Daily Archives: September 23, 2009

A Child’s Journey Through the Child Welfare System

by Sue Badeau and Sarah Gesiriech

Download Printable Version (80k .pdf, use this link for a printable version, rather than the Print button above)

* Throughout the paper, the following bullets are used:

! for facts or statistics;

! for federal law and state regulations;


for a child’s experience.

Its Almost Tuesdays’ Editors’ Notes are in purple.

This paper describes the typical progression a child makes through a state’s child welfare system. Each state’s child welfare agency1 is responsible for ensuring the safety and well-being of children.

Child  welfare systems have several chief components:

• Foster care – full-time substitute care for children removed from their parents or guardians and for whom the state has responsibility. Foster care provides food and housing to meet the physical needs of children who are removed from their homes.

• Child protective services (CPS) – generally a division within the child welfare agency that administers a more narrow set of services, such as receiving and responding to child abuse and neglect allegations and providing initial services to stabilize a family.

• Juvenile and family courts – courts with specific jurisdiction over child maltreatment and child protection cases including foster care and adoption cases. In jurisdictions without a designated family court, general trial courts hear child welfare cases along with other civil and criminal matters.

• Other child welfare services – in combination with the above, these services address the complex family problems associated with child abuse and neglect.

They include family preservation, family reunification, adoption, guardianship, and independent living.

! While 542,000 children were in foster care on September 30, 2001, 805,000 spent some time in care over the course of that year.

! Children in care in 2001 had been in foster care for an average of 33 months. More than 17 percent (91,217) of the children had been in care for 5 or more years.

Once a child is known to the child welfare agency, he and his family become subject to a series of decisions made by judges, caseworkers, legal representatives, and others, all of whom have an important role to play.

A child may encounter dozens of other new adults including foster parents, counselors, and doctors.

! Most children (60%) enter foster care when removed from their homes by a child  protective agency because of abuse and/or neglect.

! Others (17%) enter care because of the absence of their parents, resulting from illness, death, disability, or other problems.

! Some children enter care because of delinquent behavior (10%) or because they have committed a juvenile status offense (5%), such as running away or truancy.

! Roughly 5  percent of children enter care because of a disability.

For many, it represents their only access to disability services, for example, mental health care for a child with severe emotional disturbance. In these rare instances, in states that allow such placements, a child is placed in foster care voluntarily at the request of his parents.

Foster care is intended to provide a safe temporary home to a child until he can be reunited safely with his parent(s) or adopted. However, being removed from home and placed in foster care is traumatic for a child and the period of time he may spend in care can be filled with uncertainty and change.

A child in foster care is affected by a myriad of decisions established by federal and state laws designed to help him.

At each decision point, any action or inaction can profoundly influence the child’s current circumstances and future prospects.

The discussion that follows highlights typical decision points on a child’s journey through foster care.

Although the format is based on federal and common state law and practice, nevertheless it is only a model. Laws vary across states, as does the capacity and practices of child welfare agencies and courts to manage their caseloads. These factors can and often do create delays that complicate a child’s journey through the child welfare system and often extend his time there.


Abuse or neglect is reported and the CPS agency responds.

The child’s journey through foster care usually begins when a mandated reporter6 or concerned citizen makes a report of abuse or neglect to a state agency. For example, a doctor delivers a baby who has drugs in his system; a neighbor notices bruises on a child; a toddler is found abandoned in a public place; or a teacher notices a student who is unclean, unfed or severely ill.

! Child abuse and neglect, or maltreatment, are defined in both federal and state law.

Federal law provides a foundation for states by identifying a minimum set of acts or behaviors that define physical abuse, neglect, and sexual abuse.

The Federal Child Abuse Prevention and Treatment Act defines child abuse and neglect, at a minimum, as “any recent act or failure on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act which presents an imminent risk of serious harm” to a person under age 18.

States can and do expand on or clarify definitions in a variety of ways that are particular to local needs. Although any of the forms of child maltreatment may be found separately, they often occur in combination.

The U.S. Department of Health and Human Services (HHS) estimates that in 2001, CPS agencies received nearly three million referrals of  maltreatment involving five million children. Approximately 903,000 of these cases were substantiated after investigation.

(Editors’ Note:) That means only approximately 1 out of 3 cases were substantiated.

Of those, the following types of abuse and neglect occurred (some in combination with others):

Type of Abuse  & Percentage

  • Neglect 59 %
  • Physical Abuse 18.6%
  • Sexual Abuse 9.6%
  • Emotional/Psychological maltreatment 6.8%
  • Other (abandonment, congenital drug addiction) 19.5%

The ages of the victims ranged as follows:

Age & Percentage

  • Birth to 3 years 27.7 %
  • 4-7   24.1%
  • 8-11  22.8%
  • 12-15 19 %
  • 16- 21  6%
  • 16-21 or unknown 5%

More than half (56.5%) of substantiated reports were made by professionals, including teachers, law enforcement officers, and physicians.

The remaining 43.5 percent were made by family members, neighbors, and other members of the community.

The majority of the victims were maltreated by a parent (birth, adoptive or step).

The breakdown is as follows:

Relationship of Alleged Abuser to Child Percentage

  • Mothers (acting alone or with a non-parent)  46.9%
  • Fathers (acting alone or with a non-parent)   18.7%
  • Mother and Father 19.3%
  • Non-parent  11.9%
  • Unknown  3.1%

In 2001, an estimated 1,300 children died from abuse or neglect.  Eighteen of these deaths, (1.5%) occurred while a child was under the custody or supervision of the child welfare agency.

In Texas alone, the child welfare agencies had more fatalities than that, each year thereafter.

For the year 2002 – 44 children died in state care.

In 2003 – 30 children died, and

In 2005, 48 children died while in the state’s hands.

So, lets take you through the journey a child travels when going through the system intended to “protect” them, assuming they aren’t one of the fatalities that continues to happen in the very place it should never happen.

A Journey into Child “Protective” Services… (CPS)

Once a report of maltreatment has been made, the CPS agency  investigates whether abuse or neglect has occurred and assesses the risks to the child.


The CPS agency finds that the allegations of abuse and neglect are unfounded and the case is closed.


