Submitted by:
Deborah Gibbs and Kristin Siebenaler
RTI International
Richard P. Barth
University of North Carolina School of Social Work
Contract No. 100-99-0006
Submitted to:
Laura Feig Radel
U.S. Department of Health and Human Services
Office of the Assistant Secretary for Planning and Evaluation
Funded by:
U.S. Department of Health and Human Services
Administration for Children and Families
Administration on Children, Youth and Families, Childrens Bureau
Introduction
Most adoptions have positive outcomes both for children and their families. However, many families need supportive services during some part of their childs development. In response to these needs, many states have developed post-adoption service (PAS) programs as well as other supports that extend their subsidy programs beyond the federally prescribed standards. As the pace of adoptions from public child welfare systems continues to increase, in many states the number of children receiving adoption subsidies has surpassed the number of children in foster care.
This report is part of a project that examines these rapidly growing and evolving PAS programs, using a literature review (Barth, Gibbs, and Siebenaler, 2001), analysis of secondary data, and case studies of well-regarded programs. The case study component used interviews with state adoption program managers and PAS providers as well as focus groups with adoptive parents to address the following research questions:
- What are the service needs of families following adoption of a child from the public child welfare system?
- What are the characteristics of existing PAS programs?
- How are PAS programs monitoring and assessing their effectiveness?
The report focuses on services that fall within each states 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 PAS programs, described here in the context of activities in the case-study states, will be discussed in greater depth in a forthcoming report.
This project was funded by the U.S. Department of Health and Human Services (DHHS), Administration for Children and Families (ACF), under contract to the Office of the Assistant Secretary for Planning and Evaluation (ASPE). Research was conducted by RTI and the University of North Carolina at Chapel Hill. Staff involved in the five states PAS programs, as well as adoptive parents participating in focus groups, gave generously of their time to meet with the project team.
Data Collection
- 2.1 Site Selection
- 2.2 Data Collection Methods
- 2.3 Data Management
- 2.4 Case Study Analysis and Reporting
2.1 Site Selection
The RTI teams plan for selecting the sites for the case study included developing a list of recommended sites by using information collected as part of an effort by the Center for Adoption Studies at Illinois State University (ILSU). ILSU was compiling information on characteristics of post-adoption service (PAS) programs (e.g., sponsorship, services and supports provided, number of families served, funding sources) by interviewing state adoption managers. However, because ILSUs information was not available for all participating states in time for site selection, RTI also relied on expert opinion. The team contacted three individuals whose professional roles and previous work made them particularly knowledgeable about existing programs and the field of PAS generally:
- Susan Smith, faculty and co-director, Center for Adoption Studies, ILSU
- Jane Morgan, adoption specialist, U.S. DHHS, Administration for Children and Families
- Kathy Ledesma, Oregon state adoption coordinator and chair, National Association of State Adoption Programs
Asked to identify well-regarded programs, these individuals collectively mentioned 11 states, among which there was a strong degree of convergence. Using this information, ASPE selected 5 state programs for the case study: Georgia, Massachusetts, Oregon, Texas, and Virginia.
2.2 Data Collection Methods
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 two- or three-day site visits between October and December 2001. Two-person teams conducted the site visits, sharing responsibility for leading the interviews and focus group sessions and for taking notes.
2.2.1 Contact
To secure participation of the five states, the Associate Commissioner for the Childrens Bureau sent a letter to each state adoption program manager to introduce the study and to encourage support of the research effort. The RTI team then contacted each program manager to confirm participation and to develop a list of potential interviewees. In addition to the program managers, interviewees included coordinators who managed PAS programs and PAS providers who directly interacted with adoptive families. In each state, the program manager provided a list of individuals associated with the state-directed PAS program. These PAS coordinators and providers assisted in identifying and recruiting adoptive parents for the focus groups.
2.2.2 Interviews
Site interviews were semistructured, collecting information to address the studys primary research questions 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, gathering information on the opportunities and challenges in developing PAS programs, providing services, and tracking client outcomes.
Questions were based on primary research topics (Exhibit 2-1). Specific questions asked of each interviewee varied, according to the circumstances of the program and the role and expertise of the individual. The team also used additional questions based on preliminary review of the informal ILSU interviews with state adoption agency directors. At the time of this report ILSU staff had conducted interviews with state adoption coordinators in 36 states.
Need: What is the extent of need for post-adoption services and supports as measured by the following:
Existing Programs: What are the characteristics of existing PAS programs in terms of the following?
Evaluation: How are programs monitoring and assessing their effectiveness?
Note: Questions varied according to the role of the person interviewed. |
2.2.3 Focus Groups
The focus groups added the perspectives of adoptive parents as a counterpoint to those of the PAS coordinators and providers interviewed during the site visits. Topics discussed included demand for PAS, types of services desired, level of program satisfaction, and program recommendations. In addition, parents were asked about utilization of services and subsidies. Questions were based on primary research topics (Exhibit 2-2).
Need: What is the extent of need for post-adoption services and supports as measured by:
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Although setting up successful focus groups can be challenging, PAS providers were extremely helpful by actively recruiting parents and by providing a location to meet in the evenings. With the PAS providers direct involvement, the team was able to conduct focus groups with the ideal number of parents (six to eight) in each site.
Because the RTI team needed to rely on PAS providers to recruit adoptive parents for the focus groups, potential biases among these participants cannot be assessed. 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.
2.2.4 Document Collection
The RTI team asked the state adoption program managers and all interviewees for documentation related to the PAS program. Documents collected included program descriptions, authorizing legislation, needs assessments, annual reports, evaluation instruments and reports, state requests for proposals, provider proposal responses, and outreach materials. The majority of materials were collected during and after site visits. The RTI team reviewed all materials and integrated relevant information into respective interview summaries to provide contextual information for analysis and reporting.
2.3 Data Management
For interviews, handwritten notes were summarized in electronic format shortly after the interviews, using audiotapes as backup to written notes as necessary. The team sent a copy of the interview notes to interviewees for correction of any factual errors. In addition, the team sent follow-up questions to state adoption program managers to clarify certain information and fill in any gaps.
For focus groups, written notes were summarized immediately after each group using a debriefing form and audiotapes. The debriefing form captured illustrative participant quotes on specific topics, facilitators subjective impressions of emerging themes, and comments on group dynamics that were relevant to data interpretation.
The team entered interview and focus group notes into a database using a qualitative software package. Although the original intent was to develop a hierarchical coding structure to categorize text according to participant characteristic and topic, the team determined that the data could be managed and accessed effectively without further coding. The study team prepared a series of matrices to summarize data on key topics. These matrices assisted in reducing large volumes of qualitative data to a level at which patterns could be identified.
2.4 Case Study Analysis and Reporting
Following completion of data management, the team prepared this draft report summarizing data on key topics. In this report, individual programs are described from a variety of perspectives, and differences and commonalties among them are discussed. The report also presents the qualitative data, allowing review of major themes within topic areas.
