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The case study component of this project used interviews with state adoption program managers and post-adoption service (PAS) providers as well as focus groups with adoptive parents across five states. The case study report focuses on services that fall within each state’s definitions of its PAS program, although these boundaries vary somewhat across states. Also examined are how states use subsidies and other forms of support to assist adoptive families. Evaluation issues within the case-study states are discussed in the summary of the Evaluation Issues Report, Section 4.
| Case studies drew on information from adoption managers, program coordinators, providers, and parents. |
The RTI team selected candidate sites for the case study based on interviews conducted with state adoption managers by the Center for Adoption Studies at Illinois State University (ILSU) and expert opinion.(3) Using this information, ASPE selected five well-regarded state programs for the case study: Georgia, Massachusetts, Oregon, Texas, and Virginia. Data for the case study included semistructured interviews with staff from PAS programs and public adoption agencies, informal focus groups with adoptive parents, and PAS program documents. The RTI team conducted the five 2- or 3-day site visits between October and December 2001.
Site interviews were semistructured, collecting information on client needs, existing services, and program evaluation efforts. The team interviewed a broad range of service-based stakeholders with direct involvement in post-adoption programs and services. Specific questions asked of each interviewee varied, according to the circumstances of the program and the role and expertise of the individual. Topics discussed in the focus groups with adoptive parents included services desired, level of program satisfaction, utilization of services and subsidies, and areas for improvement.(4) Although findings from these focus groups cannot be generalized to the larger population of PAS recipients, the diverse opinions expressed suggest that participation was not unduly biased toward parents who were highly satisfied with the services they had received.
| Parents and PAS coordinators generally agreed on the type of services needed. |
Respite care. Most coordinators/providers mentioned respite as being a major need. Many also felt that, in addition to payment for respite care providers, families needed group respite activities such as camps, trips, and fun days. Respite care was also mentioned most often as a major need of families, across all states visited. Many adoptive parents described a dearth of available respite providers and lack of respite providers qualified to deal with special needs children. Parents also expressed a need for more group activities that would provide adopted children with opportunities to interact with one another.
Information. Adoptive parents reported that they were unclear about what PAS services were available to them and needed more information about services that they could access. They wanted to be knowledgeable about services before crises developed.
Parent training. Several coordinators/providers said that parents needed more training about adoption issues before the adoption occurred. Adoptive parents also felt that training about adoption issues was a critical need. Although some parents mentioned that parent training currently was offered, they often had found that it did not meet their needs. Parents often stated that the training was offered too soon after adoption, before they had enough experience with the issues to understand the training content.
Professional training. Coordinators/providers and adoptive parents mentioned the need for professionals competent in adoption issues, especially in the educational and mental health areas. Adoptive parents repeatedly reported having trouble finding qualified therapists who were knowledgeable about adoption issues. Parents reported that their children were stigmatized by schools when it was discovered that they were adopted. They wanted staff training as well as advocacy to help them deal with schools on their child’s behalf.
Mental health services. Another need coordinators/providers and adoptive parents often expressed was mental health services for adoptive families. Parents were concerned about finding a provider as well as being able to pay for the services when they did find a provider with whom they felt comfortable. They noted that although these services were funded through Medicaid, many mental health providers did not accept Medicaid or were not available through private insurance plans.
Child assessments and evaluations. Adoptive parents wanted more comprehensive assessments and evaluations conducted on their adoptive child when they were placed and before finalization. They also wanted to know more about the child’s and birth parents’ background, and about potential physical and mental problems before adoption finalization. Parents mentioned needing assistance in interpreting the records.
Other needs mentioned by coordinators/providers included advocacy, residential treatment, case management, support groups, and assistance with adoption subsidies.
Adoptive parents were generally satisfied with the services available to them by their state’s PAS programs, but many felt that additional funding was needed. Parents in several states expressed strong satisfaction with how effectively and quickly program staff handled crises (e.g., suicidal behavior, hospitalizations, aggressive behavior), with receipt of appropriate information about adoption issues and referrals to adoption-competent therapists and other service providers. Many parents expressed satisfaction with respite options, but they also very clearly expressed a desire for more funding for those services.