The CPS agency finds evidence that the child is at risk for subsequent abuse or neglect and conducts an assessment to determine whether the child can remain safely at home with supervision or support services.

The assessment may include

  • a visit to the family home

  • interviews with the family

  • interviews with persons outside the family.

  • These interviews with the family may help identify services that may be needed to better care for their child, such as parenting skills training or addiction services, !A substantial percentage of parents with children in foster care have substance abuse treatment needs.


The CPS agency petitions the court recommending the removal of the child from his home under the supervision of the child welfare agency. This petition initiates a series of judicial hearings.

If the CPS assessment indicates the child is at high-risk for subsequent abuse or neglect, the CPS agency conducts an investigation and requests a court order to remove the child from the home. Generally, in emergency situations, the agency will remove the child and place him in emergency or temporary foster care before receiving the court order.


Protective hearing: the court determines initial placement.

An emergency custody hearing, or protective hearing, will be held for the court to first determine whether the child has been abused or neglected. If the judge determines that abuse or neglect has occurred, the case then proceeds to an adjudicatory and dispositional hearing, where the judge will decide, based in part on the child welfare agency’s recommendation, to do one of the following:

  • Send the child home without services;


  • Send the child home with supervision and support services;


  • Remove the child from his home.

This same set of options will be considered at each subsequent hearing.


Adjudicatory & dispositional hearing(s):

The court determines that the child must be removed and approves an initial placement & reunification plan.

Once the child is removed from his home, he and his parents become formally involved with the juvenile or dependency court system. The child is considered in state custody and generally called a ‘wardor dependent’ of the court.

The child and his family are assigned a case worker from the child welfare agency.

The child’s case worker develops a case plan detailing:

(1) The types of services that the child and his family will receive, such as parenting classes, mental health or substance abuse treatment, and family counseling;

(2) Reunification goals, including visitation schedules and a target date for a child’s return home; and

(3) Concurrent plans for an alternative permanent placement options should reunification goals not be met.

The court reviews and may modify the recommended case plan.

! Federal regulations require that the child’s case plan describe how the state will achieve a safe placement for the child in the least restrictive, most family-like setting in close proximity to the child’s parents.

The case plan must also describe how the placement is consistent with the child’s best interests and special needs.

! Many jurisdictions are experimenting with innovative approaches to develop effective case plans and facilitate safe reunification.

Such approaches include mediation, family group conferencing, and co-location of services such as substance abuse assessment in the court.

! Before a State may receive federal reimbursement for the costs resulting from supporting a child after removal from his home into foster care, a judge must determine that reasonable efforts have been made to keep the family together by providing such services as parenting classes, substance abuse treatment, or subsidized  child care.

However, federal law does not require States to pursue reasonable efforts if a parent has committed specific types of felonies, or subjected the child to aggravated circumstances, such as abandonment, torture, or sexual abuse.

In 2001, the case goals for 541,998 Children in state custody were:

Case Goal Percentage (Number)

  • Reunify with Parent(s)  or Principal Caretaker(s) 44% (241,051)
  • Adoption 22% (116,653)
  • Case Plan Goal Not Yet Established 11% (62,014)
  • Long Term Foster Care 8% (45,792)
  • Emancipation 6% (32,309)
  • Live with Other Relative(s) 5% (26,555)
  • Guardianship 3%  (17,624)

In 2001, the placement settings for children in state custody were:

Placement Setting Percentage (Number)

  • Foster Family Home 48% (260,384)
  • Relative foster home 24% (130,869)
  • Institution 10% (56,509)
  • Group Home 8% (43,084)
  • Pre-Adoptive Home 4% (20,289)
  • Trial Home Visit 3% (16,685)
  • Runaway 2% (9,112)
  • Supervised Independent Living 1% (5,068)

More than 20 percent of children in foster care will MOVE AT LEAST THREE (3) TIMES and in some cases they will MOVE SEVEN (7) OR MORE times!

Children move for many reasons, including attrition and lack of training or support for foster families, lack of resources to address a child’s special needs, or because the child’s behavior may be difficult for some foster parents to manage.

REMEMBER!!! EACH TIME THE CHILD MOVES IT IS TRAUMATIC AND REQUIRES THE CHILD TO ADJUST  TO MANY CHANGES, BOTH INTERNAL AND EXTERNAL (affecting their emotional state, mental state, and environment) including factors such as the following example:

The child has been removed from his or her home, which means being separated from his or her parents *and * may be separated from his or her siblings as well.

The child will meet new temporary (foster) “parents” and must adjust to their ways.

Foster parents may have their own children or even other foster children already living in their homes who are also going through an adjustment period themselves.

The child may have to attend another new school, (and may be having difficulty concentrating or making the grades like before the removal).  The child will be leaving old friends behind and adjusting to a new teacher

(Editors’ Note:) The many changes foster children go through also include the new parents’ habits, routine, lifestyle and house rules. …and more ….

new classmates …

new rules …

new home environment …

new parents …

new siblings …

new sadnesses & emotions …

new expectations & disappointments …

new fears …

new losses …

etc.  etc.

For a child of any age, that means a lot of confusion with  many questions that probably will not be answered right away, if at all…

Where will I go next?

Why is this happening?

Will I ever go home?

What did I do to deserve this?

The child will have a caseworker assigned to him and ideally meet and visit with the child at least once or twice a month.

(Editors’ Note:) The truth is, many children have two or more caseworkers by the time it’s over with, and they are lucky to see their caseworker once a month consistently throughout their case.  Most often, CPS workers are understaffed with a heavy caseload so the job-related stress is intense coupled with the horrific situations they are dealing with seeing children injured and abused.  So the turnover rate is especially high for many reasons, primarily though, CPS workers burn out  and the victim becomes the child  yet again.  Sad part is, the caseworker chose to work in that career field, the parents chose to have children, but the child never had a choice, it was made for him, and in the end, its the child who suffers the most, and is the forgotten one without the choice. The casualties of the system, the truly innocent victimized victims.

These traumatic emotional adjustments will differ for children placed with relatives, or placed in their own neighborhood.   Remember, the child will have to make these adjustments each time he is moved.

