year 2010, 46 percent of all child welfare expenditures were from federal 

sources, while 43 percent and 11 percent were from state and local 

funds, respectively.13 Among federal funds used for child welfare 

purposes, states use a combination of funding designated solely for child 

welfare purposes and other sources of funding with broader aims.

Title IV-B is the primary source of federal child welfare funding available 

for child welfare services, representing about 9 percent of dedicated 

federal child welfare appropriations ($730 million of $8 billion) in fiscal 

year 2012. In addition to child welfare services, Title IV-B funding may 

also be used for a variety of other activities, such as child protective 

investigations and case management. Child welfare agencies may spend 

Title IV-B funds on behalf of any child or family. They receive these funds

primarily though two formula grant programs: the Stephanie Tubbs Jones 

Child Welfare Services program (CWS) under Subpart I of Title IV-B, and 

the Promoting Safe and Stable Families child and family services 

program (PSSF) under Subpart II. About $281 million in CWS funds and 

$328 million in PSSF funds were provided to states, territories, and tribes 

in fiscal year 2012.14

 

13DeVooght et al., “Federal, State, and Local Spending.” 

The purposes of Title IV-B’s two main funding 

streams are similar, as seen in table 2, below, although CWS funds may 

be used for a broader array of activities. States may spend CWS funds on 

any service or activity that meets the program’s broad goals, which 

include protecting and promoting the welfare of all children. Ninety 

percent of PSSF funds must be spent within four required categories: 

14Congress appropriated an additional $121 million under Title IV-B for fiscal year 2012 for 

a variety of grants and initiatives. The total appropriation comprised $61 million for a 

variety of competitive grants (including initiatives that address parental substance abuse 

and expand activities that engage families in efforts to remedy abuse and neglect), $20 

million for formula grants to states to improve caseworker visits, $32 million for formula 

grants to improve the handling of child welfare cases in court, and $8 million for HHSconducted research.

State and Local Child 

Welfare Agencies

Federal Funds Dedicated 

to Child Welfare
 

Page 9 GAO-13-170 Child Welfare 

family support, family preservation, time-limited family reunification, and 

adoption promotion and support.

Table 2: Purposes and Selected Requirements of Title IV-B Subpart I Child Welfare Services and Subpart II Promoting Safe 

and Stable Families Programs

Program Purposes Requirements

Subpart I: Child Welfare 

Services Program

Protect and promote the welfare of all children

Prevent child abuse and neglect

Enable children to remain with or return to their 

families when it is safe and appropriate

Promote the safety, permanence, and well-being of 

children in foster care and adoptive families

Provide training, professional development, and 

support to ensure a well-qualified child welfare 

workforce 

States must ensure that all children in foster 

care receive case review and permanency 

planning.

States are limited in using funds for child care, 

foster care maintenance payments, and 

adoption assistance payments.

No more than 10 percent of expenditures may 

be used for administration.

Subpart II: Promoting Safe 

and Stable Families 

Program

Services intended to prevent maltreatment among atrisk families

Services intended to assure children’s safety within 

the home and preserve intact families in which 

children have been maltreated

Services intended to address problems of families 

whose children have been placed in foster care in a 

timely manner so reunification can occur

Services intended to provide adoptive families the 

supports necessary for them to make a lifetime 

commitment to children

States must spend at least 90 percent of funds 

on services that fall into four categories—family 

support, family preservation, time-limited family 

reunification, and adoption promotion and 

support—with approximately 20 percent of total 

expenditures in each category.

No more than 10 percent of expenditures may 

be used for administration.

Source: GAO analysis of Title IV-B of the Social Security Act and associated regulations and guidance

Note: States that spent CWS funds on child care, foster care maintenance payments, or adoption 

assistance payments in fiscal year 2005 may continue to do so, but may not exceed 2005 

expenditure amounts in these categories. 42 U.S.C. § 624(d). 

Funds authorized under Title IV-E of the Social Security Act make up the 

large majority of federal funding dedicated to child welfare, with funds 

chiefly available for specific foster care and adoption expenses, but not for 

services. Congress appropriated $7.1 billion under Title IV-E in fiscal year 

2012 (89 percent of federal child welfare appropriations), in general to 

partially reimburse states for expenditures on behalf of eligible children and 

youth who are in foster care, have left care for adoption or guardianship, or 
 

Page 10 GAO-13-170 Child Welfare 

are aging out of care without adoptive homes.15 Title IV-E funds may be 

used to reimburse states for a portion of room and board (maintenance) 

expenses for eligible children in foster care, and for the costs of subsidies 

to parents who adopt eligible children with special needs (adoption 

assistance). States participating in the Guardianship Assistance Program 

may also receive Title IV-E reimbursement for a portion of assistance 

payments provided to relatives who become guardians (known as kinship 

guardians) of eligible children in foster care.16

The funds provided under Title IV-E serve as an open-ended entitlement 

to support the costs of caring for eligible children in foster care. However, 

there is no similar entitlement to preventive services for children at risk of 

entering into foster care. Experts and policymakers have expressed 

concerns that the federal funding structure for child welfare encourages 

reliance on foster care and does not grant states flexibility to support 

services designed to reduce the need for foster care. However, Congress 

authorized HHS to waive certain Title IV-E funding restrictions so that 

states with approved demonstration projects may spend those funds 

States may also use Title IVE funds to support case planning for eligible children in foster care, and for 

administration and training costs associated with eligible foster children and 

children adopted out of foster care. Additionally, states may use Title IV-E 

funds available through the Chafee Foster Care Independence Program 

and Education and Training Vouchers to support youth who are 

transitioning out of foster care without a permanent home, youth who have 

been adopted out of foster care after age 16, and youth who have entered 

into kinship guardianships after age 16.

 

15In fiscal year 2010, roughly 44 percent of children in foster care received Title IV-E 

assistance, based on criteria including family income and placement with licensed foster 

care providers. The proportion of children in foster care receiving support under Title IV-E 

declined from 52 percent in fiscal year 2000. This reduction is due to factors including 

income eligibility standards, which have not changed since 1996, as well as reductions in 

the total number of children entering foster care and increased adoptions, which have 

contributed to declines in the overall population of children in foster care. 

16The Fostering Connections to Success and Increasing Adoptions Act of 2008 gave 

states the option to use federal Title IV-E funding—that was previously reserved for foster 

care and adoption services—to support relatives who become guardians under certain 

circumstances. Pub. L. No. 110-351, § 101(a), 122 Stat. 3949, 3950. To receive funding, 

the child must be Title IV-E eligible, the caregiver must be a licensed or approved foster 

parent, and the child must live with the caregiver for at least 6 months. In addition, 

reunification with the child’s birth parents and adoption by the relatives must be ruled out 

as permanency options. Through kinship guardianship, a relative assumes legal 

guardianship over a child or youth without the termination of that child’s parents’ rights. 
 

Page 11 GAO-13-170 Child Welfare 

more flexibly. In order to be granted a waiver, states must demonstrate 

that their projects are cost-neutral to the federal government, among 

other requirements. States must also conduct an evaluation (carried out 

by an independent contractor) of project success in improving child and 

family outcomes. HHS’ authority to issue these waivers lapsed in 2006

but was renewed by Congress in 2011.17

Congress also appropriated $189 million in fiscal year 2012 (2 percent of 

federal child welfare appropriations) under the Child Abuse Prevention 

and Treatment Act (CAPTA) and a variety of other programs and 

initiatives, much of which was not directed explicitly to child welfare 

agencies and could be available to partner agencies and communitybased organizations as well.18 These programs and initiatives included 

competitive grants for purposes including eliminating barriers to adoption 

and providing services to abandoned children.19

 

17Pub. L. No. 112-34, § 201, 125 Stat. 369, 378 (2011). 

18CAPTA appropriations (which totaled $94 million for fiscal year 2011) included $26 

million in formula grants provided to state child welfare agencies to help improve child 

protective service systems. However, other funds were not directed explicitly to child 

welfare agencies. Specifically, Congress appropriated $26 million in competitive grants 

under CAPTA for demonstration, research, or other activities to prevent or treat child 

maltreatment. It also appropriated $42 million in Community-Based Child Abuse 

Prevention (CBCAP) formula grants. CBCAP grants are awarded to state-appointed lead 

entities (including some state child welfare agencies) for community-based child abuse 

and neglect activities.

