Child Welfare: Better Data and Evaluations Could Improve Processes and Programs for Adopting Children with Special Needs
Published: 2005-06-13T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: On September 30, 2002, the most recent date for which Department of Health and Human Services (HHS) data were available, about 126,000 foster children were waiting to be adopted. Estimates suggest that a significant portion of these children had one or more special needs, such as a medical condition or membership in a minority group, that may discourage or delay their adoption. Federal support in the form of adoption subsidies and incentive payments to states is available to promote special needs adoption. This report (1) identifies the major challenges to placing and keeping special needs children in adoptive homes, (2) examines what states and HHS have done to facilitate special needs adoptions, and (3) assesses how well the Adoption Assistance Program and the Adoption Incentives Program have worked to facilitate special needs adoptions, and determines if changes might be needed.
section_title: What GAO Found
paragraphs: According to state child welfare officials, limited resources, court processes, and delays in completing interstate placements challenged the adoption of children with special needs by hindering recruitment of adoptive families and delaying the adoption process. In particular, adoptive parents in many states received lower subsidies and fewer services than foster parents. In addition, child welfare officials, court staff, and judges said that the adoption process can take months to complete because hearings to terminate parents' rights are hard to schedule and may involve appeals. Further, officials said that interstate placements are often hampered by delays in completing home studies of prospective families, although no data exist to assess the timeliness of such placements. States and HHS have developed and implemented strategies and programs to promote special needs adoptions, but few evaluations measure their effectiveness. Four of the 5 states we visited sponsored post adoption resource centers. However, only 9 of 49 states responding to a relevant question in our survey indicated that they had evaluated the effectiveness of their services. At the federal level, HHS supported and promoted local innovation, provided technical assistance, and disseminated information, but the agency has done little to assess the effectiveness of the programs it has funded. When HHS has taken steps to have states assess funded projects, the agency has not ensured sufficient rigor to assess effectiveness. The Adoption Assistance and Adoption Incentives Programs have provided support for special needs adoptions, but data are lacking to determine if changes are needed to better facilitate adoption. The former uses an income eligibility threshold that is more restrictive than other cash assistance programs' standards of need and may not include all who might otherwise qualify. Since 1998, the Adoption Incentives Program has provided financial awards to almost all states for increasing adoptions, but does not provide a specific inducement for interstate placements. Data to track and credit states for collaborating on interstate placements are not available.

section_title: Letter
paragraphs: On September 30, 2002, the most recent date for which these data were  available, about 126,000 foster children were reported by the Department  of Health and Human Services (HHS) to be waiting for adoption. These  children, on average, were 8 years old, had been in foster care for nearly  half their lives, and 55 percent were living with an unrelated foster care  provider. According to federal program officials, a significant portion of  these children had at least one special need, such as a medical condition  or membership in a minority group that might make adoptive placements  challenging. Further, in some cases, the most appropriate adoptive  families reside in one state while waiting children reside in another.  Therefore, interstate placements, which require child welfare agencies in  both states to work together, are critical to finalizing their adoption.
In an effort to promote the adoption of children with special needs,  Congress authorized the Adoption Assistance Program in 1980 under Title  IV-E of the Social Security Act. Through this program, the federal  government partially reimburses states for subsidies they provide to  adoptive parents of eligible special needs children to assist them with  related caretaking expenses. The act defines children as having special  needs if the state has determined that the child should not or could not be  returned to the home of his or her parents, and certain factors, such as  age; membership in a sibling unit or minority group; or emotional, mental,  or physical conditions would make finding an appropriate adoptive home  difficult.
In order to qualify for the federal subsidy reimbursement, children must  meet the special needs definition and one of several eligibility criteria.  These criteria include having been removed from the home pursuant to a  judicial determination and being eligible for the Aid to Families with  Dependent Children (AFDC) program, as it existed in 1996. In each of the  fiscal years 2001 through 2003, the federal adoption assistance subsidy  reimbursement, including related administrative and training expenses,  exceeded $1 billion. In fiscal year 2002, the latest year for which HHS  could provide figures, the federal government partially reimbursed states  for adoptive families’ subsidies for about 66 percent of foster children  adopted.
In addition to the adoption subsidy reimbursement, the Adoption  Incentives Program, created by the Adoption and Safe Families Act of 1997  (ASFA) and amended in 2003, provides rewards for states that increase the  number of foster care adoptions, special needs adoptions, or adoptions of  children age 9 and older. Since the program’s inception through 2003, the  most recent year for which data are available, the federal government has  awarded nearly $178 million to states in adoption incentive payments.
To better understand the issues related to the placement and adoption of  special needs children, we (1) identified the major challenges to placing  and keeping special needs children in adoptive homes, (2) examined what  states and the Department of Health and Human Services have done to  facilitate special needs adoptions, and (3) assessed how well the Adoption  Assistance Program and the Adoption Incentives Program have worked to  facilitate special needs adoptions and what changes, if any, might be  needed to further facilitate adoptions.
To conduct our work, we gathered and analyzed data from several  sources. We developed and conducted a nationwide survey of adoption  directors in all 50 states, as well as those in Washington, D.C., and  Puerto Rico, and we received 50 responses. We visited 5 states —Georgia,  Massachusetts, Michigan, New Mexico, and Oregon—where we spoke  with child welfare agency officials, caseworkers, parents, court personnel,  and private adoption agency officials to better understand states’  strategies for placing children with appropriate adoptive families. We  selected these states for diversity in the size of their foster care  populations, location, and program administration, and for the different  degree of success they have had in finalizing adoptions. In addition, we  selected and reviewed 10 states’ Child and Family Services Plans and  Annual Progress and Services Reports—documents that HHS requires as  part of its ongoing child welfare oversight—in order to obtain information  on how states were using the adoption incentive funds. Further, we  reviewed federal adoption assistance and adoption incentive laws and  regulations, as well as additional adoption-related research and  evaluations conducted by HHS, the states, and nongovernmental  organizations. We also interviewed HHS officials and staff from  independent child welfare organizations, and we conducted discussion  groups with adoptive parents and adoption program managers from  around the country at two national conferences. We conducted our work  between May 2004 and April 2005 in accordance with generally accepted  government auditing standards. A more detailed discussion of our scope  and methodology appears in appendix I.
subsections: section_title: Background
paragraphs: Most children enter foster care when the state’s child welfare agency  determines that they have been subjected to abuse or neglect and it is not  in their best interest to immediately return home. On September 30,  2002—the latest date for which HHS figures were available for our review,  532,000 children were in foster care in the United States. Generally, after  investigating the circumstances that contributed to the abuse or neglect,  state child welfare agency staff develop a plan to help the parent make  improvements and create a safe and stable family environment. ASFA  requires that states hold a permanency planning hearing at least once  every 12 months to determine, among other things, when and if  reunification with the child’s family is a safe and practical option. HHS  estimated that just over 50 percent of the 281,000 children who exited  foster care during fiscal year 2002 were reunified with a parent or  principal caretaker.
If the parent has not followed child welfare agency plans or has failed to  change behaviors to make reunification safe, the state may identify an  alternative goal to establish a permanent home for the child. These goals  include adoption, independence, or legal guardianship. Independent living  arrangements may be attained once children reach the age of 18—or 21 in  some jurisdictions—and have not been reunified with their families or  adopted and for whom federal reimbursement for foster care expenditures  is no longer available. Legal guardianship is a judicially created  relationship between a child and a caretaker whereby the caretaker is  awarded custody and decision-making rights with respect to the child. An  October 2004 report indicated that 35 states and the District of Columbia  had established subsidized guardianship programs to help ensure  permanent families for children. The federal government typically does  not reimburse states for costs associated with subsidized guardianship.  However, 7 states have operated or are currently operating federally  funded guardianship projects through their participation in the Title IV-E  waiver program. HHS data show that 4 percent of children exited foster  care through guardianship in fiscal year 2002.