Post-Adoption Service Program Models
This section presents a brief overview of the key characteristics of the PAS program in each of five states included in the case study. (For more detail about each states program characteristics, see Section 5.)
| Program Characteristic | Georgia | Massachusetts | Oregon | Texas | Virginia |
|---|---|---|---|---|---|
| History | A state senate study committee on adoption and foster care recommended that there be a separate Office of Adoption. Subsequently, Gov. Zell Miller created the Office of Adoption in 1997. | In mid-1990s, adoptive parents formed SE Mass. Adoption Services Coalition, which eventually became statewide Mass. Coalition for Adoption. Coalitions contacted the legislature to raise awareness, resulting in PAS funding. Program called Adoption Crossroads began in October 1997. | In late 1990s, PAS program resulted from combination of adoptive parent and professional advocacy, state executive and legislative interest, state needs assessments, and timing of federal funding. Oregon Post Adoption Resource Center (ORPARC) formed in early 1999. | In late 1980s, adoptive parents filed a class-action lawsuit against state for lack of services. The state prevailed, but publicity and increased awareness prompted the legislature to authorize PAS funding. Texas has funded PAS since early 1990s. | In late 1990s, state adoption officials collaborated with other states to discuss post-adoption supports and services. Participation led to creation and design of PAS program. Adoptive Family Preservation (AFP) Project has been operating since March 2000. |
| Structure for provision of PAS | State contracted directly with PAS providers that each provide one or more specific service(s) statewide. A recently awarded contract will provide families with regional adoption liaisons, who will offer information and referral services to families and develop regional support groups. | State contracted with a lead agency, Child and Family Services, Inc., which subcontracted with five affiliates to serve families in other regions of the state. Each provider is expected to serve families with the full range of PAS. | State contracted with one provider, Northwest Resource Associates, which operated ORPARC based in Portland. | State contracted with 10 child and family service agencies to cover 11 regions. Each provider is expected to serve families with the full range of PAS. | State contracted with one lead service provider, United Methodist Family Services (UMFS) based in Richmond, which subcontracted to four additional providers to serve seven regions. Each provider is expected to serve families with the full range of PAS. The state directly funds two other organizations to provide training and respite resource development services. |
| Program goals | To achieve permanency for children adopted from foster care system |
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| Eligibility | All adoptive families for most services; some services available only for children adopted from the state. In general, children adopted from the state have priority. | All adoptive families and families in legalized guardianship arrangements. | All adoptive families, with limitations for families with children adopted through domestic or international private adoptions. | Families who adopted from the state or licensed Texas child-placing agency and receiving adoption subsidy. Children must be under 18. | All adoptive and pre-adoptive families. Priority given to families who adopted from the state. |
| Funding source | Title IV-B Subpart 2, and state funds | State funds only | Title IV-B Subpart 2 | Title IV-B Subpart 2 | Title IV-B Subpart 2, 10% match from UMFS |
| Number of children receiving subsidy* | 7,462 children | 11,758 children (including subsidized guardianship; 9,004 were adopted) | 6,716 children (6,113 receiving subsidy; 603 medical assistance only) | 13,000 children receive maximum subsidy of $516 (tiered rate being developed) | 3,617 children |
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| Evaluation | Each program required to have evaluation component collecting data on service provision and use. State staff conducted quarterly site visits. | Salem State College conducted a multiyear evaluation on client satisfaction, service provision and use, and outcome measures. | Several needs assessments conducted before creation of ORPARC and during its early development. Client tracking database used and client satisfaction survey conducted by mail. | Regional service providers developed annual client satisfaction survey. | Client tracking form used by regional offices. Providers used child assessments on a pre- and post-service basis. |
| * Estimates provided by state adoption managers in fall 2001. Promoting Safe and Stable Families Program. |
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Need for and Satisfaction with Post-Adoption Services
The views of adoptive parents, state adoption program managers, PAS coordinators,(1) and PAS providers on services needed by adoptive families were more similar than not. Many of the state adoption program managers reported the needs in terms of the services available under their PAS programs. PAS coordinators/providers and parents identified the greatest needs as respite, information and referral, counseling and crisis intervention, advocacy, and access to adoption-competent professionals (especially in mental health). States and PAS coordinators/providers reported that their tracking of client information and cases has guided service delivery. Where client satisfaction survey data were available, adoptive parents reported a high level of satisfaction with the services and their interactions with providers. Although parents generally were satisfied with the PAS they received, they expressed a strong desire for more funded services.
4.1 Service Needs
4.1.1 States, Coordinators, and Providerschap146; Perspective
State adoption program managers, PAS coordinators, and PAS providers identified similar family needs. In several states, PAS needs assessments had been conducted. Oregons most recent needs assessment, which sampled families receiving adoption subsidies, achieved a 50% response rate (Fine, 2000). Parents were asked about services they had received during the previous year and how important various services might be for their family in the coming year. Counseling for children was the service most frequently described as somewhat or very important, by 49% of interviewees, followed by professional advice about rights and services (46%), support groups (45%), and respite care (42%). Nearly one-third of the families did not view any of the listed services as important. Comparison of service needs to services received suggests a high proportion of unmet needs.
| Service | Described service as somewhat or very important % | Reported using service in previous year % |
|---|---|---|
| Counseling for children | 49 | 30 |
| Professional advice | 46 | 15 |
| Support groups | 45 | 15 |
| Respite care | 42 | 17 |
| Recreation | 38 | 6 |
| Counseling for adults | 37 | 13 |
| Residential treatment | 21 | 4 |
| Psychiatric hospitalization | 16 | 2 |
| Source: Fine, 2000. | ||
Most coordinators/providers mentioned respite as being a major need. Many also felt that, in addition to providing reimbursement or payment for respite care providers, families needed group respite activities such as camps, trips, and fun days. Coordinators/providers said that families found these activities to be beneficial but that providers were limited in their ability to offer them.
| Respite, mental health services, adoption-competent professionals, advocacy, and residential treatment were needs frequently identified by coordinators and providers. |
Another need that coordinators/providers often cited was mental health services for adoptive families. Although these services were funded through Medicaid, many mental health providers did not accept Medicaid. Oregons adoption program manager noted that if any additional funding were to be available, her first priority would be to provide counseling and crisis intervention services in each of the states service areas. In Texas, the adoption program manager saw a need for the development of home-based therapeutic services. Coordinators/providers also mentioned that families needed professionals competent in adoption issues, especially in the educational and mental health areas. Families needed educators who were aware of adoption issues as well as advocates to attend education meetings with parents to help ensure that their needs were met.
Several coordinators/providers mentioned advocacy, residential treatment, case management, support groups, and assistance with adoption subsidies as other needs of adoptive families in their state. They also said that parents needed more training about adoption issues before the adoption occurred. Some stressed that this would make parents better able to prevent later problems.
