United States General Accounting Office

GAO Report to the Ranking Minority Member,

Subcommittee on Human Resources,

Committee on Ways and Means, House

of Representatives

May 1995 FOSTER CARE

Health Needs of Many

Young Children Are

Unknown and Unmet

GAO/HEHS-95-114

GAO United States

General Accounting Office

Washington, D.C. 20548

Health, Education, and

Human Services Division

B-259319 

May 26, 1995

The Honorable Harold E. Ford

Ranking Minority Member

Subcommittee on Human Resources

Committee on Ways and Means

House of Representatives

Dear Mr. Ford:

Foster children are among the most vulnerable individuals in the welfare

population. As a group, they are sicker than homeless children and

children living in the poorest sections of inner cities. Of particular concern

is the health of young foster children since conditions left untreated during

the first 3 years of life can influence functioning into adulthood and

impede a child’s ability to become self-sufficient later in life. Yet, little

comprehensive information is available about the provision of

health-related services to meet the needs of young foster children.

Last year, we reported that the population of young foster children—those

36 months of age and younger—changed significantly between the late

1980s and the early 1990s.1

 The average monthly number of children in

foster care nationwide increased 53 percent, from 280,000 to 429,000,

during this period. The total foster care population in the three states

reviewed increased 66 percent between 1986 and 1991, while the number

of young foster children more than doubled—increasing by 110 percent. In

addition, we found that a greater proportion of young children entered the

system because of some form of neglect; came from families where at

least one of the parents was abusing drugs; had serious health-related

problems; and were at risk for future problems as a result of prenatal drug

exposure.

Understanding the ability of state child welfare agencies to meet the needs

of foster children is critical as policymakers consider restructuring federal

welfare policies and responsibilities. Federal monies are currently used to

assist states with the cost of foster care. Legislation being considered by

the 104th Congress would give the states even greater responsibility for

foster children through block grants.

1

We reported on young foster children in Los Angeles County, New York City, and Philadelphia

County. See Foster Care: Parental Drug Abuse Has Alarming Impact on Young Children

(GAO/HEHS-94-89, Apr. 4, 1994).

Page 1 GAO/HEHS-95-114 Services for Young Foster Children
B-259319 

Our earlier work responded to your request that we compare and contrast

the population sizes and distinctive characteristics of young foster

children between 1986 and 1991. This report responds to the remaining

issues in that request regarding the service needs of young foster children.

Specifically, this report provides information on (1) the health-related

services needed and received by young children in foster care, (2) the

relationship between the receipt of health-related services and foster care

placements with relatives versus placements with nonrelatives, and

(3) what responsible agencies are doing to ensure that these children are

receiving needed health-related services.

To develop this information we reviewed foster care programs in

California, New York, and Pennsylvania, the states with the largest average

monthly foster care populations in 1991. In addition, we analyzed random

samples of case files from Los Angeles County, New York City,2

 and

Philadelphia County from a combined population of 22,755 young foster

children. These locations cared for a substantial portion of each state’s

young foster children: 44 percent in California, 81 percent in New York,

and 29 percent in Pennsylvania. We analyzed electronic databases as

provided to us by state and county officials to select our samples and

determine the number of children placed with relatives and nonrelatives.

Our scope and methodology are discussed further in appendix I.

Results in Brief Our work indicates that a significant proportion of young foster children

did not receive critical health-related services in the three locations

reviewed—Los Angeles County, New York City, and Philadelphia County.

Despite state and county foster care agency regulations requiring

comprehensive routine health care,3

 an estimated 12 percent of young

foster children received no routine health care, 34 percent received no

immunizations, and 32 percent had at least some identified health needs

that were not met. Furthermore, an estimated 78 percent of young foster

children were at high risk for human immunodeficiency virus (HIV) as a

result of parental drug abuse, yet only an estimated 9 percent of young

foster children were tested for it. Early identification of HIV-infected

children begins with HIV risk assessment. Without early identification,

HIV-infected children with mild or no symptoms cannot receive the early

medical care that is known to be effective with young children.

2

New York City comprises five boroughs and is treated in the state database as a county. In this report,

we refer to it as a county.

3

County foster care regulations state the frequency for required, comprehensive medical examinations

for well children. We refer to this type of examination as comprehensive routine health care.

Page 2 GAO/HEHS-95-114 Services for Young Foster Children
B-259319 

We also found that young foster children placed with relatives received

fewer health-related services of all kinds than children placed with

nonrelative foster parents. Other research indicates that relative

caregivers often receive less monitoring and assistance from caseworkers.

For California and New York—the states where placement data were

available—the number of young children placed with relatives increased

by 379 percent between 1986 and 1991, while the number of young

children placed with nonrelative foster parents increased by 54 percent.

Consequently, because a larger number of foster children were placed

with relatives in 1991 than in 1986, substantially more children were

subjected to the lower likelihood of receiving services associated with

kinship care.

Local foster care agencies continue to grapple with designing programs to

meet the health-related service needs of children. In the locations

reviewed, agencies have revised health-related foster care regulations and

modified their programs in efforts to improve the delivery of health care to

foster children. Although the Department of Health and Human Services

(HHS) recently increased its technical assistance to states by contracting

for National Resource Centers,4

 none is designated to assist states with

health-related programs for foster children. Furthermore, while HHS audits

states for compliance with federally mandated safeguards for foster

children, these audits omit review of compliance with health-related

safeguards. Given the importance of health care during the first 3 years of

life, an improved response to the health needs of this vulnerable

population is vital.

Background Responsibility for providing care and services to foster children is shared

by federal, state, and county governments, with HHS having responsibility

for oversight of federal foster care programs. The Administration for

Children and Families (ACF) within HHS helps the states to develop plans

required under title IV-B of the Social Security Act; reviews and approves

those plans; conducts audits to certify states’ compliance with the

safeguards for foster children, thereby making states eligible for additional

federal funds; and allocates funds to states, among other duties.

The Social Security Act of 1935 was amended twice to include safeguards

for foster children. The Adoption Assistance and Child Welfare Act of 1980

(P.L. 96-272) added most of these safeguards—such as requirements that

4

The National Resource Centers assist HHS’ Administration for Children and Families staff in

responding to states’ questions and provide free technical assistance to states.

Page 3 GAO/HEHS-95-114 Services for Young Foster Children
B-259319 

the case file contain a plan for appropriate care and services, as

determined by state and local foster care policies; periodic court or

administrative reviews; and a reunification program to return children to

their parents. This act also authorized HHS to provide technical assistance

to aid states in developing programs to meet the requirements of the law.

Furthermore, the Omnibus Budget Reconciliation Act of 1989 (P.L.

101-239) added other safeguards to the Social Security Act, including a

requirement to maintain health records for foster children.

A combination of federal, state, and county funds may be used to provide

services to young foster children. States may participate in federal

programs authorized by the Social Security Act such as title IV-B, matching

grants for various child welfare services; title IV-E, an uncapped

entitlement for a portion of the maintenance of foster children who are

eligible under the Aid to Families With Dependent Children (AFDC)

program; title XIX, Medicaid, an entitlement for a portion of medical

services; or title XX, block grants for a wide array of social services for

children. In addition, the Education of the Handicapped Act, part H,

authorizes grants to states for early intervention programs for

handicapped infants and toddlers.