19Specifically, Congress appropriated $44 million in child welfare funds for states under 

the Children’s Justice Act and for organizations under the Victims of Child Abuse Act for 

grants generally related to improving the handling of child abuse and neglect cases. 

Congress also appropriated $39 million under the Adoption Opportunities Program for 

competitive grants to eliminate barriers to adoptions, and $12 million under the 

Abandoned Infants Assistance program for competitive grants to prevent child 

abandonment and to serve abandoned children.
 

Page 12 GAO-13-170 Child Welfare 

Officials from the four states we studied reported spending Title IV-B 

CWS funds in state fiscal year 2011 to support a variety of services and 

other activities, and they told us they largely spent PSSF funds for 

services in the program’s four required expenditure categories. With 

respect to CWS, Virginia used these funds for case management costs 

for children in foster care who were not eligible for Title IV-E funding. 

Florida allocated over two thirds of CWS funds for case management 

costs for children living at home, out of the home, or with adoptive 

families. Florida spent almost one third of CWS funds on children’s legal 

services, and limited funds on administration and training. Minnesota 

officials reported spending CWS funds on licensing staff, other state level 

expenses, quality assurance, and program administration. New Mexico 

largely spent CWS funds on foster care maintenance payments, which is 

permitted in limited circumstances. States report annually to ACF on how 

they plan to spend Title IV-B funds within specific categories. For fiscal 

year 2012, states nationwide planned to spend 32 percent of CWS funds 

on child protective investigations and related activities. Other common 

planned expenditure categories were family preservation services (18 

percent), family support services (13 percent), time-limited family 

reunification services (11 percent), and foster care maintenance 

payments (10 percent).20

Our four selected states had different strategies for managing PSSF 

expenditures, but state officials told us they largely spent PSSF funds on 

the four expenditure categories required under the program in state fiscal 

year 2011. (Nationally, states planned to spend 90 percent of PSSF funds 

within these categories for fiscal year 2012.21) Two states—Florida and 

Virginia—allowed local child welfare agencies to decide how to spend 

PSSF funding.22

 

20HHS, Annual Report to Congress on State Child Welfare Expenditures Reported on the 

CFS-101 (Washington, D.C.; December 2012).

Both of these states required recipient agencies to 

contribute local matching funds to the PSSF grants they received. Local 

officials in these states described using PSSF funds in these four 

categories to support a wide variety of services and other activities. 

Funded activities included home visiting programs, parenting classes, and 

21States reported spending 93 percent of PSSF funds in these categories for fiscal year 

2009. States are not required to report actual expenditures for the CWS program.

22Virginia managed adoption promotion and support services statewide, and allowed 

localities to develop their own family support, preservation, and reunification programs.

Selected States Used 

Title IV-B Funds to 

Support a Wide Array 

of Services, and 

Strategies for Using 

These Funds Varied
 

Page 13 GAO-13-170 Child Welfare 

material supports, such as emergency rent assistance. For instance, one 

Virginia locality reported spending PSSF family support funds for a home 

visiting program designed to reduce the risk of abuse and neglect by firsttime mothers, and a parenting academy for individuals ordered by the 

court to attend parenting classes and others found to have neglected or 

abused their children.

Minnesota distributed some PSSF funds to localities through competitive 

matching grants targeted at two service areas, and additional funds to all 

localities for differential response initiatives.23

New Mexico generally distributed PSSF funds to contracted communitybased service providers in targeted geographic areas. New Mexico 

issued family support contracts designed to increase placement stability 

for children living in foster and adoptive families in 18 counties, and to 

support children of incarcerated parents in 6 counties.

The first of these areas 

focused on family group decision-making practices designed to increase 

family involvement in decisions about their children’s care needs. The 

second of these areas focused on services to “screened out” families, or 

families who would not otherwise qualify for ongoing case management 

or services due to relatively low abuse or neglect risk levels. Some funds 

were also distributed to localities to support their differential response 

practices. Minnesota officials said the state began encouraging localities 

to implement differential response in the early 2000s, and PSSF funds 

played an integral role in these efforts. State officials said that because 

Minnesota localities administer and largely fund their own child welfare 

programs, they had to find creative ways to develop incentives for 

localities to adopt a differential response model. They decided to leverage 

PSSF funds along with funding from a private donor to initiate a 4-year 

pilot project that established differential response in 20 counties.

24

 

23These activities appeared to be in keeping with PSSF’s family support, preservation, 

and time-limited reunification expenditure categories. Minnesota did not spend PSSF 

funds on adoption promotion and support services. According to state officials, HHS did 

not require Minnesota to use PSSF funds for adoption services because it had substantial 

state funding dedicated to this purpose.

Officials said that 

placement stability was an area of weakness in New Mexico’s last Child 

and Family Service Review, and that the state worked with ACF to 

24New Mexico officials told us their next round of family support contracts would be 

targeted at services to birth families, but services would also be available to foster 

families.
 

Page 14 GAO-13-170 Child Welfare 

develop this strategy to improve its performance. The state’s family 

preservation contracts covered up to 4 months of intensive in-home 

services designed to prevent the need to remove children to foster care in 

families with high levels of safety and risk concerns in eight counties. In 

addition, time-limited family reunification contracts covered intensive 

services designed to enable families in 11 counties to reunite with 

children in foster care within 4 months of referral. New Mexico used PSSF 

adoption promotion and support funds statewide for activities including 

home studies, parent training, and a social networking site for adoptive 

parents.

Nationally, most states supplement Title IV-B funds with other federal 

funding that is not dedicated to child welfare, according to expenditure 

data states reported to ACF. States use widely varying approaches and 

make different choices about how to spend the federal dollars they 

receive due to a variety of competing demands. As seen in figure 2 

below, our selected states each used different combinations of federal 

funds not dedicated to child welfare to support services and other 

activities covered under Title IV-B in state fiscal year 2011. These funding 

sources were chiefly TANF, SSBG, and Medicaid. Officials in these states 

told us that they first used the most restrictive federal sources for 

activities that meet funding criteria and, after those costs were covered, 

they used more flexible sources to support services and other activities as 

needed.

Most States Rely on 

Flexible Federal 

Funding to Provide 

Additional Support 

for Child Welfare 

Services

States Use TANF, SSBG,

and Medicaid to Fund 

Services Also Covered by 

Title IV-B 
 

Page 15 GAO-13-170 Child Welfare 

Figure 2: Federal Funding Used to Finance Services and Other Activities Covered under Title IV-B for Selected States, State 

Fiscal Year 2011

Note: We did not make a legal determination regarding whether any expenditures in our selected 

states were allowable under Title IV-B. We excluded Title IV-E expenditures from the scope of our 

review for Minnesota, New Mexico, and Virginia. For Florida, which has a Title IV-E waiver, we 

excluded only Title IV-E expenditures on foster care maintenance payments and adoption subsidies. 

We also excluded Title IV-B expenditures on foster care maintenance payments in New Mexico, as 

these expenditures are only covered in limited circumstances. Minnesota reported calendar year 

2011 data on county expenditures and 2011 state fiscal year data on state expenditures. We 

combined these expenditures for our purposes. 

Most states across the country, including two of our selected states, 

chose to use TANF funding for child welfare services and other activities 

covered by Title IV-B. TANF is a federal block grant that supports four 

overarching goals, one of which is to provide assistance to needy families 

so that children can live in their homes or the homes of relatives.25

 

25The other three purposes of TANF are ending families’ dependence on government 

benefits by promoting job preparation, work, and marriage; preventing and reducing outof-wedlock pregnancies; and encouraging two-parent families. Since 1996, Congress has 

provided $16.5 billion a year in funds to states under TANF. States may spend TANF 

funds for both cash assistance to low-income families as well as a variety of other services 

that meet the purposes of TANF. In fiscal year 2011, states spent about 58 percent of 

federal TANF funds on such services. GAO, Temporary Assistance for Needy Families: 

More Accountability Needed to Reflect Breadth of Block Grant Services, 

Because TANF funds can be spent on essentially any service for eligible 

GAO-13-33 

(Washington, D.C.: December 6, 2012).
 

Page 16 GAO-13-170 Child Welfare 

families that aims to achieve one of the program’s four goals, it offers 

states flexible funding that can be used to support child welfare activities. 