HHS reports that in fiscal year 2002, 17 percent of children exited foster  care through adoption. Unless a parent voluntarily relinquishes his or her  rights, states must petition the court for a termination of parental rights  (TPR) before a foster child can be adopted. ASFA requires, with few  exceptions, that states file a TPR petition when a child has been in foster  care for 15 of the most recent 22 months, but ASFA does not address the  length of time needed to grant the petition to terminate. Before the  termination is completed, states can begin to recruit for an adoptive family  and even place a child in a pre-adoptive home with an interested family  after this family has been approved. The adoptive family approval process  generally involves background checks and a home study—a detailed  examination of a family’s circumstances, including its employment and  finances and family medical history—to ensure that the family will provide  a safe and suitable placement. The key steps in the process for adopting  children from state child welfare agencies are summarized in figure 1.
In order to be eligible to receive federal funding, ASFA requires that states  do not delay or deny the placement of a child for adoption when an  approved family is available outside the jurisdiction that currently handles  the child’s case and requires states to facilitate the timely adoptive  placement of children through the effective use of cross jurisdictional  resources. States govern the placement of children across state lines  through a compact known as the Interstate Compact on the Placement of  Children (ICPC). At the time of publication, the compact was being  rewritten to improve the process of placing children across state lines.
Families who adopt children with special needs can receive monthly  subsidies. The Adoption Assistance Program, under Title IV-E of the Social  Security Act, authorizes the federal government to partially reimburse the  states for the subsidies they provide to families who adopt special needs  children. Payments to the parents of an eligible child with special needs  can include both one-time adoption assistance for expenses such as  attorney fees and ongoing monthly assistance, which is used for any  identifiable needs of the child. Special needs children must meet at least  one criterion from the following list: (1) the child is a dependent child who  would have been eligible for AFDC, as it existed in 1996; (2) the child is  eligible for Supplemental Security Income (SSI); (3) the child is a child of  a minor parent who is in foster care already and receiving foster care  maintenance payments under Title IV-E; or (4) the child received adoption  assistance previously, but the adoption dissolved or the adoptive parents  died. If the child does not meet these eligibility criteria, but still meets the  state’s definition of special needs, the state can provide a subsidy to the  child’s adoptive family, but cannot claim federal reimbursement.
The amount of the subsidy is determined through negotiations between  the adoptive parents and a representative of the state agency based on the  needs of the child and circumstances of the adoptive family. The subsidies  are intended to help adoptive families manage the cost of caring for their  special needs children. Adopted children often have difficulties with issues  of loss, attachment, and identity formation that can lead to behavioral and  developmental problems and require professional treatment. In addition,  special needs children with physical and other mental disabilities may  require specialized care and treatment. Adoption subsidies are available to  families until children reach age 18 but may be extended to age 21 if a  mental or physical disability necessitates continuation.
In addition to reimbursing states for the adoption subsidies, the federal  government pays adoption incentive funds to qualifying states. Under the  Adoption Promotion Act of 2003, (Pub. L. No. 108-145), which amended  the Adoption Incentives Program, a state is eligible for an award if the  number of adoptions from the foster care system for the fiscal year under  review exceeds the state’s baseline year, the highest number of adoptions  in any previous year, beginning with fiscal year 2002. States may also  receive an incentive payment based on the adoptions of children having  special needs or children older than age 9. Specifically, when a state  exceeds its baseline year in each category, it will receive an incentive  payment of $4,000 for each child adopted from foster care, $2,000 for the  adoption of each special needs child younger than age 9, and $4,000 for the  adoption of each child aged 9 or older. Thus, the program encourages  adoption generally while emphasizing the adoption of children with  special needs. In fiscal year 2003, the federal government paid states more  than $17 million in incentive payments through this program.
Title IV-E adoption subsidies and adoption incentive awards are not the  only federal assistance available to support adoption. Funds authorized  under Title IV-B of the Social Security Act, the Temporary Assistance for  Needy Families program (TANF), and the Social Services Block Grant  (SSBG) have also been used to facilitate and sustain adoptions. We  reported that in fiscal year 2002 states used more than $5 million in Title  IV-B funds on adoption subsidy payments, more than $9 million on  recruitment and training for foster and adoptive parents, and nearly  $29 million on adoption support and preservation services. A recent  survey on states’ fiscal year 2002 allocations of federal funds for child  welfare found that states reported spending $56 million in TANF funds,  $44 million in Title IV-B funds, and $22 million in SSBG funds on adoption  and support services for adopted children.
HHS’s Children’s Bureau administers and oversees federal funding to  states for child welfare services under Titles IV-B and IV-E of the Social  Security Act, and states provide these child welfare services, either  directly or indirectly through contracts with private agencies. Among  other activities, HHS staff are responsible for developing appropriate  policies and procedures for states to follow and conducting administrative  reviews to ensure that states are in compliance with established policies.  HHS staff from its 10 regional offices provide technical assistance to  states, review state planning documents, assist with state data system  reviews, and assess states’ use of funds for foster care maintenance  payments. Between 2001 and 2004, HHS completed its first round of Child  and Family Services Reviews (CFSR), which assessed child welfare  outcomes in all 50 states, the District of Columbia, and Puerto Rico. These  reviews assessed states’ progress and achievement in many areas and  found weaknesses related to adoption. For example, HHS reported that at  least 27 states experienced challenges seeking terminations of parental  rights in accordance with ASFA. In addition, HHS also reported that 37 of  the 52 states failed to meet the national standard of finalizing adoptions  within 24 months of the child’s most recent entry into foster care.
To evaluate states’ performance on child welfare indicators, such as timely  adoptions, HHS relies, in part, on its Adoption and Foster Care Analysis  and Reporting System (AFCARS) to capture, report, and analyze  information collected by the states. In addition, AFCARS is used to  generate annual reports on foster care and adoption programs nationwide,  and it is the primary source of data for the Adoption Incentives Program.  We reported that the AFCARS data were not reliable and recommended  that HHS make improvements. HHS officials agreed with our findings and  stated that several data definitions in AFCARS would be updated and  revised. In June 2004, HHS officials stated that the regulations related to  making these changes were being drafted. As of April 2005, the regulations  had not been issued, and HHS officials said they did not have a specific  planned release date.
section_title: States Reported That Limited Resources, Court-Related Processes, and Interstate Placement Delays Impede the Adoption of Special Needs Children
paragraphs: States we visited reported that limited resources, court-related processes,  and delays in completing interstate placements were the major challenges  to special needs adoption. The limited resources impeded state agencies’  efforts to recruit adoptive families. Additionally, officials said that  difficulties scheduling cases and the time involved with other court  proceedings delayed finalizing adoptions. Officials also reported that  delays in completing home studies hindered adoptions that involved  interstate placements.
subsections: section_title: State Adoption Officials Report That Limited Resources Impede Adoptions
paragraphs: In part because of resource limitations, adoptive parents in many states  received lower subsidies and fewer services than foster parents. Officials  in 4 of the 5 states we visited told us that budget issues in their states have  caused reductions in or eliminations of adoption services. States are  prohibited by statute from providing monthly adoption assistance  payments that exceed the foster care maintenance payments that would  have been paid if the child had been in a foster home. Officials in 4 of the  states we visited said that most special needs children are adopted by their  foster parents, and a 2002 report found that nearly two-thirds of children  adopted from the child welfare system are adopted by their foster  parents. In responding to a question in our survey, 31 of 49 states  reported that adoption assistance payments were lower than foster care  maintenance payments in those states, and more than half of the 31 states  viewed lower adoption payments as a moderate to very great hindrance to  the adoption of special needs children. According to an official in one of  the states we visited, adoption subsidies are critical to helping families  who adopt special needs children pay for the care and services these  children need. Families adopting special needs children may face  substantial costs for medical care and mental health services, and several  of the experts we interviewed explained that prospective adoptive families  may hesitate to adopt special needs children because they are concerned  about the costs of providing services to meet their needs. In addition,  services, such as respite care, provided by the state for foster children may  be provided to a lesser degree or not at all to adopted children or to  children being cared for by legal guardians. Our survey asked states about  13 types of services. For 9 of the 13 services, fewer states reported  providing the services to adopted children than to foster children; for  every service, the fewest number of states extended these services to  children in guardianship arrangements. (See fig. 2.) Further, officials in 4  of the 5 states we visited confirmed that subsidies and services declined  when foster parents became adoptive parents.