Except for federal title IV-E expenditures, data were unavailable to

estimate federal, state, and county expenditures for services for foster

children. In the last 10 years, federal title IV-E expenditures for the

administration and maintenance of AFDC-eligible foster children increased

from about $546 million in 1985 to an estimated $2.9 billion in 1995. When

foster children do not meet title IV-E eligibility for federal funding, states

must bear the full cost for maintaining these children. However, some

states pass at least a portion of these costs to their counties.

Page 4 GAO/HEHS-95-114 Services for Young Foster Children
B-259319 

Young Foster Children

in the Locations

Reviewed Did Not

Always Receive

Needed

Health-Related

Services

All young children need routine, comprehensive medical monitoring,

treatment for minor illnesses, and immunizations to grow up healthy. In

the three locations reviewed, state and county regulations require that

children in foster care receive periodic medical examinations and

treatment.5

 Research indicates that children at risk for serious health

problems as a result of prenatal drug exposure often need additional

assessments and specialized care. Child development experts generally

agree that health care is particularly important during the first 36 months

of life as language, motor, psychological, and social skills develop.

Conditions left untreated during the first 3 years of life can influence

functioning into adulthood.

Some young foster children in the locations we reviewed did not receive

even the most basic health service—required routine care. In addition,

many children had identified health-related needs that were not met,

including the need for specialized services. Foster care agencies refer

foster parents to community-based programs and practitioners, rather

than providing the services directly. Foster children in the locations

reviewed are eligible for Medicaid to cover the cost of these health-related

community-based services.

Routine Health Care May

Not Be Ensured

Despite state and county foster care regulations, comprehensive routine

health care for young foster children may not be ensured. Specifically, an

estimated 12 percent of the children received no routine health care, and

34 percent received no immunizations in the three locations reviewed.

Furthermore, case files at all three locations did not reflect the exact

nature or extent of what services were provided in many cases. Thus,

children we noted as having received routine medical care may have

received as little care as one visit with a physician for treatment of a minor

illness rather than comprehensive or ongoing medical care. (See table II.1

in app. II.)

While Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

services are one way to ensure that children receive comprehensive

medical examinations, only an estimated 1 percent of the young foster

children in the locations reviewed received EPSDT services. EPSDT services

are specific, comprehensive medical examinations and follow-up

5

Regulations include a requirement that children receive an initial examination when they enter foster

care. Los Angeles County and New York City require an examination within 30 days of entry into foster

care; Philadelphia County requires an examination within 60 days. Children who received a

comprehensive examination within 90 days before entering foster care are exempt from this

requirement.

Page 5 GAO/HEHS-95-114 Services for Young Foster Children
B-259319 

treatment that states must offer to Medicaid-eligible children. EPSDT

examinations can serve as an effective safeguard of a child’s overall health

and development and as a gateway to other health-related services. (See

table II.1 in app. II.)

Children with no known health problems were less likely to receive

routine care than children who were at risk for or had serious health

problems.6

 For the locations reviewed, an estimated 28 percent of the

children with no known serious health problems did not receive any

health-related services. By comparison, only 6 percent of children who

were at high risk for serious health problems because of prenatal drug

exposure and 2 percent of children with serious physical health problems

did not receive any health-related services. Without routine health care,

children with no known health problems are not monitored to identify and

treat health and developmental problems as they occur. (See table II.2 in

app. II.)

Specialized Health Needs

of Young Foster Children

Were Unmet

In addition to routine health care, young foster children need many

specialized health-related services. As we previously reported, an

estimated 58 percent of young foster children in the three locations

reviewed had serious physical health problems, and 62 percent were at

high risk for serious health problems as a result of prenatal drug exposure.

Many of these children may need health-related services and treatment

beyond those needed by the average child. (See fig. 1 and table II.3 in

app. II.)

6

Serious health problems of children in our review include fetal alcohol syndrome, low birth weight,

cardiac defects or heart problems, HIV or acquired immunodeficiency syndrome (AIDS), and

developmental delays.

Page 6 GAO/HEHS-95-114 Services for Young Foster Children
B-259319 

Figure 1: Specialized Services

Received in Three Counties Percentage of Children

0

10

20

30

40

50

Medicationsa

Testsb

Specialized Examinationsc

Hospitalizationsd

Specialized

Treatmentse

Early Intervention Servicesf

Services Received

aIncludes treatment for asthma, syphilis, seizures, and kidney problems.

bIncludes blood, laboratory, and radiology.

cIncludes developmental, psychological, and cardiological.

dIncludes care for HIV, pneumonia, and failure to thrive, as well as surgery.

eIncludes apnea monitors, infant stimulation, and speech therapy.

f

Includes therapeutic day care and Head Start services.

Source: Case file review.

Although young foster children received a wide variety of services from

health care providers, many children had identified health-related needs

that were not met. Based on information collected from case files, we

matched the health-related needs identified and the services received for

each child and estimated that one-third of the children in the locations

Page 7 GAO/HEHS-95-114 Services for Young Foster Children
B-259319 

reviewed had some identified needs that were not met.7 These unmet

needs included pulmonary and speech therapy; psychotherapy;

developmental assessments; infant stimulation services; cardiological,

urological, and neurological examinations; and testing for sickle cell

anemia, syphilis, and HIV. (See fig. 2 and table II.4 in app. II.)

Figure 2: Extent to Which Identified

Needs Were Met in Three Counties

32% • Children With at Least

Some Needs Not Met

48%•

Children With

All Needs Meta

•19%

Children With

No Needs Identifieda

Note: Point estimates do not total 100 percent because of rounding and records lacking data on

identified needs.

aThe point estimates for the three locations varied widely in these two categories.

Source: Case file review.

Of those children with no identified health-related needs, about one-half in

each location received no routine health care, and less than one-half

received a toxicology screen at birth to detect recent prenatal drug

exposure. Thus, many of these children may have had health-related needs

that were not identified and, consequently, were not met.

7

The number of identified needs per child ranged from 1 to 14 and averaged approximately 5.

Page 8 GAO/HEHS-95-114 Services for Young Foster Children
B-259319 

HIV-Infected Children

Need to Be Identified

Early, but Risk

Assessments Often

Did Not Take Place

One particularly critical health need of young foster children is HIV risk

assessment8

 because most young children in the locations reviewed are at

risk for the infection as a result of parental drug abuse. Without risk

assessment, a child’s HIV status may not be determined early because

HIV-infected children can remain asymptomatic or exhibit only minimal

signs of infection for years. Recent medical advances in early

identification and treatment can enhance and prolong the lives of these

children. Early identification is also critical because HIV-infected children

should receive modified immunizations to prevent adverse reactions, and

their exposure to infectious illnesses such as measles or chicken

pox—which are particularly hazardous to these children—should be

minimized.

While state laws, and the county policies based on them, do not prohibit

HIV testing or the disclosure of test results, some can hamper HIV testing

and disclosure. State laws and county foster care policies, where they

exist, vary widely. In some locations, including the three reviewed, these

laws and policies impede HIV testing and disclosure by specifying the risk

factors that must be present in order to request HIV testing; who has the

authority to consent to testing; and to whom HIV test results can be

disclosed. For example, for the 36 states with HIV testing policies as of

1992, one-half of the foster care agencies in the states with testing policies

may not have authority to consent to an HIV test for a child, even when the

child was identified by the agency as being at high risk for HIV.

