Child Welfare: More Information and Collaboration Could Promote Ties Between Foster Care Children and Their Incarcerated Parents
Published: 2011-09-26T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Federal law sets timelines for states' decisions about placing foster care children in permanent homes, and, in some cases, for filing to terminate parental rights. Some policymakers have questioned the reasonableness of these timelines for children of incarcerated parents and expressed interest in how states work with these families. GAO was asked to examine: (1) the number of foster care children with incarcerated parents, (2) strategies used by child welfare and corrections agencies in selected states that may support contact or reunification, and (3) how the Department of Health and Human Services (HHS) and the Department of Justice (DOJ) have helped these agencies support affected children and families. GAO analyzed national data, reviewed federal policies, interviewed state child welfare and corrections officials in 10 selected states that contain almost half of the nation's prison and foster care populations, and visited local child welfare agencies and prisons.
section_title: What GAO Found
paragraphs: Foster care children with an incarcerated parent are not a well-identified population, although they are likely to number in the tens of thousands. HHS data collected from states show that, in 2009 alone, more than 14,000 children entered foster care due at least partly to the incarceration of a parent. This may be an undercount, however, due to some underreporting from states and other factors. For instance, the data do not identify when a parent is incarcerated after the child entered foster care--a more common occurrence, according to case workers GAO interviewed. HHS is currently developing a proposal for new state reporting requirements on all foster care children; however, officials had not determined whether these new requirements would include more information collected from states on children with incarcerated parents. In 10 selected states, GAO found a range of strategies that support family ties. Some state child welfare agencies have provided guidance and training to caseworkers for managing such cases; and local agencies have worked with dependency courts to help inmates participate in child welfare hearings by phone or other means. For their part, some corrections agencies ease children's visits to prisons with special visitation hours and programs. In several cases, corrections agencies and child welfare agencies have collaborated, which has resulted in some interagency training for personnel, the creation of liaison staff positions, and video visitation facilitated by non-profit providers. HHS and DOJ each provide information and assistance to child welfare and corrections agencies on behalf of these children and families. For example, both federal agencies post information on their websites for practitioners working with children or their incarcerated parents, with some specific to foster care. The HHS information, however, was not always up to date or centrally organized, and officials from most of the state child welfare and corrections agencies GAO interviewed said they would benefit from information on how to serve these children. Further, DOJ has not developed protocols for federal prisons under its own jurisdiction for working with child welfare agencies and their staff, although GAO heard from some state and local child welfare officials that collaboration between child welfare and corrections agencies would facilitate their work with foster care children and their parents. This would also be in keeping with a DOJ agency goal to build partnerships with other entities to improve services and promote reintegration of offenders into communities.
section_title: What GAO Recommends
paragraphs: GAO recommends that HHS improve its data on the foster care children of incarcerated parents and that it more systematically disseminate information to child welfare agencies. GAO also recommends that DOJ consider ways to promote collaboration between corrections and child welfare agencies, including establishing protocols for federal prisons to facilitate communication between these entities. HHS and DOJ agreed with GAO's recommendations.

section_title: Letter
paragraphs: Some of our nation’s most vulnerable children are those who have been  removed from their homes and placed in foster care, often due to neglect  or abuse. At the end of fiscal year 2009, 423,773 children were in foster  care, according to the most recent available data from the Department of  Health and Human Services (HHS). Some researchers and advocates  maintain that there has been a growth in the number of foster care  children with an incarcerated parent, due in part to an increase in the  number of incarcerated mothers over the years. While incarcerated  fathers made up more than 90 percent of the 809,800 parents in prison in  2007, according to the most recent estimates from the Department of  Justice (DOJ), the number of mothers in prison more than doubled from  1991 to 2007 (29,500 to 65,600, respectively). Some researchers and  advocacy groups have also questioned whether child welfare and  corrections systems have overlooked the rehabilitation of these parents  and the assessment of opportunities to preserve family ties, when  appropriate. They have further raised concerns about whether federal  foster care timelines for filing to terminate parental rights—intended to  place children more quickly into permanent adoptive homes—have  inappropriately affected these families, given the length of time some  parents are incarcerated. Meanwhile, although states and local agencies  have primary responsibility for administering child welfare services, the  federal government provides about $8 billion annually to states for child  welfare programs, including for foster care programs. In addition,  corrections agencies at the local, state, and federal level may play a role  in efforts to establish bonds between incarcerated parents and their  children through their policies and programs.
In this context, you asked us to address the following questions: (1) How  many children in foster care have an incarcerated parent? (2) What  strategies have child welfare and corrections agencies in selected states  used that could support contact or reunification, when appropriate,  between these children and their incarcerated parents? (3) In what ways  do HHS and DOJ help child welfare and corrections agencies in working  with these children and their incarcerated parents?
To address these questions, we used several methodologies. First, we  reviewed relevant national data on foster care children maintained by  HHS and on incarcerated parents from surveys, administered by DOJ’s  Bureau of Justice Statistics (BJS), of inmates in state and federal prisons  and local jails. We reviewed the methods and survey design used to  produce the data from both of these sources, as applicable, and, through  interviews with knowledgeable agency officials and our own analyses, we  determined that the data we used were sufficiently reliable for our  purposes. Second, we conducted structured telephone interviews with  state administrators of child welfare and corrections agencies in 10  selected states to gather relevant information on the extent to which  states collect data on our target population, state policies and programs,  and officials’ perspectives on challenges and areas in which additional  federal assistance would be useful. States were selected to represent  nearly half of the prison inmates and foster care children in the United  States and for geographic variation. Some states were also selected  because they had been identified by researchers and professionals  knowledgeable on these topics as having strategies (policies, programs,  or practices) aimed at supporting parent-child ties either statewide or in  localities within the state. For these 10 states, we also reviewed selected  child welfare statutes and other policies. Third, to gather more in-depth  information at the local level, we conducted site visits in 4 of the 10 states  and interviewed local child welfare officials and caseworkers; dependency  court judges; corrections staff primarily from prison facilities as well as a  few jails; community service providers; and, in a few cases, incarcerated  parents and former foster care youth. The information we gathered from  our phone interviews and site visits is not generalizable to all states and  localities. In addition, while we collected information about relevant  strategies used in our selected states, we did not review how widespread  these were practiced in each state. Fourth, we interviewed HHS and DOJ  officials knowledgeable about pertinent agency activities and reviewed  relevant federal laws, regulations, policies and other agency  documentation. Last, we interviewed researchers and professionals from  a range of national organizations, including family resource centers,  corrections associations, and child welfare organizations, and reviewed  available literature from these groups. See appendix I for additional  information on our methodology.
subsections: section_title: Background
subsections: section_title: Foster Care Children and the Child Welfare System
paragraphs: A child generally enters foster care after a dependency court and a child  welfare agency have determined that the child should be removed from  his or her home, for reasons such as substantiated abuse or neglect.  Children in foster care may be temporarily placed in various types of out- of-home care arrangements, including in a foster home with relatives, in a  foster home with nonrelatives, or in a group residential setting. Federal  law requires that state child welfare agencies consider giving preference  to placing children with qualified relatives, if consistent with the best  interest of the child. Approximately one-quarter of children in foster care  in fiscal year 2009 lived with relatives, according to HHS data.
Federal law also requires child welfare agencies to make “reasonable  efforts” to preserve and reunify families in most cases, but leaves it to  states to define what these efforts entail, on a case by case basis.  However, at a minimum, child welfare agencies must make a diligent  effort to identify and notify all adult relatives shortly after the child’s  removal from the custody of the parent. They must also develop a case  plan for each foster care child which, among other requirements, must  describe the services that will be provided to the parents, child, and foster  parents to facilitate the child’s return to his or her own home or permanent  placement, and address the child’s needs while in foster care. The plan  may also specify goals for placing the child in a permanent home and the  steps that a parent (or the principal caretaker) must take before a child  can be returned home, if reunification is the goal.
In general, returning children to their home is the preferred goal of state  child welfare agencies, but this goal is still dependent on various factors,  such as the extent that a parent has completed rehabilitative treatment or  maintained a meaningful role in the child’s life through visits or other  forms of contact. In fiscal year 2009, about half of the nation’s children  who exited foster care were reunified with their parent or primary  caretaker (see table 1).
The Adoption and Safe Families Act of 1997 (ASFA) was passed, in part,  in response to concerns about the length of time children were spending  in foster care and included provisions to facilitate child welfare agencies’  ability to place children more quickly into safe and permanent homes.  For example, the law requires child welfare agencies to hold permanency  hearings within 12 months of the child’s entering foster care to determine  the permanent placement for the child and requires child welfare  agencies to file a petition to terminate parental rights when a child has  been in foster care for 15 of the most recent 22 months (see fig. 1).  However, states are not required to file for termination of parental rights if  a child is in the care of relatives, the state has not provided necessary  services to the family consistent with the case plan, or the state agency  documents a compelling reason why filing for termination is not in the  best interests of the child. These timelines and possible exceptions are  relevant for incarcerated parents who have children in foster care, as 44  percent of inmates released from state prisons in 2008 served sentences  longer than a year. Since the enactment of ASFA, the number of  children in foster care nationwide has declined by more than 100,000,  based on HHS data collected on children in care at the end of each fiscal  year.