4.1.2 Adoptive Parents Perspective
Adoptive parents who participated in the focus groups identified a range of service needs, some of which were services delivered by the state-directed PAS programs. The 32 adoptive families represented in the focus groups had adopted 76 children, 66 of whom were from the public child welfare system.
Respite Care and Activities/Events
Respite care was mentioned most often as a major need of families, across all states visited. Many adoptive parents described a dearth of available respite providers. Others mentioned the lack of respite providers qualified to deal with special needs children. Parents also expressed a need for more group activities for children and families to provide adopted children opportunities to interact with one another. In an evaluation report of Adoption Crossroads by Salem State College in Massachusetts, families noted the break from parenting provided by respite as the most helpful aspect of care.
Information
| Parents felt they needed better information about available services. |
Adoptive parents in all five case-study states reported being unclear about what PAS services were available to them, saying they needed more information about services that they could access. As one parent stated, Services may be there, but parents dont hear about them. Another parent said that she did not want to feel lucky when she learned about something to help her child. Some parents also felt that they learned about services only in times of crisis and wanted to be knowledgeable about services before crises developed. As one parent said, I didnt realize adoption had the potential to be so crisis-laden. Not until a crisis occurred did I realize services were available. Another parent said, We shouldnt have to hit a crisis to get offered services. Parents in one group recommended establishing an all-inclusive program where adoptive parents could access counseling, advocacy, lawyers, respite, and other adoption-related services under one roof.
Parent Training
Adoptive parents in each state 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 had enough experience with the issues to understand the training content. At the same time, however, other parents believed that the state pre-adoption training needed to be supplemented. I went through MAPP [pre-adoption training] and said that after adoptions they should have RE-MAPP. Parent training also was thought to be needed for issues such as adopting special-needs children and dealing with cultural issues around adoptions.
Professional Training
Adoptive parents saw education of medical and community professionals regarding adoption issues as extremely important. Most mentioned 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. One parent said, If the school finds out they are adopted, its like they get an X on their back. The school is quick to put the child out or think they will have problems. They wanted staff training as well as advocacy to help them deal with schools on their childs behalf.
Mental Health Services
Adoptive parents in most groups said that access to and funding for mental health services for their adopted child was a serious need. Parents were concerned about finding a provider as well as being able to pay for the services when they did find someone with whom they felt comfortable. They noted that many community providers either did not accept Medicaid or were not included among providers that they could use with their insurance.
Child Assessments, Evaluations, and Information
| Parents particularly wanted to have more information about their childs background, history, and current assessments, and to gain a better understanding of changing needs as their child ages. |
Adoptive parents wanted more comprehensive evaluations and assessments conducted on their adoptive child when they were placed and before finalization. Parents also wanted to know more about the childs and birth parents background before adoption finalization, saying that this information was critical in helping them understand the needs of their adopted children. Parents thought that more information on their childs background would help them better prepare for future difficulties, recognize problems when symptoms begin to occur, and solve current problems. Parenting would have been a lot easier if I would have had more information. Regardless of whether this information was available or would have been helpful, parents were frustrated at not having received it.
Adoptive parents also wanted more information on the physical and mental problems their child might have. In one state, parents suggested that a law be established to require that medical records be given to adoptive parents. Parents also mentioned needing more assistance in interpreting the records they did receive. One parent said that she still was unclear about what the information she had received actually meant. Another noted that when her daughter became a teenager and began severely acting out, she went to a nurse who translated the psychological and medical information from the adoption records.
4.2 Satisfaction with Services
4.2.1 State Activities
Each of the states had implemented efforts to monitor the delivery of PAS and client satisfaction. Reports were available only from Oregon and Massachusetts, although other programs appeared to have been collecting comparable information. These reports were consistent with staff assessments in other states of increasing service utilization and high levels of satisfaction with services.
| PAS providers have measured client satisfaction with services through mail and telephone surveys. |
In addition to these utilization data, Oregon surveyed adoptive families satisfaction with these services. Fifty-three families who had received in-depth services initiated through a telephone call to ORPARC were mailed a questionnaire, and 19 responded (a 36% response rate). Findings included the following:
- About two-thirds (68%) deemed ORPARC staff excellent in their helpfulness in addressing the clients call.
- Slightly over half (53%) rated staff excellent in terms of usefulness of information provided and excellent in terms of knowledge of Oregon adoption issues.
- Almost 90% of clients were very satisfied with the way they were treated in telephone contacts with ORPARC staff.
The Salem State College annually assessed parent satisfaction with PAS provided in Massachusetts. The third-year evaluation report (Hudson et al., 2001) reported satisfaction data across six service areas. Callers were extremely satisfied with information and referral services. For all 12 types of information and referral services, at least 90% of interviewees reported being satisfied. Another 90% of those surveyed rated response team service either as very good or excellent. Of the 22 parents using respite, 18 described the services as very good or excellent. With regard to family support services, 17 out of 22 responding parents rated services as very good or excellent. Training participants were satisfied with the quality of the workshops they attended: 71% gave the training high marks.
4.2.2 Adoptive Parents Perspective
Adoptive parents who participated in the focus groups reported high levels of satisfaction with the services provided by their states PAS programs, but many felt that additional funding was needed. Parents in several states expressed satisfaction with how effectively and quickly program staff handled crises (e.g., suicidal behavior, hospitalizations, aggressive behavior). They defused the emergency, got my daughter to agree to go to counseling, and helped steer us to avenues to get long-term services. Parents in Virginia specifically mentioned that they appreciated the support groups they attended.
| Parents appreciated the prompt response from PAS providers, but expressed the desire for additional funding for services, especially respite. |
Across the five states parents also appreciated receiving appropriate information about adoption issues and referrals to adoption-competent therapists and other service providers. One parent noted that her PAS provider helped the family switch psychiatrists and attended the first two meetings with the psychiatrist. Another parent said that she was comforted to know that the PAS provider knew about the range of residential treatment options and knew the facility where her daughter was placed. Another parent liked receiving a video on how to talk to schools about adoption issues, but did not like the suggestion that parents themselves go into schools to train staff. Many parents expressed satisfaction with respite options, such as weekend stays or camp stays, but they also very clearly expressed a desire for more funding for those services.
Regarding program structure, one group of parents recommended that PAS be uniform across state lines to make it easier for families to move to other states. They felt there was too much variability in access to and availability of services from state to state. Another group recommended that services be available not only to the adopted child but also to the immediate family. They considered the well-being of the child to be dependent on the well-being of the entire family.
(1) In both Virginia and Massachusetts, lead service providers subcontracted with other providers and coordinated the overall PAS program.
Post-Adoption Service Program Characteristics
5.1 History
Formal PAS programs were instituted in the 1990s in all five case-study states, Texas being the first. 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 Massachusetts and Texas, advocacy by adoptive parents built support for PAS, although in very different ways, as described below. In Oregon, support for PAS was created through a combination of advocacy and activism from both outside and within state government. In Virginia and Georgia, PAS development largely was sparked from within state government.