THIS PAGE INTENTIONALLY LEFT BLANK  In addition, many states reported that it was difficult to recruit families  and limited resources affected their efforts. Nearly half of the 49 states  responding to a relevant question in our survey indicated that difficulty  recruiting families was a great or very great challenge to the adoption of  special needs children. In 4 of the 5 states we visited, child welfare staff  we interviewed told us that high caseloads limited the time caseworkers  could spend recruiting families and placing children. In some cases, tight  budgets led officials to make personnel decisions that made fewer  experienced staff available to recruit adoptive parents. In Georgia, officials  explained that because of budget and staffing constraints, instead of  having workers who could specialize in various processes, such as  recruiting adoptive parents, child welfare workers had to handle multiple  aspects of each case. Further, in Michigan, officials explained that a  budget saving plan to encourage early retirement led many experienced  child welfare staff to retire. While the child welfare agency hired new  workers, nearly all of them were inexperienced and needed both formal  and on-the-job training. As a result, according to the foster and adoptive  parents we interviewed in that state, these inexperienced workers were  less effective than experienced workers at meeting families’ needs.
Additionally, in part because of staffing and resource constraints, there are  concerns about how long it takes to place children with families. Both a  home study and a background check are required for adoptive families,  but according to adoptive and waiting parents in one state, high caseloads  limited the time caseworkers could spend completing these studies, and  frequently it was several months from the time families indicated interest  in adopting until their home studies were completed. In addition, states  typically provide adoptive families with an orientation to the adoption  process and relevant training, but caseworkers in one of the states we  visited told us that because of resource constraints, training of prospective  adoptive parents is limited, particularly in the rural areas.
After home studies are completed and the families have been approved,  families often wait for suitable placements. One study found that the  matching and placement phase involved more uncertainty and  misunderstanding for prospective adoptive families than any other step in  the adoption process. The same study also found that one-quarter of  potential adoptive parents felt that they were not given an accurate  estimate of the time it would take for a placement. Another report noted  that infrequent contact between caregivers—foster parents and  guardians—and case managers resulted in caregivers leaving the foster  care system and not pursuing adoption. In 3 of the states we visited,  foster, adoptive, and pre-adoptive parents told us that because of staff  shortages, high caseloads, and other duties, caseworkers did not give them  the attention they needed. As a result, some adoptive and pre-adoptive  parents who were trained lost interest or sought children through other  means, such as private placements. In New Mexico, almost all of the  potential adoptive families we talked with in one rural area had been  waiting for more than a year to adopt. They expressed frustration over the  lack of contact from the child welfare agency while they knew that there  were many children waiting for placements. Correspondingly, 20 of 46  states responding to an open-ended question in our survey reported that  high caseloads or insufficient staff were among the three greatest  challenges to facilitating or finalizing the adoption of special needs  children.
section_title: Officials Cited Court Delays as a Challenge to the Adoption of Special Needs Children
paragraphs: Court-related delays were also cited as a challenge to the adoption of  special needs children. Twenty-two of the 46 states responding to a  relevant question in our survey indicated that court-related delays were  among the three greatest challenges to the adoption of special needs  children. In 3 of the states we visited, judges told us that it was hard to  schedule termination of parental rights hearings because court dockets  were full and because of the many parties involved in some hearings. In  some cases, the participants include the judge, biological parents, foster  parents, the caseworker, and multiple attorneys—one for each child in a  sibling group, one for each biological parent, and one for the caseworker  or child welfare department. Scheduling a hearing date that fits everyone’s  schedule and allows all parties to attend can be difficult.
In addition to difficulties in scheduling hearings, termination proceedings  can last months. Many judges want to be sure that the biological parents  have had sufficient opportunity to remedy the problems that led to their  children being removed. If a parent seems to be making progress, even if  the parent is not yet ready to resume custody of his or her child, the judge  may postpone a decision. Even in cases in which the likelihood for  reunification is low, attorneys in 3 of the 5 states we visited told us that  some courts hesitate to terminate parental rights until adoptive families  are found for children. According to HHS’s analysis of its Child and Family  Services Reviews, in over half of the states reviewed between 2002 and  2004, many judges were reluctant to terminate parental rights either  because adequate services had not been provided to parents or because an  adoptive family had not been identified. Yet while some judges may not  want to create a legal orphan before an adoptive placement is identified,  judges we spoke with in 3 of the 5 states we visited said that the  identification of prospective adoptive families did not play a role in their  decision to terminate parental rights. Furthermore, the termination  process can be delayed if an appeal is filed by a biological parent or a  relative raises an objection. In Michigan, court officials told us that  children’s relatives may come forward to protest when such a decision is  imminent. Relatives’ objections can create delays because the child  welfare agency must determine whether the relatives can be involved in  the children’s care, and the court may also schedule further hearings  concerning the details of their objections.
section_title: Delays Completing Home Studies Have Hindered Some Interstate Adoptive Placements
paragraphs: Delays in completing home studies impeded the interstate placement of  children and therefore delayed the adoption process. Of the 49 states  responding to our survey, 26 cited the lengthy process to place children  across state lines as a moderate to very great hindrance to the adoption of  special needs children. In the course of seeking an adoptive placement,  sometimes a child welfare agency in the state where the child resides finds  a suitable family in another state. The agency in the state with the child,  known as the sending state, seeks a placement in the state where a  potential adoptive family lives—the receiving state. Generally,  caseworkers from the sending state request that a receiving state complete  a home study of the prospective family. However, caseworkers in the  receiving state may assign this request a low priority because conducting  the home study would take time away from their own caseloads.  According to a survey of state officials conducted by the American Public  Human Services Association (APHSA), 32 of the 45 respondents cited  staffing and workload issues as the leading cause for delay in completing  home studies requested by other states. Another frequently cited cause of  delay was the low priority assigned to interstate placements by local  workers. According to current interstate compact guidelines, 6 weeks or  30 working days is the recommended processing time from the date the  receiving state gets notice from the sending state until the placement  request is approved or denied. However, APHSA notes that sometimes the  receiving state does not complete home studies for many months. In some  cases, therefore, children linger in foster care when interstate placements  are delayed.