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| Each state contracted out its PAS program, although program structures varied. |
Formal PAS programs were instituted during the 1990s in all five case-study states. Adoption program managers reported that the development of PAS resulted from a combination of factors, including adoptive parent advocacy movements, state legislative action, and state executive initiative. In each of these states, PAS are contracted out rather than provided by state child welfare staff. State adoption program managers mentioned a variety of reasons for this approach. These reasons included cost effectiveness, the difficulties of hiring additional state staff and protecting their positions against budget cuts, and the belief that using external contractors fostered creativity and facilitated statewide service delivery in county-administered systems.
Adoption program managers and PAS coordinators described four PAS program structures:
Most of the PAS providers selected by the states have extensive experience in providing services to children and families, including adoption services and child placement. Regional PAS providers were expected to offer the full array of services for their region.
Services such as information and referral, parent training, and support groups were provided at no cost to families. However, in some cases, funding did not cover the full cost of a service that families sought through other community providers (e.g., respite, camps).
Program managers in case-study states identified several common program goals.
Preserving adoptive families. State adoption program managers shared the belief that the primary purpose of PAS programs was to help adoptive families stay together and to prevent out-of-home placements among adopted children.
Statewide access. Adoption program managers in all five states stressed the importance of offering services to adoptive families throughout the state. Regardless of program structure, adoption program managers reported that delivering services to rural areas was a particular challenge due to clustering of services around larger communities and demands of staff travel.
Family-centered services. Several adoption program managers reported that another explicit objective was to allow families to decide their level of involvement with PAS and to identify the types of services they felt they needed.
Adoptive family recruitment. In only one state did the adoption program manager expressly identify the PAS program as a tool for recruiting adoptive families. However, PAS providers in other states noted this connection, reporting that they often presented their PAS programs at pre-adoption parent trainings.
Across the case-study states, adoption program managers reported that eligibility for PAS was determined largely by adoption type and receipt of subsidy (i.e., presence of special needs). Adoption program managers in Virginia and Massachusetts reported that any adoptive family residing in the state was eligible for PAS. In Massachusetts, eligibility for services is extended to families in legalized guardianship arrangements. In Virginia, the state also opened up PAS to families prior to adoption finalization. Adoption program managers in the remaining three states primarily served families who adopted from the child welfare system in their state. Two of these states offered some lower cost services to all adoptive families.
| Funding levels varied widely, with state funds and Title IV-B Subpart 2 most commonly used. |
Two distinct patterns of funding PAS programs were seen among the five states visited, use of state funding and use of Title IV-B Subpart 2 (Promoting Safe and Stable Families program) funds. Virginia required its lead PAS contractor to contribute a 10 percent match toward the cost of the program. None of the five states reported using funding from the Adoption Incentive Program for PAS.
Annual funding for PAS in 2001 varied widely across states, ranging from $500,000 in Oregon to between $8 million and $9 million in Georgia. Given the variations in population size and program eligibility among the five states, it is difficult to compare funding levels across states, but funding levels clearly varied with the provision of higher cost services such as crisis intervention (in Georgia) and residential care (in Texas).
Adoption program managers and other officials in several states were concerned that the dramatic increase in adoption the past several years will increase future needs for PAS and require additional funds to support it. Among services providers, concern was widespread regarding the current levels of funding. Although no states reported waiting lists for PAS services, some had to restrict availability of higher cost services such as crisis intervention and residential treatment.
| Despite energetic outreach, many adoptive families are unaware of available services. |
State adoption managers and providers in the five case-study states reported a variety of strategies by which they inform families about the availability of PAS. Activities included sending letters about the program to families receiving subsidies, disseminating printed materials, meeting with local or state government social services and other community organizations, establishing community boards on post-adoption services, operating local or statewide information and referral telephone lines, and presenting the PAS program at pre-adoption parent training classes. None of the adoption program managers expressed concern that increased publicity would lead to waiting lists for services. In spite of these extensive efforts, adoptive families across the five case-study states reported that they still needed more information about the types of services offered and how to access them. This was true even for parents who had accessed the state’s PAS program.