In Massachusetts, adoptive parents, many of whom were professionals in the child and family services field, formed the Southeastern Massachusetts Adoption Services Coalition in the mid-1990s. The group eventually developed into the statewide Massachusetts Coalition for Adoption. These coalitions engaged the state legislature in meetings and conducted other activities to raise awareness about the needs of adoptive families. The state adoption program manager noted that these parents had felt that they needed resources outside of adoption subsidies, including access to adoption-competent professionals. He also recognized that the influence of advocates had been critical to the legislatures funding of PAS: It was only when private agencies, adoption support groups, and individual adoptive parents joined with the Department [of Social Services] that the legislature appropriated the money. When the state legislature agreed to fund PAS, the state developed a request for proposals (RFP) based on input from advocates and the legislature. Advocates also assisted in the review of applications. In 1997 the state selected Children and Family Services, Inc. as the lead provider of a regional network of providers, establishing the Adoption Crossroads program.
In Texas the states decision to provide formal PAS was prompted by a class-action lawsuit in the 1980s by adoptive parents against the state for lack of services. Although the state prevailed in the lawsuit, publicity from the case increased awareness of adoptive family needs, prompting the state legislature to enact legislation to enable PAS funding. The state began funding PAS providers statewide in the early 1990s.
| Parent, advocates, state legislatures, state agencies, and needs assessments influenced the development of PAS in the case-study states. |
The establishment of a PAS program in Oregon resulted from a combination of adoptive parent and professional advocacy, state executive and legislative interest, state needs assessments, and federal funding availability. Adoptive parents and adoption professionals organized around concerns with the ongoing needs of adopted children who had been exposed to methamphetamines and other drugs before birth and with the need for more disclosure about the childs history at the time of adoption. A legislative task force on adoption issues met in 1997 and gave more formal voice to these issues. In addition, the state conducted several needs assessments. As the state achieved dramatic increases in the number of adoptions, state officials became aware of the potential challenges faced by adoptive families. The state adoption program manager reported that, as a result of all of these influences, the state was poised to use Promoting Safe and Stable Families program (Title IV-B, Subpart 2) funds for PAS. Oregon developed an RFP for PAS and selected Northwest Resource Associates to operate the Oregon Post Adoption Resource Center in late 1998. ORPARC began operations in 1999.
In the mid-1990s, Virginia adoption officials collaborated under a grant with their counterparts in other states to discuss needs and strategies for post-adoption supports and services. The National Consortium for Post Legal Adoption Services was sponsored by an Adoption Opportunities grant under the auspices of the U.S. Department of Health and Human Services. Their publication, Adoption Support and Preservation Services: A Public Interest, was issued in March 1996. The adoption program manager noted that her participation in the consortium effort had directly influenced the states decision to create a PAS program and the consideration of program design options. As in Oregon, Virginia chose to establish the program using Title IV-B, Subpart 2 funds. The state released an RFP for the Adoptive Family Preservation program and in 1999 selected United Methodist Family Services of Virginia as the lead provider of a regional network of providers.
In 1997, based on recommendations from a legislative study committee on adoption and foster care, Georgias Gov. Zell Miller established the Office of Adoption as an entity separate from the Department of Family and Children Services, with its own budget and staff. The Office of Adoption is responsible for the administration and management of the adoption program, while adoption services (not post-adoption services) are provided through the county Departments of Family and Children Services. Oversight and authority for child welfare remain with the Department of Family and Children Services. The Office of Adoption developed the PAS program and oversees the contracts under the program.
5.2 PAS Program Structure
In all five case-study 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. Families preferred to access PAS without having to knock on the child welfare door, according to Oregons adoption program manager and others. Using an external contractor also facilitates statewide service delivery in county-administered systems. Some agencies are large with a number of dedicated adoption staff. Other agencies are very small with only one or two service workers, none of whom are dedicated to adoption, reported a Virginia state official.
5.2.1 Program Structure
Adoption program managers and PAS coordinators described four PAS program structures:
- A central PAS provider with staff that serve all regions (Oregon)
- A central PAS coordinator who funds regional PAS providers (Massachusetts and Virginia)(2)
- Regional PAS providers operating without a central PAS coordinator (Texas)
- Separate statewide PAS providers for specific services (Georgia)
| States have used the contracting process to encourage collaboration among service providers. |
States have used the contracting process to promote collaboration among service providers. Recognizing that several qualified service providers existed across the state, Virginia and Massachusetts required that agencies submitting proposals collaborate with other providers to offer services as teams. The lead service providers in both states approached competitors to ask them to work together. Adoption program managers and PAS coordinators/providers acknowledged that this collaboration led to formalization of relationships among providers who may not have ever worked together. PAS coordinators/providers mentioned that quarterly regional provider meetings fostered links among providers across the state. A PAS provider concluded that Virginias effort to make the program statewide and to foster collaboration had been positive and marked by regular meetings and information sharing.
Most of the PAS providers selected by the state have extensive experience in providing services to children and families, including adoption services and child placement. Some of the providers in Massachusetts and Texas have been in operation for over 100 years. In addition, Texas PAS providers are required to be child-placing agencies. Providers who are adoption agencies reported that they had been providing PAS informally to their clients before receiving state funding for PAS. However, not all PAS providers had been established entities. In order to establish services in a region that had previously had none, a PAS provider agency in Virginia was newly established as a satellite office of the lead PAS provider agency.
Regional PAS providers were expected to offer the full array of services for their region. However, their experience may be more extensive in some services than others. Interviewees in Virginia and Massachusetts noted that some PAS providers tended to focus on the services with which they have most experience. Georgias adoption program manager noted that choosing statewide providers for specific services reduced variations in service delivery across regions and allowed the state to take advantage of providers specific areas of expertise. In Texas, regional providers originally had been intended to provide the full range of PAS. When it became apparent that this was not feasible, the state agreed to let PAS providers subcontract the majority of services while retaining case management. Providers in Georgia, as well as regional providers in Virginia and Massachusetts, subcontracted or outsourced services as needed.
Outside formal PAS programs, child welfare staff provided limited information and support to adoptive families. In all five states, adoption program managers noted that state or county adoption specialists focused primarily on pre-adoption activities (e.g., recruitment of families, pre-adoption training, selection of families, home visitation, post-placement support, finalization) rather than PAS. Although adoption workers may have stayed in touch with families after finalization, they were not expected to provide continued support. Adoption subsidy workers also provided information to families in the course of their interactions. Among the states responding to the ILSU interviews, 19 of 30 (excluding case-study states) reported that state or county staff provided post-adoption assistance to families. However, many of these staff were subsidy workers, intake workers, or adoption specialists who typically provided limited information and referral for post-adoption issues.