While the Adoption and Safe Families Act includes a provision that directs  states to develop plans to facilitate the timely adoptive placement of  children through the effective use of cross-jurisdictional resources, there  are no national data to assess the timeliness of these placements. Data  from AFCARS can show whether or not children were adopted outside  their home state, and they also can be used to track the length of time  from entry into foster care to termination of parental rights and adoption.  However the system does not capture which states were involved or when  placement requests were made or completed. Without such specific data,  HHS does not know the extent to which states are cooperating, which  states may need to improve their processes, or whether certain states are  burdened by high numbers of requests for home studies in support of  interstate placement. APHSA has developed a database for tracking  interstate adoptions. Unlike HHS’s system, this database tracks the total  number of children any participating state sent out of state or received for  adoption and the total number of finalized adoptions a state made after  receiving requests from other states. Participation in the association’s  database is voluntary, and as of November 2004, 16 state agencies had  provided their information.
section_title: States and HHS Have Promoted Special Needs Adoption, but Few Evaluations Measure Program Effectiveness
paragraphs: States and HHS have developed strategies and implemented programs to  promote special needs adoptions, but few evaluations measure their  effectiveness. States used both general and targeted recruitment efforts to  help identify adoptive homes for special needs children. States have also  provided special services and programs to help sustain adoptions. To  assist states in their adoption efforts, HHS has supported many  demonstration programs over the years. Although HHS has disseminated  information and summaries about some of the programs and services,  little has been done to assess the effectiveness of such programs, and as a  result, neither HHS nor the states know which approaches have been most  successful.
subsections: section_title: States Used General and Targeted Approaches to Identify Adoptive Families and Promote Adoption
paragraphs: States have used various methods to recruit adoptive families. They have  placed ads on billboards; distributed or posted flyers and posters at booths  during public events or in special locations, such as shopping malls,  libraries, churches, and businesses; sent caseworkers to community fairs  and parades; and used special public service announcements and media  campaigns to generally recruit adoptive families. Many states have  observed and participated in National Adoption Awareness Month each  November, and some states have promoted adoptions by designating other  special days. For example, officials in Massachusetts told us that they  finalized 32 adoptions on a single day in May 2004. According to the  National Adoption Day organization, more than 3,100 adoptions were  finalized during National Adoption Awareness Month in 2003.
To help facilitate adoption, states have contracted with private adoption  agencies to recruit and train prospective families, developed Web sites,  and partnered with adoption exchanges. Of the 49 states responding to our  survey, 40 indicated that contracts with private agencies were an essential  or very important recruitment method. In addition, all 5 of our site visit  states, as well as others, operated Web sites that include photo listings of  children awaiting adoption as well as information on adoption procedures  and resources for prospective adoptive families. Also, 4 of the 5 states we  visited, as well as other states, partnered with adoption exchanges— information and referral services for prospective adoptive families—to  operate electronic registries of waiting children. For example, Michigan’s  adoption resource exchange operates a Web site containing a calendar of  training opportunities and events, a searchable database of children  awaiting adoptive families, and general information on the adoption  process.
In addition, most states used targeted recruitment strategies that focused  on a specific group of children. Of the 49 states responding to a question in  our survey on methods for recruiting adoptive families for special needs  children, 37 reported that television advertisements and stories were  essential or very important, 35 states reported that advertisements in  magazines and other periodicals were essential or very important, and 22  responded similarly regarding mass mailings or flyer distribution. For  example, Kentucky officials noted in our survey that they created a special  television public service announcement to recruit adoptive families for  special needs children. The advertisement was filmed at the Governor’s  home and included children with special needs. Another state, Georgia,  issued a photo listing book, entitled “My Turn Now,” that includes those  children who have been awaiting adoption for the longest period of time.
Many states also hosted adoption promotion events throughout the year  that targeted certain children, such as minorities or those in sibling  groups. In Massachusetts, for example, the state agency has partnered  with a local furniture store to host several adoption parties. The goal of  the event is to help match prospective families with those children in  attendance. State officials credit this business partnership with a number  of successful adoptive matches. Another targeted strategy, known as the  Heart Gallery, has been under way in New Mexico since 2001 and has also  been implemented by a number of other states. This event has showcased  professional photographs of children waiting to be adopted. Though the  organizers in New Mexico have not collected data to track matches  resulting from participation in the gallery event, one organizing official  told us that several children who were showcased at the events have been  adopted.  Further, a Massachusetts official stated that within 2 months of  implementing the Heart Gallery in that state, placements were found for  half of the children showcased.  In addition, some states are working with  local community organizations and churches to help recruit and place  particular children in adoptive homes. According to a National Governor’s  Association report, 30 states and the District of Columbia have  participated in an adoption program called One Church One Child, since  1980. The program seeks to recruit one family from each African-American  church to adopt an African-American child.
section_title: States Provided Some Services and Resources to Help Sustain Adoptions
paragraphs: As indicated earlier in figure 2, states are providing some post-adoption  services and resources, which many experts have said are critical to  helping families sustain adoptions. Generally, post-adoption services are  provided with the recognition that parents adopting children often face  challenges they did not anticipate and for which they are not fully  prepared, especially when the children have special needs. These services  are intended to help reduce the number of adoptions that are dissolved.  As previously noted, states generally provide fewer services to adoptive  families than to foster families. However, 4 of the 5 states we visited have  established centers to assist families after their adoptions were finalized— see table 1.
However, according to state adoption officials, caseworkers, and adoptive  parents we met during our site visits, better post adoptive mental health  services are needed. In addition, several of the experts we interviewed  expressed the opinion that many mental heath providers needed to  develop and improve their competencies in adoption-related topics such  as trust, abandonment, and attachment. Some states have established  programs to do just this. For example, New Jersey’s Adoption Certificate  Program, in coordination with Rutgers University School of Social Work  and Continuing Education Department, developed a 45-hour postgraduate  training program leading to an adoption certificate for mental health  clinicians. The certificate program is intended to increase the knowledge  of mental health practitioners regarding the core issues facing adoptive  families, and to expand their clinical skills in attachment-based, family- focused therapeutic interventions. Oregon’s efforts present another  example. Portland State University, in collaboration with Oregon’s  Department of Human Services and Oregon’s Post Adoption Resource  Center, has also developed a postgraduate training certificate program for  mental health providers working with adoptive families. The training  program includes hands-on strategies for coaching and working with  adoptive parents to address their children’s challenging behaviors.  According to program officials, the program has trained 27 therapists, and  15 more are expected to complete the program by June of 2005.  The  names of these therapists have been or will be forwarded to Oregon’s  adoptions resource center to be included in referral information sent to  adoptive families in need of mental health therapists.
Most states have not conducted evaluations of their post adoption  services. In responding to our survey, 9 states indicated that they have  completed evaluations of post adoption services; 8 states said that they  had evaluations under way, and 30 informed us that they had not  conducted any evaluations prior to their completion of our survey.  Evaluations play an important role in improving program operations. They  can identify which services are most important to families, as well as help  managers determine whether the services are achieving desired goals and  if they can be provided more efficiently. Evaluation results can help  individual states improve their programs and, if shared, can provide other  states with valuable information to help avoid costly mistakes.
section_title: HHS Has Administered Many Programs to Help States’ Adoption Efforts
paragraphs: Various HHS activities have helped states’ adoption efforts.  Over the  years, HHS has administered programs, sponsored campaigns, funded a  resource center, and taken steps to disseminate information about  adoptions.  According to HHS officials, special needs children constitute  the majority of children waiting for adoptive homes, and as such, they are  the beneficiaries of the agency’s efforts to support adoption.