The Number of

HIV-Infected Children Is

Largely Unknown as Few

Children Are Tested

Foster care agencies in the locations reviewed do not know the full extent

of their caseloads that is at high risk for HIV since no mechanism exists to

ensure that all young foster children are assessed for HIV risk. While two of

the three locations we reviewed currently have some HIV risk assessment

requirements, one location did not require risk assessments for all foster

children until recently, and the other has not implemented clear

assessment procedures. HIV risk has long been associated with intravenous

drug use, but more recent research has established an equally strong link

between HIV risk and the lifestyle of nonintravenous cocaine and crack

users. Using New York City’s current HIV risk factors, which include

nonintravenous drug use, we assessed our 1991 population of young foster

children on the basis of one risk factor, parental drug abuse. Accordingly,

we estimated that at least 78 percent of the children in the three locations

reviewed were at high risk for HIV.

8

An HIV risk assessment compares a child’s family history and health condition against the foster care

agency’s specified HIV risk factors to make an informed determination about whether a child should

be tested for HIV.

Page 9 GAO/HEHS-95-114 Services for Young Foster Children
B-259319 

We estimated that only 9 percent of the young foster children in the

locations reviewed were actually tested for HIV, despite the large

proportion at high risk and statistics indicating that these are locations

with a high incidence of HIV. The American Academy of Pediatrics Task

Force on Pediatric AIDS recommends HIV testing for all foster children with

high-risk factors or in areas with a high incidence of HIV to facilitate

appropriate medical treatment and follow-up. We estimated the HIV

infection rate for children born in 1993 and found that the three states

reviewed ranked 2nd, 14th, and 26th, based on national data from the

Centers for Disease Control and Prevention (CDC) on blind HIV testing of

newborns. (See table II.5 in app. II.)

Few data are available on the number of foster children infected with HIV.

One study reported that the number of foster children in New York City

known to be born to HIV-infected mothers increased 26 percent from 1991

to 1993. While data were not available for California and Pennsylvania,

1988 research found that Los Angeles had the fastest growing rate of AIDS

cases in the nation. Furthermore, anecdotal evidence suggests that in the

Los Angeles area, and the west coast in general, most AIDS in women is due

to heterosexual contact. However, according to experts on pediatric AIDS,

foster care agencies do not commonly recognize a history of high-risk

heterosexual contact as sufficient grounds for HIV testing.

Children Placed With

Relatives in Los

Angeles County and

New York City Were

Less Likely to Receive

Health-Related

Services

Young children placed exclusively with relatives—known as kinship

care—were less likely to receive health-related services than children

placed exclusively with nonrelatives—known as traditional foster care.9

Specifically, children placed in kinship care were nearly three times as

likely as those placed in traditional foster care to have received no routine

health care. Moreover, these children were less likely to receive

health-related services of all kinds. Since studies indicate that children in

kinship care remain in foster care longer, and they receive a lower level of

service, the likelihood is greater that these children will go without needed

services for longer periods. (See fig. 3 and table II.6 in app. II.)

9

We used only Los Angeles County and New York City data in our analysis of county case file data

regarding kinship and traditional foster care placements. Because the sample for Philadelphia County

contained only one child who was placed exclusively in kinship care, we eliminated that location from

this analysis.

Page 10 GAO/HEHS-95-114 Services for Young Foster Children
B-259319 

Figure 3: Services Received by

Placement Type in Los Angeles

County and New York City

Percentage of Children

0

10

20

30

40

50

60

70

80

90

100

Routine Care a

Immunizations 

b,c

Medications d

Tests e

Specialized

Examinations f

Hospitalizations 

c,g

Specialized

Treatments 

c,h

Early Intervention Services i

No Services Received c

Traditional Foster Carej

Kinship Carek

aConsists of varying amounts of medical practitioner care and/or EPSDT examinations.

bIncludes children who received at least one immunization and excludes children who were under

90 days of age.

cDifferences are statistically significant at the 90-percent confidence level.

dIncludes treatment for asthma, syphilis, seizures, and kidney problems.

eIncludes blood, laboratory, and radiology.

f

Includes developmental, psychological, and cardiological.

gIncludes care for HIV, pneumonia, and failure to thrive, as well as surgery.

hIncludes apnea monitors, infant stimulation, and speech therapy.

i

Includes therapeutic day care and Head Start services.

j

Consists of children placed exclusively in traditional foster care.

k

Consists of children placed exclusively in kinship care.

Page 11 GAO/HEHS-95-114 Services for Young Foster Children
B-259319 

Young children placed in kinship care in the two locations reviewed were

also an estimated three times more likely than those placed in traditional

foster care to be at risk for future problems because of prenatal drug

exposure.10 Furthermore, because drug-exposed children are more likely

to be at risk for HIV and developmental delays, the need for health-related

services for children in kinship care is even more critical. Yet, only

11 percent of children placed exclusively in kinship care received

specialized examinations, such as developmental evaluations; whereas,

42 percent of those placed exclusively in traditional foster care received

specialized examinations. (See table II.6 in app. II.)

While we did not determine why children in kinship care received less

health-related care, or compare other aspects of care by placement type,

we reviewed key studies on kinship care. Research found that foster care

agencies treat kinship care placements and traditional foster care

placements differently. Studies indicate that caseworkers generally

provide less monitoring and assistance to kinship care placements. Some

states have policies requiring less frequent caseworker visitations to

kinship care homes, although these homes are more likely to be

unlicensed. For example, a 1992 HHS study found that in 30 states, children

may be placed in kinship care homes whether or not the homes meet

minimum standards designed to ensure the safety and suitability of foster

homes and foster parents. Mandatory orientation and training for foster

parents are the most frequently waived licensing requirements for kinship

caregivers. A 1994 Child Welfare League of America report on kinship care

found few studies that focused on either kinship care providers or the

children in their care. These studies, which were limited in scope,

provided little information regarding the advantages of different types of

placement.

Kinship Care Increased

Dramatically

Analysis of the California and New York state databases showed the

number of children of all ages in kinship care increased by over

350 percent between 1986 and 1991, and this percentage increase was even

higher for young foster children, at 379 percent.11 (See fig. 4 and table II.7

in app. II.)

10This analysis excluded children who were at risk for serious health problems and also had serious

health conditions. When these children were included in the analysis, young children placed

exclusively in kinship care were about as likely as those placed exclusively in traditional foster care to

be at risk for future problems as a result of prenatal drug exposure.

11Pennsylvania does not have a statewide foster care database.

Page 12 GAO/HEHS-95-114 Services for Young Foster Children
B-259319 

Figure 4: Increase in Kinship and

Traditional Foster Care in California

and New York Between 1986 and 1991

Percentage Increase

0

50

100

150

200

250

300

350

400

All Children Young Children

Foster Care Population

Kinship Carea

Traditional Foster Care

Note: Counts represent all children in foster care at the end of the calendar years.

aPart of the increase in kinship care placements is due to a lawsuit filed in the New York Supreme

Court, Eugene F. v. Gross, which sought to require New York City to follow regulations to formally

include children who are placed with relatives in the foster care caseload and make them eligible

for services.

