Juvenile Courts: Reforms Aim to Better Serve Maltreated Children
Published: 1999-01-11T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Pursuant to a congressional request, GAO reviewed states' and local agencies' efforts to improve the timeliness of judicial decisions concerning the permanent placement of foster children, focusing on: (1) the key problems in the juvenile dependency court system; and (2) state and local responses to these problems.
section_title: What GAO Found
paragraphs: GAO noted that: (1) serious systemic problems continue to plague the juvenile dependency court system; (2) states GAO visited reported a lack of cooperation between the courts and child welfare agencies as well as difficult personnel and data management issues that jeopardize the courts' ability to ensure that a child's stay in the foster care system is as brief as possible and that the permanent placement decided upon is in the best overall interest of the child; (3) despite their shared involvement in the child welfare system, courts and child welfare agencies often do not work well together; (4) for example, some judges mistrust the judgments of caseworkers and routinely order additional clinical assessments to compensate for what the judges perceive as professional inadequacies; (5) in addition, courts face numerous difficulties, including increased caseloads, short tenures for judges and attorneys assigned to juvenile dependency courts, insufficient training of judges and attorneys in child welfare law and concepts, and information systems that do not adequately track the progress of individual cases or monitor the courts' compliance with statutory timeframes for achieving permanent placements; (6) in response to these problems, some states have initiated court reforms that they believe reduce the length of time children spend in foster care and improve the quality of the decisions made by the courts; (7) these reforms generally fall into two categories: (a) reforms which are designed to improve the overall operation and infrastructure of the courts, including convening multidisciplinary advisory committees to resolve differences that exist between the courts and the organizations involved in court proceedings as well as developing juvenile dependency court information systems; and (b) reforms focused on improving the quality of decisionmaking on individual cases; (8) these reforms include holding mediation sessions in which all relevant parties meet to resolve issues in dispute in a non-adversarial setting outside the courtroom, as well as increasing the time allotted for specific hearings; (9) regardless of the nature of the reform, state and local officials at the sites GAO visited identified three ingredients that successful reform efforts have in common; and (10) these essential reform components are the presence of judicial leadership and collaboration among court participants, the availability of timely information on case processing performance, and the availability of financial resources to initiate and sustain reforms.

section_title: Letter
paragraphs: Almost every day, courts that hear child welfare dependency cases across the country make critical decisions that affect the lives of the approximately 1 million children who are victims of child abuse and neglect each year, many of whom enter and remain in the foster care system for years. In this capacity, the courts—executing a variety of federal and state laws—play the central role in determining whether children will be removed from their homes; how long they will remain in the foster care system; and, ultimately, where the children will permanently reside. Over the years, the courts have struggled to balance their attempts to protect children from further harm with making timely decisions for their future.
Many states and localities have begun reforming their court systems to address problems that contribute to children spending years of their childhood awaiting court decisions concerning where they will ultimately live. While some states have initiated change on their own, many began reform efforts as a result of the federal Court Improvement Program (CIP) authorized in the Omnibus Reconciliation Act of 1993. CIP provides grants to state courts to improve their handling of child maltreatment cases. Because of your concern over the courts’ performance in achieving timely permanent placements for children, you asked us to identify (1) the key problems in the juvenile dependency court system and (2) state and local responses to these problems. In conducting this work, we reviewed the literature on problems in the juvenile dependency court system, including CIP assessments of problems in specific states, and interviewed state and federal officials and experts on the dependency court process, such as officials at national court-related organizations, judges, and researchers. To obtain first-hand information on dependency court reform activities, we visited juvenile dependency courts in five locations—Santa Clara County, California; the Ninth Judicial Circuit in Florida, comprising Orange and Osceola counties; Cook County, Illinois; Judicial District 20 in North Carolina, comprising Anson, Richmond, Stanly, and Union counties; and Hamilton County, Ohio. We chose these locations because experts at the National Council of Juvenile and Family Court Judges (NCJFCJ) and the American Bar Association (ABA) considered these locales to be implementing significant reforms, or because CIP was a major impetus for change there. We conducted our work between December 1997 and October 1998 in accordance with generally accepted government auditing standards. (A more detailed discussion of our scope and methodology appears in app. I).
subsections: section_title: Background
paragraphs: The child welfare system—composed mainly of state and local child welfare agencies and juvenile dependency courts—is supported by a complex mix of people and programs. Approximately 1 million children are the victims of abuse and neglect by their parents or caregivers each year, and each participant in the system plays a role in ensuring that maltreatment cases are resolved expeditiously while taking into account the best interests of the child. A natural tension exists between the requirement to provide quality decisions and the need to ensure the timeliness of those decisions. While courts must take time to preserve the integrity of their decisions by examining all the facts, they must also consider the child’s sense of time and the serious emotional consequences that a child who waits months or sometimes years for a permanent home can experience.
subsections: section_title: Courts Play an Expanded and Central Role in the Child Welfare System
paragraphs: The child welfare system involves many participants. Child welfare caseworkers receive and investigate reports of suspected maltreatment and recommend and locate appropriate social services. Private service providers, such as mental health professionals, work with these caseworkers to identify a family’s difficulties and supply needed help and services. Juvenile dependency courts rely on information from caseworkers, service providers, and others to reach decisions on cases presented to the courts. Court-appointed special advocates (CASA), guardians ad litem, or both are often appointed by the court to represent the child’s best interests. Some attorneys—such as public defenders—provide legal representation for indigent parents who are suspected of maltreating their children, while others—such as state or county attorneys—provide legal representation for child welfare agencies in presenting the facts and recommendations of the cases. Finally, the juvenile dependency court judge distills the facts and information presented about a case and decides whether a child should be placed in the foster care system, how long the child will remain outside the home if removed, and where the child will ultimately reside.
In 1980, the Congress enacted the Adoption Assistance and Child Welfare Act (P.L. 96-272). The primary goals of the act were to prevent the unnecessary separation of children from their families, improve the quality of care and services for vulnerable children and their families, and ensure that children did not languish in foster care. The act placed major new responsibilities on the courts to oversee child welfare cases more rigorously than before and, as a result, the number of hearings expanded dramatically. Unlike other cases, such as those dealing with criminal activities, child maltreatment cases deal with ongoing and changing conditions. As a result, seven kinds of hearings may occur in child welfare cases: (1) preliminary protective hearing, (2) adjudication hearing, (3) disposition hearing, (4) review hearing, (5) permanency planning hearing, (6) termination of parental rights hearing, and (7) adoption hearing (see table 1).