HHS has promoted innovation for many years through the Adoption  Opportunities Program and the Title IV-E Child Welfare Demonstration  Program. The Adoption Opportunities Program, authorized by the Child  Abuse Prevention and Treatment and Adoption Reform Act of 1978, as  amended, generally provides 3-to 5-year grants and contracts to public and  private adoption agencies. These grants and contracts have been used to  support states’ efforts, such as increasing placement of minority children,  recruiting minority adoptive families, and providing post adoption services  for families with special needs children. Since the program’s inception,  Congress has obligated more than $300 million for the Adoption  Opportunities Program. In 2003, HHS administered about $7.3 million in  first-year funding for 20 projects and in 2004 awarded $4.4 million in first- year funding for 13 projects. Also, to promote innovation, HHS has  administered the Title IV-E Child Welfare Demonstration Program since  1994. Among other things, this program allows states to waive certain  restrictions on the use of Title IV-E funds that heretofore have prevented  states from providing support to guardians. Since 1996, 7 states have  operated or are currently operating waiver projects that have provided  monthly payments to relatives and other caregivers who agree to become  a child’s legal guardian. The objective is to test whether providing monthly  support to guardians, which is generally less than payments made to foster  parents, can help reduce a state’s overall foster care costs and improve  permanency outcomes for children.
Since 2002, HHS has supported local efforts to recruit and support  adoptive families and increase public awareness about adoption by  sponsoring AdoptUSKids—a national initiative promoting adoption that is  operated by a coalition under contract with HHS. AdoptUSKids has  partnered with the Ad Council—a provider of public service  announcements to raise awareness about social issues—to develop a  national campaign to recruit adoptive families, and HHS has contributed  more than $4.1 million to the effort. The campaign is expected to run for  3 years and feature a variety of public service announcements on  television and radio, and in print media. Of this amount, AdoptUSKids has  allocated $2 million to support state recruitment response teams to handle  the anticipated interest the campaign is designed to generate. Members of  these state-based teams are expected to respond to calls and e-mails from  prospective parents, link them with the appropriate state agencies, keep  prospective parents engaged in the adoption process by providing a point  of contact, and help parents overcome the barriers they may face in  pursuing adoption. Response teams are also expected to encourage local  media stations to run AdoptUSKids ads and to network with local  politicians and community leaders.
The AdoptUSKids initiative also helps fund adoptive parent organizations  around the country to recruit prospective adoptive families and support  existing ones. As of October 2004, AdoptUSKids had awarded a total of  $420,000 to 105 parent groups in 44 states. To recruit prospective adoptive  parents, AdoptUSKids operates a national database of children waiting to  be adopted and has established a Web site that includes photos;  demographic profiles; and brief descriptions of interests, special needs,  and the types of adoptive families that would be the most appropriate for  the children. The site is available to the public, although prospective  adoptive families can inquire about specific children only after their state  has approved them for adoption. According to AdoptUSKids, as of April  2005, about 41 percent of the children featured on the Web site had been  placed with families in pre-adoptive homes.
Further, HHS has also dedicated the resources of one of its seven federally  funded national resource centers to specifically address special needs  adoption. Based in Michigan, the National Child Welfare Resource Center  for Adoption provides training and technical assistance to states to help  them achieve timely adoptions and develop program improvement plans to  correct weaknesses identified through federal reviews. HHS has provided  about $1 million annually to support this resource center.
HHS also has acknowledged the work of others to promote adoption and  has disseminated adoption-related information. HHS established the  Adoption Excellence Awards in 1997 and since then has presented the  award to public and private organizations, courts, and individuals. In 2004,  HHS acknowledged the efforts of 17 groups and individuals who had a role  in increasing the number of foster children placed in permanent homes.  According to agency officials, the nonmonetary awards aim to raise  awareness about adoption and publicly acknowledge best practices. To  disseminate information about its programs and other activities  concerning adoption, HHS has sponsored conferences devoted to adoption  issues and sends a monthly electronic newsletter, the Children’s Bureau  Express, to more than 9,700 readers. This newsletter highlights new  developments in the adoption field, as well as provides readers  information on conferences and funding opportunities. The agency also  maintains an e-mail distribution list of states’ adoption and foster care  program managers to help disseminate information on policies,  procedures, and practices to the states and also maintains a Web site,  operated by the National Adoption Information Clearinghouse, which  collects and disseminates information concerning all aspects of adoption.
section_title: HHS Has Done Little to Assess the Effectiveness of Its Programs
paragraphs: Although HHS has administered demonstration programs for many years,  the agency has done little to evaluate the projects funded through these  programs and therefore does not know which ones have been most  successful. For example, the Adoption Opportunities Program has been  under way since the late 1970s, but HHS did not require evaluations from  the grantees until 2002. In the absence of evaluations, the agency has  published summaries of grantees’ final reports. For example, a document  provided by HHS staff in 2002 and disseminated by the Clearinghouse  synthesized the findings from 8 of 19 projects funded under this program.  The document contains some information on the projects’ challenges,  lessons learned, and accomplishments, as well as recommendations from  the grantees. However, HHS has prefaced this material with a disclaimer,  noting that it does not represent the official views of the agency. Although  evaluations have been required for the last several years, HHS’s program  staff told us they were still in the early stages of identifying criteria to help  ensure that future evaluations from grantees will be done with sufficient  rigor to help assess effectiveness.
HHS has also required evaluations from Title IV-E waiver recipients, but  little is known about the effectiveness of these projects, even though HHS  has provided staff and technical assistance to help state grantees design,  implement, and evaluate their projects. Rigorous design is an essential  component to incorporate when evaluations are intended to develop  conclusions about the effectiveness of a project. Such design could  include random assignment or controlled quasi-experimental design.  Of  the seven state evaluations submitted between 2002 and 2004 that  addressed guardianship, two were designed in a manner that allowed for  comparisons between experimental and control groups.  For example, the  evaluation in selected regions of Illinois was the most methodologically  rigorous of the seven, and its design incorporated random assignment,  which allowed for reliable comparison between the control and  experimental groups. The Illinois evaluation’s findings suggest that  children for whom subsidized guardianship was an option experienced a 6  percent higher permanency rate than those in the control group and  guardianship was also comparable with adoption in terms of safety and  ensuring a child’s well being. The evaluations from the other 5 states were  less rigorous in their design or implementation. For example, comparison  groups used to evaluate guardianships in Oregon and New Mexico were  not necessarily comparable in composition or makeup with the  guardianship population supported by the project. Consequently, the  difference in outcomes for those in guardianships could be due to internal  differences or characteristics, rather than to the treatment (i.e.,  guardianship) itself. Other project evaluations were limited by reliance on  group numbers too small for generalization and by poor response rates to  assessment surveys and interviews. While the size of the project and the  costs associated with measuring outcomes and collecting data should be  considered in conducting evaluations, HHS officials acknowledged the  weaknesses of the current work conducted by grantees and said they have  learned more about the need for greater rigor as evaluations have been  submitted. They also indicated that evaluations are managed by the states  and HHS has very little control over how they are completed. Meanwhile,  HHS has posted summaries of projects undertaken through the waiver  program, and according to agency officials, they have drafted a synthesis  of findings reported by grantees.
section_title: The Adoption Promotion Programs Have Supported Special Needs Adoption, but Data Are Lacking to Determine if Changes Are Needed
paragraphs: The adoption assistance and adoption incentive programs have supported  the adoption of special needs children, but data are lacking to determine if  changes are needed to better facilitate adoption. The Title IV-E Adoption  Assistance Program uses an income threshold for eligibility that is  outdated and more restrictive than other cash assistance programs’  standards of needs and therefore limits eligibility. With regard to adoption  incentives, all states have increased their annual number of adoptions  enough to receive financial awards for doing so at least once but data are  lacking to assess interstate placement challenges and credit states for  collaborating.
subsections: section_title: Adoption Assistance Income Criteria Are Outdated, and Eligibility Determinations Are Difficult to Make
paragraphs: The Title IV-E Adoption Assistance Program was designed to help support  the adoption of economically disadvantaged children with special needs.  However, the income measure used to assess the standards of need in the  AFDC program, as it existed in 1996, is outdated and in many states more  restrictive than other programs’ standards of need, such as the measure  used for TANF cash assistance eligibility. For example, in Massachusetts,  a family of three could earn up to $633 per month and qualify for TANF,  but this family would not qualify for AFDC unless the earnings were no  more than $579—a difference of $54 per month. According to an HHS  official, eligibility for AFDC and TANF is governed by complex rules,  which therefore complicate comparison. Nonetheless, more than one-third  of the 39 states responding to an open-ended question in our survey, as  well as officials in 4 of the 5 states we visited, expressed the view that Title  IV-E income eligibility criteria—based on AFDC eligibility—should be less  restrictive.