HHS administers federal grant programs and provides information,  training, and technical assistance to state child welfare systems. It uses  its Adoption and Foster Care Analysis and Reporting System (AFCARS)  to capture, report, and analyze information collected by the states. On a  semiannual basis, all states submit data to HHS concerning all foster care  children for whom state child welfare agencies have responsibility for  placement, care, or supervision. HHS also uses its Child and Family  Services Reviews (CFSR) to regularly evaluate state child welfare  systems’ conformity with federal requirements and help states improve  their provision of child welfare services. These reviews examine a range  of outcomes and actions to assess states’ performance and enhance their  capacity to ensure children’s safety, permanency, and well-being. For  example, among many other factors, HHS examines states’ attempts to  preserve parent-child relationships and involve parents in discussions  about the child’s case plan. To help states provide child welfare services,  HHS offers states training and technical assistance through its Children’s  Bureau, as well as through its regional offices and various National  Resource Centers. HHS also provides information and resources through  its website, “The Child Welfare Information Gateway,” which is meant to  serve as a comprehensive information resource for the child welfare  field.
section_title: Children of Incarcerated Parents and the Corrections System
paragraphs: Many children, not only those in foster care, have an incarcerated parent,  and this number has grown over time. Since the early 1990s, the number  of individuals in prison almost doubled from a little fewer than 800,000 in  1991 to more than 1.5 million in 2009. Many of these individuals have  children. As of 2007, an estimated 1.7 million children under the age of  18 had a parent in prison—an increase of almost 80 percent since 1991  (see fig. 2). Fathers comprise more than 90 percent of the parents in  prison and their numbers increased about 75 percent between 1991 and  2007. Meanwhile, the number of incarcerated mothers, who were more  likely to be primary caretakers before incarceration, more than doubled  during this time. Children who are minorities are disproportionately more  likely to have an incarcerated parent than white children. In 2007,  compared to non-Hispanic white children, non-Hispanic black children  were more than seven times more likely to have a parent in prison and  Hispanic children were more than two times more likely.
Incarcerated parents may have a history of complex problems, such as  substance abuse, mental illness, or past trauma. For instance, in 2004,  about two-thirds of parents in state prisons met clinical criteria for having  substance dependence or abuse based on BJS’s most recent available  estimates. The federal government supports a number of residential  treatment programs that focus specifically on the treatment of parents  with substance abuse problems. Although these programs may require  parents with substance abuse problems to live away from home, they  generally serve nonincarcerated parents. (See app. II for more  information.) Mental health and medical problems were also common for  incarcerated parents, although women reported these at higher rates.  Incarcerated mothers were also much more likely than fathers to report  past physical or sexual abuse (64 percent for mothers in state prison  versus 16 percent for fathers).
The Second Chance Act of 2007 was enacted to, among other goals,  reduce recidivism and provide for services to assist people transitioning  back into the community from prisons and jails. The act amended existing  federal grant programs and established new grant programs for state  agencies and nonprofit organizations to provide a variety of programs or  services that include employment assistance, substance abuse treatment,  and help in maintaining or reestablishing family ties.
DOJ’s Federal Bureau of Prisons (BOP) oversees and establishes central  policy for 116 federal prison facilities, but it does not have authority over  or establish policies for state or local corrections agencies or facilities  (see table 2). Nevertheless, DOJ provides assistance to these entities in  the form of discretionary grants, technical assistance, and information.
section_title: Foster Care Children with an Incarcerated Parent Are Not a Well- Identified Population, but Available Data Suggest They Number in the Thousands
paragraphs: The complete number of foster care children with an incarcerated parent  cannot be identified in the database that HHS employs as part of its  oversight of state programs, but their numbers can be reasonably  estimated as being in the many thousands. HHS has proposed changes  to state reporting requirements that would shed more light on these  children; however, the department is currently in the process of revising  that proposal and officials had not yet determined if collecting additional  data on incarcerated parents will be included in the new proposed  requirements. Also, some states are attempting to better identify them  and to determine their needs.
subsections: section_title: The National Foster Care Data System Offers Limited Information, but Shows Thousands of These Children Enter Foster Care Annually
paragraphs: HHS data provided by states identified at least several thousand children  nationwide who entered foster care due to the incarceration of a parent in  a recent year, but this does not include the total population of foster care  children with incarcerated parents. Through its national data system,  AFCARS, HHS collects information about the characteristics and  experiences of children in the foster care system, such as their age, race,  and the factors associated with their removal from the home and  placement into foster care. One potential reason for a child’s removal,  among many others listed in AFCARS, is the incarceration of a parent.  From this information, it is possible to identify some foster care children  with an incarcerated parent—those who have entered foster care solely  or in part for the reason of parental incarceration—but it is not possible to  identify these children in other circumstances (see figure 3). Our analysis  of AFCARS information identified approximately 14,000 children who  entered foster care at least partly because of parental incarceration in  2009 alone (about 8 percent of all children entering foster care in 2009);  however, this is an undercount of foster care children with an incarcerated  parent for several reasons. First, this number does not include children  who enter foster care in other circumstances, such as:    When a parent is incarcerated sometime before the child enters foster  care. For example, a child welfare official and a researcher told us  that some children are placed with a relative when a parent is  incarcerated, and then enter foster care when this relative-care  situation places the child at risk of abuse or neglect.   When a parent is incarcerated sometime after the child enters foster  care.   When an incarcerated parent, such as a noncustodial father, was not  the child’s caretaker at the time of removal.
Researchers and local officials we interviewed noted that these  circumstances were more common than placement in foster care  specifically due to parental incarceration. While such additional  information about a parent’s incarceration may be in the child’s individual  child welfare case file, it is not reported in the data conveyed to HHS and  incorporated into AFCARS.
Second, state reporting on these children for AFCARS is not necessarily  as complete as HHS requires. For example:    HHS’s AFCARS regulations require state child welfare caseworkers to  report all applicable actions or conditions associated with a child’s  removal from the home, but staff sometimes enter only one reason.  One state official and one local official told us that, even if   incarceration were involved, a case worker may opt for a more  general reason, such as neglect.    New York, which has the second largest foster care population in the  United States, has historically not reported data on any reasons for  removal due to some localities’ older data systems, according to HHS  officials.   Similarly, a few states can report information on only one reason for  removal due to older data systems and, therefore, have not regularly  reported instances in which a second reason might apply.
HHS officials noted that the department assists state efforts to comply  with AFCARS reporting requirements in several ways. For example, HHS  has assessed most states’ AFCARS information systems to determine  states’ abilities to collect, extract, and transmit AFCARS data accurately,  as well as to review the timeliness and accuracy of data entry by  caseworkers. When an HHS review team determines that a state does  not fully satisfy the AFCARS standards, the state must make corrections  identified by that team. HHS regional offices also work with states to  improve their reporting by implementing training, supervisory oversight,  and quality assurance, according to HHS officials.
The fact that foster care children of incarcerated parents are not a well-  identified population nationally precludes analyzing those children’s  characteristics and experiences, or determining whether they differ from  other foster care children in terms of their backgrounds, case  management, or outcomes.
Acknowledging that much of AFCARS information on the family’s  circumstances is gathered only at the time a child enters foster care— when child welfare workers know the least about the family’s situation— HHS, in January 2008, proposed changing its state reporting  requirements to require both additional and more current information.  Specifically, the department proposed collecting additional data on  circumstances that affect the child and family, such as a caretaker’s  incarceration, at multiple times throughout a foster care case. However,  due to significant statutory amendments made in October 2008 to the  federal foster care and adoption assistance programs, in 2010, HHS  announced plans to publish a new proposal to revise AFCARS and  solicited suggestions about what case-level data would be important for  agencies to collect and report to HHS. HHS officials told us that they are  currently developing the new proposal for reporting requirements and  estimated that it would be issued for public comment in February 2012.  Officials had not yet determined whether the new proposed rule would  include the same requirements on gathering additional information on a  caretaker’s incarceration at multiple times throughout the foster care case  as had been included in the 2008 proposal. Officials also said that they  did not know when a final set of reporting requirements would be issued,  as such timing is, in part, dependent on the comments received in  response to the proposed rule.
section_title: DOJ Survey Data Suggest Thousands of Foster Care Children Have an Incarcerated Parent
paragraphs: Although HHS data do not identify the complete number of foster care  children with an incarcerated parent, BJS inmate surveys from 2004 and  2002—the most recent years available—suggest that there are many  thousands of these children. Specifically, based on the 2004 survey of  federal and state prison inmates, we estimate that about 19,300 inmates  (about 13,700 men and 5,600 women) had at least one child in foster or  agency care in 2004 and that the total number of these children likely  exceeded 22,800. Similarly, a 2002 survey of inmates in local jails  estimated that approximately 12,000 of these parents in jail had at least  one child in foster care or cared for through an agency in 2002. These  surveys asked a nationally representative sample of inmates about their  children, the care arrangements for those children, and other questions  regarding their families’ circumstances and experiences. The surveys  also found that a higher percentage of mothers have at least one child in  foster care; some state officials said that this is because fewer  incarcerated mothers, compared to incarcerated fathers, have the option  of having the other parent take care of the child (see figure 4).  Nevertheless, close to 90 percent of all parents in state and federal  prison (mothers and fathers) with a child in foster care reported that they  had shared or had been providing most of the care for their child prior to  their incarceration, based on the 2004 survey.