(Editors’ Note:) Keeping in mind the child’s overwhelming life-changes & periods of adjustment isn’t what is always remembered when it comes time for the adults to make life-changing, future-altering decisions affecting the rest of this child’s life. In fact, these are the forgotten needs, the overlooked wounds, pains, and scars that the child endures off in the distance while the adults lose them in their paperwork and meetings.

These decisions should be made only with the utmost of good faith intentions, serving the child’s, not the adult’s interest, but the bottom line remains very simple… what does the law say? wha6t makes sense financially?  What would be the most sound PLACEMENT OF THE CHILD as a whole, to keep things flowing, balancing the books not drying the tears…

Its obvious that once removed from their natural home, the child will need to be placed in a setting that (should be) preferable to the home the child was removed from.  The new setting (should be ) better suited to serve the needs of the child  with paramount concern being health & safety (not emotional stability) of the child’s welfare.

! Federal law recognizes a preference for placement with relatives. However, the regulations clarify that health and safety are the paramount considerations when any placement decision is made regarding a child in foster care, including care with a relative.

What does that mean?

It all boils down to money.

! Generally, relatives do not receive foster care payments unless they are licensed foster care providers.  Although the total number of licensed family foster homes in the United States is not known, at the end of the 1990’s, 38 states reported a total of 133,503 homes.

Foster parents do receive money stipends to cover room and board. They may also receive Medicaid coverage for the children in their care.  So while preference lies with the relatives for placement morally and emotionally, financially, the better resources are available to the non-relative foster homes, who receive the financial assistance, unlike most relative placements.

(Editors’ Note:) They also become eligible to receive  assistance to meet their basic needs, such food stamps, clothing, school supplies, etc. however, state laws do vary, and many states are changing their laws when it comes to relative placements or kinship care – offering more assistance than before.

Still, 30 to 50 percent of foster parents quit working for the system every year.

(Editors’ Note:) There is a shortage of foster homes and an abundance of need. Unfortunately, turnover among foster parents is also very high;  Finding good long-standing foster homes is not easy.with half of the foster parents dropping out each year, but the number of foster children intake is still going up – its no wonder the system is failing…

The numbers alone say it would take a miracle to see the system survive much less succeed.  So we reach a very important decision point.

DECISION POINT Placement of the child.

The child is placed in the home of a relative…


The child is placed in a non-relative foster family home…


The child is placed in a residential facility or in a group home.

(Editors’ Note:) To find a way for the adults to beat the odds in the numbers and to actually work together the way they should so the system works the  way it was intended is asking for a miracle. We would like to hope for miracles but the sad reality of it is that the child welfare system isn’t working, and even with total reform, major overhauls with 100 % true effort and complete cooperation between agencies, and families, the best we can hope for is to see some forward progress and lower incidents of abuse and neglect in natural homes AND foster care.  still, it is an impossible battle in one of the most important areas of life – our children and they are our children, it is our responsibility and whatever happens will become our futures so the stakes are too high to be forgotten.

The last option for placement is group homes, residential treatment facilities, or therapeutic camps. The child may be placed in therapeutic foster care, residential child care, or residential psychiatric care if he has emotional, behavioral, physical or medical needs and requires a higher level of supervision and treatment. A child may be placed in group home care because of a shortage of foster family homes.  Group home care is more frequently used for older children.

What is the difference between a group home & a residential treatment facility?

! A group home is a licensed or approved home providing 24-hour care for children in a small group setting that generally has from 7 to 12 children.

! An institution is a child care facility operated by a public or private child welfare agency and providing 24-hour care and/or treatment for children who require separation from their own homes and group living experiences, i.e. child care institutions, residential treatment facilities, and maternity homes.

! Federal child welfare funds cannot be used to support children in public facilities that serve more than 25 children or used to maintain children in facilities that are operated primarily for the detention of delinquent youth.


The court reviews the family’s progress every six months and holds a permanency hearing after 12 months has passed.

Periodic reviews are held in the court and are reported to the court.

! Federal law requires states to review a child’s case at least every six months after placement in foster care to determine whether the placement is still necessary and appropriate, whether the case plan is being properly and adequately followed, and whether progress has been made toward reunifying the family.

The case review must also set a target date for the child’s return home, adoption, or other permanent placement.

Permanency planning hearings are always held in court.

! Federal law requires states to hold a permanency planning hearing for each child in foster care within 12 months of initial placement, or after a determination that reasonable efforts to reunite are not required.

Some states require this hearing sooner. Foster parents, pre-adoptive parents, and relative caregivers must be given notice and an opportunity to be heard at case reviews and permanency hearings.

Some advocates believe that a child should not remain in foster care longer than 12 months. Other advocates believe that this is too short a period to address the complex and multiple needs of the family, particularly families with substance abuse or mental health needs.

A judge may choose from among several permanency options for the child.

In 2001, 263,000 children exited foster care in the following ways:

Outcomes for Children Exiting Foster Care Percentage (number)

  • Reunification with Parent/Primary Caretaker 57%    (148,606)
  • Living with Other Relative(s) 10% (26,084)
  • Adoption 18% (46,668)
  • Guardianship 3%   (8,969)
  • Emancipation 7% (  19,008)
  • Transfer to Another Agency 3% (7,918)
  • Runaway 2% (5,219)
  • Death of Child less than 1% (528)


The child is reunified with his birth family.

If the parents are successful with the court-ordered treatment plan, the child is reunited with his parents, and the case is closed.

! In 2001, more than 57 percent (148,606) of children in out-of-home care were reunited with their families.

! However, other studies have noted that approximately 33 percent of children who were reunified with their families re-entered foster care within three years. And, approximately 17 percent of children who entered foster care had been in foster care before.


The birth family does not complete the court-ordered reunification plan. The child welfare agency petitions the court for the termination of parental rights (TPR).

If a parent fails to comply with the reunification plan, the child welfare agency will petition the court to terminate the parents’ rights to the child. At any point during the court process, a parent may seek to voluntarily relinquish their parental rights.36 When

the parents’ rights are terminated, a permanent plan for the child will be created.

! Federal law requires states to initiate TPR proceedings for (1) children who have been in foster care for 15 of the most recent 22 months, (2) infants determined to be abandoned, or (3) cases in which a parent has killed another of his/her children, or (4)  certain other egregious situations.