Source: State electronic databases.

The dramatic increase of children in kinship care between 1986 and 1991

resulted in nearly equal numbers of placements in kinship and traditional

foster care in the three counties reviewed. We estimated that 49 percent of

the young children had been placed in kinship care at some time during

the 1991 review period, while 53 percent had been placed in traditional

foster care. (See table II.8 in app. II.)

Some studies contend that the increase in kinship placements may have

been due, at least initially, to a shortage of traditional foster homes. Other

Page 13 GAO/HEHS-95-114 Services for Young Foster Children
B-259319 

studies posit that this increase may be the result of state and county

interpretations of the Adoption Assistance and Child Welfare Act of 1980

as implying a preference for relative placements. In recognizing that foster

care would continue to be a necessary child welfare service, this act

required states to place children in the “least restrictive (most family-like)

setting available,” which has been interpreted by many states as implying a

preference for kinship care. As of 1992, 44 states commonly placed foster

children in kinship care, and 29 states had policies in place requiring foster

care agencies to give preference to relatives of foster children.

Health-Related Needs

of Foster Children

Often Go Unmet

Despite Agency

Efforts

The foster care agencies reviewed struggle to ensure that the

health-related needs of children in their care are met. About one-third of

all states, including the three reviewed, have established only broad

guidelines within which counties administer foster care programs. Thus,

counties in these states develop and implement programs with

considerable autonomy, which results in a variety of approaches being

used.

County foster care agencies in the locations reviewed have altered their

health-related policies, regulations, and programs in efforts to improve the

agencies’ ability to meet the health needs of foster children. For example,

one of the foster care agencies we reviewed continues to develop and

implement recordkeeping systems in an attempt to improve its ability to

ensure that foster children receive needed services. The agency is

currently implementing its third variation of a medical recordkeeping

system in recent years. Implementation of the first two versions was

unsuccessful, and the third was too recently implemented for us to

determine its success. However, because the third version is substantially

similar to its predecessors, its likelihood of success is limited.

Other efforts by this agency have focused on establishing medical clinics

for foster children. It established a comprehensive assessment center at

the county-run children’s emergency shelter, but that effort appears to

have met with only limited success. Medical staff at the center told us that

it is seldom used by foster children of any age who reside outside the

shelter. The foster care agency is also supporting the development of an

ambitious and complex system of multidisciplinary assessment and

medical clinics for foster children. This most recent effort, while

promising, depends on factors largely outside the control of the foster care

agency, such as the continuing involvement of the academia-based

physicians who proposed the system and the viability of a complex design

Page 14 GAO/HEHS-95-114 Services for Young Foster Children
B-259319 

for funding services. Furthermore, the system needs strong support from

within the agency and procedures that direct foster children to the new

system if—unlike the current assessment center—it is to reach even a

sustainable level of utilization.

Recognizing that states need assistance in improving their child welfare

programs, including foster care, ACF recently increased its technical

assistance efforts. Within the past year, HHS contracted for 10 National

Resource Centers to assist ACF staff in responding to states’ questions and

to provide free technical assistance to states. Each resource center

specializes in a child welfare issue such as permanency planning,

abandoned infants, or special needs adoption. However, none of the

resource centers is designated to help states with ensuring health-related

services for foster children.

ACF also audits states to certify states’ compliance with the safeguards for

foster children specified in the Social Security Act. However, the audits do

not examine compliance with all safeguards. The safeguards include a

requirement that case files of foster children contain up-to-date

health-related information, such as records of immunizations and a child’s

health conditions. We previously reported that HHS did not audit states on

their compliance with all required safeguards for foster children, and we

recommended that it expand its audits to include all safeguards.12 In

March 1995, ACF officials confirmed that their audits still do not examine

whether states are complying with the health-related safeguards. An HHS

determination that a state has passed its compliance audit entitles the

state to receive the full federal child welfare funding available by law.

However, since HHS does not audit for compliance with the health-related

safeguards, states have no federal financial incentive to comply with them.

ACF plans to include these safeguards in future audits, according to the

same officials.

Conclusions Important health-related needs, including routine medical examinations

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

the young foster children in the locations reviewed. Additionally, most

young foster children in the locations reviewed were at high risk for HIV as

a result of parental drug abuse, yet few children were actually tested for

the infection. Furthermore, those in kinship care were less likely than

12Foster Care: Incomplete Implementation of the Reforms and Unknown Effectiveness

(GAO/PEMD-89-17, Aug. 14, 1989).

Page 15 GAO/HEHS-95-114 Services for Young Foster Children
B-259319 

those placed in traditional foster care to receive needed health-related

services.

Despite federal safeguards for foster children, as well as regulations of

responsible agencies to ensure adequate health care for foster children,

agencies continue to struggle to meet the complex health needs of young

children. Federal efforts to help states design and implement effective

foster care health programs have been extremely limited, as evidenced by

the lack of both ACF audits and technical assistance to states on

health-related issues. Our work confirms our earlier recommendation that

ACF audits be expanded to include all foster care safeguards. We continue

to believe that ACF should take this action.

Finally, foster care agencies have been slow to respond to one critical

health need—HIV risk assessment—which is the first step in identifying

HIV-infected children so that they can receive appropriate and timely health

care. Yet, even if all foster children were systematically assessed, HIV

testing of high-risk children can still be hampered by state laws and county

policies. Finally, while we do not know why children in kinship care

generally receive fewer health-related services than children in traditional

care, research indicates that kinship caregivers receive less monitoring

and assistance from foster care agencies than traditional foster caregivers.

These findings are particularly disturbing given the vulnerable nature of

the population of young foster children. Whether the federal government

retains the foster care program in its current form or creates block grants

to the states, these issues warrant attention.

Agency Comments

and Our Evaluation

We provided HHS as well as the cognizant social services agencies of the

three states and locations reviewed with the opportunity to comment on a

draft of this report. We received comments13 from the state of New York,

New York City, and Los Angeles County. Philadelphia County responded

that it could not comment on the specifics of the report because of a

pending lawsuit. However, it indicated a few general concerns. We did not

receive comments from HHS, the state of California, or the state of

Pennsylvania.

One aspect of our report was commented on by three respondents. New

York State, Los Angeles County, and Philadelphia County expressed

13We received comments from the New York State Department of Social Services, the New York City

Human Resources Administration, the Los Angeles County Department of Children and Family

Services, and the Philadelphia Department of Human Services.

Page 16 GAO/HEHS-95-114 Services for Young Foster Children
B-259319 

concern about the age of our data. While our report is based on 1991 data,

those were the most current data available when the study began. To

ensure the continuing usefulness of the data and other aspects of our

study, we continued to monitor the locations reviewed through spring

1995 to determine if any changes in policies and programs had occurred

that could substantially alter our conclusions. While some promising

changes have occurred, either the locations that provided comments to

our draft provided us with no data to support their assertions that the

delivery of services has improved or it is too early to determine the impact

of the changes. For example, New York City commented that it is

implementing a state early care intervention program and has trained staff

in the use of the program. However, it is too early to judge the impact of

this new effort.