Estimates of the number of inmates with children in foster care may be a  conservative indicator of the number of children of inmates that are in  foster care settings. This is because the inmate surveys do not fully  account for inmates who have more than one child in foster care. Also,  some of the children reported as living with relatives may be in relative  care that is supervised by the child welfare system, according to two  researchers we interviewed. Finally, prisoners may be generally reluctant  to report that they have children or provide information on their children  for various reasons, according to DOJ and several state and local  officials. On the other hand, it is possible that incarcerated parents  surveyed could report on the same child, since both mothers and fathers  were survey subjects, though DOJ officials overseeing the survey and  data said this situation was probably rare.
section_title: Some States Are Gathering Additional Data to Understand the Population Better
paragraphs: Several state child welfare and corrections agencies are collecting  additional data on foster care children with incarcerated parents to better  understand such children and their parental circumstances. Officials from  several states said that their state information is too limited to understand  the population and that more data would be useful to help policymakers  decide on policies or programs that might affect these children. Of the 10  state child welfare agencies we interviewed, three said they were  collecting additional data not required by AFCARS that could help identify  these children. For example, officials in New York’s child welfare agency  said the agency has begun to collect more information in its state child  welfare information system that would indicate whether the parent is in a  correctional facility, based on the parent’s address. Moreover, officials  at two corrections agencies in states we interviewed said they wer collecting information on inmates’ children and their care arrangements  while the parent is incarcerated.  Oregon’s Department of Corrections,  for example, currently collects data on all prisoners regarding whether  they have children and their children’s living arrangements, though this  information is not housed in an automated system. Officials from  e  Oregon’s Department of Corrections said that, based on surveys and  interviews of offenders in Oregon state prisons in 2000, 2002, and 2008,  about 10 percent of incarcerated mothers and about 6 percent of  incarcerated fathers had children living in foster care.
Child welfare officials from California informed us that they have done  some limited analysis of the parental address information the state  collects, in response to a request from the California legislature to provide  numbers on the foster care children of incarcerated parents. At our  request, California officials updated and expanded this research, and said  that 2,288 of California’s 52,561 children in foster care (about 4 percent)  had an incarcerated parent as of January 1, 2011. Of those children,  1,268 had an incarcerated father and 1,020 had an incarcerated mother,  according to the California officials. Officials also said that children with a  case plan goal of adoption were slightly more likely to have an  incarcerated parent than children with a goal of reunification.
section_title: Strategies for Preserving Families Include Flexibility in Timelines for Terminating Parental Rights, Programs for Parents, and Interagency Collaboration
paragraphs: In our examination of 10 states and their child welfare and corrections  agencies, we found states employed a number of strategies to support  family ties for all children of incarcerated parents, including some  strategies designed specifically for children in foster care. These  strategies are intended to address some of the challenges incarcerated  parents may face related to maintaining their parental rights and contact  with their children or to aid caseworkers in managing such cases. While  state and local officials discussed examples of these strategies, we did  not review how widely these strategies were used in each state, nor did  we evaluate the effectiveness of these strategies.
subsections: section_title: Several State Child Welfare Statutes Specifically Address the Special Circumstances of Incarcerated Parents
subsections: section_title: Termination of Parental Rights Provisions
paragraphs: Federal law allows for exceptions on a case-by-case basis to the  requirement that states file to terminate parental rights when a child has  been in foster care for 15 of the most recent 22 months. In addition to  these federal exceptions, some of the 10 states included in our review  have enacted explicit statutory provisions that could prevent or delay  filing for termination of parental rights for incarcerated parents in certain  circumstances. For example:    Nebraska prohibits filing for termination of parental rights solely on the  basis that the parent is incarcerated.   California and New York require child welfare agencies and courts to  consider the particular barriers faced by incarcerated parents—such  as whether parents are able to maintain contact with their children or  whether they lack access to rehabilitative services that would support  reunification—when making certain decisions regarding termination.   New York and Colorado include provisions related to the requirement  to file for termination of parental rights when a child has been in foster  care for 15 of the most recent 22 months. New York allows child  welfare agencies to delay filing for termination beyond standard  timelines in certain cases where a parent is incarcerated. Specifically,  in 2010, New York amended its statute to provide that the child  welfare agency need not file for termination when a child has been in  foster care for 15 of the most recent 22 months if, based on a case- by-case determination, the parent is incarcerated and maintains a  meaningful role in the child’s life. Colorado does not require courts to  consider the fact that the child has been in foster care for 15 of the  most recent 22 months when deciding whether to terminate parental  rights if the reason for the child’s length of stay is due to  circumstances beyond the parent’s control, such as the parent’s  incarceration “for a reasonable period of time.”
While many of the state child welfare officials we spoke to said that  federal timelines were difficult to meet for parents serving lengthier  sentences, many state and local child welfare officials as well as child  advocacy representatives did not think that such timelines should be  changed specifically for incarcerated parents. Officials we spoke with said  these timelines are important for being able to place children, especially  younger children, as soon as possible into permanent homes. On the  other hand, several local child welfare officials and caseworkers in New  York and California told us these exceptions can make the difference in  whether some parents can meet requirements in a case plan needed to  reunify with their children.
Federal law requires that child welfare agencies make reasonable efforts  to reunify foster care children with their families before filing for  termination; however, these efforts are subject to certain exceptions. In  managing a foster care case involving an incarcerated parent, child  welfare agency staff may work with both the parent and corrections  officials at several junctures, as shown in figure 5.
Federal law does not define what constitutes “reasonable efforts,” leaving  it to states to define, on a case-by-case basis. Among our selected states,  California and New York specify in statute what such efforts may entail  with regard to incarcerated parents, such as:    Maintaining the parent-child relationship. New York law directs the  child welfare agency to arrange for transporting the child to visit the  correctional facility, if it is in the best interests of the child. California  law provides examples of services that may be provided to  incarcerated parents, which may include such things as facilitating  parent-child telephone calls and transportation services, where  appropriate.
Involving the parent in the child’s case. Both states have statutes that  may permit the use of videoconference or teleconference in certain  circumstances, when such technology is available. In New York an  incarcerated parent may use such technology to participate in  developing the family service plan, including the child’s permanency  plan. In California, courts may allow incarcerated parents to use it to  participate in certain court hearings.
Identifying rehabilitative services for the parent or documenting if such  services are not available. New York requires child welfare agencies  to provide incarcerated parents with information on social or  rehabilitative services, including wherever possible transitional and  family support services in the community to which they will return  upon their release. California requires the caseworker to document in  the case plan the particular barriers faced by incarcerated parents in  accessing court-ordered services (such as counseling, parenting  classes, or vocational training).
In 2008, California amended its law to allow courts to extend court- ordered services for recently released parents who are making significant  progress in establishing a safe home for the child, if there is a substantial  probability that the child will be returned to the parent within the extended  period or if reasonable services were not provided to the parent. A few  caseworkers we spoke to considered this extension unfair to parents who  had not been incarcerated. On the other hand, a dependency court judge  we interviewed did not consider the law a “free pass” for incarcerated  parents, since her decision would, as in other foster care cases, balance  the likelihood that a parent could improve over time with a child’s  immediate need for stability.
section_title: Some State Agencies Provide Guidance and Training, and Some Local Agencies Make Additional Efforts to Involve Parents in the Case or Contact Their Children
subsections: section_title: Agency Guidance and Training
paragraphs: Five of the 10 state child welfare agencies we spoke to have developed  either statewide guidance or training on managing cases with children of  incarcerated parents. California and New York officials said their general  statewide training includes specific information for caseworkers on how to  work with incarcerated parents in accordance with their state laws. New  York officials said they also recently provided training on the new law that  excuses filing for termination of parental rights under the standard  timelines for certain incarcerated parents. Additionally, Michigan and  Florida state child welfare officials said that new guidance to local  agencies had resulted from recent state court cases involving  incarcerated parents who had successfully appealed the termination of  their parental rights. For example, Michigan officials reported holding a  statewide webinar and providing information to local agencies after the  Michigan Supreme Court reversed the termination of parental rights for an  incarcerated parent because, among other reasons, the child welfare  agency failed to provide sufficient reunification services.
State and local officials we interviewed reported a number of local  initiatives that have been undertaken by child welfare agencies,  dependency courts, and correctional facilities to address the logistical  barriers, expense, and disincentives involved when including an inmate in  a child’s foster care case. For example, when the prison facility is located  far from a county dependency court, transportation can be costly and  require an extended absence from the facility. In the latter case, the  parent can lose certain privileges or programming opportunities,  according to child welfare and corrections officials. To address these  barriers, dependency courts and several state prisons in Los Angeles,  California, initiated, under a recently enacted state law, a pilot program  that allows an inmate to participate in certain child welfare hearings via  videoconference. Additionally, a few counties in Florida and  Pennsylvania, while not guided by legislation, have begun to hold child  welfare hearings via video or telephone for incarcerated parents,  according to state officials. State officials we interviewed in Nebraska,  Florida, and Michigan and local officials in California also described  holding a child’s case planning meetings at the jail or including the parent  by phone in some situations. Further, to address some of the logistical  barriers to contact between these parents and their children, several local  child welfare agencies in New York and California said they used  assistants to help drive children to prisons or to supervise parent-child  visits. State child welfare officials in a few other states also said that they  had policies to provide prepaid phone cards to incarcerated parents or  policies to accept collect calls from the parents to discuss their child’s  case.
section_title: Corrections Agencies Provided Programs and Facilitated Parent-Child Visits and Communication
subsections: section_title: Parenting and Rehabilitation Programs
paragraphs: Officials with correctional departments we interviewed offered a range of  services to their general inmate populations relevant to parent  rehabilitation, such as parenting programs and substance abuse  treatment. However, the extent of such services varied among states and  facilities. Officials at all 10 state departments of correction we interviewed  reported having parenting classes in at least at a few facilities, although  most said such classes sometimes had wait lists and some were only at  women’s facilities. These parenting classes have been aimed at the  general inmate population, although officials from a few facilities we  visited told us that their parenting classes have covered the topic of  parental rights, which may be more applicable to parents with children in  foster care. Further, state corrections officials from Nebraska and Oregon  told us that their agencies had taken steps to align their parenting  curricula to meet child welfare standards and prevent parents from having  to retake these classes to satisfy child welfare requirements upon  release.