States may opt not to initiate TPR if

(1) the child is in a relative’s care

(2) the child welfare agency has documented a compelling reason that TPR would not be in the child’s best interest, or

(3) the state has not provided necessary services to the family.

! In 2001, more than 65,000 children’s living parents had their parental rights terminated.

! Federal law requires that the permanency plan document the steps taken to place the child and finalize the adoption or legal guardianship and document child specific recruitment efforts taken to find an adoptive family or legal guardian for a child.

! Federal regulations direct states to concurrently begin to seek and approve a qualified adoptive family for the child whenever a state initiates TPR proceedings.


The child is placed with an adoptive family and the court holds an adoption hearing to finalize the adoption.

Some children will leave foster care through adoption.

! In 2001, 51,000 children were adopted.

Nearly 59 percent were adopted by their foster family and nearly 24 percent were adopted by a relative.

” Because children adopted from foster care may have been abused, neglected, or may have lived in multiple homes, the transition to an adoptive home can be difficult.

Some states are beginning to explore ways to offer post-adoption services, such as respite care, to ensure the adoptions stay intact.

! In 2001, more than 126,000 children in foster care were considered waiting to be adopted because they have the goal of adoption or because of TPR. These children had been in foster care for an average of more than 3½ years, and their average age was eight.


The child is placed with a legal guardian, often a relative.

Some children will leave foster care through placement in the custody of a guardian. The guardianship can be granted to relatives, foster parents, or another adult who has a relationship with the child.46 Guardianship is not as legally secure as adoption. However, it does provide a measure of permanency and stability without requiring the termination of parental rights.

! Federal law defines legal guardianship as a judicially-created relationship between child and caregiver intended to be permanent and self-sustaining. The following parental rights with respect to the child are transferred to the caretaker: protection, education, care and control, custody, and decision-making.

! Subsidized legal guardianships are a means by which some states provide relative (and in some states non-relative) foster parents with financial assistance after they have obtained legal guardianship of the child and the child has exited the formal child welfare system. Subsidized guardianships can provide an alternative form of support for children whose relatives have chosen not to adopt.

The federal government does not provide States reimbursement for costs associated with subsidized legal guardianship payments.


The child reaches age 18 with no permanent home.

Some children will reach 18 and leave foster care without being reunited with their families, adopted, or placed in another permanent home. In these cases, the child welfare agency may provide basic living skills training, housing assistance, and educational opportunities through federally funded independent living programs.

! In 2001, approximately 19,000 youth left foster care when they reached the age of 18 (or 21, in some cases).

” Studies have found significantly lower levels of education, higher rates of unemployment, and higher rates of homelessness for adults who spent time in foster care as children.

For example, a study by Westat, Inc. reported that only 54 percent of young adults who grew up in foster care had completed high school, 40 percent continued to rely on public support in some way (were receiving public assistance, incarcerated, or receiving Medicaid) and 25 percent had been homeless for some period.

Other studies indicate that a significant percentage of the homeless population in many cities were adults who once had been foster children.

As this paper indicates, the rate at which a child progresses through the foster care system, and the nature of his experience there, depends on many factors. These include federal and state financing, timelines, and legal provisions: good and timely decisions; the availability of services for birth and adoptive families; and the availability of licensedfoster homes willing to care for children. Many of these factors are interrelated. But each can contribute to the length and quality of a child’s time in foster care.

1Public child welfare agencies are often called by different names such as the Department of Human Services (DHS), Department of Health and Social Services (DHSS), Department of Children and Families (DCF), or the Department of Social Services (DSS).
2 U.S. Department of Health and Human Services, Children’s Bureau, The AFCARS Report #8 (March 2003). Available online at www.acf.dhhs.gov/programs/cb/publications/afcars report8.htm.
3 Ibid.
4 Karen Spar, Specialist in Social Legislation, Domestic Social Policy Division, Congressional Research Library, Library of Congress, Testimony before the Subcommittee on Human Resources, July 20, 1999. The figures in this paragraph represent Fiscal Year 1994 data.
5 Ibid.
6 State laws identify certain professionals who are mandated to report suspected abuse. They generallyinclude medical professionals, teachers, day care workers, photo lab developers, and law enforcement.
7 42 U.S.C. 5106g.
8 U.S. Department of Health and Human Services, Administration on Children, Youth and Families, Child Maltreatment 2001, p.21 (Washington, DC: U.S. Government Printing Office, 2003).
9 Ibid, 21. The percentages total more than 100 percent of victims because children may have been victims of more than one type of maltreatment.
10 Ibid, p. 23.
11 Ibid, pp. 3 & 7.
12 Ibid, pp. 43 & 45.
13 Ibid, pp. 51 & 55.
14 The Oklahoma Department of Human Services, The Child Welfare Journey. Available online at http://www.okdhs.org/cfsd/howtos/cw/journey.htm.
15 Child Welfare League of America, Behavioral Health Division, Alcohol and Other Drugs. Available online at http://www.cwla.org/programs/bhd/aod.htm.
16 42 U.S.C. 675(5).
17 U.S. Department of Health and Human Services, National Clearinghouse on Child Abuse and Neglect
Information, Overview of the Civil Child Protective Court Process.
Available online at
18 42 U.S.C. 671(a)(15)(D).
19 The AFCARS Report #8.
20 Ibid.
21Kathy Barbell and Madelyn Freundlich, Foster Care Today (Casey Family Programs, Washington, DC, 2001), pp. 3-4. These figures were based on 1994 data from the U.S. House of Representatives, 2000.
22 42 U.S.C. 671(a)(18). 11
23 Children’s Defense Fund, Child Welfare and Mental Health Division, The Adoption and Safe Families Act (ASFA) Regulations and Kinship Care Families – Frequently Asked Questions (Spring 2000) andFederal Register, Vol.65, No. 16, (January 25, 2000), pp. 4032-4033.
24 U.S. Department of Health and Human Services, Administration for Children & Families, National Clearinghouse on Child Abuse and Neglect Information, Foster Care National Statistics April 2001.
25 University of Tennessee Family Foster Care Project, Foster Family Forum, Issue 1. (July 2002).
26 U.S. Department of Health and Human Services, Administration on Children, Youth and Families, Child Maltreatment 1999: Annual Report (Washington, DC: U.S. Government Printing Office, 2001). Some states may include settings with fewer than seven children as group homes.
27 Ibid.
28U.S. Department of Health and Human Services, Administration for Children and Families,Administration for Children, Youth and Families, Program Instruction, ACYF-PI-89-09 (October 1989).
29 Overview of the Civil Child Protective Court Process.
30 42 U.S.C. 675 (1)(5)(C).
31 These deaths resulted from all causes including accidental and natural. Only 18 resulted from abuse.
32 The AFCARS Report #8.
33 Ibid. 34 U.S. General Accounting Office, FOSTER CARE Recent Legislation Helps States Focus on Finding Permanent Homes for Children , but Long-Standing Barriers Remain (GAC-02-585) (Washington, DC: U.S. Government Printing Office, 2002), p. 10.                                                                                                                                      35 Foster Care National Statistics April 2001 (2000b).
36 The Child Welfare Journey.
37 Ibid.
38 42 U.S.C. 675(1)(5)(E). In the case of an abandoned child, regulations require States to initiate TPR  within 60 days of a court determination of abandonment and in the case of a child whose parent has been convicted of a felony specified in the law 60 days of a court determination that reasonable efforts to reunite
are not required.
39 The AFCARS Report #8.
40 42 U.S.C. 675 (1)(E).
41 42 U.S.C. 675 (5)(E).
42 The AFCARS Report #8. This figure is based on the most recent revisions to AFCARS, which onlyinclude adoption outcomes. This figure differs from the figure presented in the table showing outcomes for children exiting foster care. That figure is based on preliminary data which will be revised once all the outcomes are updated.
43 Ibid.
44 Ibid.
45 Ibid.
46 The Child Welfare Journey.
47Steve Christian, A Place to Call Home Adoption and Guardianship for Children in Foster Care, p.28
(National Conference of State Legislatures, 2000)
48 42 U.S.C. 675.
49 The Adoption and Safe Families Act (ASFA) Regulations and Kinship Care Families – Frequently Asked Questions.
50 The AFCARS Report #8.
51 State of Tennessee, Comptroller of the Treasury, Foster Care Independent Living Programs (1998).
52 1994 Green Book (Washington, DC: U.S. Government Printing Office, 1994).
53 National Alliance to End Homelessness. Web of Failure: The Relationship between Foster Care and Homelessness (1995). Available online at http://www.endhomelessness.org/pub/fostercare/webrept.htm.