According to national data reported by states to ACF, in the spring of 

2011, 31 states spent TANF funds, including state maintenance of effort 

funds,26 for purposes covered by Title IV-B.27 For fiscal year 2011, we 

estimate these expenditures to have been at least $1.5 billion.28

Moreover, nationally states reported spending these funds for a variety of 

purposes. For example, 16 states reported using TANF funds for in-home 

services, family preservation services, or both.29

 

26States are required to maintain a specified level of their own past spending on certain 

welfare programs, referred to as state maintenance of effort, to receive all of their TANF 

funds. 

Another 9 states 

reported using TANF for child protective investigations and related 

activities. Among the four states we studied, Virginia spent TANF funds 

on family support and family preservation programs. Florida used TANF 

for a number of different purposes including case management, child 

protective investigations, and a state-sponsored home visiting program.

New Mexico and Minnesota, in contrast, did not use TANF for child 

welfare. New Mexico officials said that their state had a relatively high 

27HHS, Engagement in Additional Work Activities and Expenditures for Other Benefits and 

Services, April-June 2011: A TANF Report to Congress (Washington, D.C.: February 13, 

2012). ACF’s TANF expenditure reporting form for states does not provide specific 

information on state spending for child welfare activities. Under the Claims Resolution Act 

of 2010, states were required to submit additional information to ACF on certain 

categories of TANF expenditures for March 2011 and April through June 2011, such as 

information on state spending for child welfare activities. The act only required these 

reports in 2011, and did not require ongoing reporting for following years. Pub. L.

No. 111-291. 124 Stat.3064, 3160.

28To create this estimate, we analyzed descriptions of child welfare expenditures reported 

under three categories included in HHS, A TANF Report to Congress—”other” child 

welfare payments, “other” child welfare services, and child welfare “authorized solely 

under prior law”—to determine which expenditures were for purposes covered under Title 

IV-B. We arrived at an annual estimate by multiplying expenditures for one quarter by four, 

which is an imperfect method because actual expenditures fluctuate across quarters. Our 

estimate is also imperfect because, due to reporting limitations, it may exclude some 

expenditures for purposes covered by Title IV-B. In particular, we excluded some state 

expenditures because they included both activities covered and not covered under Title 

IV-B. Additionally, some relevant expenditures may not have been captured by this report. 

Officials in one selected state, Virginia, told us they reported some child welfare 

expenditures under categories not covered by ACF’s April through June 2011 report. 

29We analyzed services and other activities states identified under the category “other” 

child welfare services in HHS, A TANF Report to Congress. States also reported child 

welfare expenditures in two other categories.
 

Page 17 GAO-13-170 Child Welfare 

poverty rate and spent most of its TANF funds on cash assistance.30

Most states, including all four of our selected states, also used SSBG 

funds for child welfare services and other activities. SSBG is a federal 

block grant under which states are provided funding to support a diverse 

set of policy goals.

As a 

result, New Mexico officials said they had few TANF funds available for 

other purposes—including child welfare.

31 These goals include preventing or remedying child 

abuse and neglect, preventing or reducing inappropriate institutional care, 

and achieving or maintaining self-sufficiency.32 In addition to their annual 

SSBG allotments, states are permitted to transfer up to 10 percent of their

TANF block grant to SSBG. According to ACF data, 44 states including 

the District of Columbia spent fiscal year 2010 SSBG funding (including 

TANF transfer funds) in three reporting categories covered by Title IV-B.33

(Fiscal year 2010 was the most recent year for which national SSBG 

expenditure data were available.) Specifically, 35 states reported 

spending $377 million for services to children in foster care and other 

related activities, which accounted for 13 percent of total SSBG 

expenditures. Covered activities included, but were not limited to, 

counseling, referral to services, case management, and recruiting foster 

parents. Thirty-nine states also reported using $290 million in SSBG 

funds (10 percent) for child protective investigations and related activities,

such as emergency shelter, initiating legal action (if needed), case 

management, and referral to service providers. Twenty-two states 

reported spending $31 million on adoption services and other activities, 

such as counseling, training, and recruiting adoptive parents.34

 

30New Mexico reported spending 80 percent of its federal TANF funds on cash assistance 

during fiscal year 2011. New Mexico did not transfer any TANF funds to SSBG in fiscal 

year 2011.

All four of 

31For fiscal year 2012, Congress appropriated $1.7 billion in SSBG funds. 

3242 U.S.C. § 1397.

33States may also report expenditures for child welfare purposes covered by Title IV-B in 

other SSBG reporting categories. For instance, 28 states reported spending $179 million 

in SSBG funds on prevention and intervention services for fiscal year 2010. However, this 

reporting category includes services designed to prevent both the abuse and neglect of 

vulnerable adults as well as children.

34State expenditures of TANF transfer funds in each of these three categories included

approximately: (1) $249 million for services to children in foster care; (2) $171 million for 

child protective investigations and related activities; and (3) $10 million for adoption 

services. 
 

Page 18 GAO-13-170 Child Welfare 

the states we selected to study used SSBG for services and other 

activities covered by Title IV-B. In state fiscal year 2011, New Mexico 

used SSBG for purposes including administrative costs associated with 

child protective investigations, foster care, and adoptions. In that same 

year, Florida spent SSBG funds on purposes including child protective 

investigations, child legal services, and the state’s hotline for reporting 

abuse and neglect.

Nationwide, some child welfare agencies also claimed federal Medicaid 

reimbursement for services they provide to Medicaid beneficiaries.35 The 

amount of federal Medicaid reimbursement claimed by child welfare 

agencies is unknown. Under the Medicaid targeted case management 

benefit, child welfare agencies can be reimbursed for case management 

activities designed to assist targeted beneficiaries in gaining access to 

needed medical, social, educational, and other services.36 One of our 

selected states, Minnesota, claimed $24 million in federal reimbursement 

for Medicaid targeted case management for children at risk of placement 

in foster care and their families in calendar year 2011.37 Another selected 

state, Virginia, reported claiming $1.9 million in federal Medicaid 

reimbursement for targeted case management activities related to 

children in foster care in state fiscal year 2011.38

 

35In order to qualify for Medicaid reimbursement, child welfare agencies must have a 

provider agreement with the state Medicaid agency.

Child welfare agencies 

36Covered beneficiaries are targeted primarily on the basis of shared characteristics, and 

may include children or adults with chronic mental illness or developmental disabilities. 

There are some circumstances when states are prohibited from claiming Medicaid 

reimbursement for child welfare activities under the targeted case management benefit. 

For instance, states may not cover certain case management activities for children in 

foster care, including arranging foster care placements and conducting home 

investigations. 42 U.S.C. § 1396n(g)(2), 42 CFR § 441.18(c). 

37Minnesota also had a targeted case management program for children with serious 

emotional disturbances, which included some children in the child welfare system. We 

excluded these expenditures from the scope of our review because the targeted group 

included children not in the child welfare system. 

38The Centers for Medicare & Medicaid Services (CMS) must approve amendments to 

state plans to reimburse and cover Medicaid targeted case management services. CMS 

officials said the agency had received state plan amendments from six states which were 

approved since 2009 to make changes to Medicaid targeted case management services. 

Changes included revising payment for foster care targeted case management (1 state), 

removing foster care targeted case management from the Medicaid state plan (3 states) 

and adding or revising coverage or payment to include at-risk children and not restricted to 

children in the custody of child welfare (2 states).
 

Page 19 GAO-13-170 Child Welfare 

may also obtain federal reimbursement for services they provide to 

Medicaid beneficiaries covered under home and community-based 

service waivers. Under these waivers, states may cover a wide range of 

services and other activities to allow targeted individuals, such as children 

with developmental disabilities or serious emotional disturbances who 

would otherwise require institutional care, to remain at home or live in a 

community setting. Among our selected states, Minnesota claimed $1.8 

million in federal reimbursement for services to children with disabilities 

under a home and community-based services waiver in calendar year 

2011. Child welfare agencies can also claim federal Medicaid 

reimbursement for administrative case management activities, including 

making Medicaid eligibility determinations.39 Two of our selected states—

Florida and New Mexico—claimed federal Medicaid reimbursement for 

administrative costs associated with case management activities. For 

example, Florida claimed $1.3 million in federal reimbursement for 

activities that included applying for Medicaid benefits and arranging 

appointments.40

Child welfare agencies nationwide also accessed other federal funding 

sources dedicated to child welfare to support services and other activities. 