Further, making the income determinations has presented problems for  some states. We asked officials in each of our 5 site visit states to  comment on the administrative burden associated with the income  eligibility criteria. Officials in 4 states said that determining whether  children met the income requirements, by virtue of the parents’ income,  was time-consuming and challenging, particularly if their incomes were  not readily available through a state-maintained database. Between fiscal  years 2000 and 2004, HHS found that nearly all states had made errors in  applying the income criteria and determining the income eligibility for  foster care maintenance determinations. Since states must also base  adoption assistance income eligibility on parents’ income, similar mistakes  are likely. HHS fined 50 of the 52 states it reviewed between 2000 and 2004  more than $14 million for claiming foster care maintenance payments for  ineligible cases, and one of the most frequent reasons for fines, according  to HHS officials, was the inappropriate application of the AFDC income  criteria.
section_title: Data Are Lacking to Estimate the Cost of Changing or Eliminating the Income Requirement
paragraphs: While members of Congress, the Administration, and others have  proposed changing or eliminating income requirements, HHS lacks data to  assess the likely cost to the federal government of doing so. Nevertheless,  state officials and adoption subsidy managers from 4 of the 5 states we  visited recommended that Title IV-E not be tied to criteria once used for  the old AFDC program. The Pew Commission on Children in Foster  Care—a national nonpartisan group formed in 2003 and composed of  legislators, judges, child welfare administrators, and others—has  estimated that eliminating the AFDC criteria from the foster care and  adoption programs would cost the federal government $1.6 billion  annually. The commission based its figure on fiscal year 2002 expenditure  data as well as estimated projections of the percentage of children who  qualify under current regulations. A more reliable estimate cannot be  made because HHS does not maintain critical data on those children and  their families who are not eligible. Specifically, for those children deemed  ineligible, HHS does not maintain family income data or data on the  presence or absence of special needs. As a result, no one can determine  how many families just missed the eligibility criteria and how many of  these children had special needs. According to an HHS official, the agency  has not done a formal cost estimate of expanding Title IV-E eligibility  criteria, but it has been developing an approach in support of proposals  that the administration has made since 2004.  According to one agency  official, these proposals would eliminate income eligibility determinations  for foster care. However, without critical data and a cost estimate, the  extent to which expanding eligibility for the Adoption Assistance Program  would contribute to the nation’s growing fiscal imbalance is unknown.
section_title: All States Have Claimed Adoption Incentive Funds at Least Once
paragraphs: With regard to the Adoption Incentives Program, as figure 3 indicates, all  states have been able to increase their annual number of adoptions enough  to receive financial awards at least once since 1998.
From 1998 to 2003, only South Dakota and Texas claimed the award each  year, and 42 states earned it at least three times. The number of states  receiving the award has fluctuated from year to year, however, as figure 4  illustrates. In 1999, 44 states earned the award—a reflection, perhaps, of  states’ implementation of ASFA and their pursuit of permanency through  adoption. By 2001, though, the number of states receiving the award  dropped to 24, which may have been due to states’ inability to sustain high  levels of adoptions. Since 2001, the number of states receiving the award  has been on the rise. However, fewer states received the award in 2003  than in 1998, when the program began.
Adoption incentive award amounts have varied, and states have used the  funds to support an array of activities. For example, award amounts Texas  earned ranged from $68,000 to nearly $3 million. States participating in a  2000 study reported using these awards to fund a variety of onetime  activities, such as investing in post adoption services and making  performance-based awards to local offices or counties. Our review of  Child and Family Services Plans and Annual Progress and Services  Reports from 5 states that received the award in 2002, found that these  states used the funds to develop ad campaigns to recruit adoptive families,  provide free legal services for adoption, and support child care for  adoptive families.
The Adoption Incentives Program rewards states for exceeding baselines.  Some states reported that they focused on adoption prior to the  implementation of the program but have since seen declines in the rate at  which children enter foster care, and thus have been unable to finalize  enough adoptions to claim the reward. According to officials from  Massachusetts, while the state has continued to focus on adoption, it does  not perceive the program to be an appropriate incentive because it simply  rewards states for exceeding baselines rather than for other improvements  such as placing children who have been in care the longest. As figure 5  indicates, a state theoretically could increase adoptions in the years  subsequent to the establishment of its baseline and still not be in a  position to claim the reward, especially if its baseline had been calibrated  at a level it might not reach again.
According to our survey, respondents had mixed opinions about the extent  to which the program served as an incentive to promote special needs  adoption. Twenty-two of the 49 states responding to a relevant survey  question said the program was a great or very great incentive, while 24  responded that the program was a moderate or weak motivator. In  addition, several of these respondents suggested that HHS further modify  its baseline calculations. For example, states suggested adding a category  to reward states for the adoption of children who have been in foster care  for long periods of time, or altering the baseline to reflect increases year- to-year rather than rewarding states for exceeding historic baselines.
section_title: Data Are Lacking to Assess Interstate Placement Challenges and Credit States for Collaborating
paragraphs: In addition, the program does not provide a specific inducement for  interstate placements. Under the program’s authorizing statute, the  sending state can count the finalized adoption in its totals, but the  receiving state does not get any credit for facilitating a placement, even  though the receiving state must conduct the home study—a critical step in  the adoption process. We do not have estimates of the costs incurred by  states for conducting a home study, but officials in 1 state told us that  prospective adoptive families who adopt through private agencies may pay  as much as $3,000 to complete home studies. HHS officials noted that it  would be difficult to track which states should be receiving the credit for  facilitating interstate placements, given the limitations in the data  collected in AFCARS. Furthermore, officials informed us that they do not  have the authority to split the incentive award. Nevertheless, they  acknowledged the challenges states face with regard to interstate  placement and expressed the view that changes that would provide an  incentive to facilitate interstate adoptions could help.
section_title: Conclusions
paragraphs: While many states have increased the adoption of children with special  needs, data and evaluations are lacking to assess the degree to which  federal and state programs have promoted special needs adoptions.  Interstate placements have delayed adoptions, but data to assess the  timeliness of these placements are not available. Without such data, HHS  cannot identify those states that may need to improve their processes or  those burdened by requests for assistance. As a result, delays associated  with interstate placements will likely persist, and some special needs  children may linger in foster care. Although states and HHS have  developed strategies and innovative programs to promote and support  special needs adoptions, HHS has done little to assess the effectiveness of  its programs and funded projects. As a consequence, HHS does not know  which projects have been most successful and cannot be assured that  federal funds used to support state projects have been used wisely. While  Title IV-E Adoption Assistance has supported special needs adoption, it is  unclear how many more children would qualify for the program if income  standards were adjusted to today’s income standards of need. Further,  without critical data and a cost estimate of expanding eligibility, the extent  to which increasing the number of qualified children would contribute to  the nation’s growing fiscal imbalance is unclear. As for the Adoption  Incentives Program, it does not encourage states to collaborate on  interstate placements, therefore failing to support an area that already  presents barriers.
section_title: Recommendations for Executive Action
paragraphs: We are making three recommendations to further improve the process and  programs related to special needs adoption.