What if it was your child?

(editors’ comments):

With Obama’s Medical Reform Bill under scrutiny at this time, I thought it was important and relevant to look at its effects on our families, children, and especially, the foster care system.

In 2004 Carole Strayhorn launched an investigation into Texas Foster Care System, and found an alarming amount of foster children were given psychotropic medications.  Most of these medications were not approved by the FDA for use on children, and were being given in high doses to children as young as 2 years old.  The States’ Medicaid program paid the costs.

This investigation took years to take place by the constant barricades put up by Governor Perry and DHHS in reporting true figures by which the investigators could look into.   By the time the investigation was complete, the findings were shocking, and Senate Bill 6 addressed the concerns as it was created to reform the Child Welfare System.

Though many programs and laws were created, they were not, as of 2006, implemented.

I am currently researching the current status, and also reviewing the proposed Health Care Reform bill, myself, to see what I mght find. According to news reports I read, it does seem to open the doors to further CPS involvement in families, allowing them easier access in a “home visitation program” for expecting women in impoverished areas.

This concerns me.

In case you are not aware of what was going on with our foster children in the arena of psychotropic medications in foster care, here’s some excerpts from Carol Strayhorns Report of 2006 following her investigation.

Keep on reading deep into whats really going on, these children are counting on us to stop these atrocities. Please.  My son was one of them.

What if it was your child?


Excerpts from Report of December 14,2006 issued by Texas Comptroller Chairman, Carol Strayhorn, Medicaid and Public Assistance Fraud Oversight Task Force

Medical Concerns

This report reveals a number of significant medical concerns within the state’s foster care system.

Lack of Medical Histories

DFPS still (as of 2006:) does not provide its foster children with a “medical passport” explaining their medical history, including diagnoses and prescriptions although the passport is required by law.

Instead, foster children often move from one placement to another, seeing new physicians or counselors who have little or no knowledge of their past medical histories. A medical passport would help provide more consistent care for these children.

In September 2006, DFPS stated that it “is working with HHSC on the development of the health passport, scheduled to be implemented September 2007”— more than three years after the Comptroller’s first published recommendation. Psychiatric Hospitalizations DFPS has no rules, guidelines or monitoring procedures concerning the psychiatric hospitalization of foster children.

In fiscal 2004, 1,663 Texas foster children were hospitalized for psychiatric care for a total of 33,712 days, at a cost of $16 million based on daily rates of more than $500 per day.

DFPS has no rules, guidelines or monitoring procedures concerning the psychiatric hospitalization of foster children.

More than 400 foster children spent than a month each in psychiatric facilities in fiscal 2004. Some of these foster children were “dumped” into psychiatric hospitals, by foster parents who decided that they could not deal with the child’s behavior.

DFPS caseworkers often left foster children in such facilities long after they were authorized for release.

Medically Fragile Children

The Comptroller’s office e(stimates that about 1,600 “medically fragile” children were in Texas foster care in fi scal 2004. These children have serious and continuing medical conditions requiring specialized care and treatment. About 49 percent of them were four years old or younger.

Many of these children were in “basic” service-level homes, because DFPS places more emphasis on behavioral conditions than on physical conditions and needs.


DFPS has been particularly negligent in caring for foster children with fatal and incurable human immunodeficiency virus (HIV) or acquired immune deficiency syndrome (AIDS). These children are not receiving consistent care and counseling.

Some have been enrolled in clinical trials and did not have advocates appointed for them. At least one foster facility that cared primarily for children with HIV and AIDS was closed due to poor living conditions and substandard care.