These other dedicated federal funding sources included CAPTA and ACF 

discretionary grants. CAPTA funds can be used for a wide variety of 

purposes. For example, among our four selected states, New Mexico 

used a $136,000 CAPTA state grant for purposes including training, 

investigations, and case management in state fiscal year 2011. Florida 

spent about $1.4 million in CBCAP funds to support its chapter of a child 

abuse prevention organization, parent leadership and support groups, a 

child abuse prevention month campaign, and fatherhood initiatives.

Other government entities whose missions intersect with those of child 

welfare agencies may also use federal funds for purposes covered under 

Title IV-B for children and families they serve. These entities, such as 

behavioral health agencies, housing authorities, and the courts, typically 

serve a broader population than children and families affected by abuse 

 

39Child welfare agencies may only perform and receive Medicaid reimbursement for 

administrative case management activities if the agencies enter into interagency 

agreements with their state Medicaid agency.

40Less than 1 percent of Florida’s federal expenditures for purposes covered under Title 

IV-B were from Medicaid. These expenditures are not reflected in figure 2 above.
 

Page 20 GAO-13-170 Child Welfare 

or neglect. However, some serve children and families who are also in the 

child welfare system. These entities may access a variety of federal funds 

to benefit these children and families. For example:

• Behavioral health agencies that oversee home visiting programs may 

use Maternal, Infant, and Early Childhood Home Visiting Program 

funds to provide home visiting services to families at risk of abuse or 

neglect.41

• Housing authorities that participate in the U.S. Department of Housing 

and Urban Development’s (HUD’s) Family Unification Program may 

provide housing vouchers to families at risk of losing their children to 

foster care or who face difficulty achieving family reunification due to 

inadequate housing.

They may also access Substance Abuse Prevention and 

Treatment Block Grant funds for substance abuse treatment for 

individuals in the child welfare system, including pregnant women and 

women with dependent children.

42

• Courts receive Court Improvement Program formula grants to improve 

the handling of child abuse and neglect cases.

Although states are generally prohibited from funding services, such as 

parenting classes and substance abuse treatment, with Title IV-E funds, 

ACF has granted waivers permitting some states to do so. As of October 

2012, 14 states had implemented or were approved to initiate Title IV-E 

waiver demonstration projects that allow them to use those funds for 

services covered by Title IV-B.43

 

41The Maternal, Infant, and Early Childhood Home Visiting Program was authorized under 

the Patient Protection and Affordable Care Act. HHS announced $224 million in funding 

for this program in fiscal year 2011. 

These projects were designed to test new 

42These housing vouchers are awarded competitively by HUD. Vouchers are reserved for 

families for whom the lack of adequate housing is a primary factor in risk of foster care 

placement or delay in reunification after foster care placement, as well as for youth 

transitioning out of foster care without a permanent home. The Family Unification Program 

received a $15 million line item appropriation in both fiscal years 2010 and 2011, but not in 

fiscal year 2012.

43There were 15 demonstration projects in these states—6 were active and 9 were 

approved. Illinois had an active waiver that focused on substance abuse treatment to 

enable reunification of children in foster care with their parents as well as a waiver that 

was approved in 2012 to provide trauma-informed care to young children.

Some States Have Waivers 

that Permit Them to Use 

Title IV-E Funding for 

Services Covered under 

Title IV-B 
 

Page 21 GAO-13-170 Child Welfare 

financing and service delivery approaches that may result in lower foster 

care costs and increased available funding for new or expanded services. 

States with waivers are required to ensure that their Title IV-E expenditures 

under the waiver do not exceed what they would have spent without a 

waiver. These states would be solely responsible for covering additional 

costs incurred if the number of children in foster care, or costs of caring for 

such children, exceeded state estimates. States with active and recently 

approved waivers have used various methods to determine that their 

projects were cost neutral. First, states with flexible funding waivers agree 

to receive a capped (or fixed) amount of Title IV-E funding in exchange for 

flexibility to use those funds for an expanded array of services, similar to a 

block grant. In other states, the amount of funding received for children 

participating in the waiver project is determined by the average amount of 

funding received for children in a control group who are not receiving 

waiver services, ensuring that funding for the waiver group is comparable 

to what it would have been without the waiver.

The goals of each Title IV-E waiver project vary and include: (1) reducing 

the time children and youth spend in foster care and promoting successful 

transition to adulthood for older youth, (2) improving child and family 

outcomes, and (3) preventing child abuse and neglect, and the re-entry of 

children and youth into foster care. ACF encouraged states to develop 

projects that included evidence-based and evidence-informed practices to 

promote children’s social and emotional well-being and to collaborate with 

state Medicaid agencies when possible.44

 

44In a recent memo to states, ACF stated that evidence-based and evidence-informed 

practices are those that show measurable improvements or promising results in aspects of 

children’s well-being, such as decreasing emotional or behavioral symptoms and helping 

traumatized children and youth form and maintain healthy attachments. HHS, ACF, 

Information Memorandum: Promoting Social and Emotional Well-Being for Children and 

Youth Receiving Child Welfare Services (Washington, D.C.: April 17, 2012).

Approved waiver projects 

reflect these priorities in a variety of ways (see figure 3). For instance, 

Illinois plans to provide specialized training to parents and other 

caregivers of very young children in Cook County who exhibit effects of 

trauma, using a control- and treatment-group design. Wisconsin plans to 

implement post-reunification support services, including evidence-based 

therapies designed to address trauma (trauma-informed care), for families 

reunified after foster care.
 

Page 22 GAO-13-170 Child Welfare 

Figure 3: Active and Approved Title IV-E Waiver Demonstration Projects

a

For California, “other” includes case-specific, time-limited assistance with material needs. 

b

For Indiana, “other” includes case-specific, time-limited assistance with material needs. 

c

For Ohio, “other” includes case-specific, time-limited assistance with material needs. 

d

For Massachusetts, “other” includes congregate care reform. 

e

For Michigan, “other” includes case-specific, time-limited assistance with material needs. 

f

Pennsylvania has a goal of expanding implementation of its Title IV-E waiver to more counties based 

upon the state’s assessment of the readiness and capacity of each additional county. 

g

For Washington, “other” includes case-specific, time-limited assistance with material needs. 

h

Wisconsin plans to test their Title IV-E waiver during the first year in a single county before 

expanding implementation statewide. 
 

Page 23 GAO-13-170 Child Welfare 

Among the four states we studied, only Florida had an active Title IV-E 

demonstration waiver project. Florida’s waiver demonstration project was 

implemented in 2006 as part of a statewide reform effort that included 

transferring management of child welfare cases to community-based lead 

agencies that work with a network of purchased service providers after 

the state has concluded its initial child protective investigation. Florida’s 

demonstration waiver goals are to: (1) improve child and family outcomes, 

(2) expand the array of community-based services and increase the 

number of children eligible for services, and (3) reduce administrative 

costs related to service provision.45

State and local officials in Florida told us their waiver helped expand 

services aimed at preventing children from being placed in foster care. 

From state fiscal years 2005 to 2011, the number of children placed in 

out-of-home care decreased by 27 percent,46

Some officials in selected states without active waivers noted that 

additional Title IV-E funding flexibility would improve their ability to fund 

preventive and other non-foster care services. Virginia officials said that 

they had spent Title IV-E funds available for foster care placement costs 

(which are administrative in nature) on services to prevent children from 

being placed in foster care. However, HHS disallowed $28 million of 

as compared to an 18 

percent decrease nationwide. Officials from one local lead agency said 

that the waiver has allowed them to fund a greater variety of preventive 

services, particularly in-home services. These officials also said that 

waiver funds have helped them to shore up other areas with funding 

shortfalls, such as services to youth who are aging out of foster care 

without a permanent home. However, Florida’s waiver evaluation also 

showed that under the waiver, several key indicators of child well-being 

either remained unchanged or improved only slightly.