Some corrections agencies we interviewed also administered treatment  programs that allow incarcerated mothers to live with their young children  who were not in foster care. For instance, some BOP facilities allow  incarcerated women who are pregnant and meet certain criteria to go to a  community program outside the facility for 3 months after the child is born  in order to promote bonding and parenting skills. Likewise, officials in five  states reported having in-prison nurseries or similar programs in at least  one of their correctional facilities. In these programs, mothers live with  their infants at the facility for a period of time after birth, up to 18 months,  often receiving treatment and services, such as pre- and post-natal care,  parenting classes, and counseling. Eligibility criteria for mothers may  include being classified as a low security risk or having a limited amount  of remaining time on their sentence. A state prison official commented  that their facility’s 18-month nursery program affords mothers time to  make amends with family members who may be more willing to care for  the children while the mother completes her sentence. According to this  official, most of these mothers give their infants to family caregivers  without involving the child welfare system. In addition, state corrections  agencies in California and Nebraska have allowed young children to live  with their parents in residential drug treatment programs as an alternative  to incarceration. For example, since 1999, California’s corrections  department has administered the Family Foundations Program which  provides substance abuse treatment and other services to mothers with  nonviolent convictions and sentences of 36 months or less.
Some corrections agencies had general policies or programs to mitigate  the distance between prisoners and their families. Experts, advocates,  and officials from both child welfare and correctional agencies we  interviewed noted that the distance between incarcerated parents and  their families was a major challenge for preserving family ties, particularly  as prisons tend to be located far from urban areas. State corrections  agencies in California, Pennsylvania, and Florida have formal policies to  consider the location of an inmate’s family when assigning the inmate to a  facility. Circumstances such as mental health or security needs take  precedent over proximity to family, according to officials, and such  policies were generally not realizable for women due to the limited  number of female prison facilities. In addition, some corrections agencies  provided free bus transportation for families to visit inmates. For example,  New York and Pennsylvania’s departments of correction provide free or  subsidized bus transportation between large cities and prison facilities  hours away for children and adults visiting inmates.
The Osborne Association (Osborne), a  nonprofit community provider, working with  the New York Department of Corrections  recently set up video conferencing for  children to ‘visit’ with their incarcerated  parents. Osborne currently has an  agreement to conduct tele-visits with one  state women’s prison.  Fifteen to 20 children  from 2–17 years of age currently participate  to varying levels in tele-visits lasting 45  minutes to an hour, according to Osborne  staff. During visits, parents and children  usually participate in activities or crafts  together similar to an in-person visit.
Further, because on-site visits were not always possible, a few  correctional facilities in California, New York, and Pennsylvania were  starting to use technology so that incarcerated parents could visit virtually  with their children. Children participate through video equipment located  at community service organizations or other sites such as local parole  offices.
Also, most corrections agencies had strategies to make visiting prisons  more comfortable for children, sometimes specifically for foster care  children. Officials representing seven different state departments of  correction, as well as federal BOP officials, said that some of their  facilities (often at least half) had special child-friendly visiting areas— particularly for women’s facilities. Several corrections agencies also had  special procedures and trained staff to meet visiting children at the  correctional facility entrance and guide them through a separate  screening process. Also, corrections agencies in New York, California,  Nebraska, and Colorado had specific policies for caseworkers and foster  care children, such as visiting hours on weekdays in addition to usual  weekend visitation so that caseworkers can transport the children.
Extended visitation programs that allow parents and children to visit within  the prison for longer periods of time, such as a full day or week, were  offered in at least a few facilities within 8 of our 10 states. Some of the  programs have bonding activities where parents work on reunification and  parenting strategies with their children. For example, corrections officials  from 3 of our 10 states told us that the Girls Scouts Beyond Bars program  occurred in one or more of their women’s prisons. This program,  originally developed by DOJ, typically provides regular visits and  interaction between incarcerated mothers and their daughters.
section_title: Some Corrections and Child Welfare Agencies Have Collaborated to Align Their Program Requirements and Assign Liaisons
subsections: section_title: State Level Collaboration
paragraphs: Child welfare and corrections officials in 6 of our 10 states collaborated at  the state level to clarify policies, develop procedures, and provide  information to staff. For example, in response to a recent state supreme  court case reversing the termination of parental rights for an incarcerated  parent, Michigan’s child welfare agency worked with state corrections  officials to draft a memorandum to prison supervisors on ways to support  child welfare staff who are working with incarcerated parents. Specifically,  the memorandum required that corrections staff allow inmates to  participate via phone in court hearings and planning meetings with child  welfare officials, when requested, and any programs that will help  improve their parenting skills. In New York, according to state officials, the  recent legislation on filing for termination of parental rights for  incarcerated parents was, in part, the impetus for the joint development of  protocols for ways state corrections and child welfare agencies should  coordinate. Per these protocols, child welfare staff must contact  corrections staff to schedule meetings with parents and arrange children’s  visits while corrections staff should return such calls within one week. The  agencies also collaborated to develop training on the protocols for their  respective staffs. New York’s state child welfare office also developed  materials on the legal rights and responsibilities of parents that child  welfare staff can use with incarcerated parents (see fig. 6).
In some instances, state legislation directed government agencies to  collaborate to meet the needs of children with incarcerated parents. In  Oregon, according to officials, legislation passed in 2001 led corrections  and child welfare agencies to collaborate to gather and share data,  conduct joint training and outreach sessions, and better coordinate  services for released inmates.  More recently, officials from  Pennsylvania told us about a 2009 legislative resolution that directed the  creation of an advisory committee to study children of incarcerated  parents and recommend ways to assess their needs, the services  available to them, and the barriers to accessing those services.
Many of the child welfare caseworkers we interviewed cited difficulty  reaching staff at correctional facilities and navigating prison or jail policies  as a challenge. However, we were told in interviews about examples of  liaisons, in 5 of our 10 states, who facilitate communication between the  agencies. These liaisons understand the procedures and operations of  both agencies and work with officials to navigate each system and serve  as a single point of contact. For example, in California, Texas, and  Alabama, one or more state women’s prisons have employed a social  worker who helps child welfare caseworkers locate offenders or helps  inmates enroll in classes or services that the child’s case plan requires.  More commonly, we heard of examples of cooperation between county  jails and local welfare agencies due to their shared county jurisdiction and  being geographically close. For example, in San Francisco, California, a  liaison based at a county jail was responsible for notifying parents about  their case; facilitating parent-child visits; and providing updates to  parents, child welfare caseworkers, and jail staff about the visits. On a  larger scale, staff of New York City’s Children of Incarcerated Parents  Program, supported by the city’s child welfare agency, facilitate visits to  24 correctional facilities within New York. Such staff also prepare child  welfare staff and foster parents for visits with incarcerated parents.  Officials from agencies with liaison-type positions noted that they found  the relationship helpful.
section_title: HHS and DOJ Provide Some Relevant Information and Assistance, but State Agencies Are Not Always Aware of These Resources
paragraphs: HHS and DOJ each provide information and assistance to child welfare  and corrections agencies related to children with incarcerated parents,  albeit not usually focused on foster care children in particular. In the  course of its on-site reviews of state and local foster care systems,  however, HHS assesses whether state agencies have taken steps to  work with incarcerated parents. Both HHS and DOJ post information on  their websites relevant to practitioners working with children or their  incarcerated parents. However, some state child welfare and corrections  agencies we interviewed were not necessarily aware of these resources  or told us that more information would be useful. Although the Second  Chance Act gives DOJ discretionary authority to collect and disseminate  information on best practices in collaboration between state corrections  and welfare agencies, DOJ has not taken initiative in this area.
subsections: section_title: HHS Encourages Child Welfare Agencies to Work with Incarcerated Parents but Has Not Promoted Available Information about Such Families
paragraphs: HHS examines how state and local child welfare agencies work with  incarcerated parents in the course of its regular and recurring state  performance reviews, the CFSRs. For instance, one of HHS’s CFSR  instruments assesses whether agencies have “encouraged and facilitated  contact with incarcerated parents (where appropriate) or with parents not  living in close proximity to the child,” as part of its examination of a state’s  effort to strengthen parent-child relationships. HHS’s most recent CFSR  reports for our 10 selected states (conducted between 2007 and 2010)  also afford evidence of this oversight. For three states, HHS reviewers  cited instances in need of improvement, such as when child welfare  agencies in the state had not tried to facilitate visits between parents and  their children or needed to improve their efforts to locate and involve a  noncustodial incarcerated parent in case planning. HHS reviewers  commended agencies in six states for their efforts to work with  incarcerated parents, citing agencies in New York for facilitating parent- child visits, in Pennsylvania for enabling incarcerated parents to  participate in group decision-making meetings by phone, and in Alabama  for coordinating with other government agencies to help incarcerated  mothers reenter communities and reconnect with their children.