5.2.2 Funding Mechanisms
Funding mechanisms followed the program structure. Oregon funded its statewide PAS provider, and Massachusetts and Virginia funded the PAS coordinator, who in turn subcontracted to regional PAS providers. Georgia contracted directly with statewide PAS providers for each service. In Texas, the regional PAS providers were given an annual budget limit up to which they could bill the state directly for case management services and other allowable services performed by subcontractors.
| PAS providers reported a degree of flexibility in transferring funds among services. |
PAS providers had some flexibility in their management of state funds. In Texas, PAS providers reported being allowed to transfer up to $5,000 across service categories without contract amendment. In Massachusetts, PAS providers noted that they could transfer funds among services, although they could not pull funds out of respite. The Massachusetts adoption program manager said that the flexibility in funding was intentional.
PAS providers in all five states reported that in-house 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).
Contract periods for PAS providers varied across states from three to five years. In Massachusetts, the lead PAS provider noted that having a five-year contract provided the opportunity to fully implement the program and conduct an evaluation.
5.3 Program Goals and Objectives
Adoption program managers across the five case-study states believed that the primary goal of PAS was to keep adoptive families together and prevent dissolution of the adoption. Other objectives included providing core services through a statewide network and creating a consumer-driven program. An added benefit/result of PAS would be to boost recruitment for future adoptions.
PAS coordinators/providers appeared to understand and share the states goals and objectives for the program. Adoption program managers and PAS coordinators/providers realistically assessed the challenges and opportunities they faced in meeting these goals and objectives, especially around achieving statewide access to and availability of services.
5.3.1 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. The Georgia adoption program manager reported that the concept of permanency had been integrated into the goals of the state adoption program. A Texas PAS provider felt that a family was considered to be together, even if a child were placed outside the home, if the adoptive parents were still involved in the childs care.
Adoption program managers noted that PAS programs were part of larger efforts to support and preserve adoptive families. Oregons adoption program manager described the PAS program as one side of a triangle of services for adoptive families, with the other two sides being adoption subsidies and the states open door policy designed to extend ongoing support to families who adopted children from the state. In Virginia, the adoption program manager and the PAS coordinator reported that the PAS program was designed to create incentives for system change by (1) developing post-adoption services; (2) increasing community coordination and collaboration in providing these services; and (3) increasing adoption competency and cultural sensitivity among health, mental health, and education providers who serve adoptive families.
5.3.2 Statewide Access
| States structured their programs to provide a full array of PAS, to allow consumer direction, and to provide PAS regardless of geographic location. |
Adoption program managers in all five states indicated the importance of offering services to adoptive families throughout the state. As noted in Section 5.2, a variety of program structures were created to achieve the shared goal of statewide access. These structures included a network of regional providers (Massachusetts, Texas, and Virginia), a central provider with staff assigned to regions of the state (Oregon), and separate contracts with providers to offer specific services on a statewide basis (Georgia).
The use of regional PAS providers offered an opportunity to tailor the program to the needs and resources of each area, ensuring it was flexible enough to respond to regional issues, according to Virginias adoption program manager. However, several program managers and PAS coordinators/providers noted that PAS providers had varying levels of experience in providing the full range of services, leading to unintended variations in service delivery. As mentioned earlier, the adoption program manager in Georgia indicated that contracting with agencies with particular expertise ensured consistent quality of PAS statewide.
Delivering services to rural areas was a particular challenge regardless of program structure, according to adoption program managers. Although having regional PAS providers offered the potential of wider access to services, adoption program managers and PAS coordinators/providers in those states (Massachusetts, Texas, and Virginia) acknowledged that services tended to be clustered around the regional providers location (typically the larger community in the service area). Providers in several states reported difficulties in maintaining statewide coverage due to the demands of staff travel.
5.3.3 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 believed they needed. One program manager reported that providing supportive services in a family-centered manner, all services being consumer driven, was critical to the success of the program. One PAS provider stated that the best part of the program was its ability to tailor services to the needs of families, that the program did not put families in a box. Another PAS provider noted that a strength of the program was that services were not mandated, allowing families to access services on their own accord.
5.3.4 Adoptive Family Recruitment
Virginia was the only state in which the state adoption program manager expressly identified the PAS program as a tool for recruiting adoptive families. She reasoned that if families learned about state-supported PAS before adopting, they would be more likely to feel secure enough to adopt and to seek out PAS after adoption. PAS providers in Texas and Massachusetts noted this connection, however, reporting that they often presented their PAS programs at pre-adoption parent training, raising awareness about PAS and helping to encourage potential adoptive parents.
5.4 Eligibility
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). They all reported that their PAS program served families who adopted from the child welfare system in their state. If these families moved out of state, they retained the ability to access information and referral; however, several adoption program managers said that it was not feasible to provide other services due to geographic limitations. In several of the states, eligibility of families who adopted privately (domestic or international) or from another states child welfare system is limited. Exhibit 5-1 summarizes the eligibility for each state.
| Georgia | Massachusetts | Oregon | Texas | Virginia | |
|---|---|---|---|---|---|
| Children adopted from state | Yes | Yes | Yes | Yes | Yes |
| Children adopted from other states who now reside in state | Limited access | Yes | Yes | Limited access | Yes |
| Children adopted through private adoptions | Limited access | Yes | Limited access | Limited access | Yes |
Adoption program managers in Virginia and Massachusetts reported that any adoptive family residing in the state was eligible for PAS. In Massachusetts, eligibility is extended to families in legalized guardianship arrangements. In Virginia, the state opened up PAS to all adoptive families as a way to prevent future foster care placements for children whose needs are not met.
| In two of five states, adoptive families, regardless of adoption type, could access the full array of PAS services |
The availability of sufficient funds to serve all adoptive families is a concern in these two states, although neither has needed to ration services according to adoption type. Service providers in Virginia are directed to prioritize services to special-needs children, children adopted from the state, and transracially adopted children. In Massachusetts, the adoption manager reported encountering some initial resistance to the idea of opening the program to all adoptive families. Many of the adoptive parents who had been engaged in the grassroots effort to develop PAS had adopted from the state and worried that resources would be spread too thin if all families were eligible.
Among the states responding to the ILSU interview, the majority reported offering services to all adoptive families. However, these services may be more limited than the PAS programs in the case-study states. Several states also reported limitations for certain services.(3)
Adoption program managers in the three states that did not extend full PAS to all adoptive families were interested in doing so but believed they did not have sufficient funding. Oregon and Georgia offered some services to all adoptive families while restricting provision of their higher cost services to families who had adopted from the state. Texas was more restrictive in limiting its services.
| In states with limited access, families that adopted privately (domestic or international) were able to access information and referral, but not counseling, crisis intervention, or respite services. |
In Oregon, ORPARC staff provided information and referral services to all families and allowed families who adopted privately to access the lending library for a fee and to attend parent training sessions on a space-available basis. Oregons adoption program manager indicated that if more funding became available, the first priority would be to expand the range of services offered to families adopting from the state, although it would be preferable to serve all families if possible. Families who adopted from other state systems are fully eligible for ORPARC services.