 

45Under waiver terms negotiated prior to the project’s implementation, Florida received a 3 

percent annual increase in its Title IV-E allocation. Florida negotiated these terms with 

ACF using analysis of historical trends in Title IV-E expenditures. Florida’s waiver 

authority was originally set to expire in October 2011. ACF has extended Florida’s waiver 

authority through March of 2013 under the same terms and conditions as the original 

waiver. Florida has applied for renewal of its waiver, and if the waiver is renewed, its Title 

IV-E allocation will be renegotiated. 

46Vargo et al., IV-E Waiver Demonstration Evaluation Final Evaluation Report SFY 11-12, 

a Title IV-E waiver evaluation submitted to the Florida Department of Children and 

Families, March 15, 2012.
 

Page 24 GAO-13-170 Child Welfare 

these placement expenditures.47 According to Virginia officials, Title IV-E 

funding restrictions such as these seem misaligned with federal policy 

principles and fail to create incentives for states to invest in services 

designed to prevent foster care placement. In New Mexico, a state official 

said that increased Title IV-E flexibility would allow them to expand 

investments in services that prevent foster care placement. At the same 

time, another state official said that Title IV-E funds were an important 

source of guaranteed support for children in foster care, and cautioned 

that New Mexico may have difficulty ensuring that adequate resources 

are devoted to those children if Title IV-E funds are used for different 

purposes. Some experts and policymakers have also suggested reforms 

to how child welfare services are funded and have put forth proposals that 

would change the way states can use Title IV-E funding. These proposals 

include instituting various mechanisms for allowing states to increase 

their focus on services that aim to keep families together while also 

preserving adequate funding for those children who must be placed in 

foster care.

 

47In 2006, GAO reported that Title IV-E administrative expenditures grew by $173 million 

between 2000 and 2004, largely due to increased foster care placement costs. According 

to this report, an ACF official reported that some states claimed placement costs for foster 

care candidates more aggressively than others. In 2005, HHS’s Office of Inspector 

General and ACF regional staff recommended large disallowances in costs claimed by 

Virginia for foster care candidates. Specifically, HHS denied $28 million of Virginia’s Title 

IV-E claims for 8 quarters in fiscal years 2003 through 2005 for absence of a methodology 

for allocating costs, charging unallowable activities, failure to demonstrate that the children 

were eligible, and other problems with documentation. GAO, Foster Care and Adoption 

Assistance: Federal Oversight Needed to Safeguard Funds and Ensure Consistent 

Support for States’ Administrative Costs, GAO-06-649 (Washington, D.C.: June 15, 2006). 
 

Page 25 GAO-13-170 Child Welfare 

Data from a national survey conducted by ACF indicate that not all 

children and families in the child welfare system receive the services they 

need. The survey included interviews with a sample of over 5,000 

children and caregivers with child protective investigations closed 

between February 2008 and April 2009. Many of these children and 

caregivers reported that they had not received services for which they 

had a demonstrated need in the 12 months prior to being interviewed.48

For instance, an estimated 91 percent of caregivers who needed 

substance abuse services had not received them (see table 3). 

Additionally, an estimated 58 percent of younger children and 48 percent 

of adolescents at risk for behavioral, emotional, or substance abuse 

problems had not received any behavioral health services during this 

same time period.49

 

48Service need was determined by a combination of objective measures, caseworker 

observations, and self-reported need. Standard errors used to calculate confidence 

intervals were provided by ACF and were not calculated by GAO. Additionally, because 

child and caregiver interviews took place about 4 months, on average, after the child 

welfare investigation had concluded, data on services received within the past 12 months 

may include services obtained prior to the family’s involvement with the child welfare 

system. 

49Past GAO work corroborates these findings. In a 2006 GAO survey of 50 state child 

welfare directors, most directors expressed dissatisfaction with the level of mental health 

and substance abuse services provided to parents and children and with the adequacy of 

transportation and housing services for parents. GAO, Child Welfare: Improving Social 

Service Program, Training, and Technical Assistance would Help Address Long-standing 

Service-Level and Workforce Challenges, GAO-07-75 (Washington, D.C.: Oct. 6, 2006).

Child Welfare 

Agencies Have 

Difficulty Securing 

Many Services Due to 

a Variety of 

Challenges

Gaps in Child Welfare 

Services Include 

Substance Abuse and 

Mental Health Services
 

Page 26 GAO-13-170 Child Welfare 

Table 3: Percent of Caregivers and Children with Selected Service Needs Who 

Reported They Had Not Received Related Services in the Past 12 Months: 2008-

2009

Service need

Percent of individuals not 

receiving needed service 

in past 12 months

95 percent 

confidence interval

Caregivers

Substance abuse services 91 88 – 95

Domestic violence services 88 84 – 92

Mental health services 48 43 – 53

Children

Individualized Family Service Plan 

or Individualized Education 

Program to address developmental 

problems in children 5 and under

87 82 – 92

Behavioral health services 

(1.5- to 10-year-olds)

58 50 – 65

Behavioral health services 

(11- to 17-year-olds)

48 40 – 56

Sources: H. Ringeisen et al., NSCAW II Baseline Report: Caregiver Health and Services, OPRE Report #2011-27d (Washington, 

D.C.: 2011). H. Ringeisen et al., NSCAW II Baseline Report: Children’s Services, OPRE Report#2011-27f. (Washington, D.C.: 2011)

ACF reviews of state child welfare systems also suggest that children and 

families may not receive the services they need. ACF’s most recent Child 

and Family Services Reviews, conducted from fiscal years 2007 to 2010, 

showed that 20 of 52 states did not have an appropriate range of services 

to adequately identify and address the needs of children and families.50

 

50The District of Columbia and Puerto Rico were treated as states for the purposes of 

these reviews.

ACF defined an appropriate range of services as those that help create a 

safe home environment and enable children to remain at home when 

reasonable, and help find other permanent homes for foster and adopted 

children. ACF officials told us that, while the reviews do not include formal 

data on the availability of specific services, their reports on individual 

states indicate that the most commonly unavailable services included: 

behavioral health services, including child psychologists and psychiatrists; 

substance abuse treatment for adults and youth; housing; and domestic 

violence services. In a survey funded by Casey Family Programs, 25 out 

of 41 of state child welfare agencies responding reported waiting lists for 
 

Page 27 GAO-13-170 Child Welfare 

at least one service provided by child welfare agencies or their purchased 

service providers.51

Officials from our 13 selected localities echoed these concerns. In 

response to a GAO data collection instrument, most of these localities 

reported key service gaps in the areas of substance abuse assessment 

and treatment services; assistance with material needs, such as housing 

and transportation; and in-home services (see figure 4).

(This survey did not ask states about the length of 

time a child or family remained on the waiting list before receiving 

services.) These services included in-home services, home visiting 

services, and substance abuse assessment and treatment. The absence 

of a waiting list, however, does not necessarily indicate that services are 

available. A service provider may not maintain a waiting list even if there 

are families waiting to be served.

Figure 4: Top Child Welfare Service Gaps Reported by 13 Selected Localities (3 

Selections per Locality)

Note: The “other” service gaps reported were inadequate public transportation infrastructure and lack 

of Medicaid-participating medical, dental, and behavioral health service providers. Respondents were 

asked to choose the top three service gaps in their area. Thus, localities may have also experienced 

service gaps in other areas not selected. Additionally, this data collection instrument did not ask local 

officials to identify gaps related to service quality. In particular, it did not ask whether available 

services incorporated evidence-based or evidence-informed practices. 

 

51The District of Columbia and Puerto Rico were treated as states for the purposes of this 

survey. K. DeVooght et al., The 2011 Casey Family Programs State Prevention Policy 

Survey: A Patchwork of Policies and Programs to Prevent Child Maltreatment. 

(Washington, D.C.: Casey Family Programs, June 2012).
 

Page 28 GAO-13-170 Child Welfare 

Service gaps can negatively affect outcomes for children and their 

families. Specifically, according to officials in our 13 selected localities, 

previous GAO work, and some research, service gaps can complicate 

efforts to prevent placement in foster care, hinder chances of reunification 

after foster care, and harm child well-being.