The preliminary protective hearing, the first hearing in a juvenile abuse or neglect case, occurs either immediately before or after a child is removed from the home in an emergency. The main purpose of this hearing is to decide, on the basis of an assessment of risks and dangers to the child, whether or not the child can be immediately and safely returned home while the trial on the alleged maltreatment is pending. During this hearing, the court determines if the child welfare agency made reasonable efforts to preserve the family. During the adjudication hearing, the judge determines if allegations of abuse or neglect are sustained by the evidence and, if so, are legally sufficient to support state intervention on behalf of the child. If the allegations are sustained, the court proceeds to the disposition hearing, where the reasonable efforts that were made to prevent the child’s removal from the home are again discussed and decisions concerning who will have custody and control of the child are made. Review hearings are then held periodically in accordance with federal and state laws to ensure that children spend as short a time as possible in temporary placement and to modify the case plan for family services as necessary. The permanency planning hearing is a special type of court proceeding designed to reach a decision concerning the permanent placement of the child. Possible permanent placements include the child’s return home and the child’s adoption. Choosing adoption necessitates holding a termination of parental rights hearing to end the rights of the parents to visit, communicate with, and obtain information about the child or to ever regain custody. Finally, the adoption hearing builds a new legal relationship between the child and the individuals who are to become the child’s adoptive parents.
section_title: Federal Government Continues to Monitor and Assist Juvenile Dependency Courts
paragraphs: In 1980, the same year the Adoption Assistance and Child Welfare Act was enacted, in part, to improve judicial consideration of child maltreatment cases, NCJFCJ established the Permanency Planning Project for Children—primarily with private funding—that provided limited training and technical assistance to courts. A separate grant from the Edna McConnell Clark Foundation allowed NCJFCJ to establish model jurisdictions in 14 states to improve the implementation of reasonable efforts to reunite children with their families. The success of these privately funded initiatives helped prompt the Department of Health and Human Services (HHS) to provide funds to NCJFCJ in 1983 to expand these model court efforts to three additional states. In 1984, the Department of Justice (DOJ) provided the first phase of funding to establish state permanency planning task forces and to support interdisciplinary training and technical assistance for improving juvenile court systems. DOJ provided additional funding between 1992 and 1997, for a total of $4.25 million. Approximately $1.5 million was used to develop a document to set forth the elements of a high-quality judicial process in child maltreatment cases, including the essential elements of properly conducted court hearings and the requirements of juvenile and family courts in fulfilling the role given them by federal and state laws. The resulting Resource Guidelines: Improving Court Practice in Child Abuse and Neglect Cases was issued in 1995 and endorsed by the ABA and the Conference of Chief Justices. The remaining funds are being used to support model court initiatives in 17 locations to improve court practice in child maltreatment cases.
Because of perceptions that problems were still present in juvenile dependency courts, the Omnibus Reconciliation Act of 1993 authorized funds for CIP to be administered by HHS. The act set aside $35 million—$5 million for fiscal year 1995 and $10 million for each of fiscal years 1996, 1997, and 1998—in entitlement grants for state courts to help them perform their role in making decisions about families and children at risk. The first year of CIP funds was to be used to conduct assessments of state foster care and adoption laws and judicial processes and to develop a plan for improvements. Funding in subsequent years was targeted for implementing improvements according to the plan. CIP funding was awarded to 48 states and the District of Columbia; 42 states and the District of Columbia have completed the required assessment, and 46 states and the District of Columbia have begun implementing various reform activities. These reforms generally affect the quality and content of hearings; legal representation of parties such as children and parents; timeliness of decisions; notice to and participation of parties in court proceedings; treatment of parties; quality and professionalism of judges and other judicial officers; staffing of courts in child protection cases; use of technology; training or education of judges and court staff; and state legislation, court rules, forms, or court-related policies.
section_title: Recent Legislation Has Created New Requirements for the Courts
paragraphs: Just as the 1980 Adoption Assistance and Child Welfare Act sought to improve the way child maltreatment cases were handled by increasing judicial oversight, the Congress enacted the Adoption and Safe Families Act (ASFA) in November 1997 in part as a response to the fact that more children were entering the foster care system each year than were exiting. The act firmly established safety, permanency, and child well-being as the national goals for children in the child welfare system. Many of the act’s provisions exert new pressure on the courts to move cases more quickly and affect how the courts conduct child maltreatment proceedings. For example, states are now required to file a court petition to terminate parental rights if the child has been in foster care for 15 of the most recent 22 months. Although some exceptions to this provision exist, a preliminary HHS estimate is that approximately 177,600, or 34 percent, of the children in foster care as of March 31, 1998, will fall into this new category. Some practitioners believe this provision will increase the number of termination of parental rights hearings that must be held as well as the overall court calendar time needed, since these hearings can take several days to conduct. Further, the permanency planning hearing—previously held about 18 months after the child’s original placement in foster care—must now take place no later than 12 months after the child is considered to have entered foster care. In addition, ASFA reauthorized funding for CIP for an additional 3 years, providing $10 million for each of fiscal years 1999, 2000, and 2001.
section_title: Juvenile Dependency Courts Face Serious Problems That Hamper Effective Decision-Making
paragraphs: Juvenile dependency courts are fraught with systemic problems that affect their ability to make sound decisions in a timely manner regarding where a child will ultimately reside. We found two key problems to varying degrees in all five states we visited: (1) a lack of cooperative working relationships between the courts and other participants involved in the child welfare system, including conflict over how courts and child welfare agencies resolve issues, and (2) difficult personnel and data management issues, such as inadequate numbers of judges and attorneys to handle large caseloads; frequent turnover among judges and attorneys; inadequate training of judges and attorneys in the area of child welfare; and a lack of efficient, automated information systems for tracking case data. Together, these problems hinder the courts’ ability to produce decisions within time frames that meet both the needs of children as well as the requirements of child welfare legislation.
subsections: section_title: Courts and Agencies Lack Cooperative Working Relationships
paragraphs: The courts and child welfare agencies each play key roles in the child welfare system. Despite this shared involvement in handling child maltreatment cases, the courts and agencies often do not work well together. Experts we interviewed confirmed a lack of effective working relationships among the courts and other participants in the system, and local officials at all five sites we visited stated that there was a lack of cooperation before reform efforts were instituted and that it may still exist to some extent. This lack of effective working relationships is illustrated in a variety of ways.