Twenty-six Texas foster children received at least one HIV medication and had at least one outpatient HIV procedure in fiscal 2004. More than 15 had at least one outpatient procedure with an HIV-related diagnosis code, but did not receive any HIV medications—a peculiar and disturbing pattern.

Many of these children were categorized at the lowest, basic service level.

In fiscal 2004, 63 foster children were raped while in care; of these, only 16 received HIV tests.

Meaning that 75 percent of those raped were not tested for HIV following the rape, as required by law.

One foster child with HIV who was also medically fragile had more than 600 outpatient claims and more than 200 prescription drug claims in fiscal 2004.

This child lived in rural Texas, in a 1,300 square-foot mobile home with four other foster children, one of whom also was medically fragile. A review of the DFPS records indicated that this small home was not licensed to care for more than four children.

Sexually Transmitted Diseases

Some Texas foster children are suffering from sexually transmitted diseases (STDs).

Many are sexually active or were sexually abused while in care, while others come into care with the disease. In fiscal 2004, more than 200 foster children were diagnosed with STDs.

Most of them were teenagers between the ages of 15 and 19. DFPS should recognize this problem and actively address it through education, testing and appropriate treatment.

The review team found irregularities in prescribing practices and counseling delivered to foster children with STDs; females in foster care were six times more likely to be diagnosed with a STD than males.

Pregnant Foster Children

In fiscal 2004, 142 foster children delivered babies. The DFPS guidelines regarding birth control, pregnancy and abortion are vague and are not given to providers and foster parents. Some pregnant foster teens received powerful psychotropic medications that are not recommended for use in pregnant women.

And many were moved repeatedly throughout their pregnancies, because many residential treatment centers and foster homes will not take them.

Some pregnant foster teens received powerful psychotropic medications that are not recommended for use in pregnant women.

Texas has few specialty maternity homes that can offer services to these teens. Foster teens and their new babies, moreover, often were not placed in the same home in a timely manner following their discharge from the hospital.

Contraceptives and Foster Children

In fiscal 2004, Medicaid spent $176,814 on more than 4,300 birth control prescriptions for more than a thousand Texas foster children. Medical claims for these children suggest that not all sexually active foster children receiving these medications were given their recommended yearly gynecology examinations.

A 15-year-old mentally retarded foster child received eight different prescriptions for birth control pills in fi scal 2004, but had no claims for a gynecological examination.

And, a 17-year-old foster child received six different prescriptions for birth control patches in fi scal 2004, but had no claims for a pap smear or gynecological exam. This child was diagnosed with a sexually transmitted disease early in fi scal 2004.

Injuries and Deaths

In fiscal 2004, 46 Texas foster children died while in care. DFPS determined that five of these deaths resulted from abuse and neglect, but 15 cases were left “open” and abuse and neglect were not ruled out. Many other foster children were taken to emergency rooms or hospitals with very severe injuries and medical conditions. Medicinal Poisonings More than 150 foster children were poisoned by medication in fiscal 2004, and not all of these cases were investigated by DFPS.

Some foster children remained in the same foster homes after they survived the poisoning.

DFPS and HHSC should ensure that every poisoning from medication is investigated.

The DFPS hotline received a report that a nine-year-old child was being overmedicated, but the agency did not investigate the case.

Foster Children and Clinical Trials.

It was revealed in May 2005 that HIV positive Texas foster children had been enrolled in experimental clinical drug trials. This news sparked nationwide coverage of the topic, since the children were being exposed to potentially serious and even lethal side effects of the trial drugs.

Because of the confidential nature of clinical trials, it is not possible to find out details regarding Texas foster children enrolled in such studies, but some questionable indicators were uncovered – such as medications were billed with no record of medication payment and foster children that are HIV positive with no Medicaid billings for medications.

Section 6544 of the DFPS Handbook states: …no HIV infected child in DFPS conservatorship may participate in any experimental drug therapy…unless the child or child’s caregiver first secures the written approval of the child’s physician or program director of the child’s conservatorship unit.

The review team asked DFPS how many foster children participated in any experimental drug therapy or clinical trials from fiscal 2004 to 2006, and how such participation is reported or tracked and if there is detail by disease or condition.

The agency responded as follows: There are currently no clinical trials for HIV, so no children in foster care were enrolled in this type of trial between FY 2004 and FY 2006. A few children in foster care may be enrolled in other clinical trials.

This response is vague and it is clear DFPS either does not know how many foster children are in clinical trials—or chooses not to tell. According to the U.S. National Institutes of Health website in September 2006, there were 1,928 clinical trials under way in Texas, including several related to HIV. Executive Summary and Systemic Recommendations

More than 150 foster children were poisoned by medication in fiscal 2004, and not all of these cases were investigated by DFPS. 􀃍 Foster Children: Texas Health Care Claims Study – Special Report — vii The Medications In fiscal 2004, Texas Medicaid spent $30 million for powerful, expensive psychotropic prescriptions for Texas foster children. Many of these children received multiple medications. Psychotropic medications can have very serious side-effects and their use should be strictly monitored; a large number of them are not approved for use in children or adolescents.

The review team found that Texas foster children receive more psychotropic medications than their counterparts in mid- Atlantic and midwestern states. DSHS has set voluntary parameters for the use of psychotropics by foster children. These guidelines were released in February 2005 and were supposed to be revised annually.

A committee met in August 2006 to discuss the revision; the first revised parameters were scheduled for release in October 2006. Key concerns identified by this review include: Costly Psychotropic Medications In fiscal 2004, psychotropic drugs accounted for more than 76 percent of the cost of all medications prescribed to foster children, which totaled $39 million for all medications.

All other drug categories, including a wide variety of drugs from antibiotics to cancer medications, accounted for just over 23 percent of the total or $9.2 million. Of all drugs prescribed to children in foster care, three psychotropic drug classes —antidepressants, antipsychotics and stimulants— were the most frequently prescribed.

In fiscal 2004, Texas Medicaid spent more money on antipsychotic drugs for foster children, more than $14.9 million or 38 percent of the total, than on any other class of drugs. The average cost per prescription for psychotropic drugs was $114.69. The average for all other drugs, by contrast, was $52.17 per prescription. Antipsychotics: In fiscal 2004, Texas Medicaid spent nearly $15 million on 65,469 anti-psychotic prescriptions for Texas foster children.