Another aspect of our report was commented on by two respondents. New

York State and Philadelphia County questioned the appropriateness of

combining the results of our analysis of cases across the three locations

reviewed. As we stated in the report, we determined that the conclusions

drawn from our analysis were similar for each location with two

exceptions: Philadelphia County was dropped from analyses of kinship

care, and data depicted in figure 2 included two categories where the

results varied widely by location. With these exceptions, the results were

sufficiently consistent across all three locations that we do not believe that

presenting the aggregate results unfairly portrays the situations in any of

the locations.

The State of New York and

New York City Comments

The state of New York questioned the adequacy of the sample size. We

arrived at our sample size using accepted statistical procedures that gave

us an adequate level of precision at the 95-percent confidence level to

support our findings. Our detailed methodology is presented in appendix I

and the confidence intervals are presented in appendix II.

The state also expressed doubts about the accuracy of several of our

statistical findings, conveying its belief that an ongoing state study

regarding foster care medical services will produce different results. It

believes that its ongoing study will produce a more favorable picture of its

ability to meet the needs of foster children. However, we cannot evaluate

this opinion because the state did not provide us with any results from this

study. Furthermore, the state provided little information on the

methodology being employed, and we do not know whether the state

Page 17 GAO/HEHS-95-114 Services for Young Foster Children
B-259319 

plans to conduct such analyses as would make it possible to compare their

results with ours.

New York City raised different issues related to our methodology. It

questioned whether inadequate caseworker recordkeeping provided an

incomplete depiction of the health-related services received by young

foster children. Before beginning the case file review, to test the feasibility

of using this method, we reviewed the case files of a small sample of

children and then requested the foster care agencies in the three locations

reviewed to provide information on those same children from all possible

sources, including service providers and foster parents. In general, we

found that the additional information provided from these other sources

did not change the conclusions we had reached on the basis of our case

file review regarding the level of services these children received. On this

basis, we concluded that the information in the case files would be

sufficient for our analytical purposes.

New York State agrees with the importance of risk assessment for HIV and

agrees that it does not know the full extent of HIV-infected children in

foster care. However, it disagrees that this occurs in New York City

because of a lack of a mechanism to carry out risk assessments.

Furthermore, the state asserted that more children are now being assessed

and tested for HIV as a result of changes in its policies. We agree that this

state has the most comprehensive policies on risk assessment of the three

locations reviewed. For this reason, we used a portion of their risk

assessment policies as criteria in one analysis. However, the large gap we

reported between the number of children who were at risk for HIV, based

on one New York City risk criterion, and the number actually tested

indicated that the mechanisms in place did not ensure that their

procedures were consistently carried out. While it is possible that recent

changes in New York State or New York City policies may have improved

the ability to identify HIV-infected children, state officials pointed out that

they have not been able to formally implement regulations that would put

their latest policy changes in place because of a state moratorium on

regulatory action.

New York State agrees that children placed in kinship care were less likely

to receive services than children placed in traditional foster care, and this

finding was confirmed by the state’s own study. However, it disagrees with

the inclusion in the report of data on the growth in kinship care because it

asserts that such data do not reflect the proportion of children actually in

kinship care and traditional foster care. We agree that it is useful to

Page 18 GAO/HEHS-95-114 Services for Young Foster Children
B-259319 

understand the proportion of children in different types of care, and this

information is included in the report. However, we believe that presenting

data on the large growth in kinship care placements between 1986 and

1991 is also useful to understand that the utilization of kinship care has

changed significantly since the mid-1980s.

New York State agrees with our conclusion that periodic reviews for

compliance with federal standards are appropriate. It also made technical

comments on our characterizations of county versus state regulations and

of New York City as a county, and our description of HIV testing policies.

On the basis of these comments, we modified the report as appropriate.

Los Angeles County

Comments

Los Angeles County commented that its current internal audits of medical

assessments show that compliance is at approximately 90 percent. We

agree with that estimate of the receipt of required medical examinations,

which we refer to as routine care. As stated in our report, about 12 percent

of young foster children did not receive any routine health care; Los

Angeles County’s current estimate of 10-percent noncompliance with its

regulations regarding medical assessments falls within our 95-percent

confidence interval cited in appendix II.

Los Angeles County also commented that it has made a number of changes

over the last few years that were designed to meet the health care needs of

foster children. Specifically, it discussed the HIV risk assessment policy, the

comprehensive multidisciplinary assessment center it established at a

children’s emergency shelter, and the new system of multidisciplinary

assessment and medical clinics. We acknowledge that Los Angeles County

has a policy of evaluation for risk of exposure to HIV as an ongoing process

for all foster children. However, in September 1994, numerous county

program officials told us that the county has no procedures to

systematically ensure that risk assessments take place; consequently, this

policy does not ensure that foster children who are at high risk for HIV will

be identified and tested. In addition, in fall 1994, we visited the assessment

center at the children’s emergency shelter and interviewed key program

officials and medical staff. We acknowledge that this assessment center

was designed to provide a variety of comprehensive health-related

evaluations. However, as stated in our report, this assessment center is

little used by foster children who reside outside the emergency shelter.

Finally, as we stated in our report, we agree that the multidisciplinary

medical clinics are a promising approach to meeting the complex

health-related needs of young foster children. However, it was not until

Page 19 GAO/HEHS-95-114 Services for Young Foster Children
B-259319 

September 1994 that the first of the seven planned assessment center

clinics was funded to hire staff; thus, this system is in its infancy and is

substantially untested.

We will send copies of this letter to the Secretary of Health and Human

Services and program officials in the states reviewed. We will also send

copies to all state welfare program directors and make copies available to

others on request. Please contact me at (202) 512-7215 if you or your staff

have any questions. Other GAO contacts and contributors are listed in

appendix III.

Sincerely yours,

Jane L. Ross

Director, Income Security Issues

Page 20 GAO/HEHS-95-114 Services for Young Foster Children
Page 21 GAO/HEHS-95-114 Services for Young Foster Children
Contents

Letter 1

Appendix I 

Scope and

Methodology

24

Statewide Data 24

County Case File Data 24

Appendix II 

Analysis Results

27

Appendix III 

GAO Contacts and

Acknowledgments

32

Bibliography 33

Related GAO Products 36

Tables Table I.1: Initial Population and Sample Sizes for Children in

Foster Care

25

Table I.2: Subpopulation Sizes 26

Table II.1: Health Care in Three Counties 27

Table II.2: Proportion of Children Receiving No Health Services

by Health Condition

28

Table II.3: Specialized Services Received in Three Counties 28

Table II.4: Extent to Which Identified Needs Were Met in Three

Counties

29

Table II.5: HIV-Infected Newborns for Three States in 1993 29

Table II.6: Services Received by Placement Type in Los Angeles

County and New York City

30

Table II.7: Increase in Kinship and Traditional Foster Care in

California and New York Between 1986 and 1991

31

Table II.8: Distribution of Children in Kinship and Traditional

Foster Care in Three Counties

31

Figures Figure 1: Specialized Services Received in Three Counties 7

Figure 2: Extent to Which Identified Needs Were Met in Three

Counties

8

Page 22 GAO/HEHS-95-114 Services for Young Foster Children
Contents

Figure 3: Services Received by Placement Type in Los Angeles

County and New York City

11

Figure 4: Increase in Kinship and Traditional Foster Care in

California and New York Between 1986 and 1991

13

Abbreviations

ACF Administration for Children and Families

AFDC Aid to Families With Dependent Children

AIDS acquired immunodeficiency syndrome

CDC Centers for Disease Control and Prevention

EPSDT Early and Periodic Screening, Diagnosis, and Treatment

HHS Department of Health and Human Services

HIV human immunodeficiency virus

Page 23 GAO/HEHS-95-114 Services for Young Foster Children
Appendix I 

Scope and Methodology

To accomplish the objectives of our review, we obtained and analyzed

data on state foster care programs and the children in them from the three

states with the largest average monthly foster care populations in

1991—California, New York, and Pennsylvania. Over 50 percent of the

nation’s foster children are under the jurisdiction of these three states.