For example, the CIP assessment of Cook County, Illinois, found a pervasive mistrust among officers of the court directed toward the caseworkers assigned to addressing the needs of children and their families. Judicial officers indicated that because children’s cases may be managed by several caseworkers in different agencies, the court is left with the sense that only the court is considering the interests of the entire family. The assessment further reported that because judges do not trust the judgments of caseworkers, they routinely order additional clinical tests and assessments by experts and may require frequent progress reports and case status hearings to ensure that caseworkers are conducting their assigned tasks appropriately, thus lengthening the court process for resolving cases.
In addition, relationships among the participants can at times be adversarial. According to the Illinois CIP assessment, the many attorneys involved in dependency cases may focus on winning those cases rather than on obtaining services for the family. The attorneys, each representing a different party to the proceedings, may have separate agendas. For example, a district attorney in California representing children in the juvenile dependency court commented that her office may recommend a different course of action for a child than the one proposed by the child welfare agency. While the social worker oversees the plan for the entire family, the attorney approaches the case from the child’s perspective only. In addition, CIP and court officials as well as an attorney for the child welfare agency in Illinois pointed out that the courts and child welfare agencies have frequently blamed each other for failures of the child welfare system, such as child deaths. The adversarial nature of litigation can make the process of finding permanent homes for abused and neglected children less efficient. For example, attorneys representing the child welfare agency and children in North Carolina’s District 20 told us that when key participants in the system do not work together at the beginning of a case to develop plans for solving the family’s problems, the delivery of social services can be delayed. This delay, in turn, can lengthen the time it takes to find a permanent home for a child or to return a child to his or her biological parents.
section_title: Courts Face Difficult Personnel and Data Management Issues
paragraphs: A number of personnel and data management problems in the juvenile dependency courts also hamper the process of finding permanent homes for abused and neglected children. First, the courts in many jurisdictions do not have a sufficient number of judges and attorneys to handle the large number of child maltreatment cases in an expeditious manner. Second, some juvenile dependency courts experience frequent turnover of both judges and attorneys, which reduces the level of expertise they bring to the dependency process. Third, the courts may not always ensure that judges and attorneys have received training in the legal and nonlegal aspects of child maltreatment before they begin working in the dependency field. Last, the courts do not have adequate automated information systems in place to monitor their dependency caseloads.
subsections: section_title: Personnel Issues
paragraphs: Child welfare proceedings can be long and complex. According to experts in the juvenile dependency court process, to complete the demanding work of the court, there must be enough judicial officers and attorneys who possess sufficient expertise to ensure that children are protected and placed in a permanent home in a timely fashion. Further, experts such as those at NCJFCJ also report that judicial and attorney caseloads have risen at the same time that court demands, such as the number of hearings and parties involved in child maltreatment cases, have increased. The problem of large caseloads appeared in the CIP assessments of three of the states we visited and was confirmed by local officials at four of the five local sites we visited. Although formal caseload size standards do not exist, two juvenile court jurisdictions—Hamilton County, Ohio, and Kent County, Michigan—are recognized by experts and cited by ABA as successful courts with appropriate judicial caseloads. Hamilton County judicial officers each handled an average of 239 child protection cases in 1991, while Kent County judicial officers each handled approximately 181 cases in 1993. Court caseloads in four of the five sites we visited, however, often exceed these suggested levels. For example, the presiding judge at one site we visited handles approximately 1,000 cases per year. As part of its court improvement program, California studied judicial resources and found that many counties needed additional judges to meet the ratios in effect in Hamilton County, Ohio. In Los Angeles County, for example, about 53 additional judges were needed, while San Bernardino County needed about 12 more judges.
Similarly, local officials at the sites we visited reported excessive attorney caseloads, and experts confirmed that caseloads for attorneys in many jurisdictions are unreasonably large. According to the ABA, a caseload of 40 to 50 active cases for a full-time staff attorney for a child welfare agency is reasonable. By comparison, attorneys in the Cook County, Illinois, Public Defender’s Office have an average of 650 juvenile dependency cases at any given time, while the state’s attorneys each have about 1,000 such cases on average. In Santa Clara County, California, the Deputy District Attorney, whose office represents children, reported average attorney caseloads of 600. Similarly, a managing attorney for the child welfare agency at that site reported that 13 attorneys handle 4,000 child maltreatment cases at any given time. California’s CIP assessment showed that large caseloads are also a problem in other locations in the state. Of attorneys in six counties responding to a survey as part of the California CIP assessment, half had caseloads of more than 150, 25 percent had 250 or more, and the 10 percent with the largest caseloads had 600 or more.
Experts in the juvenile dependency court process note that large caseloads result in hearings that may not be substantive and may be frequently delayed or continued, ultimately contributing to the courts’ failure to meet statutory deadlines for moving children out of the foster care system. For example, although NCJFCJ’s Resource Guidelines suggest hearing times for the various hearings in the dependency process, CIP assessments from California, Florida, and Illinois confirmed that hearings often do not meet these minimum time frames. The guidelines indicate that preliminary protective hearings should last about 1 hour, but Florida reported that 56 percent of its preliminary protective hearings lasted only 4 minutes. In Cook County, Illinois, the average preliminary protective hearing lasted about 16 minutes. Similarly, CIP assessments in four states cite continuances as problematic. For instance, the Cook County, Illinois, assessment indicates that the most observable manifestation of delay in the court is the continuance. Adjudication and permanency hearings had the highest rates of continuances, at 54 and 51 percent, respectively. Permanency hearings were continued an average of 75 days, with a range of 8 to 203 days. Similarly, Florida’s assessment noted that in the 882 court observations conducted, all of the 169 requests for continuances were granted. Both Florida and Illinois link such continuances to the courts’ inability to meet statutory time frames for finding permanent homes for children. Florida’s assessment noted that missed deadlines between the preliminary protective hearing and termination of parental rights translate, on average, to nearly an additional year that a child spends in the dependency process. Illinois’ assessment found that 90 percent of children who entered foster care from 1993 through 1994 were still in nonpermanent placements in 1996.