These very powerful and expensive medications were prescribed despite a lack of studies demonstrating their safety and efficacy in children. There are questions regarding the long-term safety of these medications; documented serious side-effects include menstrual irregularities, gynecomastia, galactorrhea, possible pituitary tumors, hyperglycemia, type 2 diabetes and liver function abnormalities.

Close monitoring of these medications by physicians is essential; Texas foster children are not receiving this attention. In addition, more than 400 foster children were prescribed antidyskinetics drugs to control side effects from antipsychotics. Side effects from antipsychotics include tremors, tics, dystonia, dyskinesia and tardive dyskinesia.

Stimulants: In fi scal 2004, Texas Medicaid spent $4.5 million on 45,318 stimulant prescriptions for more than 6,500 Texas foster children.

Nearly all of these medications are Schedule II controlled substances, due to their high potential for abuse and severe psychological or physical dependence. More than a quarter of all male foster children and nearly 15 percent of female foster children received prescriptions for stimulants in fiscal 2004; nearly 200 of these children were aged four or younger.

In addition, some foster children received many questionable high-cost, high-dose prescriptions.

One prescription for a foster child was written for 360 pills of the stimulant Adderall XR 30mg—for a 30-day supply. Yet, Adderall XR is an extended-release medication meant to be taken only once daily.

Anticonvulsants (Mood Stabilizers): accounted for more than 76 percent of the cost of all medications prescribed to foster children, which totaled $39 million for all medications. 􀃍

In fiscal 2004, Texas Medicaid spent nearly $4.8 million on nearly 43,000 mood stabilizer prescriptions for about 4,500 Texas foster children.

This included 133 children aged four and younger.

These medications are used to treat bipolar disorder, anxiety and depression; some also are also used to treat seizures and epilepsy.

Trileptal and Topamax, which together accounted for about 38 percent of all mood stabilizer prescriptions, have no established efficacy for psychotropic use in either children or adults.

Antidepressants: In fiscal 2004, Texas foster children received more than 66,000 prescriptions for antidepressant medications, making this drug class the most commonly prescribed medication.

Antidepressant medications ranked fourth in the total cost of prescriptions for fiscal 2004, at $3.8 million.

In June 2003, the U.S. Food and Drug Administration (FDA) began to investigate the use of antidepressants to treat children and adolescents.

In October 2004, the FDA ordered drug manufacturers to place a “black box” warning on all classes of antidepressants stating that they may increase the risk of suicidal behavior in children and adolescents.

Anxiolytics (Anti-anxiety): In fiscal 2004, 688 foster children received 3,113 anti-anxiety prescriptions.

The largest subclass of these drugs, and the most widely prescribed, are the benzodiazepines. These drugs have been used with success to treat anxiety, but their use is limited because they have sedating side effects and may be habit-forming when taken for a long time or in high doses.

Anxiolytics are regulated under Schedule IV, by the U.S. Drug Enforcement Administration (DEA). Hypnotic/Sedatives: In fiscal 2004, Medicaid spent more than $72,000 on nearly 2,500 hypnotic/sedative prescriptions for about 1,000 Texas foster children, including 232 children aged four and younger.

These medications are used to treat anxiety or sleep disorders. They can cause dependency in just a few days and tolerance in a few weeks.

Psychotropic Use by the Very Young

In fiscal 2004, 686 foster children aged four and under received more than 4,500 prescriptions for psychotropic medications, the majority of which are not approved by the FDA for use in children.

A two year-old foster child with no diagnoses indicating psychosis received seven prescriptions for Risperdal, a powerful antipsychotic, totaling more than $700.

Controlled Substances

In fiscal 2004, Medicaid spent $4.6 million on more than 53,000 prescriptions for controlled substances for more than 9,600 Texas foster children.

The U.S. Drug Enforcement Administration (DEA) has placed these substances on the controlled substances list because of their high potential for abuse.

More than 2,300 Texas foster children, including 871 children age four and younger, received more than 3,200 prescriptions for addictive narcotic syrups.

A total of 177 foster children received more than 1,100 prescriptions for phenobarbital.

Long-term Risks and Polypharmacy

The Zito & Safer External Review notes that the widespread use of antipsychotics in children and adolescents raises particular concerns regarding long-term safety.

Serious questions exist regarding this issue, which involves documented, side effects.

Little is known about the long-term effects of early and prolonged exposure to psychotropic medications on the development of children’s brains.

These findings underline the importance of further research to determine the safety and efficacy of pediatric psychotropic drugs and polypharmacy.

The use of psychotropics in the Texas Medicaid population of children and adolescents tripled from 1996 to 2000.

A 2004 Texas study by the HHSC’s Office of the Inspector General revealed that foster children receive more psychotropic drugs on average than other Texas Medicaid children.

Psychotropic use by Texas pre-school-aged foster children was three times higher than among similar foster children in the Mid-Atlantic states. Instances of “polypharmacy,” the prescription of two or more psychotropics for one person—has increased rapidly as well.

Complex psychotropic drug therapy tends to result in ever-increasing combinations that tend to increase in continuously enrolled populations and present risks for long-term safety in developing youth.

Off -label Usage

Most psychotropic medications have not been studied extensively for efficacy and safety in children.

The National Institutes of Mental Health notes that about 80 percent of psychotropic drugs are not approved for use in children or adolescents.

Their use in this population is described as “off-label.” Yet the off-label use of these drugs in children is common.

Efficacy Questions

Many medications prescribed to Texas foster children have been shown to have no or minimal efficacy. Among antidepressants, for instance, FDA findings from clinical trials showed little or no efficacy from the use of escitaloram (Lexapro), paroxetine (Paxil) and venlafaxine (Effexor).

Yet prescription patterns among foster children appears to ignore such findings from clinical trials that show a lack of or minimal efficacy. In fiscal 2004, Texas foster children received the following:

•escitaloram (Lexapro): nearly 12,000 prescriptions totaling $763,000.

• paroxetine (Paxil): more than 550 prescriptions totaling almost $50,000.