We used a variety of approaches to meet our objectives. We analyzed

electronic state and county foster care databases; conducted a case file

review based on generalizable random samples; interviewed HHS, state, and

county foster care officials; conducted a telephone survey of child welfare

advocacy groups and other child welfare experts; conducted group

interviews with foster parents and caseworkers; reviewed foster care and

related literature; reviewed applicable portions of the Social Security Act

and other legislation; and reviewed foster care agency regulations and

other documents. Studies cited in this report are listed in the bibliography.

Statewide Data To determine the number of foster children in different types of

placements in the states, we analyzed electronic foster care databases for

the two states where they were available, California and New York. State

officials provided us with automated records for all children who were in

foster care at any time during calendar years 1986 and 1991. We could not

obtain comparable electronic records for Pennsylvania as that state has

not established an automated case record system.14

County Case File Data To determine the health-related services needed and received by young

foster children, their health conditions, and the types of placements they

were in, we reviewed statistically representative samples of foster care

case files for the county with the largest foster care population in 1991 for

each of the states reviewed: Los Angeles County, New York City,15 and

Philadelphia County. To identify those locations, we again used the state

foster care databases for California and New York; for Pennsylvania, we

relied on information provided by state officials. Philadelphia County

officials provided us with an electronic database of the records for foster

children in that county in 1991.

14For the three states reviewed, the 110-percent increase in young foster children that was previously

reported combines data from electronic databases and aggregate state data. For California and New

York, states with electronic databases, the counts are for foster children under the age of 3 years. For

Pennsylvania, the count is for foster children under the age of 5 years, as that state’s aggregate data did

not break out children under age 3 years.

15New York City comprises five boroughs and is treated in the state database as a county.

Page 24 GAO/HEHS-95-114 Services for Young Foster Children
Appendix I 

Scope and Methodology

Before drawing the sample, we narrowed the databases to include only

foster children whose third birthday occurred no later than December 31,

1991. This resulted in population sizes of 8,249 for Los Angeles County,

13,171 for New York City, and 1,335 for Philadelphia County. Then we

selected random samples from each of these locations resulting in a total

sample of 414 children. The population sizes and initial sample sizes are

shown in table I.1.

Table I.1: Initial Population and Sample

Sizes for Children in Foster Care

Population

Initial

sample

Final

sample

Percentage of

initial sample

used

Los Angeles County 8,249 137 114 83.2

New York City 13,171 150 142 94.7

Philadelphia County 1,335 127 104 81.9

Total 22,755 414 360 89.8a

aPercentage total is a weighted average showing the percentage of the total population covered

by the final samples.

We requested all foster care case files for each child in the sample. A few

cases were dropped from the sample because the children did not meet

the criterion of being in foster care during the review year or were not of

the appropriate age. Other cases were dropped because county officials

could not locate the records. Finally, we dropped cases of children who

were in foster care during our review period for less than 30 days in Los

Angeles County and New York City, and less than 60 days in Philadelphia

County. We did this to eliminate cases in which a child’s tenure in foster

care was shorter than the time foster care agencies were allowed, by their

local regulations, to complete initial medical examinations. This resulted

in final samples totaling 360 young foster children in our three locations.

We examined the foster care case files for the period covering a child’s

first entry into foster care until the end of the review year or until the child

was discharged from foster care, whichever occurred earlier. We used an

automated data collection instrument to record information from the case

files. The recorded information was reviewed for accuracy by the

individual preparing it before finalizing each electronic record. We also

reviewed the case file data for consistent coding among individuals; minor

adjustments were made to the coding as a result of that review.

We analyzed the case file data using univariate and bivariate analyses,

descriptive statistical methods. We found that for some of the data, the

Page 25 GAO/HEHS-95-114 Services for Young Foster Children
Appendix I 

Scope and Methodology

results varied among the three locations; however, the conclusions we

drew from the analyses of each location were similar. Thus, the locations

could be combined for analysis. Finally, when combining these data, we

weighted them to adjust for disproportionate sampling and produced

aggregate estimates. However, the results pertain to only the three

locations combined and do not necessarily reflect populations of foster

children at the state or national level.

For data derived from the case file review, the percentage estimates

reported in the letter and the numerical estimates reported in appendix II

are point estimates. Because the estimates are based on combined results

from three samples, each is subject to sampling error. The size of the

sampling error reflects the precision of the estimate; the smaller the error,

the more precise the estimate. Sampling errors for the estimates were

calculated at the 95-percent confidence level except where noted. We are

95-percent confident that the actual percentages fall within the confidence

intervals reported in appendix II. In other words, there is a 5-percent

chance that the confidence intervals do not contain the actual population

percentages.

Analysis of Placement

Type and Service Delivery

For the analysis comparing the subpopulations of children in kinship and

traditional foster care, we used only records of children who had been

placed exclusively in kinship care or exclusively in traditional foster care.

Furthermore, because the sample for Philadelphia County contained only

one child who was placed exclusively in kinship care, we eliminated that

location from this analysis. The subpopulation sizes are shown in table I.2.

Table I.2: Subpopulation Sizes

Traditional foster

care

Kinship

care

Los Angeles County 20 33

New York City 41 43

Total 61 76

This is the second report responding to this request. We conducted our

review for both reports between November 1992 and March 1995 in

accordance with generally accepted government auditing standards. We

analyzed the electronic databases as provided to us by state and county

officials, and we performed limited tests of the completeness of the case

files.

Page 26 GAO/HEHS-95-114 Services for Young Foster Children
Appendix II 

Analysis Results

This appendix presents the numerical values for the data discussed in the

body of this report. Where appropriate, point estimates and confidence

intervals are provided. The appendix includes case file review results for

the review year 1991 and statewide data for calendar years 1986 and 1991.

Table II.1: Health Care in Three Counties

Confidence interval at 95-percent confidence

level

Health carea

Point estimate,

number

Point estimate,

percent Upper bound, percent Lower bound, percent

Services not received

Routine careb 2,434 11.9 15.4 8.4

Immunizationsc 6,885 34.3 42.7 28.0

Service received

EPSDT 267 1.3 3.5 0.7

aWe dropped cases for children who were in foster care during our review period for less than 30

days in Los Angeles County and New York City, and less than 60 days in Philadelphia County. We

did this to eliminate cases in which a child’s tenure in foster care was shorter than the time foster

care agencies are allowed, by their local regulations, to complete initial medical examinations.

bChildren are exempt from initial examination requirements if they received an equivalent

examination within 90 days before entering foster care. Of children who received no routine care

during our review period, three were required, because of their age at entry and length of stay, to

have an initial examination if they did not have an examination 90 days before entering foster

care. We believe, based on the case file data, that these children did not meet the prior

examination requirement.

cIncludes children who received at least one immunization and excludes children who were under

90 days of age.