Judicial and attorney turnover is another problem. Turnover impairs expertise in child welfare issues, according to experts such as those at the National Center for Juvenile Justice (NCJJ) and the ABA. For example, the ABA testified before the Congress in 1997 that juvenile dependency courts are confronted with frequent rotation of judges who may or may not have expertise or an interest in child welfare law. Similarly, CIP officials in three of the five states we visited said that judicial rotation is a problem. For instance, a Florida CIP official told us that some judges may be rotated out of juvenile dependency court after only 6 months, with the result that many dependency cases are heard by judges who are unfamiliar with dependency law. California CIP officials stated that judicial officers change constantly—for example, interested and dedicated judges may be rotated out after 1 year on the bench. The frequent rotation of judges can contribute to decisions that are not based on a thorough knowledge of the individual child and family and can result in unnecessary delays in reaching decisions about permanent homes, according to experts in the dependency court process. For example, one expert noted that in some cases a series of judges makes sequential decisions about the child—that is, one judge removes the child from the home, another oversees efforts to reunify the family, another handles permanency planning, and yet another terminates parental rights. These dependency court experts also commented that a succession of judges unfamiliar with the family and the child increases the potential that key facts about the case will be overlooked.
Juvenile dependency courts also experience high rates of attorney turnover, according to experts in the dependency court process and local officials in four of the five sites we visited. In its review of 25 state CIP assessments and in a related study on attorney representation, NCJFCJ found that frequent rotation of prosecutors and agency attorneys is a problem. California’s CIP assessment found rapid rotation of some county public defenders and noted that parents should not have to adjust to two to four attorneys over the life of a case. Local attorneys in Illinois, North Carolina, and Ohio confirmed that rapid turnover occurs among various attorneys in the dependency arena. Experts agree that the parties to child maltreatment proceedings need consistent legal representation to ensure that the information these attorneys supply to the judge is complete and thorough. According to one expert, children, in particular, need a single representative to retain their history, including the reasons they entered the child welfare system.
Limited or underutilized child welfare-related training opportunities further affect the level of skill and experience the participants bring to the courtroom. According to experts, such as officials at HHS and NCJJ, and CIP assessment reports, some judges and attorneys lack training specific to child welfare law, as well as to other family-related topics, such as child development and the dynamics of child maltreatment. For example, HHS’ CIP “Program Instruction,” a document that describes the program and its requirements, cites insufficient training in child welfare issues for many participants in the system as a common problem. Additionally, the principal finding of a national research project conducted by NCJFCJ was the need for improved training in both the legal and nonlegal aspects of dependency cases. The CIP assessment of Cook County, Illinois, noted that attorneys are poorly trained to handle the types of social service issues inherent in child maltreatment cases. The North Carolina assessment noted that judges are not subject to any specific training requirements other than possessing a law degree. Similarly, attorneys in Illinois, North Carolina, and Ohio; judges in Florida and Ohio; and local child welfare officials in California and Ohio stated that dependency court participants need further training. For example, a judge in Florida remarked that juvenile dependency court judges must understand the dynamics of child maltreatment cases and have a grasp of child psychology. According to this official, many judges have preconceived notions about child sexual abuse that are changed after the judges take a class on the impact of child maltreatment.
Experts in the dependency court process agree that a lack of training and experience in dependency law can also reduce the quality of decisions in child maltreatment cases. According to these experts, this lack of training and experience inhibits judicial officers’ ability to gather enough facts about a case to make fully informed decisions about the child and family. Similarly, experts indicate that hearing effectiveness is negatively affected if attorneys are not adequately trained to handle the special demands of child maltreatment cases and to expedite the cases.
section_title: Data Management Issues
paragraphs: The lack of adequate automated information systems to effectively manage child maltreatment case flow is a nationwide problem, according to NCJFCJ. Information about individual cases is critical for diagnosing and responding to the problems of the children and families that come before the court. For example, courts need data such as the name, age, and ethnicity of the child; the type of alleged abuse or neglect; dates of scheduled court hearings; and information on nondependency cases involving the same family, including domestic violence, divorce, or criminal actions. The California CIP assessment reported that California lacks statewide standards for information systems and that, although the courts studied have information systems in place, none are well-designed for tracking dependency cases, with the possible exception of the Los Angeles system. North Carolina’s assessment indicated that most of the information necessary to measure court performance is available, but it is dispersed among the guardians ad litem, the Administrative Office of the Courts, and the child welfare agency. Furthermore, many juvenile courts in North Carolina completely lack automated systems. Fewer than half of the juvenile court clerks in 40 North Carolina counties surveyed reported using a computer for any purpose, and none reported using any court management software or preparing case management information reports for use at the district or county level. In addition, all 25 state CIP assessments reviewed by NCJFCJ cited the need for improved data systems in juvenile dependency courts.
The lack of effective information systems not only affects the courts’ ability to reach decisions about permanent homes for children but may also lead to other serious consequences. Experts in the dependency court process indicate that without automated data systems that track key events in the court process, courts may not be able to reliably follow the progress of individual cases through the system and, as a result, may miss statutory deadlines for making permanency decisions. Furthermore, dependency courts may be unable to track civil or criminal cases in other courts within the jurisdiction or in other jurisdictions or simply to share information between courts. For example, a juvenile dependency court judge in California related an incident in which he gave custody of a child to one of the parents. However, because the different courts do not share case information, this judge did not know the details of the parents’ divorce suit pending in another court. As a consequence, the other parent’s attorney was able to change the terms of the custody arrangement during divorce proceedings and essentially overturn the juvenile dependency court decision. A new juvenile court hearing became necessary to resolve the conflicting decisions. More serious consequences are also possible. According to a report on information management in the Cook County, Illinois, juvenile court, the presence of an automated information system that maintained critical case information in a usable format might have made a significant difference in a prominent case involving the death of a child. The report said that, in this case, important information was amassed only in hard copy, and caseload demands prevented the judge and attorneys from becoming familiar with essential facts. The judge who last heard the case had no prior experience with the family and relied on the assurances of others regarding necessary actions. While many factors contributed to the child’s death, an independent committee identified a collective failure to provide the court with crucial information as a major systemic failing and concluded that information must be more timely and better disseminated.
section_title: State and Local Reforms Seek to Improve Quality and Timeliness of Decisions, but Evaluation Is Needed
paragraphs: States we visited have implemented a variety of reforms to address some of the problems that have hindered the courts’ ability to quickly resolve dependency cases. These reforms can be divided into two categories: those that seek to improve the overall operation and infrastructure of the courts, such as convening multidisciplinary advisory committees and developing automated information systems, and those that target improving decision-making in individual cases, primarily by using information-gathering and dispute-resolution techniques in addition to formal court hearings. Regardless of the methods chosen to change the way juvenile dependency courts handle child maltreatment cases, state and local officials identified three components essential to instituting and sustaining reforms over time. Although some progress in reducing caseloads and shortening case processing times has been noted since reform efforts began, most locations are just beginning to evaluate and document results. As a result, states and localities currently do not know which interventions have improved their courts and which have not.