Many families heard of PAS programs through referrals from the child welfare agency or other service providers. In several states, however, PAS coordinators/providers and adoptive families reported that child welfare intake staff and adoption subsidy workers failed to refer families to PAS programs. In spite of extensive outreach efforts, providers reported that many adoptive families came to them for the first time in crisis situations, rather than receiving support in a preventive manner. Adoptive families in the focus groups confirmed that they often were unaware of the PAS program prior to a crisis situation.
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| Common PAS include I&R, counseling, respite, training, advocacy, and support groups. |
Across the five states, the services most widely offered by PAS programs included information and referral, counseling, crisis intervention, respite, case management, training for parents and professionals, advocacy, and support groups. Some variation existed among the states. Texas was the only state to offer residential treatment within the PAS program; Georgia was the only state to offer tutoring; and Oregon was the only state that did not include counseling, crisis intervention, and respite.(6)
Information and referral (I&R). States used diverse strategies for information and referral services: 24-hour phone lines, websites, lending libraries, databases of adoption-competent professionals, printed materials (both about the program and about specific resources for families), and newsletters. Two states operated lending libraries (including books and videos), which were said to be well used, and one state was preparing to place regional advisors around the state.
As part of their response teams, the Virginia and Massachusetts programs used parent liaisons, who were themselves adoptive parents, to provide information and referrals. Parent liaisons in both states talked with the families who had contacted their agencies, identified their needs, and worked to locate needed resources.
PAS programs in the five states provided families with referrals to community mental health and other service providers. In Massachusetts, a subcontractor to the lead service agency provided families with free access to its extensive provider database.
Counseling and crisis intervention. In four of the case-study states, counseling and crisis intervention was available directly from the PAS providers or through referrals to community mental health agencies that were reimbursed by the PAS provider. A variety of approaches was used in delivering counseling and crisis intervention services, including multidisciplinary teams and in-home services. Providers did not expressly mention conducting comprehensive clinical assessments and testing, a need expressed by adoptive parents.
Respite. In four of the case-study states, respite was provided through the PAS program in several forms, including reimbursement or vouchers for a caregiver, sending a child to camp or on an outing, holding special events (e.g., annual parties), or art therapy. In Virginia, the Client Fund gave PAS providers the flexibility to fund an array of services identified by clients, including respite. Due to the high demand for caregiver respite, many programs limited the availability of respite funding. Finding respite providers who were acceptable both to families and to the state often was challenging. Only one state allowed adoptive families to use other family members to provide respite.
Virginia funded an effort to increase respite resources for adoptive families through the Virginia Institute for Developmental Disabilities (VIDD), an organization affiliated with Virginia Commonwealth University. The VIDD coordinator visited each region to discuss resource development and developed a resource guide for adoptive parents based on her experiences with respite for families with developmentally delayed children.
Case management. PAS providers in the five states engaged in varying levels of case management in conjunction with providing crisis intervention, counseling services, and/or information and referral. All of the states used client-tracking systems to assist staff in case management activities. Events that were tracked included incoming referrals, case openings, service use, and case status.
Parent training. State adoption program managers and PAS coordinators/providers reported providing training not only on adoption-specific issues (e.g., grief and loss) but also on child development issues relevant to adoptive families (e.g., fetal alcohol syndrome). While many of the trainings were one-session events, providers also reported offering workshops and a series of sessions on a particular topic. Providers also sent families to adoption conferences.
Professional training. In all five case-study states, state adoption program managers and PAS coordinators/providers also reported offering professional training on adoption-specific issues and child development issues. Training audiences included child welfare workers, mental health professionals, teachers and other school staff, court system staff, and medical practitioners. Topics offered to professionals included cross-cultural competency, transracial adoption, attachment in adoption, respite care for adoptive families, education law and advocacy, and openness in adoption. In several case-study states, PAS providers themselves also received training.
Advocacy. PAS providers described accompanying client families to meetings and conferences with schools and community service providers. Staff in one Texas region attended community review board meetings for cases where the child’s needs extended to several state agencies. Parent liaisons provided advocacy for families in Virginia.