In Georgia, all adoptive families were able to access information and referral services, parent trainings, camp stays, and crisis intervention. However, respite (other than camp stays), attachment therapy, and tutoring were provided only for children adopted from the state and receiving adoption assistance. The state adoption program manager noted that, in practice, higher cost services such as crisis intervention were provided to any adoptive family if the child was identified by the child welfare system as being at risk of placement in foster care or in a residential treatment facility.
Texas restricted all services (except limited information and referral) to children adopted from its child welfare system. The state adoption program manager said that the priority was to assist children who were placed by the state child protective services system. Funding was insufficient to serve private or international adoptions or adoptions from other states. In addition, the legislation that enabled PAS funding did not extend to these adoptions.
| PAS providers in all five states reported a strong interest in providing services to families before adoptions were finalized. |
Virginia is the only one of the case-study states whose PAS program is open to families prior to adoption finalization, on the theory that these families are equally at risk of reentry into the system. In other states, providers expressed a desire to serve families prior to the finalization of the adoption. There is a feeling of being somewhat limited in not being able to serve families post-placement, pre-finalization, noted a PAS coordinator. Regional PAS providers in Massachusetts asserted that they had the expertise and capacity to help at-risk families prior to finalization of their adoptions, noting that these families experienced some of the same problems as adoptive families.
5.5 Sources and Levels of Funding
5.5.1 Source of Funding
Two distinct patterns of funding PAS programs were seen among the five states visited, as shown in Exhibit 5-2. In Massachusetts, Adoption Crossroads received state funds set aside by the legislature in the Department of Social Services annual budget. These funds were dedicated to PAS inside the foster care account. The remaining states used Title IV-B, Subpart 2 funds, with additional funding sources that varied by state. Virginia required its lead PAS contractor to contribute a 10% match toward the cost of the program. Adoption program managers in Virginia and Oregon reported that all Title IV-B, Subpart 2 funds available for adoption promotion and support were spent on PAS.
| Sources | Georgia | Massachusetts | Oregon | Texas | Virginia |
|---|---|---|---|---|---|
| Title IV-B, Subpart 2* (including 25% state match) | Yes | No | Yes | Yes | Yes |
| Adoption Incentive Program | No | No | No | No | No |
| State funding (excluding Title IV-B, Subpart 2* match) | Yes | Yes | No | No | No |
| Provider match | No | No | No | No | Yes |
| * Commonly known as Promoting Safe and Stable Families program. | |||||
None of the five states reported using funding from the Adoption 2002 Initiative toward PAS.
The case-study states use of funding streams differed from that reported by states responding to the ILSU survey. Excluding the 5 case-study states, the funding source most commonly reported among the remaining 31 states was state funding (23 states) followed by Title IV-B, Subpart 2 (20 states) and Adoption 2002 (15 states). Some of the state funds cited in this survey may represent the 25% state match for federal Title IV-B, Subpart 2 funds.
5.5.2 Funding Level
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 (Exhibit 5-3). In Texas it grew from $1.3 million in the early 1990s to $3.9 million. Given the variations in population size and program eligibility among the five states, it is difficult to compare funding levels across states; however, 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 across the states reported that PAS funding had been relatively stable in recent years with some midyear fluctuations. Although they believed that more funds were needed for their PAS programs, significant increases were not anticipated, especially in light of state budget crises and slowing economies.
| Georgia | Massachusetts | Oregon | Texas | Virginia | |
|---|---|---|---|---|---|
Annual funding (in millions of dollars) | 89 | 1.25 | .5 | 3.9 | 1.1 |
Among services providers, concern was widespread regarding the current levels of funding, and a range of measures had been taken in response to funding concerns. Although no states reported waiting lists for PAS services, some had to restrict availability of higher cost services. In Georgia, a provider of crisis intervention services noted that her agency had reduced the service period from six months to 90 days. Georgias adoption program manager also noted that the state was planning to change how respite rates were determined. The state planned to pay caregivers a flat rate ($9.00/hour), instead of deciding on a case-by-case basis.
| States and PAS providers noted fairly stable levels of funding, but providers expressed concern over the high cost of respite services, crisis intervention, counseling, and residential treatment. |
A regional PAS provider in Texas said his agency was developing a strategy for securing private grant funds to supplement state funds for respite because the agency perceived the need for respite as greater than the current state funding level allowed. His counterparts in Massachusetts noted that they had had the same budget for five years while serving an increasing number of clients. The lead PAS provider said that available funds were inadequate to cover families respite needs across the state and that low salaries had increased staff turnover in some regions. Massachusetts had not limited service availability, however, but recently eased limitations on the number of counseling appointments.
The Texas programs budget was particularly vulnerable to the influence of residential care. PAS providers expressed concern that residential treatment costs were limiting their ability to provide other services. One noted that residential treatment drives the budget, often requiring shifting of funds to cover it, and that the flat reimbursement rates reduced flexibility in responding to families particular needs. Faced with funding shortages, PAS providers in Texas met in the mid-1990s and mutually agreed to limit the coverage of residential treatment only to the highest level of care and to not cover therapeutic foster care for adoptive children. They also reduced the coverage of camp stays from two weeks per year to one week per year.
Adoption program managers and other officials in several states expressed concern that the dramatic increase in adoption in the past several years will increase future needs for PAS and require additional funds to support it. A budget official in Oregon noted that as adoption assistance under Title IV-E increases, the funding available for PAS through Title IV-B, Subpart 2 will not increase accordingly. The state expanded its Social Services Block Grant (SSBG) plan to include PAS and independent living services so that future SSBG funds can be allocated to supplement Title IV-B, Subpart 2 funds, if necessary. A PAS provider in Texas expressed fear that increases in adoptions will create enormous pressures for service delivery, especially for residential treatment. With increases in the number of adoptions in the past 5 years and the increasing average age of adoptive children, there will be a crisis in residential care due to the critical mass and flat [reimbursement] rates.
Midyear fluctuations in funding also can affect providers ability to plan and deliver services. Providers in Massachusetts and Virginia reported that midyear increases in respite funding had allowed them to fund additional camp stays for children; however, this led to dissatisfaction among parents in subsequent years when those funds were unavailable. In Texas, one PAS provider reported being concerned that the annual budgets were shrinking over time and that midyear budget cuts occurred. [We] do not have a guarantee of how much money is available.
5.6 Outreach and Referral
5.6.1 Outreach
State adoption managers and providers in the case-study states reported a variety of strategies by which they inform families about the availability of PAS. These 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, and presenting the PAS program at pre-adoption parent training classes. In the two states in which the PAS program was open to all adoptive families, outreach was broadly targeted and did not include specific efforts to reach families who had adopted privately or from overseas. None of the adoption program managers expressed concern that increased publicity would lead to waiting lists for services.