To better understand delays associated with interstate placements, the  Secretary of HHS should assist states in collecting and reporting data  related to the interstate placement processes, especially the time needed  to complete home studies and the sending and receiving state for each  child placed across state lines. Such assistance could include modifying  HHS’s central data system, AFCARS, in conjunction with the agency’s  ongoing efforts to update and revise this system. HHS should analyze the  data to assess the extent to which home studies cause delays or impede  interstate adoptions and to identify which states are facilitating timely  interstate placements. If supported by its findings, HHS should consider  proposing legislation to amend existing law so that both sending and  receiving states could claim an interstate adoption for purposes of  determining award eligibility.
To improve HHS’s ability to assess the effectiveness of its funded projects,  the Secretary of HHS should develop guidance to ensure that rigorous  design elements are incorporated into projects and related evaluations.  Such guidance could consider the nature and structure of the projects and  include measures to control costs.
To assess the extent to which Title IV-E adoption assistance eligibility  criteria exclude some economically disadvantaged children with special  needs, the Secretary of HHS should (1) gather data on the economic  circumstances of special needs children who do not currently qualify for  IV-E and (2) develop a model to estimate the federal cost of expanding  eligibility.
section_title: Agency Comments
paragraphs: We received written comments on a draft of this report from HHS.  These  comments are reproduced in appendix II. HHS also provided technical  comments, which we incorporated when appropriate.
HHS did not explicitly agree or disagree with the recommendations, but  stated that two of our recommendations were being considered as part of  a process to determine what, if any, revisions would be made to the  agency’s central data system, AFCARS.  Specifically, HHS stated that the  recommendation to collect data related to interstate placements and the  recommendation to gather data on disadvantaged children with special  needs would be considered as part of its AFCARS review.
With regard to our recommendation that HHS develop guidance to  improve project evaluations and help assess the effectiveness of funded  projects, HHS stated that such actions were unnecessary and noted that it  had taken steps to strengthen evaluation requirements and provided  technical assistance. Nevertheless, HHS acknowledged that a number of  demonstration projects have sometimes yielded results of limited utility  because of problems adhering to negotiated evaluation protocols.  Also,  HHS stated that it is committed to continuing to improve the quality of  information generated by funded projects and it will continue to work with  states to identify rigorous, administratively feasible evaluation strategies.   We continue to recommend that HHS develop additional guidance to  improve evaluations.  Such guidance is needed to improve the quality of  the results from funded projects which will enable managers to assess  their effectiveness.
HHS also commented on our findings related to the evaluations conducted  under the Title IV-E waiver program. HHS stated that our summary of  these evaluations was somewhat misleading. It noted that several states in  which guardianship is a focus of the demonstration have used  experimental design. Also HHS said that the Oregon demonstration was  focused primarily on testing the use of flexible funding, and therefore the  evaluation of the guardianship components used other methods and  focused on descriptive data.  We modified the report to clarify the aspects  of rigorous design. However, we did not change our description of the  Oregon evaluation because it accurately portrayed the evaluation, which  included information on the impact and effectiveness of the guardianship  component of the project.
We also provided a copy of our draft report to child welfare officials in the  5 states we visited and received technical comments from Georgia,  Massachusetts, Michigan, and Oregon.  We incorporated these comments  when appropriate.
As arranged with your office, unless you publicly announce its contents  earlier, we plan no further distribution of this report until 30 days from its  issue date.  At that time we will send copies of this report to the Secretary  of Health and Human Services, state child welfare directors, and other  interested parties. In addition, we will make copies available to others on  request. Also, this report will be available at no charge on GAO’s Web site  at http://www.gao.gov. If you or your staff have any questions about this  report, please contact me at (202) 512-8403 or AshbyC@gao.gov.  Contact  points for our Offices of Congressional Relations and Public Affairs may  be found on the last page of this report.  GAO staff who made major  contributions to this report are listed in appendix III.
section_title: Appendix I: Objectives, Scope, and Methodology
subsections: section_title: Objectives
paragraphs: The objectives of our study were to (1) identify the major challenges to  placing and keeping special needs children in adoptive homes, (2) examine  what states and the Department of Health and Human Services (HHS)  have done to facilitate special needs adoptions, and (3) assess how well  the Adoption Assistance Program and the Adoption Incentives Program  have worked to facilitate special needs adoptions and what changes, if any  might be needed to further facilitate adoptions.
section_title: Scope and Methodology
paragraphs: To gather information about these objectives, we utilized multiple  methodologies: (1) a Web-based survey to state child welfare agencies;  (2) site visits to 5 states; (3) interviews with HHS officials, staff from key  National Resource Centers, and child welfare researchers and  practitioners, as well as discussion groups with adoptive parents and state  adoption program managers; (4) a review of 10 selected states’ 5-year  reports and 5-year plans that HHS requires as part of its ongoing child  welfare oversight, as well as a review of federal adoption assistance and  promotion laws and HHS regulations; and (5) a review of adoption-related  studies and evaluations conducted by HHS, the states, and  nongovernmental organizations. We conducted our work between May  2004 and April 2005 in accordance with generally accepted government  auditing standards.
section_title: Survey
paragraphs: To gather information about states’ experiences with special needs  adoption, we distributed a Web-based survey to the adoption program  managers in all 50 states, the District of Columbia, and Puerto Rico on  September 17, 2004. The survey contained a number of both closed- and  open-ended questions. To determine whether the survey questions were  clear, unbiased, and used appropriate language, we pretested the survey  instrument with officials in Delaware, Pennsylvania, Maryland, New York,  Virginia, Ohio, and the District of Columbia prior to distribution. After an  appropriate period of time had passed after initial survey distribution, we  conducted an extensive follow-up process that included e-mails and phone  calls to states that had not yet completed the survey. At the culmination of  this process, we received and analyzed responses from 50 states.
Because this was not a sample survey, there are no sampling errors.  However, the practical difficulties of conducting any survey may introduce  errors, commonly referred to as nonsampling errors. For example,  difficulties in how a particular question is interpreted, in the sources of  information that are available to respondents, or in how the data are  entered into a database or were analyzed can introduce unwanted  variability into the survey results. We took steps in the development of the  questionnaire, the data collection, and the data analysis to minimize these  nonsampling errors. For example, social science survey specialists  designed the questionnaire in collaboration with GAO staff with subject  matter expertise. Then, the draft questionnaire was pretested with a  number of state officials to ensure that the questions were relevant, clearly  stated, and easy to comprehend. When the data were analyzed, a second,  independent analyst checked all computer programs. Since this was a  Web-based survey, respondents entered their answers directly into the  electronic questionnaire. This eliminated the need to have the data keyed  into a database, thus removing an additional source of error.
We took several steps to assess the reliability of the data obtained through  our survey. During our pretests, we asked state officials questions to  determine the reliability of the data they could provide, such as how  accurate their data entry systems were and how confident they would be  estimating the data we requested. On the basis of these responses, we  decided to include an open-ended question in the survey instrument that  would give states an opportunity to discuss any limitations in the data they  sent us. After receiving final surveys from 50 states, we examined the  responses to that particular open-ended question, along with all the  closed-ended data questions, and made decisions about which to report  on. We then examined the output to test for inconsistencies, took steps to  resolve these inconsistencies with the relevant states, and determined that  the data were sufficient and reliable for the purposes of our report.
section_title: Site Visits
paragraphs: To gather more detailed information about the challenges states face  promoting and sustaining adoption, as well as some of the practices  they’ve implemented to overcome challenges, we selected 5 states to  visit—Georgia, Massachusetts, Michigan, New Mexico, and Oregon— based on differences in their success achieving adoption incentive awards,  along with their differences in location, size of child welfare population,  degree of privatization of services, and whether they had state or locally  administered systems. In preparation for the visits and to understand the  unique circumstances in each state, we talked with HHS’s regional office  staff and field experts and obtained and reviewed relevant literature from  each of the 5 states, such as studies of adoption efforts and promising  practices. During our visits to each state, we talked with officials from the  state child welfare agency, along with officials and staff from at least one  local agency office. Specifically, in each state we spoke with the adoption  program manager; caseworkers and supervisors; foster and adoptive  parents; judges, attorneys, and other court personnel, such as guardians  and advocates; and private agency officials under contract with the state.
section_title: Interviews and Discussion Groups
paragraphs: To gather information about HHS’s role in promoting special needs  adoption and generating related research and evaluation, we interviewed  HHS officials from Central Office and all the Regional Offices. We also  spoke with staff from National Resource Centers involved in special needs  adoption and permanency issues and interviewed nearly 20 child welfare  experts and researchers to learn additional information about challenges  confronting states’ promotion and maintenance of special needs adoption.