Support groups. PAS providers operated support groups for parents and/or children, either by leading them or through more limited assistance (e.g., offering a location, providing refreshments, mailing flyers). In addition to PAS staff, counselors, parent liaisons, and graduate students helped facilitate the support groups. Most often, providers formed support groups according to age and level of need (e.g., therapeutic support group). A regional PAS provider in rural Virginia started an online support group. Although providers considered support groups an essential component of PAS, recruiting and retaining families had been a continuing challenge. Many tried to increase and sustain attendance by, for example, holding child and parent groups simultaneously, offering child care for parent support groups, and providing transportation.
Families who have adopted children from public child welfare systems generally have access to adoption subsidies in addition to whatever PAS program may be available to them. The five case-study states offered substantial flexibility in their subsidy programs. All allowed establishment of deferred subsidies, which allowed families who did not require a subsidy at the time of adoption to request one at a later date if circumstances changed. In addition, all five states noted that subsidies could be renegotiated as family circumstances changed. Flexibility in policy is of limited value, however, unless adoptive families understand what resources may be available to them and how they can be accessed. In four of the five states, adoptive parents participating in focus groups expressed considerable frustration and confusion related to subsidies.
Data on state adoption support policies compiled by the North American Council on Adoptable Children (NACAC) suggest that in the five case-study states, strong PAS programs are accompanied by relatively generous subsidies and other supports (Bower and Laws, 2002). However, case study data did not reveal any suggestion of a planned effort to coordinate the various forms of support to which families have access.
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Better data needed for planning. High-quality data on families’ needs are needed to support improved planning for PAS. While many states have conducted needs assessments, their usefulness is often limited by modest response rates. In addition, these surveys rarely provide enough detail to establish when services are most likely to be needed, in terms of children’s ages or elapsed time since adoption. A national probability-based sample of adoptive families would help to provide a picture of underlying needs among those families that have, and have not, obtained PAS from state sources. At the state or program level, needs assessments should be conducted with enough rigor and detail to inform ongoing planning and program adaptation.
Services appreciated, but unmet needs remain. PAS representatives and adoptive parents identified similar priorities for service to adoptive families. Adoptive parents confirmed the usefulness of services offered by the PAS programs, especially information and referral, respite, advocacy, crisis intervention, and counseling. They also identified additional needs beyond the boundaries of typical PAS programs, including more usable information about their children, better information about supports available to them, and improved access to service providers of their choice.
Satisfaction with PAS generally high. Many states collect data on satisfaction with PAS programs, which, like needs assessments, may be biased by low response rates. Available data suggest that most families are very satisfied with services offered, and focus group participants confirmed this impression. Of particular value to adoptive parents was the level of insight and sensitivity to adoption issues that were inherent in the services they received from the PAS program. The only major source of dissatisfaction was the desire for additional services not currently offered by the PAS program.
Federal funds necessary but not sufficient for PAS development. There is no doubt that the growth in PAS programs has been encouraged by the recent availability of federal funding for this purpose. In the case-study states, however, advocacy by adoptive parents and program champions within state agencies or legislatures appeared to have been even more influential than the influx of federal funds. The experience for this limited set of states suggests that while federal funding may be necessary for PAS programs development, these resources did not by themselves lead to program development.
Adoptive families face disparities based on residence. Available research strongly suggests that some adoptive families need specialized supports for part or all of their child’s development. However, the availability of both PAS programs and support to families through adoption subsidies varies widely among states. It does not appear that states with strong PAS programs provide less generous subsidies, or vice versa. Disparities in subsidies and services mean that children’s long-term outcomes may vary according to their state and county of residence/adoption.
Common goals, diverse strategies. All of the programs studied shared the common goal of keeping adoptive families intact, although the services they delivered in working toward this goal varied across states. More variation was seen in the ways in which programs worked to influence the service delivery environment. Most programs offered training for mental health, education, and legal professionals likely to serve adoptive families. These efforts to change delivery systems also are necessary to increase the extent to which other service delivery systems can meet the needs of adoptive families.
Eligibility restrictions limit program impact. Three of the five states in this study restricted eligibility for at least some of their services to families who had adopted from their state’s child welfare system. Although restrictions may be necessary to conserve scarce program resources, this policy raises two concerns. First, the effort to increase the rate of adoptions from foster care will be hampered to some degree if families who subsequently move across state lines know they will have limited access to PAS. Second, limiting services for families who have adopted privately or from other states may increase their eventual risk of needing high-cost services. PAS programs may be more effective in both preserving adoptive families and encouraging adoptions from foster care if they are able to serve all adoptive families. Only one of the case-study states offered PAS to families prior to legal adoption, although many providers and parents identified this as a need.