• venlafaxine (Effexor): about 3,000 prescriptions totaling more than $300,000.

Many anticonvulsant drugs are being used as mood stabilizers for Texas foster children, including oxcarbazepine and topirimate.

These drugs have been found to be ineffective for psychiatric purposes. Nevertheless, they were widely prescribed to Texas foster children in fi scal 2004:

• oxcarbazepine (Trileptal): nearly 13,000 prescriptions totaling  $1.98 million.

• topiramate (Topamax): more than 3,300 prescriptions totaling more than $500,000.

Compound Drugs In fiscal 2004,572 foster children received nearly 2,000 prescriptions for compound drugs.

The FDA is concerned that such drugs carry a risk of contamination and the efficacy and potency can be effected. Fraud and abuse can also be a factor in compound drug prescriptions.

Recommendations to improve the Texas Foster Care system that should be implemented immediately:

1. The Health and Human Services Commission, Office of Inspector General should fully investigate areas of concern and cases of interest identifi ed in this report.

2. DFPS should hire a full-time physician to serve as its medical director, to oversee the care, treatment and medications provided to Texas foster children. The medical director should evaluate medical care provided to foster children and report the results to the DSHS and HHSC annually. The medical director should establish an analysis team to assist with the evaluation. The team should consist of psychopharmacologists and child and adolescent psychiatrists from medical schools.

3. The newly created DFPS medical director should be responsible for ensuring that all foster care parents and facilities receive “medical passport” information within 48 hours of the foster child’s placement. The “passport” should be updated consistently and should document all medical treatments, prescriptions, psychological diagnoses and counseling to provide continuity of care.

4. DSHS should review this report and begin implementing its recommendations as soon as possible, including those from the external review by Zito/Safer.

5. DFPS, in coordination with DSHS and HHSC, should examine the best practices of successful foster care providers to develop and implement means to reduce the system’s reliance on psychotropic medications to treat foster children.

6. DFPS should establish strict rules regarding participation by foster children in any type of clinical trial. In addition, DFPS should track and monitor all foster children who are enrolled in clinical trials. All foster parents and providers should be made aware of the rules and the potential risks of clinical trials.

Additional recommendations more specific to each problem are made in later chapters in this report. Foster Children: Texas Health Care Claims Study – Special Report


Some foster children receive counseling services, but not all do, and others do not receive consistent counseling.

According to the American Counseling Association, “Professional counselors help clients identify goals and potential solutions to problems which cause emotional turmoil; seek to improve communication and coping skills; strengthen self-esteem; and promote behavior change and optimal mental health. Counseling is a technique that can be used by individuals coping with a mental illness, recovering from a trauma, managing stress, or dealing with family issues.”

While some foster children suffer from severe mental illness, others have milder problems. The various options described below may help to reduce the number of psychotropic prescriptions prescribed to Texas foster children. Innovative Therapeutic Provider One Texas therapeutic foster care provider consciously uses a different approach to treat very troubled foster children, most of whom are classifi ed by service level as specialized.

This facility employs intensive therapeutic intervention that focuses on teaching children appropriate ways to problem-solve and make healthy and positive choices in their lives.

In an interview regarding the usage of psychotropic medications, a staff member stated that children at this facility are held accountable for their actions and are taught to manage their behavior with as few psychotropic medications as possible.

He (a staff member) also said that some children come into their program so heavily medicated that they are “drooling.’

An innovative therapeutic foster care provider has been successful in lowering the number of psychotropic medications given to foster children in its care.

Not all foster children who need counseling are receiving it on a regular basis. •

DFPS is not doing all it can to promote mentorship for foster children.

Since publication of the Comptroller’s Forgotten Children report in April 2004, the Department of Family and Protective Services (DFPS), the Health and Human Services Commission (HHSC) and the Department of State Health Services (DSHS) have been addressing psychotropic medication use by foster children.

DSHS has established medication parameters to help monitor and reduce the number of prescriptions.

Yet many psychotropic medications still are being prescribed to all ages of foster children. While medication may be beneficial in treating mental disorders, a “pill” cannot solve all of the emotional issues and problems foster children face while in care.

The Zito/Safer External Review states,

“poverty, social deprivation and unsafe environments do not necessarily require complex drug regimes.”

Often when foster children experience emotional problems they undergo psychiatric evaluations and are then taken to a physician, frequently a psychiatrist (but not always) who then prescribes one or more medications to help treat the problem.

While medication may be beneficial in treating mental disorders, a “pill” cannot solve all of the emotional issues and problems foster children face while in care.

A check of this provider’s Medicaid claims for foster children in its care showed that their usage of psychotropic medications decreased.

It is also important to analyze underlying causes that can affect mental health. Britain’s Mental Health Foundation has observed that,

“An integrated approach, recognizing the interplay of biological, psychological, social and environmental factors, is key to challenging the growing burden of mental ill-health in western nations.”2

Researchers are discovering how aspects of environment and social class can be associated with children’s poor health and behavior.3

Britain’s National Health Service has found that mental health problems are more common among people in poor living conditions, members of certain minority groups and the disabled.4

In Forgotten Children and its subsequent studies, the Comptroller’s office has found that Texas foster children often come from unhealthy living environments, and some remain in unstable and unsafe living conditions while in the foster care system. These include medically fragile children living in very small homes with many children, in mobile homes and in remote, isolated areas of the state.

Administrators at psychiatric hospitals told the review team that some children they treat have refused to return to their previous placements because they were so unhappy there.

Medical records revealed about 200 claims for scabies and multiple claims for the treatment of parasites in fiscal 2004, involving about 1,500 prescriptions at a cost of $80,000.

Scabies often is found among people living in crowded and unsanitary conditions. An unhealthy living environment can affect the mental health of already emotionally fragile children.

Alternatives to Psychotropic Medications – Psychotherapy

Psychotherapy is a common treatment that can help children understand and resolve their problems and modify their behavior. It can come in many forms, including individual, family and group therapy, play therapy and cognitive behavioral therapy.5

Many foster children need therapy because they have been removed from their homes, which can be very stressful. The Comptroller’s office has found that Texas foster children often come from unhealthy living environments, and some remain in unstable and unsafe living conditions while in the foster care system.