We also conducted separate discussion groups with adoptive parents and  state adoption program managers. We conducted a discussion with 11  adoptive parents from 8 states who were attending the annual conference  of the North American Council on Adoptable Children to learn their  perspectives on the adoption process, subsidy rates, and post-adoption  services. We also held a discussion group with adoption program  managers from 18 states during the annual meeting of the National  Association of State Adoption Programs. During this discussion, we  learned more about the federal role in promoting and sustaining adoption  and obtained managers’ perspectives on Title IV-E funding and the  provision of subsidies to adoptive parents.
section_title: Review of States’ Reports, Federal Laws, and HHS Regulations
paragraphs: To learn more about how states were spending the adoption incentives  funds they had received and what their plans were to recruit and retain  adoptive families using federal funds, we reviewed 10 states’ 2005-2009  Child and Family Services Plans and 2004 Annual Progress and Services  Reports—documents required by HHS as part of federal funding  participation. We selected 10 states—half of which received an adoption  incentive award in 2002—the latest date for which figures were available  at the time of our selection and analysis—and half of which did not. Since  we wanted to include documents from our 5 site visit states in the sample,  we collected the plans and reports from another 5 states, selected  randomly based on their receipt or nonreceipt of the award. Among the 10  states whose documents we reviewed, Georgia, Kentucky, New  Hampshire, Oregon, and Pennsylvania received an award in 2002, and  Alaska, Massachusetts, Michigan, Mississippi, and New Mexico did not. We  summarized the plans and reports that HHS’s regional offices provided to  us for these states, including excerpts from unapproved plans, and  included this information where appropriate. We also reviewed relevant  laws and regulations describing the Adoption Assistance and Adoption  Incentives Programs.
section_title: Review of Studies and Evaluations
paragraphs: During the course of the work, we reviewed more than 20 adoption studies  that had been conducted by states, university professors, and independent  child welfare researchers. We also reviewed 14 evaluations, including  those required under the federal Title IV-E waiver program, that were  designed to assess the effectiveness of adoption, permanency, and post  adoption projects. For each of the selected studies that are used in this  report, we determined whether the study’s findings were generally  reliable. To do so, two GAO social science analysts evaluated the  methodological soundness of the studies using common social science and  statistical practices. For example, they examined each study’s  methodology, including its limitations, data sources, analyses, and  conclusions.
section_title: Appendix II: Comments from the Department of Health and Human Services
section_title: Appendix III: GAO Contact and Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to those named above, Joy Gambino, Joah Iannotta,  Kopp Michelotti, Vernette Shaw, and Carolyn M. Taylor made key  contributions to this report. Susan Bernstein, Karen Burke, Michele Fejfar,  Catherine Hurley, Kevin Jackson, Stuart Kaufman, Jason Kelly,  Luann Moy, and Jay Smale also provided key technical assistance.
section_title: Related GAO Products
paragraphs: Indian Child Welfare Act: Existing Information on Implementation  Issues Could Be Used to Target Guidance and Assistance to States. GAO- 05-290. Washington, D.C.: April 4, 2005.
Foster Youth: HHS Actions Could Improve Coordination of Services and  Monitoring of States’ Independent Living Programs. GAO-05-25.  Washington, D.C.: November 18, 2004.
D.C. Child and Family Services Agency: More Focus Needed on Human  Capital Management Issues for Caseworkers and Foster Parent  Recruitment and Retention. GAO-04-1017. Washington, D.C.:  September 24, 2004.
Child and Family Services Reviews: States and HHS Face Challenges in  Assessing and Improving State Performance. GAO-04-781T.  Washington, D.C.: May 13, 2004.
Child and Family Services Reviews: Better Use of Data and Improved  Guidance Could Enhance HHS’s Oversight of State Performance. GAO- 04-333. Washington, D.C.: April 20, 2004.
D.C. Family Court: Operations and Case Management Have Improved,  but Critical Issues Remain. GAO-04-685T. Washington, D.C.:  April 23, 2004.
Child Welfare: Improved Federal Oversight Could Assist States in  Overcoming Key Challenges. GAO-04-418T. Washington, D.C.:  January 28, 2004.
D.C. Family Court: Progress Has Been Made in Implementing Its  Transition. GAO-04-234. Washington, D.C.: January 6, 2004.
Child Welfare: States Face Challenges in Developing Information  Systems and Reporting Reliable Child Welfare Data. GAO-04-267T.  Washington, D.C.: November 19, 2003.
Child Welfare: Enhanced Federal Oversight of Title IV-B Could Provide  States Additional Information to Improve Services. GAO-03-956.  Washington, D.C.: September 12, 2003.
Child Welfare: Most States Are Developing Statewide Information  Systems, but the Reliability of Child Welfare Data Could Be Improved.  GAO-03-809. Washington, D.C.: July 31, 2003.
D.C. Child and Family Services: Better Policy Implementation and  Documentation of Related Activities Would Help Improve Performance.  GAO-03-646. Washington, D.C.: May 27, 2003.
Child Welfare and Juvenile Justice: Federal Agencies Could Play a  Stronger Role in Helping States Reduce the Number of Children Placed  Solely to Obtain Mental Health Services. GAO-03-397. Washington, D.C.:  April 21, 2003.
Foster Care: States Focusing on Finding Permanent Homes for Children,  but Long-Standing Barriers Remain. GAO-03-626T. Washington, D.C.:  April 8, 2003.
Child Welfare: HHS Could Play a Greater Role in Helping Child Welfare  Agencies Recruit and Retain Staff. GAO-03-357. Washington, D.C.:  March 31, 2003.
Foster Care: Recent Legislation Helps States Focus on Finding  Permanent Homes for Children, but Long-Standing Barriers Remain.  GAO-02-585. Washington, D.C.: June 28, 2002.
District of Columbia Child Welfare: Long-Term Challenges to Ensuring  Children’s Well- Being. GAO-01-191. Washington, D.C.:  December 29, 2000.
Child Welfare: New Financing and Service Strategies Hold Promise, but  Effects Unknown. GAO/T-HEHS-00-158. Washington, D.C.: July 20, 2000.
Foster Care: States’ Early Experiences Implementing the Adoption and  Safe Families Act. GAO/HEHS-00-1. Washington, D.C.: December 22, 1999.
Foster Care: HHS Could Better Facilitate the Interjurisdictional  Adoption Process. GAO/HEHS-00-12. Washington, D.C.:  November 19, 1999.
Foster Care: Kinship Care Quality and Permanency Issues. GAO/HEHS- 99-32. Washington, D.C.: May 6, 1999.
Foster Care: Agencies Face Challenges Securing Stable Homes for  Children of Substance Abusers. GAO/HEHS-98-182. Washington, D.C.:  September 30, 1998.