Most of HHS’s support for foster care children with incarcerated parents is  in the form of informational resources across multiple websites that are  not centrally organized. HHS’s Child Welfare Information Gateway posts  reports under topic areas labeled “Children in Out-of-Home-Care With  Incarcerated Parents” and “Services to Children & Families of  Prisoners.” When we reviewed these websites, most publications listed  under these topic areas were from prior to 2006. Further, these topic area  websites did not cross-reference other HHS-supported websites with  more recent information. For example, HHS’s Office of the Assistant  Secretary for Planning and Evaluation has a list of citations on its website  under “Research and Promising Approaches” for families with  incarcerated parents. Additionally, the HHS-funded National Resource  Center for Permanency and Family Connections posts research studies  as well as various state-produced resources on how to work with foster  care children of incarcerated parents. Although the Gateway is meant to  serve as a comprehensive informational resource for the child welfare  field, its relevant topic areas, such as “Children in Out-of-Home-Care With  Incarcerated Parents,” did not cross-reference these other websites  where we found more recent information.
Moreover, we found that some of the state child welfare agencies we  interviewed were not aware of the HHS resources for working with foster  care children and their incarcerated parents. Officials from few of our 10  selected states had used or were aware that the Child Welfare  Information Gateway website had relevant information. Officials from four  states said that, while they had used this website for other resources,  they were not aware that it had any information about working with  children in child welfare and their incarcerated parents. Additionally, state  child welfare officials in 8 of the 10 states said they would like to have  more information for working with incarcerated parents. In particular,  officials from several states said that they would like examples of what  might constitute “reasonable efforts” with such parents. Similarly, a  number of state child welfare officials we interviewed said that they would  like to know of promising practices used by other states or localities such  as how to better work with corrections agencies.
DOJ’s National Institute of Corrections is  developing a “Gender Informed Practice  Assessment” designed to help correctional  facilities develop policies and practices  that are appropriate for female offenders;  improve the safety and welfare of women;  and, ultimately, reduce recidivism.  Several items in the assessment recognize  the role of children in female offenders’  lives such as designing visitation areas  that are friendly and respectful to families,  providing programming that facilitates  healthy parent-child relationships,  and informing women of their legal rights,  including those involving custody of  their children. According to the National  Institute of Corrections, the assessment  was developed based on evidence-based  practices, standards in the field, and  expert recommendations. The institute is  developing the assessment in collaboration  with the Center for Effective Public Policy,  a nonprofit organization that provides  training and technical assistance to  practioners in criminal and juvenile  justice issues.
HHS has also administered two discretionary grant programs aimed at all  children with incarcerated parents or the incarcerated parents,  themselves. One is the Mentoring Children of Prisoners program,  authorized in 2002 in response to the growing number of children with an  incarcerated parent. Through one-on-one community-based mentoring,  the program was intended, in part, to help alleviate some of the  behavioral and academic risks that these youth face, as a result of their  parent’s incarceration and other related factors. Until fiscal year 2010,  HHS received about $50 million annually to administer grants to public  and private entities operating the mentoring programs. However, this  program was not funded for fiscal year 2011, according to HHS officials.  The other program, known as the Healthy Marriage Promotion and  Responsible Fatherhood grant program, funds some projects which offer  parenting and family strengthening services for incarcerated and formerly  incarcerated fathers and their partners. HHS is currently evaluating 12  such grant projects for incarcerated fathers to determine their  effectiveness on outcomes such as marital stability, recidivism, and family  financial well-being.
section_title: DOJ Provides Some Assistance and Information to Corrections Agencies to Help Families, but Not on Ways to Work with Child Welfare Agencies
paragraphs: DOJ’s relevant information and assistance to corrections agencies largely  focuses on all offenders and their children. The department’s National  Institute of Corrections has provided information and technical assistance  to state corrections agencies, for example, on setting up in-prison nursery  programs, developing corrections training curricula about offenders’  children and families, and developing practices specifically for female  offenders, according to DOJ and state officials we interviewed.
Officials with 8 of the 10 corrections agencies we interviewed reported  using the National Institute of Corrections’ general resources related to  offenders with children. In addition, the National Institute of Justice— DOJ’s research, development, and evaluation branch—has published and  funded research on children of incarcerated parents, some of which has  looked specifically at children in foster care.
DOJ has engaged in some activities related to children of incarcerated  parents under the Second Chance Act. For example, according to DOJ  officials, the department administered about $7.4 million in grants in fiscal  year 2010 to state and local government agencies serving incarcerated  adults to incorporate family-based treatment practices in their facilities.  A local sheriff’s department in California, for instance, reported using  grants from this program to support its jail-based parenting class program  among other activities to promote family relationships for incarcerated  parents who will reenter their communities. DOJ has also led the Federal  Reentry Interagency Council that supports reentry efforts by enhancing  communication, coordination, and collaboration across the federal  government. Other federal departments represented on the council  include HHS and the U.S. Departments of Labor, Education, and Housing  and Urban Development. The council recently undertook an education  campaign to clarify federal policies regarding the families of incarcerated  or formerly incarcerated individuals, by producing one-pagers entitled,  “Reentry Myth Busters.” One such leaflet, developed through  collaboration between HHS and DOJ, cites as “myth” the belief that child  welfare agencies are required to terminate parental rights for incarcerated  parents and explains that federal law gives child welfare agencies and  states “discretion to work with incarcerated parents, their children and the  caregivers to preserve and strengthen family relationships.”  (See figure 7.)
However, beyond this activity, DOJ has not taken initiative to act on a  provision of the Second Chance Act that authorizes DOJ, at its discretion,  to collect and disseminate information on best practices for collaboration  between child welfare and corrections agencies to support children of  incarcerated parents, including those in foster care, and to support  parent-child relationships, as appropriate. According to officials from the  National Institute of Justice, which would be responsible for implementing  this provision, no specific activities are planned. Officials said that no  funds have been appropriated specifically for this provision, and although  DOJ did receive a $10 million research appropriation in fiscal year 2010  that could have been used to fund activities under this provision, that  money was primarily used to fund three evaluation research grants  related to reentry programs. These officials maintained that the National  Institute of Justice has long supported research on children of  incarcerated parents, typically in collaboration with HHS; nevertheless,  neither it nor the National Institute of Corrections has taken steps to  identify and disseminate examples of successful collaboration between  child welfare and corrections agencies, as authorized by the act.
BOP has also not developed any protocols to the federal prisons under its  own jurisdiction for working with child welfare agencies and their staff.  BOP has established some national standards and protocols for all of its  facilities, such as for parenting classes and visiting areas. However, it has  not set such protocols for how its facilities should deal with child welfare  agencies trying to meet the needs of inmates with children in foster care,  according to officials from BOP’s Central Office. Although we found a few  state and local corrections agencies that had taken initiative to facilitate  communication with child welfare agencies, such as by having a  designated point of contact, we did not find these efforts in the two federal  prisons we visited. Moreover, a number of child welfare officials, local  caseworkers, and dependency court judges told us that it can be  particularly difficult to establish appropriate contact with federal prisons  and several said that more collaboration from federal prisons would help  facilitate their work with foster care children with incarcerated parents.  Several judges we interviewed said that it could be difficult to have federal  inmates participate in child welfare dependency hearings, for example,  because prison officials were unresponsive. Several local child welfare  officials said that it was challenging to reach staff at a federal prison to get  information on an incarcerated parent. Neither of the two federal facilities  we visited had a designated staff position or a process for handling child  welfare inquiries. Officials from one facility said that, at any one time, a  different official might field questions from child welfare workers or  inmates with children who are involved in child welfare. A few  incarcerated mothers with whom we spoke said corrections staff vary as  to how helpful they are, and they expressed the view that a designated  position would be helpful. Further, BOP Central Office officials said that  establishing protocols on how its facilities should deal with child welfare  agencies could enhance or facilitate communication between the two  parties. This is in keeping with one of BOP’s strategic planning goals that  aims to build partnerships with other entities to help improve the  effectiveness of its services and promote reintegration of offenders into  communities.
Moreover, among the officials from the 10 state corrections agencies and  the BOP who we interviewed, 8 said that additional information from DOJ  on how child welfare and corrections could better collaborate to address  these children and their families would be very useful. Officials said that  corrections agencies would benefit from practices that could improve  prison visits for foster care children, tools that could facilitate  communication between child welfare and corrections staff, and ways to  share their data on affected families. State corrections and BOP officials  we interviewed told us that they could use additional information from  DOJ on other practices, programs, or policies that would support family  ties between offenders and their children. (See fig. 8.)
section_title: Conclusions
paragraphs: For children in foster care with an incarcerated parent, reunification is  often not possible or appropriate, especially if the prison sentence is long  or the parent-child tie is already compromised by abuse, neglect, or other  complex problems such as substance abuse. Yet, for children and  parents who have the potential for reunification or who would benefit from  maintaining their parent-child ties, the lack of information about these  cases may affect policymakers’ decisions and limit opportunities to  improve these families’ outcomes. Given concerns about whether  incarcerated parents can maintain their parental rights under federal child  welfare timelines, as well as state legislation to address the special  circumstances of children with incarcerated parents, the lack of complete  data leaves legislators less able to assess the impact of these policies on  this group of children.