subsections: section_title: Many Reforms Seek to Improve Working Relationships and the Availability of Court Process Information
paragraphs: To improve cooperation between the courts and agencies, states and localities we visited convened multidisciplinary advisory committees to (1) work on resolving turf battles, (2) dispel the mistrust among system participants, and (3) develop and implement other reforms. At the state level, all five states convened multidisciplinary CIP advisory committees, typically including representatives from key participant groups, such as child welfare agencies, CASAs, the state bar, judges, state attorneys, and other advocates. The advisory committees planned and oversaw the CIP assessment process, analyzed the results, and jointly developed an action plan to implement reforms. According to CIP officials, the value and benefits derived from these committees far exceed expectations, given the small size of the CIP state grants. CIP officials at all sites credited the program with providing the impetus to assemble a statewide group of key individuals to consider court reform, adding that the committees represented the first time system participants were talking and working together statewide. According to these officials, this unifying force has proven invaluable in initiating and institutionalizing reforms.
Similarly, the Cook County, Illinois, juvenile court convened local advisory committees to work on local issues. One such committee, the Table of Five, which consists of the presiding judge and the heads of the child welfare agency and the Offices of the Public Guardian, State’s Attorney, and Public Defender, meets to discuss systemic problems and the pressing issues surrounding the dependency court. In addition, Table of Five members work to resolve turf battles, to dispel fear and mistrust, and to model the right behavior for their employees. Cook County’s Child Protection Advisory Group, composed of 32 individuals representing all offices of the court, the child welfare agency, private social service agencies, legal service providers, advocacy groups, and universities, is charged with advising the presiding judge on all matters relating to improving the court’s Child Protection Division. The Group is divided into subcommittees that focus on various issues, such as alternatives to court intervention, making decisions in the best interests of the child, and terminating parental rights.
Multidisciplinary conferences and training sessions are used in all five states we visited to impart information to juvenile dependency court participants on child welfare concepts and court priorities and goals, to build relationships, and to cross-train to learn each others’ roles in the child welfare system. According to CIP and court staff in these states, understanding each others’ roles and identifying common goals have helped reduce the adversarial environment of the court. California’s CIP convened a December 1997 Beyond the Bench Conference, for example, to enhance collaboration among all participants and to cover court improvement-related topics, such as collaborative ways to improve child protection, establishing dependency mediation programs, ensuring quality in court-appointed attorney representation, and addressing child sexual abuse. The conference also served as the kick-off activity for CIP, whose staff encouraged each county’s participants to brainstorm as a team on needed court improvements. North Carolina’s District 20—the state’s CIP pilot site comprising four rural counties—initiated CIP with a joint meeting of key child welfare system participants, such as county social service directors, mental health directors, and guardian ad litem administrators. Monthly training sessions allow court participants to take part in making reform decisions. The four counties host the sessions on a rotating basis, with some sessions being county-oriented, some district-oriented, and some oriented by job discipline. According to CIP staff, training across disciplines helps each participant learn about the roles and responsibilities of others as well as builds camaraderie among and a higher degree of professionalism in all court participants.
For courts to meet statutory time frames and to understand the dynamics and needs of the clients they serve, information is critical. To improve this key element of court infrastructure, three of the five locations we visited—California, Illinois, and North Carolina—are developing information systems statewide or in specific counties. A fourth location—Hamilton County, Ohio—developed its current juvenile court information system beginning in 1992 and continues to enhance its capability. Although the county’s Juvenile Case Activity Tracking System is not linked to the child welfare agency’s computer system, the court downloads information to the agency as needed. The systems in the sites we visited are used, or will be used, to gather and track case data, evaluate trends, manage workload, and share information. For example, California’s CIP is providing computers to all jurisdictions and has created an Internet Web page for information sharing and networking among the various counties. The Web site will contain a variety of items, such as case summaries—since some courts do not have law libraries—and judicial opinions. Cook County, Illinois, is developing a comprehensive computer system for the county’s entire juvenile court, known as the Juvenile Enterprise Management System (JEMS). JEMS electronically links the court and its agencies (such as the public guardian, public defender, sheriff, and state’s attorney) to gather case data and manage workload. North Carolina’s CIP is developing a case management system using laptop computers and case tracking software developed by the guardian ad litem program.
section_title: Other Reforms Are Focused on Improving Individual Case Decision-Making
paragraphs: Other reforms under way in the states we visited focus on making decisions in an individual child’s case, intervening at key points in the process to gather and share comprehensive information among court participants, and resolving issues outside the courtroom. State and local officials believe additional time invested at the beginning of a case can shorten the length of time it takes to make a permanent placement decision. For example, Day One Conferences in North Carolina’s District 20 are held on the first business day after a child is taken into custody by the child welfare agency. In attendance are the parents, child welfare caseworkers, guardians ad litem, public and mental health liaisons, attorneys, public education liaisons, child support liaisons, law enforcement officers, and the court improvement case manager. These meetings provide a forum to arrange services for the family immediately, on the basis of the belief that the more quickly the family receives services, the more likely the family will be able to stay together or be reunified. The meetings also provide an opportunity to reach agreement on many aspects of the case outside the courtroom and can reduce the number of times a case is continued. The Day One group discusses the need for continued out-of-home placement, case planning and services provided to the family before removal of the child from the home, and future service needs. Should a decision be made for the child to remain in out-of-home care, paternity, parental visitation, and financial support are also discussed. Cook County, Illinois, has initiated Court Family Conferences, similar to Day One Conferences, to provide an opportunity for parents to participate in the process to expedite their children’s return home. These conferences are held approximately 55 days after the preliminary protective hearing to discuss issues in the case and, if possible, set a realistic target date for a successful return home. Attempts are made to reach agreement on key issues, such as the facts that led to removal of the children, the tasks the parents must complete in order to have their children returned, and the date by which social services will be provided.