Officials in our selected localities reported that difficulty securing highquality, timely treatment for families with parental substance abuse 

problems can decrease the likelihood of recovery and reunification.52 In 6 

of 13 selected localities, officials reported waiting lists for substance 

abuse treatment services. Officials in one of these localities noted that 

clients often wait 2 to 3 months for these services.53

Some research corroborates the views of local officials that lack of access 

to timely, intensive treatment may negatively affect a family’s chances of 

reunification. A 2007 study of nearly 2,000 women in Oregon who were 

substance abusers and had children in foster care found that mothers 

were more likely to be reunited with their children if they entered 

treatment quickly and spent more time in treatment.

Further, officials in 

five localities said that available inpatient services were of poor quality or 

too short in duration to meet client needs. New Mexico officials told us 

their state’s behavioral health entity covered a maximum of 30 days of 

inpatient substance abuse treatment, which they said is insufficient for 

long-term addicts.

54

 

52HHS has estimated that between one- and two-thirds of children in the child welfare 

system have at least one parent with a substance abuse problem. See The Department of 

Health and Human Services, Blending Perspectives and Building Common Ground 

(Washington, D.C.: April 1999). In addition, researchers at Chapin Hall at the University of 

Chicago drew upon NSCAW data from 2000 to estimate that 61 percent of infants and 41 

percent of older children placed in foster care had at least one caregiver affected by 

substance abuse. See F. Wulczyn, M. Ernst, and P. Fisher, “Who Are the Infants in Outof-Home Care? An Epidemiological and Developmental Snapshot,” Chapin Hall Issue 

Brief (May 2011). 

Similarly, in 

California, a study of more than a thousand mothers who participated in a 

drug treatment program in 2000 found that mothers who completed or 

53Officials in six localities also reported wait times for counseling or mental health 

services. In five of these localities, officials reported that wait times were 2 to 3 months or 

longer.

54B.L. Green, A. Rockhill, and C. Furrer, “Does Substance Abuse Treatment Make a 

Difference for Child Welfare Case Outcomes? A Statewide Longitudinal Analysis.” 

Children and Youth Services Review, vol. 29 (2007).

Gaps in Services May Lead 

to Poorer Outcomes for 

Children and their Families
 

Page 29 GAO-13-170 Child Welfare 

spent at least 90 days in treatment were about twice as likely to reunify 

with their children as those who spent less time in treatment.55 GAO 

previously reported on family-centered residential drug treatment 

programs, which can last up to 24 months and may allow women to bring 

their children with them. These programs help women address issues 

underlying their substance abuse, build coping strategies, and enhance 

parenting skills, which can reduce chances that children will need to be 

removed to foster care. The Substance Abuse and Mental Health 

Services Administration (SAMHSA) evaluated performance data from 

residential treatment programs for mothers and found that 6 months after 

treatment ended, fewer children of participating women were living in 

foster care and most children who accompanied their mothers to 

treatment were still living with them.56

Officials in several of our selected localities also said it could be difficult 

for families experiencing substance abuse to achieve reunification within 

mandated deadlines.57 Delays in receiving treatment can make it difficult 

for treatment to be completed within these deadlines. In addition, a 

previous GAO report found that mandated reunification deadlines can 

conflict with the amount of time required to successfully address the 

needs of these families.58

 

55C.E. Grella et al., “Do Drug Treatment Services Predict Reunification Outcomes of 

Mothers and Their Children in Child Welfare?” Journal of Substance Abuse Treatment, 

vol. 36, no. 3 (2009).

One ACF official told us that timely access to 

high-quality, evidence-based treatment is essential to achieving 

reunification within mandated timelines. Officials in one selected locality 

said they frequently terminate parental rights due to parents’ inability to 

establish sobriety within limited time frames. However, officials in another 

locality reported that judges are sympathetic to substance-abusing 

56Although these findings suggest positive outcomes of such programs, the SAMHSA 

study was not designed to demonstrate that the treatment caused those effects. GAO, 

Child Welfare: More Information and Collaboration Could Promote Ties Between Foster 

Care Children and Their Incarcerated Parents, GAO-11-863 (Washington, D.C.: 

Sept. 26, 2011).

57Under Title IV-E, states must file a petition to terminate parental rights, with certain 

exceptions, when a child has been in foster care for 15 of the most recent 22 months, and 

some states begin this process after less than 15 months in foster care. 42 U.S.C. 

§ 675(5)(E).

58GAO-11-863. 
 

Page 30 GAO-13-170 Child Welfare 

parents’ efforts to engage in services, and frequently extend their 

permanency deadlines.59

According to past GAO work and officials in selected localities, lack of 

affordable housing may also contribute to children’s removal into foster 

care or may prevent families from reunifying. In 2007, GAO surveyed 48 

state child welfare directors about African American children in foster 

care. Officials from 25 states cited a lack of affordable housing options as 

one factor that contributed to disproportionately high rates of foster care 

placement among African American children in the child welfare system. 

This report found that affordable public housing is a critical support that 

can help low-income families stay together.60 Similarly, officials in 3 of our 

13 selected localities told us that a parent’s inability to obtain housing 

could prevent family reunification even if all other reunification criteria had 

been met.61

GAO previously reported that failure to provide services to address the 

trauma of abuse or neglect may negatively affect children’s well-being in 

both the short and long term. GAO reported that children may experience 

traumatic stress as a result of maltreatment, which significantly increases 

their risk of mental health problems, difficulties with social relationships 

and behavior, physical illness, and poor school performance. Early 

detection and treatment of childhood mental health conditions can 

improve children’s symptoms and reduce the likelihood of negative future 

outcomes, such as dropping out of school or becoming involved in the 

juvenile justice system.

However, officials in one locality said they work with families 

to find them appropriate housing and would not keep a child from his or 

her parents based solely on the family’s housing situation.

62

 

59Similarly, in 2002 GAO found that judges in some states would not necessarily pursue 

terminating parental rights within these timeframes if a parent was engaged in substance 

abuse treatment and making progress toward reunification. GAO, Foster Care: Recent 

Legislation Helps States Focus on Finding Permanent Homes for Children, but LongStanding Barriers Remain, 

ACF has also made the social and emotional 

GAO-02-585 (Washington, D.C.: June 28, 2002).

60GAO, African American Children in Foster Care: Additional HHS Assistance Needed to 

Help States Reduce the Proportion in Care, GAO-07-816 (Washington, D.C.: July 11, 

2007). 

61An ACF official said that a review of the agency’s Child and Family Services Reviews 

indicated that stakeholders in some localities reported Section 8 waiting lists were a 

barrier to reunification. However, those barriers were not the main reason for state 

noncompliance with child welfare standards.

62GAO-13-15. 
 

Page 31 GAO-13-170 Child Welfare 

well-being of children receiving child welfare services an agency priority, 

and is encouraging child welfare agencies to focus on improving 

behavioral and social-emotional outcomes for the children they serve.63

Officials from 8 of our 13 selected localities reported a shortage of 

substance abuse treatment providers. Some officials cited a shortage of 

treatment in general, while others discussed shortages of specific kinds of 

treatment. For instance, officials from six localities reported an inadequate 

number of inpatient treatment providers. Officials from two selected 

localities also reported particular difficulty finding providers that offered 

appropriate substance abuse treatment services for adolescents. In one 

Virginia locality with extremely high rates of substance abuse, officials 

said that in order to address this shortage, their local behavioral health

agency had hired a counselor dedicated to treating youth with substance 

abuse problems. However, this counselor served five counties and had 

difficulty keeping up with demand.

Officials from nine selected localities as well as three state officials from 

our discussion group reported a shortage of mental health service 

providers. Officials from six localities and three state officials from our 

discussion group also noted shortages of certain types of specialists. For 

example, officials from multiple localities in three out of four selected 

 

63ACF, Information Memorandum: Promoting Social and Emotional Well-Being. 

In Our Selected Localities, 

Service Gaps Were Caused 

by Factors Including 

Provider Shortages and 

Challenges Accessing 

Services of Partner 

Agencies

Provider Shortages
 

Page 32 GAO-13-170 Child Welfare 

states reported acute shortages of child psychiatrists.64

Officials in several localities across three states and from one state in our 

discussion group reported a shortage of mental health, substance abuse, 

and/or other service providers who accept Medicaid. GAO has previously 

reported on this issue. In a recent survey of states, GAO found that 17 

states reported challenges ensuring enough mental health and substance 

abuse providers for Medicaid beneficiaries.