Meanwhile, although not seemingly widespread, pockets of activity  among child welfare agencies, corrections departments, courts, and  community providers are occurring that may support children in foster  care and their incarcerated parents. As evidenced by the Second Chance  Act, there is growing attention in the field of corrections on keeping  offenders connected with their families to facilitate reentry and, ultimately,  lower recidivism. Many parties may be interested in learning about new  ways to serve the often invisible children in child welfare with incarcerated  parents and to help address some of the serious challenges that these  children face. Given fiscal constraints and competing demands placed on  agencies at every level, however, initiatives made on behalf of these  families are likely to be hindered without information about existing  practices and available resources that they could leverage. Moreover,  while this group of children and their parents are likely a relatively small  part of the larger systems of child welfare and corrections, they are  greatly affected by these systems and their practices. Without more  proactive efforts to create awareness and share information about these  families, opportunities to improve their future may be easily overlooked.
section_title: Recommendations
paragraphs: We are making two recommendations to the Secretary of Health and  Human Services:  1.  To better understand the magnitude of the population and inform  federal or state initiatives that affect children in foster care with  incarcerated parents, the Secretary of HHS should identify ways to  strengthen the completeness of state-reported data on those children.  For example, in implementing new reporting requirements for the  AFCARS system, the agency could take into consideration its 2008  proposed changes in which states would be required to provide  additional information on each foster care child and his or her family  circumstances, including a caretaker’s incarceration, at several times  during the child’s stay in foster care and not only when a child first  enters care. 2.  To improve outcomes for these children, the Secretary of HHS should  take steps to more systematically increase awareness among state  and local child welfare agencies about available resources for children  in child welfare with incarcerated parents. For example, HHS could take steps to update and more centrally organize relevant  information posted on the Child Welfare Information Gateway,  which is meant to serve as a comprehensive information resource  for the child welfare field, such as by regularly updating the  information listed under the Gateway’s relevant topic areas (e.g.,  “Children in Out-of-Home-Care With Incarcerated Parents”) with  links to more recent material posted on other HHS-supported  websites; identify or provide additional information on promising  approaches, such as those listed by the Office of Assistant  Secretary for Planning and Evaluation;   use relevant findings from the CFSR process as an opportunity to  remind states about available resources and post information on  promising approaches identified in the reviews; or facilitate awareness among all child welfare agencies about HHS’s  available resources through an e-mail or a teleconference/webinar  that would allow state and local agencies to share information on  practices or strategies.
We are also making two recommendations to the U.S. Attorney General:  1.  To better address the needs of children with incarcerated parents,  including those in foster care, the U.S. Attorney General should  consider including—among DOJ’s ongoing and future information  collection and dissemination efforts—activities that would assist state  and local corrections agencies share promising practices for these  children, including those that involve communication and coordination  with child welfare agencies. For example, using some of the  informational resources it already makes available to state and local  corrections agencies, DOJ could compile and publicize examples of  successful collaboration between corrections and child welfare  agencies.  2.  To improve collaboration between federal correctional facilities and  state and local child welfare agencies and help federal inmates  maintain important family relationships, the U.S. Attorney General  should direct BOP to consider developing protocols for facilities  regarding offenders who have children in the child welfare system.  These protocols could include:  responses/actions when child welfare agency workers contact  BOP facilities to confirm an inmate’s location, request to  communicate directly with inmates, or inquire about inmates’  current or future participation in programs or services that may be  part of a child welfare case plan;   processes for responding to requests for inmates’ participation in  child welfare hearings or ways to facilitate participation when  desired by the inmate, such as setting up teleconferencing  abilities; or   whether facilities could designate a specific staff position to  address all such inquiries or questions, including those from child  welfare agencies, dependency courts, or offenders.
If developed, these protocols could be shared with states and local  corrections agencies as examples.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to HHS and DOJ for review and  comment. HHS’ comments are reproduced in appendix IV. DOJ did not  provide written comments; however, in an e-mail dated September 13,  2011, from the agency liaison, DOJ agreed with our two  recommendations for the department. HHS and DOJ also provided  written technical comments which we incorporated as appropriate.
In its comments, HHS concurred with our two recommendations for the  department. Specifically, HHS agreed that it was important to better  understand the circumstances and needs of foster care children with  incarcerated parents and would consider our recommendation on  strengthening state-reported data in developing the final rule for  AFCARS. HHS also agreed with our recommendation to more  systematically increase awareness of available resources to improve  outcomes for these children. For example, HHS said it would take steps  to update and more centrally organize relevant information posted on the  Child Welfare Information Gateway, as well as facilitate awareness  among child welfare agencies and states about available resources, such  as through newsletters or links to new information. HHS also agreed that  it would use relevant findings from the CFSR process as an opportunity to  remind states about available resources and post information about  promising approaches.
Finally, both HHS and DOJ noted that, as part of their participation on the  Federal Interagency Reentry Council, they would continue to collaborate  to clarify policies, remove barriers, and promote promising practices in  order to help ex-offenders reintegrate into their communities. Both  agencies noted that addressing issues on children and families with an  incarcerated parent was a core part of this collaboration and that they  would work together to help criminal justice and child welfare systems  make well-informed decisions for affected families.
We will send copies of this report to appropriate congressional  committees and the Secretary of HHS, the U.S. Attorney General, and  other interested parties. The report also will be available at no charge on  the GAO website at http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me at (202) 512-7215 or brownke@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. Key contributors to this report are listed in  appendix VI.
section_title: Appendix I: Scope and Methodology
paragraphs: To address the objectives of this study, we used a variety of methods.  Specifically, we    examined pertinent data from two federal data sources;  conducted phone interviews with 10 state child welfare and  corrections agencies and the Federal Bureau of Prisons (BOP), and  reviewed relevant state laws and policies pertaining to children in  foster care with incarcerated parents; conducted site visits in 4 of the 10 phone interview states; and conducted interviews with federal agencies, as well as professionals  from a range of national organizations, including family resource  centers, corrections associations, and child welfare organizations.
subsections: section_title: HHS and DOJ Data Sources
paragraphs: To examine the extent to which the Department of Health and Human  Services (HHS) collects information on the number of foster care children  with incarcerated parents, we reviewed relevant national data on children  in foster care from HHS’s Adoption and Foster Care Analysis and  Reporting System (AFCARS). HHS uses AFCARS to capture, report, and  analyze information collected by the states concerning all foster care  children for whom the state child welfare agency has responsibility for  placement, care, or supervision, and all adopted children who were  placed by the state agency or for whom the state agency is providing  adoption assistance, care, or services. We looked at the AFCARS  variable that denotes “parental incarceration” as a reason for a child’s  removal from the home and entry into foster care, which is the only  variable in AFCARS that captures information about parental  incarceration.
We reviewed AFCARS data for all cases that were active in fiscal year  2009 and had useable information on reason codes (615,040 in all), the  most recent data available, and identified cases in which children had  been removed from their home and entered foster care for reasons  including a reason of parental incarceration. For all of these cases active  in 2009—regardless of when the child most recently entered foster care— 42,890 cases (about 7 percent) were children who were removed solely  or in part due to the incarceration of a parent. We analyzed active 2009  cases by the year that the child entered foster care, to get an indication of  how prior years’ cases that involved an incarcerated parent as a reason  for entry could accumulate. (See table 3.)
We excluded from our analyses any case that did not contain data on the  reason the child was removed from the home, those cases with  problematic entry dates (such as entry dates occurring subsequent to exit  dates), and data from three states that contained almost no cases that  identified “parental incarceration” as a reason. Taken together, we  excluded about 11 percent of all cases from our analyses. To confirm the  reliability of these data, social science methodologists at GAO reviewed  documentation about the collection and reporting of AFCARS data and  conducted electronic testing of AFCARS data. We also interviewed  relevant HHS officials to clarify data elements, procedures, and reasons  for missing information. The AFCARS data were found to be sufficiently  reliable for the purposes of this engagement.
In addition to our review of the AFCARS data, we also reviewed relevant  national data on incarcerated parents and their children from surveys of  inmates in state and federal prisons and local jails, administered by the  Department of Justice (DOJ) through its Bureau of Justice Statistics (BJS).  We used these surveys to estimate inmate characteristics, such as the  percentage of inmates with minor children reported to be in foster care or in  other placement settings. Specifically, we estimated numbers and  characteristics of inmate populations using the 2004 Survey of Inmates in  Federal Correctional Facilities, the 2004 Survey of Inmates in State  Correctional Facilities, and the 2002 Survey of Inmates in Local Jails.
We also used these surveys to estimate a conservative lower bound on  the number of children of inmates who are in foster care. Based on our  analysis of the 2004 surveys, we are 95 percent confident that the  number of state and federal inmates’ children in foster care in 2004  exceeded about 22,800. Further, based on the 2002 survey of jail  inmates, we are 95 percent confident that between 4,634 and 19,060  inmates had at least one child in a foster care setting in 2002. While the  jail inmate survey covers a different time period than the federal and state  inmate survey, it does provide an indication that additional children of  inmates (beyond what was found in the state and federal inmate surveys)  may be in foster care settings.
In addition, for background purposes, we present BJS published  estimates of the number of inmates and children of inmates for 1991,  1997, 2004, and 2007. Although the BJS report describes its estimation  methodology and several adjustments that were made to produce  estimates that would be comparable over several years, it does not  include estimates of sampling error for those estimates. However, we  were able to calculate and report the confidence intervals for other  estimates produced from the 2004 surveys elsewhere in this report. Since  the 1991–2007 estimates are based on similar surveys and on  information developed from the 2004 survey, we report these BJS  estimates for background purposes only and without accompanying  confidence intervals.