Mediation—seen as a way to handle escalating court caseloads and possibly decrease court hearings—is used at a variety of different points in the court process in two of the five local sites we visited. Mediation involves the intervention of a neutral third party who has no authoritative decision-making power. The mediator helps the parties—such as the parents and other relatives, assigned social workers, and child advocates—come to agreement on issues in dispute in a nonadversarial setting. Mediations allow all parties to be active in the decision-making process and to develop a plan in the best interests of the child, thus reducing the number of issues the court must decide.
The Ninth Judicial Circuit in Florida, for example, uses mediation for the more difficult cases and a companion initiative—case plan conferences—for the remaining ones. Case plan conferences follow the mediation protocol but are not facilitated by a trained mediator. One goal of these initiatives is to have parents acknowledge the problems that brought them into the system. According to circuit officials, each method allows the parties to reach resolution faster and enhances the quality of trials because every issue in the case does not need to be discussed in court. Further, the number of trials has decreased as more cases have been fully resolved in mediation. Circuit officials believe the juvenile dependency court system has become less adversarial and that the focus has shifted away from winning or losing a case. Mediations and case plan conferences, however, place additional resource demands on the system because the mediation or conference must take place between the preliminary protective hearing and when the abuse and neglect petition is officially filed—generally a 3-week period in the Ninth Circuit. Similarly, Santa Clara County, California, began using mediation in 1992 after the state legislature encouraged its use as a way to intervene in cases in a more constructive manner. Mediation may be used at any stage in the court proceedings. After all areas of agreement are presented to the court, the court determines the acceptability of any agreements reached.
Another reform—the one-judge model of case management—is used in four of the five local sites we visited—Hamilton County, Ohio; Santa Clara County, California; the Ninth Judicial Circuit in Florida; and District 20 in North Carolina. This staffing process requires the judicial officer presiding over the preliminary protective hearing to also conduct all subsequent hearings until the child is returned home or a decision has been reached about where the child will permanently reside, generally no later than 12 months after the child is considered to have entered foster care, as required by federal law. The one-judge model can enhance case management and guarantees that one person has all the information regarding the child. According to NCJFCJ’s Resource Guidelines, a judge who remains involved with a family is more likely to make decisions that are consistent with the best interests of the child.
Finally, two of the five local sites we visited have increased the length of the preliminary protective hearing. NCJFCJ’s Resource Guidelines recommend that courts allocate 1 hour for these hearings—which are generally held immediately after a child’s removal from the home—to allow adequate time to conduct a thorough assessment of the case. Cook County, Illinois, created an adjunct to its preliminary hearing, known as the extended temporary custody hearing, resulting in an increase in the average time spent from about 7 minutes to about 45 minutes. The extended temporary custody hearings are conducted off-the-record and cover topics such as visitation plans, placement options, and the initial service needs of the family, as well as reasonable efforts made by the child welfare agency and a court review of the necessity of removing the child from home. At the conclusion of the hearing, information is summarized and presented to the court at the official preliminary protective hearing. The Hamilton County, Ohio, juvenile court generally schedules an initial hearing for 1 hour on the same day the petition has been filed to initiate the court process. The purpose of the extended hearing is to get the case moving quickly and to review the child welfare agency’s initial handling of the case before the preliminary protective hearing. Counsel for parents and a guardian ad litem for the child are appointed, and the court makes an in-depth inquiry regarding the child’s current placement, early parental visitation, and the availability of relatives to care for the child.
section_title: Key Ingredients Are Necessary for Successful Reform
paragraphs: The experiences of the states and localities that have begun efforts to reform their juvenile dependency court systems provide valuable lessons to other jurisdictions contemplating similar reform efforts. During our field work, state and local officials that have undertaken reforms identified three ingredients that are key to successful reform efforts: (1) the presence of judicial leadership and collaboration among child welfare system participants, (2) the availability of timely information on how the court is currently operating and processing cases, and (3) the availability of financial resources to initiate and sustain reform.
subsections: section_title: Judicial Leadership and Collaboration Are Critical
paragraphs: Experts as well as state and local officials in all five locations we visited agree that reforms cannot occur without strong judicial leadership. These experts and officials believe that judges set the tone for how reform will occur; have the authority to institute new court rules, policies, and practices; and are key to bringing all child welfare system participants on board. For example, in 1995 the ABA reported on reforms undertaken in the Kent County, Michigan, juvenile dependency court. The ABA found that a key element of that court’s ability to perform the additional functions designed to help achieve permanent and safe homes for maltreated children was a strong commitment from the presiding judge, other judges, and almost all court staff to meet the individual needs of children and to achieve safe permanent placements for maltreated children. According to the NCJFCJ, judges in juvenile dependency courts need to feel comfortable taking a leadership role beyond their traditional role. The juvenile court judge is expected to actively develop resources and services for at-risk children and families and to encourage interagency cooperation and coordination.
Similarly, the juvenile court system is unique in its reliance on the work of a variety of nonlegal professionals—such as caseworkers, private agency social workers, and physicians—to make the most informed decisions possible about an individual child. Collaboration of these participants is necessary to get reforms under way and keep reforms moving. This collaboration is critical because these individuals share responsibility with the judiciary for providing care, representation, and protection for children removed from their homes. Two ABA reports document the importance of interdisciplinary collaboration. In 1993, the ABA’s Center on Children and the Law concluded in a book for child welfare administrators that the biggest mistake made by child welfare agencies is underestimating their ability to solve problems together with the court. According to the Center, agencies should develop well-reasoned strategies for working with the juvenile courts and give it top priority. Similarly, the ABA’s 1995 report on the model juvenile court in Kent County, Michigan, found that the court’s interdisciplinary efforts to resolve individual cases as well as systemic problems was a key element in its successful reform. HHS and state and local officials in all five states we visited emphasize using a team approach for identifying and implementing reforms, drawing in all relevant groups within the system. For example, in its CIP “Program Instruction,” HHS strongly encouraged state courts to coordinate and collaborate with other interested parties, programs, and resources, such as state child welfare agencies, guardians ad litem, and attorneys, in administering the CIP and designing new systems. Similarly, Florida CIP officials commented that the strength of the CIP program is its multidisciplinary focus. The Florida CIP assessment represented the first time all court participants had been asked their opinion about the condition of child welfare and the courts. The high level of animosity between the court and the child welfare agency has diminished, and dialogue between court participants has increased. Officials added that new child welfare legislation could not have been passed without the teamwork of the court and the child welfare agency.