Most programs contracted out by states. Each of the states in the case study contracted out its PAS program to providers who delivered services either statewide or regionally, and the ILSU survey suggests that this is the dominant model nationally. State adoption program managers identified several advantages to this model, including better protection against fluctuations in state agency budgets, the ability to standardize services throughout the state, and the avoidance of the stigma many adoptive parents feel in approaching the child welfare agency for PAS.
Serving rural families remains challenging. States consciously worked to make their PAS programs consumer-driven, providing families with an array of services from which to choose. Although adoptive parents did not specifically mention these consumer-driven efforts, it was clear that they had taken advantage of the flexibility. Although PAS programs shared the goal of making services available statewide, coordinators reported difficulty in making services truly accessible in rural areas. Barriers to delivery of services in rural areas include the scarcity of mental health services, difficulty in gathering participants for trainings or support groups, and increased travel time for program staff. New communication technologies, such as the online support group in Virginia, may be a useful strategy.
Support needed from child welfare system as well as PAS providers. While many states choose to contract out PAS services, some level of post-adoption support should be maintained within public child welfare agencies. Adoption workers typically remain accessible to adoptive families for some time after finalization, and many families will turn to adoption workers as the “first responders.” However, adoptive families reported that adoption workers often lacked interest in their ongoing welfare or expressed surprisingly negative attitudes toward families who returned with difficulties. Some PAS programs in the case-study states were addressing this issue by offering training in adoption issues to public agency workers. If families are to feel confident about support from the system, system support should be consistently communicated to them at any point of entry to PAS, even if the content of the interaction consists only of a referral to the PAS program.
Services adapted to local conditions. The case-study states were fairly consistent in offering a core set of services (information and referral, education and training, support groups, respite, and counseling). Within this core, the variety with which states addressed these core services reflects considerable creativity in program design and commitment to adapting service delivery to local conditions. It also suggests the potential usefulness of systematic program evaluation in shedding light on which service delivery approaches work best under various circumstances.
Respite care highly valued but difficult to provide. Respite care appears to be a particularly challenging need to address. Families consistently reported it as a need — in the literature, in state needs assessments, and in these focus groups — and states have tried a variety of approaches in providing respite. Two states offered respite in congregate settings, but this model may not meet the needs of many children whose parents were most in need of respite. States struggled with the challenges of finding or training providers who were acceptable both to parents and funding agencies. For the most part, limitations on funding meant that only a very limited level of relief was available for parents who were dealing with extremely challenging children.
PAS often used in crisis mode. Both PAS providers and focus group participants reported that PAS programs are more often used during times of crisis than as a preventive measure. A better understanding of the type of need and extent of need for both preventive and crisis services could improve service planning and provide impetus for better coordination and referral systems between adoption workers and PAS providers.
PAS planning must encompass subsidies and existing services. Adoptive parents often face a patchwork of services and supports, from which essential pieces may be missing. A comprehensive approach to serving adoptive families would encompass subsidies and existing service delivery systems, as well as PAS programs. Such a network would be challenging to develop, requiring coordination among agencies involved in health, mental health, education, and child welfare. However, comprehensive planning eventually could offer states more efficient use of their resources while improving the delivery of services to adoptive families.
(3) RTI spoke with Susan Smith, faculty and co-director, Center for Adoption Studies, ILSU; Jane Morgan, adoption specialist, U.S. DHHS, Administration for Children and Families; and Kathy Ledesma, Oregon state adoption coordinator and chair, National Association of State Adoption Programs.
(4) The 32 adoptive families represented in the focus groups had adopted 76 children, 66 of whom were from the public child welfare system.
(5) Virginia did contract separately with two providers for PAS in addition to funding a network of providers. One provider offered professional training, and the other developed respite resources.
(6) Although Oregon’s PAS program did not include counseling, one of the state’s service areas used state funding to support a Post-Adoption Family Therapy (PAFT) unit whose staff provided counseling and crisis intervention to families who adopted from the state and live in the Portland area.
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