BJS data are limited because they do not distinguish between children’s  temporary or permanent living arrangements, including various types of  relative care, such as relatives who provide foster homes overseen by the  child welfare system, relatives who are informally caring for children with  no involvement of the child welfare system, and relatives who serve as  permanent legal guardians. BJS data also do not fully distinguish  children’s current living arrangements when inmates are reporting on  multiple children. Additionally, as noted in this report, some prisoners may  be inclined to under report how many minor children they have for various  reasons, such as avoiding having to pay child support, according to  several state and DOJ officials we interviewed. Finally, BJS surveys are  conducted intermittently, limiting our ability to compare results across  years. A GAO social science analyst with expertise in survey methods  and a statistician reviewed the methods and survey design used in these  studies and, through interviews with knowledgeable DOJ and BJS  officials and our own analyses, we determined that the data we used  were sufficiently reliable for the purposes of this engagement.
section_title: State Phone Interviews
paragraphs: We administered structured telephone interviews to both the state child  welfare and corrections agencies in 10 selected states. We selected  these states based on several criteria (see table 4). First, states were  selected to represent nearly half of the total foster care and prison  populations in the United States (47 and 48 percent, respectively). We  selected the six states with the largest child welfare population, which are  also among the highest in terms of state prison populations. Other states  with smaller populations of foster care children and prisoners were  selected for variation. Additionally, selected states differed in their  geographic location and whether child welfare services in the state were  administered at the state or local level. Finally, some states were selected  because they were identified in our interviews with researchers and  professionals knowledgeable on these topics as having policies,  programs, or practices aimed at supporting parent-child ties at the state  level or in localities within the state. We also administered the corrections  phone interview to officials from BOP’s Central Office.
For our interviews, we developed two structured protocols—one for child  welfare officials and one for corrections officials. Using these protocols,  we asked officials about the extent their agencies track whether foster  care children have an incarcerated parent or whether inmates have  children and if their children are in foster care. Additionally, we asked  about relevant statewide policies, challenges to supporting family contact  or reunification, and strategies employed in their state that may help  address challenges. Last, we inquired about relevant types of federal  assistance received and areas in which additional assistance might be  useful. We developed our protocols by interviewing researchers,  professionals, and associations, as well as reviewing their documents and  other literature. In addition, we asked several researchers and  professionals we interviewed to review our protocols and pretested these  protocols with child welfare and corrections officials in one state. We  asked these parties for input on the clarity and objectivity of the questions  and whether respondents could provide the information we sought and  revised the protocols, accordingly.
In addition to our interviews with state officials, we reviewed selected  child welfare statutes and policies of our 10 selected states. For example,  we examined whether state child welfare statutes related to federal  requirements, such as efforts to reunify children in foster care with their  families and timelines to file for termination of parental rights, included  specific guidelines for incarcerated parents. Our review was limited to  state child welfare statutes pertaining to termination of parental rights and  reasonable efforts to preserve and reunify the family; we did not examine  other statutes, regulations, or case law, unless specifically identified as  relevant by state officials or other experts. See appendix III for summaries  of the selected provisions of the 10 states’ child welfare statutes and  more detailed information on our methodology in conducting and verifying  this research. We also verified other relevant corrections and child  welfare policies identified through our state phone interviews by reviewing  agency documents.
section_title: Site Visits
paragraphs: To gather more in-depth information from local child welfare agencies,  correctional facilities, and others, we conducted site visits to four of the  ten states we interviewed: California, New York, Oregon, and Texas. We  selected these states because they capture a large portion of the foster  care and prison populations nationally, represent geographic variation,  and include some states with promising or innovative strategies at the  state or local level, as identified by researchers and professionals  knowledgeable on the subject. We also based these selections on the  type of child welfare program administration (state administered and  locally administered with state supervision); the number of children in  foster care; the number and security level of inmates in the facility; and  recommendations from experts we interviewed.
In each state, we spoke with local child welfare officials from at least two  localities, one large urban area and one non-urban county when possible.  Specifically, we met with local child welfare officials and staff in San  Francisco and Stanislaus counties in California; Dutchess county and  New York City in New York; Marion, Multnomah, and Washington  counties in Oregon; and Bell and Harris counties in Texas. During these  interviews, we collected information on state and local processes for  collecting and reporting data, policies and procedures, and challenges  and strategies related to cases specifically involving children in foster  care with incarcerated parents. We also interviewed several dependency  court judges, attorneys, and community organizations that provided  services for foster care children. Across the states, we interviewed  officials at nine state prisons (seven women’s and two men’s), two federal  women’s prisons, and three local city or county correctional facilities or  jails. At most correctional facilities we were able to tour the facility, and  in a few instances we observed their implementation of strategies such as  nursery programs and parenting classes. At a few facilities, we also  interviewed inmates about contact with their children and, if children were  in foster care, their interactions with child welfare agencies or the courts.
On the basis of our site visit information, we cannot generalize our  findings beyond the states or localities we visited. Information we  gathered on our site visits represents only the conditions present in the  states and local areas at the time of our site visits. We cannot comment  on any changes that may have occurred after our fieldwork was  completed.
section_title: Interviews with Agencies, Researchers, and Others
paragraphs: We interviewed officials from HHS and DOJ about their programs  pertaining to foster care children with incarcerated parents, and reviewed  relevant federal laws, regulations, guidance, and other agency  documentation. Additionally, we interviewed researchers and  professionals from a variety of national organizations, including family  resource centers, corrections associations, and child welfare  organizations, and reviewed available literature from these groups. These  included the American Bar Association Center on Children and the Law,  the American Public Human Services Association, the Annie E. Casey  Foundation, the National Association of Social Workers, American  Correctional Association, the National Center on Substance Abuse and  Child Welfare, the National Council of Juvenile and Family Court Judges,  the National Resource Center for Children and Families of the  Incarcerated, National Resource Center on Permanency and Family  Connections, the Rebecca Project for Human Rights, and the Sentencing  Project, among others. We also interviewed two former foster care youth  whose parents had been incarcerated. In addition, two analysts, one with  specialized expertise in social science, reviewed several studies (one  unpublished) and found them to be sufficiently reliable for our purposes.
section_title: Children with Parents in Residential Drug Treatment Programs
paragraphs: To describe the approaches and outcomes of residential drug treatment  programs that may support family reunification presented in appendix II,  we interviewed staff from four family-centered residential drug treatment  programs. We conducted site visits to three of the programs and their  community partners in Maryland and Illinois and interviewed officials with  the fourth program in California via telephone. During the site visits, we  toured program facilities; spoke with representatives from the programs’  community partners, such as social services agencies and transitional  housing providers; and also spoke with some program clients. In selecting  these four family-centered residential drug treatment programs, we  considered criteria including expert recommendations, receipt of federal  grants, and geographic location. We obtained expert recommendations  on specific programs to interview from a number of federal and nonprofit  organizations. Those organizations include several offices within HHS— such as the Substance Abuse and Mental Health Services Administration  (SAMHSA), the Administration for Children and Families (ACF), the  Assistant Secretary for Planning and Evaluation (ASPE)—and nonprofit  organizations, such as the Rebecca Project for Human Rights. Staff with  SAMHSA, ACF, ASPE, and the Rebecca Project for Human Rights  provided examples of family-centered treatment programs that  emphasized family reunification or program evaluation. In addition, during  our interviews with officials from SAMHSA, ACF, ASPE, and the Rebecca  Project for Human Rights, we discussed the practices of family-centered  residential drug treatment programs and federal efforts to fund and  evaluate them.
We reviewed relevant HHS reports on substance abuse and child welfare,  family-centered treatment for women with substance abuse disorders,  and best practice guidance for substance abuse treatment. We reviewed  grant documentation for two federal grant programs that fund and  evaluate family-centered residential drug treatment programs: the  Services Grant Program for Residential Treatment for Pregnant and  Postpartum Women administered by SAMHSA and the Regional  Partnership Grant Program administered by ACF. We chose to focus on  these programs because they target family-based treatment for parents  and their children, as opposed to other grant programs that provide funds  for different treatment types and populations. To describe the outcomes  that these programs track and assess, we reviewed grant documentation,  including the notices of funding availability, grant evaluations, and the  Regional Partnership Grant program’s First Annual Report to Congress.  We also reviewed documents from the four residential treatment  programs that we contacted, which included descriptions of program  rules, practices, and outcome studies.
We conducted this performance audit from July 2010 through September  2011 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
section_title: Appendix II: Children with Parents in Residential Drug Treatment Facilities
paragraphs: HHS estimates that approximately one-third to two-thirds of children  involved in the child welfare system have at least one parent with a  substance abuse problem, such as alcohol abuse or drug addiction. In  addition, a study of 2,639 clients from 44 drug treatment programs in  California reported that 29 percent of these parents had one or more  children removed from their custody by child welfare services. Children  whose parents have substance use disorders may experience parental  neglect and be at risk of social, emotional, and behavioral disorders.  Parents with substance use disorders, including those who come to the  attention of the child welfare system—predominately mothers—may face  additional challenges such as co-occurring mental disorders and  involvement with the criminal justice system. Successfully addressing the  multiple needs of these parents and their children takes time, which, as  with children with incarcerated parents, can conflict with the timelines set  by the Adoption and Safe Families Act of 1997 to make decisions about a  child’s permanent placement and to file for termination of parental rights.