Each of the states conducted extensive outreach to families that had adopted, or were in the process of adopting, from the child welfare system. Methods included announcements sent to all families receiving subsidies at the time of program implementation, program descriptions provided to families when they first received a subsidy check, and information inserted into the states adoption handbook. In several states, adoptive parents received materials about the PAS program when the adoption agreement was signed. Providers also reported presenting the PAS program in pre-adoption parent classes, either through PAS staff or parents who had used the services. They used these interactions with future adoptive parents to mitigate the sense of failure attached to seeking out help when it is needed. Hopefully, were planting seeds, said a provider in Texas. In Texas, regional providers disseminated materials about PAS at recruitment events.
| PAS providers reported a broad range of initial outreach to families receiving subsidy and adoption professionals, but did not report sustained outreach initiatives. |
PAS programs in several states produced a variety of printed materials (primarily brochures) to publicize their existence. These materials provided information on providers, types of services available, and how to contact a provider (e.g., through a toll-free telephone number for information and referral). In Texas, brochures were printed in English and Spanish. In several states, PAS providers supplemented state-printed materials with their own (e.g., brochures, flyers, newsletters, direct mailings, bookmarks, magnets). Regional directors in Massachusetts reported sending materials to schools, courts, churches, adoption agencies, and clinics.
Providers also met with community agencies to raise awareness about the PAS programs and to establish links to those agencies. A provider in Massachusetts reported that her agency still did the road show because of the high staff turnover at local social services offices. In Virginia, service providers were directed to establish advisory boards to provide input on the delivery of PAS. These boards, which typically met quarterly, included adoptive parents, local county staff, school staff, and other service agencies. In Georgia, outreach efforts varied by provider (each operating statewide); several reported disseminating information to schools, adoption professionals, and state staff.
Each PAS program also maintained statewide and/or regional toll-free numbers that families could call to learn about the program or to access services. PAS providers operating regionally within the state reported that they received calls directly from parents in their service area or via the central hotline. In Oregon, where there was a single central PAS provider, staff took calls from across the state, although staff members were assigned to a specific region for which they developed resources.
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 states PAS program. Parents remarked on the lack of communication about available services. Services may be there, but parents dont hear about them. Several parents reported having learned new information about service availability and access during the case-study focus groups.
5.6.2 Referral from Other Service Providers
| PAS providers noted the challenges of getting referrals from adoption workers, and of getting referrals before families were in crisis. |
Many families went to PAS programs through referrals from the child welfare agency or other service providers. However, in several states, PAS coordinators/providers and adoptive families reported that child welfare workers, including intake staff and adoption subsidy workers, did not refer families consistently to the PAS programs. The ORPARC director reported that intake workers were not very familiar with the program, even though it was intended to complement efforts by state staff to help families. The Oregon adoption program manger agreed that state intake staff were probably less familiar with or less open to referring families to ORPARC because these staff were focused on protection against abuse; she hoped that the renewed push for the open door policy on helping all families in need would assist with referrals back to ORPARC.
In spite of extensive outreach efforts, providers reported that many adoptive families first came to them time in crisis situations, having been referred to the PAS program by local professionals or child welfare staff. This included families who had adopted children through the PAS providers child-placing agency and were already known to the agency. Many service providers expressed the desire that adoptive families would access services preventively rather than in a crisis mode. Adoptive families in the focus groups confirmed that they often had heard about, or been referred to, the PAS program during a crisis situation.
(2) 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 was developing respite resources.
(3) In 12 states PAS were limited to children adopted from a public child welfare program; 20 states provided PAS to all adoptive families.
Services Offered by PAS Programs
For the purposes of this study, state officials and PAS providers were asked primarily about services provided under the auspices of their PAS program. Across the five states, the services most widely considered to be part of the PAS programs included information and referral, counseling, crisis intervention, respite, case management, training for parents and professionals, advocacy, and support groups (Exhibit 6-1). Some variation existed among the states. Texas was the only state to offer residential treatment within the PAS program; Georgia was the only one to offer tutoring; and Oregon was the only state that did not include counseling, crisis intervention, and respite. This section discusses other, more subtle, differences among the programs.
| Core Services | Georgia | Massachusetts | Oregon | Texas | Virginia |
|---|---|---|---|---|---|
| Information and referral | x | x | x | x | x |
| Counseling | x | x | В | x | x |
| Crisis intervention | x | x | В | x | x |
| Respite | x | x | В | x | x |
| Case management | x | x | x | x | x |
| Parent training | x | x | x | x | x |
| Professional training | x | x | x | x | x |
| Advocacy | x | x | x | x | x |
| Support groups | x | x | x | x | x |
| Residential treatment | В | В | В | x | В |
| Tutoring | x | В | В | В | В |
| Note:В Families that adopted privately or from another state have limited access to some of these services in Georgia, Texas, and Oregon as described in Section 5.4. | |||||
All of the 36 states responding to the ILSU interviews reported providing at least one of the services listed above to adoptive families. However, many of these services were not consistently provided to all adoptive families or were provided outside the context of a formal PAS program.
The five case-study states all had a broader network of supportive services for adoptive families that extended beyond their PAS programs, including adoption subsidies, mentoring, mediation, adoption search and registry, tuition reimbursement, health care (e.g., Medicaid) residential treatment, and day care. The availability of these supports is discussed in Section 7.
6.1 Information and Referral
Strategies used for information and referral services were diverse: 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. Providers in Massachusetts and Oregon operated lending libraries, which were said to be well used. In addition to offering a wide selection of books and videos in English, the Oregon library had a small collection of Spanish-language materials.
| In two of five states, adoptive parent liaisons were matched with families to provide information, referrals, and advocacy. |
Georgia recently awarded a contract to establish a Statewide Adoptive Parent Support Network. The network will provide a statewide information, referral, and access system (e.g., toll-free information and referral phone number), place regional advisors around the state, establish a lending library and website, and initiate a quality assurance program for adoption services.
The Virginia and Massachusetts programs used parent liaisons, who were themselves adoptive parents, to provide information and referrals. In both states parent liaisons talked with the families that had contacted their agencies, identified their needs, and worked to locate needed resources. Both states considered parent liaisons to be part of the response teams, providing nonclinical services such as accompanying families to meetings at school or facilitating support groups.
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. Across states, providers noted the care with which referrals were made. The Oregon PAS coordinator noted that staff made referrals in an objective manner, not endorsing particular therapists or service providers. To empower families, staff encouraged them to call the service provider themselves. PAS providers in Texas said that they relied on several factors to ensure the quality of the professionals receiving their referrals, including routine reviews of status reports and notes from subcontracted therapists, annual renewal of contracts, and input from families.