Without the leadership of judges, reform efforts can fail. We found evidence of this type of failure in North Carolina, where reforms were originally scheduled for piloting in two judicial districts. Although reforms were implemented in District 20, the second district dropped out of the pilot project primarily because of a lack of judicial commitment and vision, according to a CIP document. The document outlines the problems encountered and states that although this district had other positive attributes that increased its chances of implementing successful reforms—such as cooperative working relationships between the court and the child welfare agency—the lack of complete support and commitment from the juvenile court judges impeded the district’s ability to identify common goals and priorities for change. This lack of support was manifested in several ways, including the court system’s tolerance for attorney tardiness at mediation sessions, disagreements among judges on how mediation results would be presented in court, and a lack of judges’ involvement in CIP committee meetings and training.
section_title: Baseline and Ongoing Information on Court Operations Is Necessary
paragraphs: State and local officials in some of the states we visited indicated that statewide baseline data on how well their courts were meeting statutory permanency time frames and on the nature of delays in the court process provided the necessary information to structure reform efforts and to convince others of the need for change. For example, Florida presented the results of its CIP assessment at a statewide summit to show participants their role in delaying case resolution. As a result, judicial officers came to understand the nature of problems in the juvenile court and how the officers contribute to delays in reaching decisions about permanent homes for children. According to a CIP official, never before has Florida experienced such judicial activism or court participants seeking change on the basis of data and analysis. Similarly, Illinois officials indicated that the results of the statewide data collection for the CIP assessment provided the proof of what everyone suspected was wrong with the system, gave validity to the need for reform, and helped identify the types of reform needed. Judicial officers in California said the CIP assessment was potentially the most powerful document involved in getting court improvement moving.
Effectively managing abuse and neglect cases over time is essential for successful permanency planning. According to NCJFCJ, a key component of case management is the use of a monitoring and information system capable of measuring court progress in moving cases and identifying cases that have been seriously delayed, among other things. Similarly, ABA’s 1992 report on the Hamilton County, Ohio, court stated that a key to this court’s successful reforms was its routine collection and use of data. California CIP officials told us that data are critically needed because the state does not know how many children are under the jurisdiction of the court. These officials are requiring all local CIP projects to provide data because they believe such data are critical for making good decisions and policies for children.
section_title: Financial Resources Are Essential to Seed and Sustain Reform Efforts
paragraphs: HHS and DOJ have provided and administered funds for a variety of reforms, such as development of model courts, the Resource Guidelines, and CIPs. These funding streams are significant because experts and state and local officials agree that juvenile dependency courts have few resources to independently undertake reform activities. In 1995, ABA reported that child maltreatment cases still have low priority in most court systems, in terms of attention by court administrators, assignment of qualified judges, and allocation of resources.
Some state and local officials echoed this concern, adding that programs such as CIP were critical to the reform work now occurring. According to these officials and other experts, CIP provided funding to help the courts improve the handling of maltreatment cases, enabling and mandating each state to gather the necessary baseline information and orchestrate reforms. For example, a Cook County, Illinois, official told us the court had previously tried to gather baseline information about the permanency process to no avail—the project was difficult because funding was not available from federal, state, or local sources. Similarly, Florida CIP officials and court staff told us that, as a result of CIP’s initiation and funding, juvenile dependency courts are in the spotlight for the first time, and judges are more interested than they were previously in implementing court improvements. These officials added that the Florida assessment would not have been possible without CIP funding and that no other entity would have funded other critical activities, such as the establishment of working groups to develop major revisions to the state’s child protection statute.
section_title: Local Officials Note Progress, but Few Results Are Documented
paragraphs: Most sites we visited are just beginning the process of evaluating and documenting the effectiveness of implemented reforms, although progress has been made in addressing some of the problems that plague juvenile dependency courts. For example, Cook County, Illinois, has seen its court caseload drop from 58,000 in 1994 to 38,000 in 1997, and Hamilton County, Ohio’s, caseload dropped from 4,000 in 1979 to 1,500 in 1995. Cook County and Hamilton County officials view the drop in caseload as an improvement in their dependency court process. In addition to smaller court caseloads, local officials told us anecdotally that other improvements are occurring, such as (1) fewer court continuances are requested, granted, or both; fewer cases are contested; and cases seem to be resolved more quickly; (2) judges are more active in cases, and court participants are working toward developing a less adversarial environment; and (3) services for the family begin earlier, and better information on the family’s progress may be available for court decision-making on cases.
These improvements, however, have not been formally evaluated. Although determining the right measures for evaluation can be difficult, without this kind of information, officials are unable to determine which interventions have improved their courts and which have not. Evaluation plans in the states we visited are limited. For instance, the CIP Advisory Committees in all five states are in the early stages of developing evaluation plans. Illinois CIP officials have required all projects funded with CIP dollars to provide regular status reports and conduct an evaluation of the project. Projects previously funded are currently working on developing evaluations, and projects funded in 1998 must provide a reporting and evaluation plan to the CIP Committee before receiving the money. In addition, all projects must provide baseline data so that change can be measured. Illinois officials acknowledge that evaluation will be difficult, since several changes may be undertaken in one location and it will be hard to separate out results. In addition, good statistical data are usually lacking in the counties, which impedes baseline development.
Similarly, a Florida CIP official told us that the state plans to evaluate court improvements statewide using a self-evaluation tool sent to the local circuits. Unfortunately, judicial circuits are not required under CIP to maintain statistics, and therefore some do not.
section_title: Concluding Observations
paragraphs: The juvenile dependency courts face numerous systemic problems that hinder their ability to oversee, monitor, and guide decision-making to protect children and ensure that they are placed in an appropriate, permanent home. To address these problems, states and localities have initiated reforms aimed at improving the quality and timeliness of judicial decisions, in order to minimize the amount of time children spend in the foster care system. However, if the courts are to move forward in addressing children’s long stays in the foster care system, they must remain cognizant of the essential reform components—such as strong judicial leadership—that we found are common to successful reform efforts. Adding to the demands of reforming dependency courts, new federal legislation poses challenges for courts in their attempts to change the way they monitor and process child maltreatment cases. ASFA requires states and localities to file a court petition to terminate the parental rights of the child’s parents if the child has been in foster care for 15 of the most recent 22 months, as well as to hold the permanency planning hearing no later than 12 months after the child is considered to have entered foster care. These provisions exert new pressure on the courts to move cases more quickly and affect how the courts conduct child maltreatment proceedings. States and localities not actively engaged in reform will need to recognize the importance of identifying and implementing new ways to more quickly move children through the dependency court process and meet the requirements of this legislation. States and localities already implementing changes will need to anticipate the consequences of their reform efforts and restructure them, if necessary, so additional problems are not created. For example, as the amount of time it takes to establish plans for where children will permanently live diminishes, states and localities may see increases in the number of children for whom parental rights have been severed and for whom they will need to identify potential placements.