Historically, women with children have faced barriers to entering  substance abuse treatment programs. In our past work, we noted that  state child welfare directors were dissatisfied with the low level of  services, including substance abuse treatment services, provided to at- risk families in the child welfare system. In addition, we noted that,  according to state child welfare directors, families living in impoverished  neighborhoods often do not have access to substance abuse treatment  services, which can in turn influence their children’s entry into the child  welfare system. HHS has funded programs that allow eligible parents  with substance use disorders to bring their children into treatment with  them, such as SAMHSA’s Services Grant Program for Residential  Treatment for Pregnant and Postpartum Women (PPW). According to  SAMHSA officials, this program is designed to expand the availability of  sustainable, comprehensive quality treatment, recovery support, and  family services for pregnant and postpartum women and their children  age 17 and under. This program, which SAMHSA funds and oversees, is  implemented by private nonprofit and public drug treatment providers and  targets low-income women.
In contrast to corrections facilities, some residential drug treatment  programs allow mothers to bring at least some of their children to live with  them during treatment. Some of these programs employ a family- centered treatment approach, more formally known as the  Comprehensive Substance Abuse Treatment Model for Women and their  Children, which SAMHSA describes as:    often long-term and residential;  focusing on an individualized treatment plan for each woman;   addressing the full range of each woman’s needs, in addition to  focusing on the relationships in the woman’s life, including her role as  mother; including a wide variety of integrated services, some of which may be  available to children and other family members; and sensitive to culture and gender.
Family-centered residential drug treatment programs use a variety of  approaches to strengthen and reunite families. Officials from four family- centered residential drug treatment programs we interviewed told us that  these programs help strengthen and reunite families by, among other  things:    Allowing children to reside with their mothers. According to drug  treatment program officials, the possibility that women can bring at  least some of their children with them removes a significant barrier to  treatment: reluctance to enter treatment if their children do not have a  safe place to stay. In addition, some women are reluctant to enter  treatment because they fear that as a result of doing so, they will lose  custody of their children. Having them close by, such as at an on-site  childcare center, decreases these fears and makes it more likely that  a woman will stay in treatment and overcome her substance abuse,  according to program officials.   Focusing on long-term recovery. In contrast to short-term drug  treatment programs, which may consist of a brief, hospital-based  inpatient phase and some outpatient follow-up, family-centered  residential drug treatment programs can last up to 24 months. During  this extended time, the programs attempt to address long-term,  underlying issues in an effort to foster lasting recovery and thus  heighten the chances of family reunification. In this effort, these  programs aim to help women build new coping strategies and social  networks, as well as strengthen their relationship with their children by  teaching them parenting skills. By recognizing that addiction is cyclical  and chronic, these programs help women learn how to overcome  relapses and move toward long-term recovery. In addition, once the  women graduate, some programs continue to provide extended  assistance to help them transition out of the program, such as  temporary housing or access to ongoing support networks and  therapy.   Addressing mental health needs, including trauma. Extensive mental  health services offered by the family-centered treatment programs we  examined better position women for the work needed to help them  recover and rebuild their families, according to program officials. For  example, such programs help women identify, acknowledge, and  appropriately respond to traumatic events in their lives. According to  treatment program staff and federal officials, many women in long- term residential drug treatment have experienced some form of  trauma or suffer from other mental health problems, which in turn can  influence their substance use. Programs may also help children, who  may also be traumatized from living in an environment where there is  substance abuse or from having been removed from their homes by  child welfare officials.   Offering a variety of supportive services to children and other family  members. According to federal and drug treatment program officials,  offering a variety of services to family members can help promote a  more stable recovery since a woman’s recovery is often dependent on  the health of her family, broadly defined. Some programs offer  services specifically aimed at children, such as early intervention  programs for preschool children and parenting programs that enable  both mothers and fathers to hone their parenting skills. Other  services, such as education and employment programs, aim to help  families by making family members stronger and more self-sufficient.   Collaborating extensively with other state and local agencies.  Because family-centered residential drug treatment programs  collaborate extensively with other agencies and organizations with  which women come into contact (see fig. 9), they are able to better  address complex family needs, according to program and federal  officials.
According to an official from one treatment program, the program’s  collaboration—joint monitoring and assessment of women’s progress— with a local family dependency court helps heighten the prospects for  family reunification. Drug treatment program staff and state officials also  told us that drug treatment programs and child welfare agencies  frequently collaborate, and that child welfare and court officials tend to  view a woman’s participation in the family-centered treatment programs  positively for the woman. In addition to collaborating around the needs of  the women and their children, treatment programs may work closely with  child welfare agencies to educate them about the nature of substance  abuse and to provide insight into the extent to which a woman’s relapse  may endanger her children. Finally, program officials told us that their  collaboration with other service providers, such as the public school  system and agencies specializing in children’s developmental disabilities,  also helps them better leverage their own skills and resources to support  the whole family.
subsections: section_title: Outcomes for Women in Residential Drug Treatment Programs
paragraphs: The federal government has funded a number of grants that support and  assess family-centered residential drug treatment programs. For  example, SAMHSA’s PPW grants support the development of treatment  programs, including residential treatment programs, to serve mothers with  substance use disorders and their children aged 17 and under. In the  PPW program, grantees are required to track information about, among  other things, the woman’s substance use, involvement with the criminal  justice system, mental health, and living arrangements. Grantees also  collect limited information on the women’s children, including the total  number of children per woman, the number of children living with  someone besides the woman due to a child protection order, and the  number of children for whom the woman’s parental rights have been  terminated.
SAMHSA funded a cross-site analysis of the PPW program and an earlier  grant program, the demonstration grant program for Residential  Treatment for Women and Their Children (RWC), that examined data  collected from 1996 to 2001 from more than 1,000 women at 50 RWC  and PPW programs. To assess the treatment outcomes, the study  compared women’s responses at admission interviews to their responses  at follow-up interviews, which were administered 6 months after their  treatment ended. The study found that 6 months after treatment ended  women reported fewer instances of substance use, fewer arrests, fewer  mental health problems, and higher rates of employment. Regarding child  outcomes, the study found fewer children living in foster care and that  most of the children who accompanied their mothers to the RWC or PPW  programs were still living with their mothers 6 months after treatment.  Although these findings suggest that RWC- and PPW-funded drug  treatment programs may lead to some positive outcomes for women and  their children, according to study’s authors, the cross-site study was not  designed to demonstrate that the treatment actually caused those effects.
In 2006, ACF began implementing the Regional Partnership Grant (RPG)  program, which provides 3- or 5-year grants to support partnerships  among child welfare and other organizations, including drug treatment  agencies, to increase well-being, enhance safety, and improve  permanency outcomes for children placed in or at risk of being placed in  out-of-home care because of a parent’s substance abuse. Among the 53  partnerships that received RPG funding in 2007, 21 include programs that  provide family-centered residential drug treatment services. The drug  treatment programs that received RPG funding must also collect  information related to a subset of 23 performance indicators pertaining to  the women, children, and families in their programs (see table 5). HHS  uses those performance indicators to gauge grantees’ progress on  meeting their programs’ intended goals.
HHS requires RPG grantees to conduct evaluations to determine program  outcomes, and most grantees designed evaluations that use treatment  and comparison groups, allowing them to compare outcomes of families  in family-centered residential treatment to outcomes of families in other  forms of substance abuse treatment. Of the 21 RPG grantees that  provide family-centered residential drug treatment services, 16 designed  evaluations that use treatment and comparison groups. Since the grant  period for the RPG program began in 2007 and may last up to 5 years,  ACF officials anticipate that all RPG grantees will submit final evaluation  results by December 31, 2012. Subsequently, the agency plans to  present the evaluation results in a series of reports to Congress.
section_title: Appendix III: Provisions from Selected State Statutes on Termination of Parental Rights and “Reasonable Efforts” That Specifically Address Incarcerated Parents
paragraphs: This appendix provides summaries of selected statutory provisions that  specifically address termination of parental rights and reasonable efforts  to preserve and reunify families for child welfare cases involving  incarcerated for the 10 states included in our study. The 10 selected  states were Alabama, California, Colorado, Florida, Michigan, Nebraska,  New York, Oregon, Pennsylvania, and Texas. The information contained  in this appendix is not intended to be an exhaustive summary of all laws,  regulations, or case law related to children in foster care with incarcerated  parents for these states.
To compile this appendix, we searched legal databases for state statutes  on termination of parental rights and reasonable efforts that specifically  refer to incarcerated parents. The provisions we identified are  summarized briefly in tables 6 and 7. These summaries may omit some  details from the cited provisions and are not intended to reflect all aspects  of state law. In addition, these summaries do not reflect the federal  requirements for states that receive federal child welfare funding. They  also do not include the requirements of other state statutes, regulations,  or case law that may directly or indirectly apply to families with  incarcerated parents. We provided these summaries to knowledgeable  state officials in each state for their verification, and the information in this  table was verified to be accurate as of August 2011.
section_title: Appendix IV: Comments from the Department of Health and Human Services
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: Gale Harris, Assistant Director, and Theresa Lo, Analyst-in-Charge,  managed this assignment. Sara Schibanoff Kelly and Eve Weisberg  managed the portion on residential drug treatment centers presented in  appendix II. Analysts Miriam Hill, Melissa Jaynes, Andrew Nelson, and  Rebecca Rose made important contributions to this report. James  Bennett and Mimi Ngyuen provided graphic assistance, and Susan  Bernstein and David Chrisinger provided writing assistance. Kirsten  Lauber, Jean McSween, Mark Ramage, Beverly Ross, and Shana  Wallace provided data analysis and methodological assistance, and  Sarah Cornetto provided legal assistance.