Source: Case file review.

Page 27 GAO/HEHS-95-114 Services for Young Foster Children
Appendix II 

Analysis Results

Table II.2: Proportion of Children Receiving No Health Services by Health Condition

Confidence interval at 95-percent confidence

level

Health condition

Point estimate,

number

Point estimate,

percent Upper bound, percent Lower bound, percent

No known serious health problemsa 1,094 28.4 48.6 8.2

At risk for serious health problemsb 723 5.6 11.4 2.6

Serious health problemsc 241 2.1 8.0 0.6

aIncludes children who had minor illnesses.

bConsists of prenatal drug exposure (including alcohol exposure) and drug withdrawal or

symptoms. We considered a child to be prenatally drug-exposed if any of the following conditions

were documented in the child’s foster care records: mother reported that she used drugs during

pregnancy, toxicology test results for mother or infant were positive for drug use, or infant was

diagnosed as having drug-withdrawal symptoms.

cConsists of fetal alcohol syndrome, low birth weight, cardiac defects or heart problems,

HIV-positive or AIDS, developmentally delayed, and other serious problems.

Source: Case file review.

Table II.3: Specialized Services Received in Three Counties

Confidence interval at 95-percent confidence

level

Services

Point estimate,

number

Point estimate,

percent Upper bound, percent Lower bound, percent

Medicationsa 9,607 47.0 52.9 41.2

Testsb 7,499 36.7 42.4 31.0

Specialized examinationsc 6,211 30.4 35.9 24.9

Hospitalizationsd 5,025 24.6 29.8 19.4

Specialized treatmentse 4,619 22.6 27.5 17.7

Early intervention servicesf 725 3.6 6.0 1.6

aIncludes treatment for asthma, syphilis, seizures, and kidney problems.

bIncludes blood, laboratory, and radiology.

cIncludes developmental, psychological, and cardiological.

dIncludes care for HIV, pneumonia, and failure to thrive, as well as surgery.

eIncludes apnea monitors, infant stimulation, and speech therapy.

f

Includes therapeutic day care and Head Start services.

Source: Case file review.

Page 28 GAO/HEHS-95-114 Services for Young Foster Children
Appendix II 

Analysis Results

Table II.4: Extent to Which Identified Needs Were Met in Three Counties

Confidence interval at 95-percent confidence

level

Needs met

Point estimate,

number

Point estimate,

percenta Upper bound, percent Lower bound, percent

Children with at least some needs not met 6,591 32.1 37.7 26.5

Children with all needs metb 9,763 47.6 53.4 41.8

Children with no needs identifiedb 3,924 19.1 23.1 15.2

aPoint estimates do not total 100 percent because of rounding and records lacking data on

identified needs.

bThe point estimates for the three locations varied widely in these two categories. The range of

point estimates was 60.6 to 24.6 percent for “all needs met” and 45.6 to 4.9 percent for “no needs

identified.”

Source: Case file review.

Table II.5: HIV-Infected Newborns for

Three States in 1993

States

Ranking of selected states by

estimated rates of HIV-infected

newborns

Estimated HIV-infected

newborns per 1,000 live

birthsa

California 26 0.14

New York 2 1.43

Pennsylvania 14 0.40

Note: We calculated these rates from data supplied by CDC from its study of blind HIV testing of

newborns. Forty-four states and the District of Columbia participated in this study. The six states

that did not participate were Idaho, Indiana, Nebraska, North Dakota, South Dakota, and Vermont.

While the District of Columbia was the only nonstate location included in this comparison of

estimated HIV-infected newborns, it ranked first.

aReflects the estimates of children who are HIV-infected, excluding those who falsely test positive

at birth. CDC’s estimates of the number of HIV-infected newborns are based on a 25-percent

transmission rate; in other words, one-quarter of the number of newborns who test HIV-positive at

birth are estimated to be HIV-infected rather than merely carrying their HIV-infected mothers’

antibodies.

Source: GAO analysis.

Page 29 GAO/HEHS-95-114 Services for Young Foster Children
Appendix II 

Analysis Results

Table II.6: Services Received by Placement Type in Los Angeles County and New York City

Traditional foster carea Kinship careb

Confidence interval at

95-percent confidence

level

Services

Point

estimate,

number

Point

estimate,

percent

Point

estimate,

number

Point

estimate,

percent

Difference

between

point

estimates,

percentage

points

Upper

bound,

percent

Lower

bound,

percent

Routine carec 4,476 93.2 4,689 81.4 11.8 22.1 1.4

Immunizationsd 3,352 72.5 3,209 57.4 15.1e 31.2 –1.1

Medicationsf 2,963 61.7 1,826 31.7 30.0 46.1 13.9

Testsg 2,496 52.0 850 14.8 37.2 52.5 22.0

Specialized examinationsh 2,002 41.7 652 11.3 30.4 44.8 15.9

Hospitalizationsi 1,558 32.4 1,124 19.5 12.9e 27.9 –2.1

Specialized treatmentsj 1,300 27.0 888 15.4 11.6e 25.6 –2.3

Early intervention servicesk 411 8.6 0 0.0 8.6 15.8 1.3

No services received 329 6.8 925 16.0 –9.2e 0.7 –19.1

Note: Because the sample for Philadelphia County contained only one child who was placed

exclusively in kinship care, we eliminated that location from this analysis.

aConsists of children placed exclusively in traditional foster care.

bConsists of children placed exclusively in kinship care.

cConsists of varying amounts of medical practitioner care and/or EPSDT examinations.

dIncludes children who received at least one immunization and excludes children who were under

90 days of age.

eDifferences are statistically significant at the 90-percent confidence level.

f

Includes treatments for asthma, syphilis, seizures, and kidney problems.

gIncludes blood, laboratory, and radiology.

hIncludes developmental, psychological, and cardiological.

i

Includes care for HIV, pneumonia, and failure to thrive, as well as surgery.

j

Includes apnea monitors, infant stimulation, and speech therapy.

k

Includes therapeutic day care and Head Start services.

Source: Case file review.

Page 30 GAO/HEHS-95-114 Services for Young Foster Children
Appendix II 

Analysis Results

Table II.7: Increase in Kinship and

Traditional Foster Care in California

and New York Between 1986 and 1991 Placements 1986 1991

Percentage

increase

All children

Kinship carea 15,241 69,590 356.6

Traditional foster care 64,225 80,443 25.3

Young children

Kinship carea 2,941 14,072 378.5

Traditional foster care 12,007 18,457 53.7

Note: Counts represent children in foster care at the end of the calendar years.

aPart of the increase in kinship care placements is due to a lawsuit filed in the New York Supreme

Court, Eugene F. v. Gross, which sought to require New York City to follow regulations to formally

include children who are placed with relatives in the foster care caseload and make them eligible

for services.

Source: State electronic databases.