One state official 

who participated in our discussion group also reported particular difficulty 

finding mental health providers who offered evidence-based therapies 

specifically designed to address trauma in children. Officials in one 

Florida locality said that service providers in their community were 

interested in becoming trained in certain evidence-based practices, but 

found it too costly to do so. To address mental health provider shortages, 

Minnesota’s Department of Human Services contracted with the Mayo 

Clinic to provide phone-based psychiatric consultation services to primary 

care doctors across the state. Officials said the initiative would improve 

the quality of psychiatric care for children, including children in the child 

welfare system.

65 Additionally, GAO found in 

2011 that more than three times as many primary care physicians 

reported difficulty referring children enrolled in Medicaid or the Children’s 

Health Insurance Program (CHIP) to specialists as compared with 

privately-insured children.66

 

64GAO recently reported that mental health specialists, such as child psychiatrists and 

psychologists, were the among most difficult specialist referrals to obtain for children. 

GAO, Medicaid and CHIP: Most Physicians Serve Covered Children but Have Difficulty 

Referring Them for Specialty Care, GAO-11-624 (Washington, DC: June 30, 2011). 

Additionally, the Institute of Medicine has reported that a shortage of mental health 

providers is a major factor affecting access to services, especially for children. Institute of 

Medicine of the National Academies, Committee on Crossing the Quality Chasm: 

Adaptation to Mental Health and Addictive Disorders, Improving the Quality of Health Care 

for Mental and Substance-Use Conditions: Quality Chasm Series (Washington, 

D.C.: 2006).

65GAO, Medicaid: States Made Multiple Program Changes and Beneficiaries Generally 

Reported Access Comparable to Private Insurance, GAO-13-55 (Washington, D.C.: 

Nov. 15, 2012).

66CHIP provides federal matching funds to states to provide health coverage to children in 

low-income families whose incomes exceed the eligibility requirements for Medicaid. 

These physicians reported that referrals to mental health specialists were among the most 

difficult to obtain for both children enrolled in Medicaid or CHIP and privately-insured 

children. GAO-11-624. 
 

Page 33 GAO-13-170 Child Welfare 

Finally, provider shortages were cited as particularly challenging in rural 

areas. Officials in localities across all four selected states and two state 

officials from our discussion group reported provider shortages in rural 

areas. Officials from some rural localities described difficulty attracting 

and retaining service providers. A local Florida official said that one of his 

agency’s behavioral health purchased service providers had been 

advertising a child psychiatrist position for 5 years without success. In 

several localities, officials said provider shortages often result in families 

traveling long distances to receive services in more urban areas.

Inadequate health coverage among some children and families in the 

child welfare system also contributes to service gaps. In 6 of 13 localities, 

officials cited lack of health insurance as a factor contributing to difficulty 

securing medical services for families. Officials from selected localities 

reported that in some cases services were more difficult to obtain for 

parents than for their children, due to lack of health insurance.67

 

67Under federal law, states are currently required, at a minimum, to extend Medicaid 

eligibility to children up to 6 years of age in families with income at or below 133 percent of 

the federal poverty level. States also must cover children from 6 to 19 in families with 

income at or below 100 percent of the federal poverty level under Medicaid and must 

extend this coverage up to 133 percent of the federal poverty level no later than January 

2014. Under CHIP, states may cover children in families with higher income levels who 

are ineligible for Medicaid and do not have access to other insurance. For parents, 

however, mandatory coverage generally is more limited under Medicaid. States must, at a 

minimum, cover parents who meet the state’s 1996 Aid to Families with Dependent 

Children eligibility criteria. In addition, some states have expanded eligibility to cover 

additional parents through other eligibility paths available in the Medicaid program. 

In 

addition, undocumented immigrants are not eligible for Medicaid and may 

lack private health insurance as well. Officials in several localities 

described particular difficulty obtaining services for these families. There 

are, however, a variety of approaches local officials reported using in 

order to obtain services for families. In some cases, agencies were able 

to turn to behavioral health agencies. And in one locality, officials said a 

local non-profit sometimes funded mental health assessments for clients 

without insurance. In other cases, officials said their agencies paid for 

these services with their own funds. Additionally, fewer parents in the 

child welfare system may lack health insurance after January 1, 2014, 

when states may expand eligibility for Medicaid coverage to non-elderly 

non-pregnant adults with incomes at or below 133 percent of the federal 

Lack of Health Insurance
 

Page 34 GAO-13-170 Child Welfare 

poverty level, as provided for under the Patient Protection and Affordable 

Care Act.68

Lack of transportation is also a widespread impediment to obtaining 

services, especially in rural areas. Officials in all selected agencies that 

served rural areas reported difficulty with transportation for rural clients, 

and discussion group participants from two additional states reported 

similar difficulties. A number of local officials said that providing services 

in the home could help mitigate transportation challenges, as well as 

allow providers to better assess and address challenges in the home 

environment. Some officials noted that in-home services are typically 

more expensive than office-based services. However, officials in one 

Florida locality reported that they had made in-home services a budgetary 

priority due to transportation challenges in their area.

While state child welfare agencies receive reimbursement under Title IVE for many costs related to children in foster care, funding for services 

designed to prevent the need to remove children from their homes and 

place them in foster care is more limited. State and local child welfare 

agencies may face difficult decisions when determining which of these 

prevention activities to prioritize and fund, particularly in light of the 

ongoing fiscal challenges states face. For instance, local officials in New 

Mexico described challenges in securing resources to provide services to 

children and families at risk of foster care placement. New Mexico state 

officials told us they contracted for services designed to avoid foster care 

placement or reunite families after foster care entirely with Title IV-B 

PSSF family preservation and reunification funds and did not allocate 

state or other federal funds to support these contracts. Because Title IV-B 

funds were limited, the state targeted services only to selected counties 

with the highest need. Officials in one New Mexico county said that most 

of their family preservation and reunification services were cut for fiscal 

year 2013, in part because they had been successful in reducing the 

number of children in foster care and were no longer considered a high 

need county.

 

68Pub. L. No. 111-148, § 2001, 124 Stat. 119, 271 (2010) (PPACA), as amended by the 

Health Care and Education Reconciliation Act, Pub. L. No. 111-152, 124 Stat. 1029 

(2010). PPACA also provides for a 5 percent income disregard when calculating modified 

adjusted gross income for determining Medicaid eligibility, which effectively increases this 

income level to 138 percent of the federal poverty level.

Inadequate Transportation

Limited Funding for Preventive 

Services 
 

Page 35 GAO-13-170 Child Welfare 

Fiscal challenges have also affected child welfare partner agencies. For 

example, one ACF official we interviewed noted that most states have 

experienced budget cuts in social services, which affect both child welfare 

and substance abuse services. In addition, officials from SAMHSA told us 

that since 2008, states have had more difficulty maintaining state funding 

of behavioral health services.

Many localities experienced gaps in services provided by partner 

agencies, in some cases due to the fiscal constraints of those agencies. 

For example:

• Officials in 7 of the 13 localities, as well as one state official from our 

discussion group, said that their local housing authorities had long 

waiting lists (in some cases up to 3 or 4 years) for Section 8 housing 

vouchers.69

• In a few localities, officials said that families with children in foster 

care could not obtain approval for public housing units until they had 

regained custody, which hindered efforts to reunite children with their 

families.

As a result, families referred to the housing authority often 

did not receive assistance.

70

• Officials in two localities in different states, as well as one state official 

from our discussion group, noted that their state Medicaid programs 

required diagnoses of mental health disorders to cover services, even 

for very young children (ages 0 to 3 years). Officials stated that these 

requirements could make obtaining needed services difficult in some 

cases, and could result in inappropriate diagnoses in other cases.

One ACF official said that, in response to GAO’s inquiry, 

the agency initiated discussions with HUD about improving outreach 

to local housing authorities about this issue.

71

 

69Section 8, also known as the housing choice voucher program, is the federal 

government’s major program for assisting very low-income families, the elderly, and the 

disabled to afford housing in the private market. Housing choice vouchers are 

administered locally by public housing agencies, which receive federal funds from HUD.

70HUD regulations stipulate that public housing authorities should include children who are 

temporarily away from the home because of placement in foster care when determining a 

family’s size for Section 8 housing purposes. 24 C.F.R. §§ 982.402(b)(4) and 945.303(e). 

