Child Welfare: Better Data and Evaluations Could Improve Processes and Programs for Adopting Children with Special Needs
Released: 2005-07-13T00:00:00

Letter

Background

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.

States Reported That Limited Resources, Court-Related Processes, and Interstate Placement Delays Impede the Adoption of Special Needs Children

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.

State Adoption Officials Report That Limited Resources Impede Adoptions

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.

Officials Cited Court Delays as a Challenge to the Adoption of Special Needs Children

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.

Delays Completing Home Studies Have Hindered Some Interstate Adoptive Placements

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.

States and HHS Have Promoted Special Needs Adoption, but Few Evaluations Measure Program Effectiveness

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.

States Used General and Targeted Approaches to Identify Adoptive Families and Promote Adoption

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.

States Provided Some Services and Resources to Help Sustain Adoptions

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.

HHS Has Administered Many Programs to Help States’ Adoption Efforts

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.

HHS Has Done Little to Assess the Effectiveness of Its Programs

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.

The Adoption Promotion Programs Have Supported Special Needs Adoption, but Data Are Lacking to Determine if Changes Are Needed

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.

Adoption Assistance Income Criteria Are Outdated, and Eligibility Determinations Are Difficult to Make

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.

Data Are Lacking to Estimate the Cost of Changing or Eliminating the Income Requirement

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.

All States Have Claimed Adoption Incentive Funds at Least Once

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.

Data Are Lacking to Assess Interstate Placement Challenges and Credit States for Collaborating

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.

Conclusions

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.

Recommendations for Executive Action

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.

Agency Comments

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.

Appendix I: Objectives, Scope, and Methodology

Objectives

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.

Scope and Methodology

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.

Survey

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.

Site Visits

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.

Interviews and Discussion Groups

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.

Review of States’ Reports, Federal Laws, and HHS Regulations

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.

Review of Studies and Evaluations

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.

Appendix II: Comments from the Department of Health and Human Services

Appendix III: GAO Contact and Acknowledgments

GAO Contact

Staff Acknowledgments

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.

Related GAO Products

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.