section_title: Agency and Other Comments
paragraphs: We obtained comments on a draft of this report from HHS, state CIP officials, and local judges responsible for the juvenile dependency courts in the five locations we visited. HHS commented that it has actively worked with the states to address court reform issues since the inception of CIP and outlined a variety of activities the Department has undertaken. HHS also provided technical comments, which we incorporated where appropriate. State CIP and local officials from the five juvenile dependency courts generally agreed with the report’s findings and provided technical clarifications about the reforms under way, which we also incorporated in the report as appropriate.
We are sending copies of this report to the Secretary of Health and Human Services, state CIP liaisons, state child welfare agencies, and other interested parties. Copies will also be made available to others on request. If you or your staff have any questions about this report, please call me at (202) 512-7215. Other major contributors to this report are listed in appendix II.
section_title: Scope and Methodology
paragraphs: To determine what problems the juvenile dependency courts face, we reviewed the relevant literature and interviewed experts in the dependency court process, such as officials at national court-related organizations and researchers. We obtained the perspectives of representatives of the National Council of Juvenile and Family Court Judges (NCJFCJ), American Bar Association (ABA), National Center for Juvenile Justice, National Center for State Courts, National Court-Appointed Special Advocates (CASA) Association, National Association of State Foster Care Managers, Annie E. Casey Foundation, and Kellogg Foundation. In addition, we interviewed officials of the Department of Justice, Office of Juvenile Justice and Delinquency Prevention, and the Department of Health and Human Services, Children’s Bureau. Finally, for the states we visited, we reviewed assessments of foster care and adoption laws and judicial processes in child maltreatment proceedings. These assessments were required under the Court Improvement Program (CIP).
To obtain first-hand information on dependency court activities, we conducted field visits in California, Florida, Illinois, North Carolina, and Ohio, where we reviewed reforms funded by CIP as well as by other programs. We chose these five locations—Santa Clara County, California; the Ninth Judicial Circuit in Florida, composed of Orange and Osceola counties; Cook County, Illinois; Judicial District 20 in North Carolina, composed of Anson, Richmond, Stanly, and Union counties; and Hamilton County, Ohio—because experts considered them to be implementing significant reforms or because CIP had been a major impetus for change there. We also chose a mix of rural, suburban, and urban locations. Florida and North Carolina were chosen because CIP had been the catalyst for change in those states. Florida’s Ninth Judicial Circuit was chosen because its CIP pilot project had implemented several reforms, including several of the provisions proposed under the Adoption and Safe Families Act but not yet enacted by the Congress when Florida’s pilot began in August 1997. North Carolina, a predominantly rural state, had established a CIP pilot project in Judicial District 20. We also selected three states—California, Illinois, and Ohio—that had reforms under way before CIP. California was chosen because it contained approximately 23 percent of the nation’s foster care population in fiscal year 1996, and Santa Clara County, because of its history of reform since the early 1980s. The presiding judge in Santa Clara County is also seen as a leading expert in reforming child maltreatment proceedings, according to the ABA and NCJFCJ. Illinois was also chosen because of its high share of the nation’s foster care population—about 9 percent in fiscal year 1996—and Cook County, because of its urban character, known problems in the courts, and status as an NCJFCJ model court. Finally, Hamilton County, Ohio, was selected because it has been actively reforming its juvenile dependency courts since the mid-1980s and is considered a model for other courts seeking to reform.
In each state, we met with state CIP officials to obtain an overview of ongoing and planned court improvement efforts throughout the state, as well as with state child welfare officials to discuss their involvement in court reform. We also obtained state officials’ views of problems in their courts and challenges that lie ahead. At the local sites we selected, we met with a variety of participants in the child welfare system, including judicial officers, attorneys, guardians ad litem, CASA representatives, court administrative staff, child welfare officials, and service providers. We discussed problems and barriers to reforms, progress achieved under the reforms in place, and remaining obstacles. Finally, we observed court child maltreatment proceedings in each site.
section_title: GAO Contacts and Staff Acknowledgments
subsections: section_title: GAO Contacts
section_title: Staff Acknowledgments
paragraphs: Ellen Soltow also made important contributions to this report.
section_title: Related GAO Products
paragraphs: Child Welfare: Early Experiences Implementing a Managed Care Approach (GAO/HEHS-99-8, Oct. 21, 1998).
Foster Care: Agencies Face Challenges Securing Stable Homes for Children of Substance Abusers (GAO/HEHS-98-182, Sept. 30, 1998).
Foster Care: Challenges Faced in Implementing the Multiethnic Placement Act (GAO/T-HEHS-98-241, Sept. 15, 1998).
Foster Care: Implementation of the Multiethnic Placement Act Poses Difficult Challenges (GAO/HEHS-98-204, Sept. 14, 1998).
Parental Substance Abuse: Implications for Children, the Child Welfare System, and Foster Care Outcomes (GAO/T-HEHS-98-40, Oct. 28, 1997).
Child Protective Services: Complex Challenges Require New Strategies (GAO/HEHS-97-115, July 21, 1997).
Foster Care: State Efforts to Improve the Permanency Planning Process Show Some Promise (GAO/HEHS-97-73, May 7, 1997).
Child Welfare: States’ Progress in Implementing Family Preservation and Support Activities (GAO/HEHS-97-34, Feb. 18, 1997).
Child Welfare: Complex Needs Strain Capacity to Provide Services (GAO/HEHS-95-208, Sept. 26, 1995).
Child Welfare: Opportunities to Further Enhance Family Preservation and Support Activities (GAO/HEHS-95-112, June 15, 1995).
Foster Care: Health Needs of Many Young Children Unknown and Unmet (GAO/HEHS-95-114, May 26, 1995).
Foster Care: Parental Drug Use Has Alarming Impact on Young Children (GAO/HEHS-94-89, Apr. 4, 1994).
Residential Care: Some High-Risk Youth Benefit, but More Study Needed (GAO/HEHS-94-56, Jan. 28, 1994).
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