71States may place appropriate limits on accessing services based on medical necessity 

or utilization control procedures. 42 C.F.R. § 440.230.

Challenges Accessing Services 

from Partner Agencies 
 

Page 36 GAO-13-170 Child Welfare 

However, in some cases, selected child welfare agencies coordinated 

with other service agencies to improve families’ access to services. For

example:

• Three selected localities had coordinated with their local housing 

authority to apply for a grant through the federal Family Unification 

Program, which sets aside housing vouchers for families in the child 

welfare system.

• Two selected localities had Family Dependency Treatment Courts, 

which coordinate court, treatment, and child welfare services for child 

welfare cases in which parental substance abuse is a primary factor.

• One Virginia locality collaborated with partner agencies to use funding 

provided under the American Reinvestment and Recovery Act for 

homelessness prevention and rapid re-housing to help families at risk 

of eviction.72

There are also other opportunities on the federal, state, and local level for 

child welfare and partner agencies to coordinate to improve service 

delivery for children and families in the child welfare system. For instance:

As these funds were about to expire, they worked with 

community partners to identify other sources of funding to allow this 

homelessness prevention program to continue.

• ACF awards regional partnership grants for projects designed to 

increase the well-being of, and improve the permanency outcomes 

for, children affected by substance abuse through interagency 

collaboration and program and service integration. In 2012, ACF 

awarded 17 new regional partnership grants and approved 2-year 

extensions for 8 of 53 grants awarded in 2007.

• In September 2012, ACF awarded five grants totaling $25 million for 

collaborative partnerships between child welfare agencies and 

housing/ shelter organizations. Grants were awarded to projects 

focused on improving safety, family functioning, and child well-being 

in families at risk of homelessness and child maltreatment.73

 

72Pub. L. No. 111-5, 123 Stat. 115, 221 (2009).

73Private foundations have committed to funding technical assistance and project 

evaluations.
 

Page 37 GAO-13-170 Child Welfare 

• Also in 2012, ACF awarded nine grants totaling almost $29 million 

over 5 years for projects to improve the social and emotional wellbeing of children and youth in the child welfare system. The purposes 

of these grants, which are in the form of cooperative agreements, 

include improving adoption outcomes through interagency 

collaboration and supporting child welfare agencies in assessing 

children’s mental and behavioral health needs.

• The Commissioner of ACF’s Administration on Children, Youth and 

Families told us the agency is encouraging states to collaborate with 

state Medicaid agencies to solve issues affecting families in the child 

welfare system, including barriers to accessing Medicaid-funded 

mental health services for infants. As an example, he said ACF’s most 

recent Title IV-E waiver announcement encouraged state child welfare 

agencies to submit proposals in conjunction with state Medicaid 

agencies. According to the Commissioner, six out of nine approved 

waiver proposals explicitly indicate a partnership with the state 

Medicaid agency.

• In fiscal year 2012, SAMHSA awarded 16 grants totaling almost $16 

million to implement systems of care (which involve collaboration 

across government and private agencies, providers, and families) for 

children and youth with serious emotional disturbances. According to 

agency officials, 14 grantees were coordinating with child welfare 

agencies to address service development, funding, and access to 

care for children and youth in the child welfare system and those at 

risk of abuse or neglect.

Child welfare agencies, like other state agencies, operate in an 

environment of ongoing fiscal constraint. They must make difficult choices 

about how to allocate their limited resources to support services critical to 

ensuring children’s safety and well-being. Despite their use of Title IV-B 

funding in combination with other federal dollars to supplement their state 

and local funds, these agencies continue to struggle to meet the complex 

needs of children not in foster care and their families. Given current state

and federal fiscal constraints, they will likely continue to struggle. The 

waivers HHS has granted to some states to use their Title IV-E funding 

more flexibly may provide useful information about the effects of shifting 

available resources from foster care costs to support services intended to 

reduce the need for foster care without increasing funding overall.

Concluding 

Observations
 

Page 38 GAO-13-170 Child Welfare 

We provided a draft of this report to the Secretary of Health and Human 

Services for review and comment. HHS indicated in its general 

comments, reproduced in appendix I, that it agreed with GAO’s finding

that gaps exist in services to address the effects of child maltreatment, 

and provided additional information about the agency’s emphasis on 

trauma-informed care and its efforts to encourage child welfare agencies 

to respond more effectively to trauma. The agency also agreed with 

GAO’s concluding observations that ongoing fiscal constraints contribute 

to challenges in meeting the needs of children and families, and offered 

two steps child welfare agencies could take to more effectively use 

available resources: (1) identify currently funded services that do not yield 

desired results and shift resources toward evidence-based programs and 

practices; and (2) use outcomes (specifically those related to child wellbeing), rather than services delivered, to measure program success. Our 

report did not address the effectiveness of specific services; however we 

agree that information about effective practices is an important tool that 

child welfare agencies can use to determine how best to allocate 

available funds. Additionally, our work has long shown that using 

outcomes is an important component of measuring program success.74

HHS also discussed the use of TANF funds for child welfare purposes in 

its comments, and noted that in addition to the services described in our 

report, TANF funds are spent on foster care maintenance payments and 

adoption subsidies, as well as relative foster care maintenance payments 

and guardianship subsidies. Because this report focuses on expenditures 

for services typically covered under Title IV-B, we did not include 

maintenance payments and adoption subsidies in the scope of our 

review. We have clarified that, due to the similarity among these payment 

types, we excluded relative maintenance payments and guardianship 

subsidies as well. HHS also noted that states may spend federal TANF 

funds on purposes authorized solely under prior law that do not meet a 

TANF purpose, and that many of these expenditures are for child welfare 

purposes. We have also clarified that our analysis includes these 

expenditures, as appropriate. Finally, HHS described planned revisions to 

its TANF expenditure reporting form to capture more detailed information 

about how states spend TANF funds on child welfare payments and 

services. We have not reviewed these plans; however, we recently 

 

74GAO, Agency Performance Plans: Examples of Practices That Can Improve Usefulness 

to Decisionmakers, GAO/GGD/AIMD-99-69 (Washington, D.C.: February 26, 1999).

Agency Comments

and Our Evaluation
 

Page 39 GAO-13-170 Child Welfare 

recommended that HHS develop a detailed plan and specific timelines to 

help monitor its progress in revising these TANF reporting categories.75

In addition to these general comments, HHS also provided us with 

technical comments that we incorporated, as appropriate.

We are sending copies of this report to relevant congressional 

committees, the Secretary of Health and Human Services, and other 

interested parties. In addition, this report will be available at no charge on 

GAO’s website at http://www.gao.gov. 

If you or your staffs have any questions about this report, please contact 

me at (202) 512-7215 or brownke@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this report. GAO staff that made key contributions to this 

report are listed in appendix II.

Kay E. Brown 

Director

Education, Workforce

and Income Security Issues

 

75GAO-13-33
Appendix I: Comments from the Department of 

Health and Human Services 

Page 40 GAO-13-170 Child Welfare 

Appendix I: Comments from the Department 

of Health and Human Services
Appendix I: Comments from the Department of 

Health and Human Services 

Page 41 GAO-13-170 Child Welfare 
Appendix I: Comments from the Department of 

Health and Human Services 

Page 42 GAO-13-170 Child Welfare 
Appendix I: Comments from the Department of 

Health and Human Services 

Page 43 GAO-13-170 Child Welfare 
Appendix II: GAO Contact and Staff 

Acknowledgments

Page 44 GAO-13-170 Child Welfare 

Kay E. Brown, (202) 512-7215 or brownke@gao.gov

In addition to the contact name above, the following staff members made 

key contributions to this report: Elizabeth Morrison, Assistant Director; 

Lauren Gilbertson; James Lloyd; Erin McLaughlin; Ellen Phelps Ranen; 

and Deborah Signer. Also contributing to this report were: Susan 

Anthony, Jeff Arkin, Carl Barden, James Bennett, Jessica Botsford, 

David Chrisinger, Kim Frankena, Ashley McCall, Phillip McIntyre, Jean 

McSween, Almeta Spencer, Hemi Tewarson, James Rebbe, and 

Carolyn L. Yocom.

Appendix II: GAO Contact and Staff 

Acknowledgments 

GAO Contact

Staff 

Acknowledgments

(131141)
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