Table II.8: Distribution of Children in Kinship and Traditional Foster Care in Three Counties

Confidence interval at 95-percent confidence

level

Placement type

Point estimate,

number

Point estimate,

percent Upper bound, percent Lower bound, percent

Kinship care 9,976 48.8 55.0 42.7

Traditional foster care 10,773 52.7 58.9 46.6

Note: Point estimates represent the proportion of children who were in each type of placement at

any time during the review period. Since some children were in both types of placements during

the review period, point estimates total more than 100 percent.

Source: Case file review.

Page 31 GAO/HEHS-95-114 Services for Young Foster Children
Appendix III 

GAO Contacts and Acknowledgments

GAO Contacts Kerry Gail Dunn, Evaluator-in-Charge, (415) 904-2000

Robert L. MacLafferty, Assistant Director, (415) 904-2000

Acknowledgments In addition to those named above, the following individuals made

important contributions to this report: Susan Riggio led the fieldwork in

California and Pennsylvania and coauthored the draft; Ann Walker led the

data analysis and coauthored the draft; Helen Cregger, Sheila Murray,

Tranchau Nguyen, and Cameo Zola conducted case file reviews and

interviews.

Page 32 GAO/HEHS-95-114 Services for Young Foster Children
Bibliography

American Academy of Pediatrics, Committee on Early Childhood,

Adoption, and Dependent Care. “Health Care of Children in Foster Care.”

Pediatrics, Vol. 93, No. 2 (Feb. 1994), pp. 335-38.

American Academy of Pediatrics, Committee on Practice and Ambulatory

Medicine. “Recommendations For Preventive Pediatric Health Care.”

July 1991.

American Academy of Pediatrics, Task Force on Pediatric AIDS.

“Guidelines for Human Immunodeficiency Virus (HIV)-Infected Children

and Their Foster Families.” Pediatrics, Vol. 89, No. 4 (Apr. 1992),

pp. 681-83.

Besharov, Douglas J., ed. When Drug Addicts Have Children—Reorienting

Child Welfare’s Response. Washington, D.C.: Child Welfare League of

America, Inc., and American Enterprise Institute, 1994.

Center for the Future of Children and The David and Lucile Packard

Foundation. “Drug Exposed Infants.” The Future of Children, Vol. 1, No. 1

(Spring 1991).

Child Welfare & AIDS Project. Child Welfare Protocols for Children with HIV

Infection: Guidelines for Development and Evaluation. Berkeley, Calif.:

School of Social Welfare, University of California, Berkeley, Jan. 1991.

Child Welfare League of America. Kinship Care: A Natural Bridge.

Washington, D.C.: 1994.

Child Welfare League of America. Standards for Health Care Services for

Children in Out-of-Home Care. Washington, D.C.: 1988.

Cohen, Felissa, R.N., Ph.D., F.A.A.N., and Wendy Nehring, R.N., Ph.D.

“Foster Care of HIV-Positive Children in the United States.” Public Health

Reports, Vol. 109, No. 1 (Jan./Feb. 1994), pp. 60-67.

Congressional Research Service. “Kinship” Foster Care: An Emerging

Federal Issue. Washington, D.C.: Sept. 27, 1993.

Deering’s California Codes. “Annotated Health and Safety Code of the

State of California,” pp. 106-107. San Francisco: 1990.

Page 33 GAO/HEHS-95-114 Services for Young Foster Children
Bibliography

English, Abigail. “The HIV-AIDS Epidemic and the Child Welfare System:

Protecting the Rights of Infants, Young Children, and Adolescents.” Iowa

Law Review, Vol. 77, No. 4 (1992), pp. 1509-60.

National Abandoned Infants Assistance Resource Center. Report to the

Congress on Effective Care Methods for Responding to the Needs of

Abandoned Infants and Young Children. Berkeley, Calif.: Family Welfare

Research Group, School of Social Welfare, University of California,

Berkeley, undated report.

Pinkney, Deborah. “America’s Sickest Children.” American Medical News,

Jan. 10, 1994, pp. 15-19.

Sterk, Claire. “Cocaine and HIV Seropositivity.” Lancet, Vol. I, No. 8593

(May 7, 1988), pp. 1052-53.

Teare, Catherine, Abigail English, J.D., Susan Lockwood, M.S.W., and

Kirby Clark, J.D. HIV/AIDS Policies and Guidelines: State Child Welfare

Agencies. Iowa City, Iowa: University of Iowa National Maternal and Child

Health Resource Center, 1992.

U.S. Department of Health and Human Services. Maternal Drug Abuse and

Drug Exposed Children: Understanding the Problem. Washington, D.C.:

1992.

U.S. Department of Health and Human Services, Office of Inspector

General. Using Relatives For Foster Care. Washington, D.C.: July 1992.

U.S. Department of Health and Human Services, Public Health Service,

Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report.

Vol. 6, No. 1 (1994).

U.S. Department of Health and Human Services, Public Health Service,

Centers for Disease Control and Prevention, National Center for Infectious

Diseases. Unpublished data on blind HIV testing of newborns in 44 states

and the District of Columbia. Atlanta: 1993.

Page 34 GAO/HEHS-95-114 Services for Young Foster Children
Bibliography

Page 35 GAO/HEHS-95-114 Services for Young Foster Children
Related GAO Products

Foster Care: Parental Drug Abuse Has Alarming Impact on Young Children

(GAO/HEHS-94-89, Apr. 4, 1994).

Childhood Immunization: Opportunities to Improve Immunization Rates at

Lower Cost (GAO/HRD-93-41, Mar. 24, 1993).

Drug Abuse: The Crack Cocaine Epidemic: Health Consequences and

Treatment (GAO/HRD-91-55FS, Jan. 30, 1991).

Drug-Exposed Infants: A Generation at Risk (GAO/HRD-90-138, June 28, 1990).

Foster Care: Incomplete Implementation of Reforms and Unknown

Effectiveness (GAO/PEMD-89-17, Aug. 14, 1989).

Pediatric AIDS: Health and Social Service Needs of Infants and Children

(GAO/HRD-89-96, May 5, 1989).

(105822) Page 36 GAO/HEHS-95-114 Services for Young Foster Children
Ordering Information

The first copy of each GAO report and testimony is free.

Additional copies are $2 each. Orders should be sent to the

following address, accompanied by a check or money order

made out to the Superintendent of Documents, when

necessary. Orders for 100 or more copies to be mailed to a

single address are discounted 25 percent.

Orders by mail:

U.S. General Accounting Office

P.O. Box 6015

Gaithersburg, MD 20884-6015

or visit:

Room 1100

700 4th St. NW (corner of 4th and G Sts. NW)

U.S. General Accounting Office

Washington, DC

Orders may also be placed by calling (202) 512-6000 

or by using fax number (301) 258-4066, or TDD (301) 413-0006.

Each day, GAO issues a list of newly available reports and

testimony. To receive facsimile copies of the daily list or any

list from the past 30 days, please call (301) 258-4097 using a

touchtone phone. A recorded menu will provide information on

how to obtain these lists.

PRINTED ON RECYCLED PAPER
United States

General Accounting Office

Washington, D.C. 20548-0001

Official Business

Penalty for Private Use $300

Address Correction Requested

Bulk Mail

Postage & Fees Paid

GAO

Permit No. G100
GAO/HEHS-95-114 Services for Young Foster Children