6.2 Counseling and Crisis Intervention
All study states except Oregon included counseling and crisis intervention in their array of PAS.(1) Counseling and crisis intervention were available directly from the PAS providers or through referrals to community mental health agencies that were reimbursed by the PAS provider.
| Crisis intervention and counseling were integral components of PAS in four of five states; in two states, teams comprising counselors, parent liaisons, and clinicians worked with families. |
The four states used a variety of approaches in delivering counseling and crisis intervention services, including multidisciplinary teams and in-home services. In Virginia, each region had a regional response team that consisted of a family counselor, a mental health clinician, and a parent liaison. In Georgia, the provider offering crisis intervention used teams consisting of counselors and clinicians located around the state. Providers in Georgia and Massachusetts reported that families received crisis intervention and counseling in their homes and in the providers offices. In Texas, the Department of Protective and Regulatory Affairs recently added in-home therapy to its list of allowable services. Counseling often was family-oriented and could have been offered to siblings and parents as well as adopted children. One provider noted that couples counseling also was provided if it was integral to the adopted childs well-being. Providers did not expressly mention conducting comprehensive clinical assessments and testing, a need mentioned by adoptive parents.
One PAS provider offering crisis intervention services felt strongly that these services were cost-effective by preventing family disruption. Its a lot less expensive to provide our services than to maintain a child in residential placement or [incur] the cost of a disrupted adoption. She noted that the intervention services need not be provided for long but should be available in a crisis, especially early in the adoption. The Georgia state adoption program manager asserted that crisis intervention was one of the most successful aspects of the program.
In Oregon, where the PAS program does not offer counseling or crisis intervention services, the state adoption program manager said that such services were supposed to be available from the county mental health system but acknowledged that the services provided may not have met the specific needs of adoptive families. However, she noted that discussions with the states mental health providers about funding adoption-specific therapies had led to increased information sharing about the needs of adoptive families.
6.3 Respite
In the four states where respite was provided through the PAS program, providers reported that these services came in several forms, including providing reimbursement or vouchers for a caregiver, sending a child to camp or on an outing, holding special events (e.g., annual parties), or offering art therapy. In Virginia, the state created a Client Fund that gave PAS providers the flexibility to fund an array of services identified by clients, including respite. One PAS provider in Virginia reported that she tried to leverage respite funds with support from private sources such as vouchers from hotels and restaurants.
Due to the high demand for caregiver respite, many programs limited the availability of respite funding. In Virginia, providers were allowed to spend up to $500 per adoptive child per year under the Client Fund. (The limit originally was $500 per family.) In Massachusetts, each provider received $12,000 per year to spend on respite services for families in their region. In Texas, each family was allowed to receive $28 per day. In Georgia, families were approved for up to 20 hours per month and could borrow into the next month.
PAS providers in the four states reported that camp stays also had been limited due to high demand and limited funding. In Texas, families were eligible for a one-week stay at any camp. Demand for camperships in Massachusetts often exceeded the availability of funds. In Georgia, the state-sponsored camp was limited to 30 slots on a first-come first-served basis. In Virginia, a regional provider was negotiating with a childrens camp to reserve a week specifically for adoptive children, seeking private funds to support the cost of the week at camp.
| Reimbursing family members for providing respite care remained a contentious issue for PAS providers and adoptive parents. |
Finding respite providers that were acceptable both to families and the state often was challenging. In several states, adoptive families could not receive payments for respite provided by other family members. However, providers in Georgia reported that they allowed adoptive families to use other family members to provide respite. A regional provider in Virginia had developed respite circles, connecting families with similar children and parenting styles who could provide respite for each other.
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. VIDD had a separate state contract to work with regional PAS providers to develop respite resources in their region. 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.
6.4 Case Management
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. One provider described the broad role of the case manager by saying, families need a relationship with someone who knows a lot about adoption, a lot about the issues of loss and separation, some basic counseling and social worker skills, who can make appropriate referrals.
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.
Case management was most formal in Texas, where PAS providers billed the state for reimbursement. Case managers were required to develop service plans that the families and state liaison approved. Providers stipulated what services were needed in the plan and then submitted an authorization form to the state, which served as a basis for reimbursement of those services. Every six months (sooner if residential treatment was provided) a state liaison reviewed the service plan.
| The sophistication of care management systems varied widely, from spreadsheets to a Web-based system. |
In the other four states, program staff documented their activities in spreadsheet or Web-based programs. In Massachusetts, a Web-based case management system was developed that all service providers could access.
PAS providers in four of the five case-study states admitted having had difficulties adjusting to more formal case management requirements, particularly in the early stages of implementation. However, they said that they had come to appreciate the ability to monitor cases and produce service statistics.
6.5 Parent Training
State adoption program managers and PAS coordinators/providers in all five states felt that training for parents on adoption issues was an integral part of the program. They provided 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). Other examples of trainings offered included managing difficult behaviors for traumatized children, preparing for the teen years, post-traumatic stress disorder, and parenting sexually troubled children. Although 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.
In Oregon, PAS program staff noted that training logistics, including when the trainings were scheduled and whether child care and/or transportation were provided, greatly influenced attendance. The program had experimented with training schedules to find the best day and time to maximize attendance. The PAS program director reported having experimented with the statewide teleconference system for training but discontinued its use after initial trainings had poor attendance. Outside experts originally had been hired to conduct training, but now PAS program staff had enough expertise and experience to conduct training themselves. Georgia provided training around the state through a provider, which offered trainings on a variety of adoption-related topics. Sessions were scheduled for parents and professionals on successive days.
As discussed in Section 5, providers in several states raised awareness about their PAS program by attending pre-adoption parent trainings. One PAS provider in Virginia said the agency planned to better integrate the PAS program with its placement program to address parental concerns during the placement period. A PAS provider in Texas also reported trying to reach out beyond presenting at training sessions to make personal contacts with families before adoptions are finalized. His agency was applying for a grant to contact adoptive families at finalization to discuss the PAS program.
6.6 Professional Training
| PAS providers continued to explore training methods and topics for adoptive parents and professionals. |
Providing training to professionals on adoption issues is a basic component of all PAS programs studied. PAS providers in all five states 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.
Training mental health professionals to be aware of the specific needs of adopted children and families was a concern among PAS coordinators/providers and adoptive parents. Georgia was sponsoring a training program on attachment therapy for mental health providers. Oregon was considering a model that was being piloted in Washington, in which the state collaborates with a local university to offer a certificate program in adoption issues to mental health practitioners.
In several case-study states, the PAS providers themselves also received training. For example, one regional PAS provider in Virginia with extensive experience in training around adoption issues provided training on a regular basis to the other PAS providers. Georgias crisis intervention services provider offered ongoing training in adoption issues for other team members.
6.7 Advocacy
PAS providers reported that advocacy came in many forms in dealing with adoptive families. Staff 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 childs needs extended to several state agencies. As discussed earlier, many adoptive families reported a particular need for advocacy with respect to education because they felt school professionals did not understand the potential special needs of adopted children.
| Educational advocacy was particularly important to adoptive parents. |
Several PAS providers across the five states noted that, although they were advocates for families, they also wanted families to feel ownership of the effort so that they could maintain balance in their families. One provider asserted that her agency upheld a strong emphasis on parent self-determination and family responsibility and a focus on empowering families rather than serving as a rescuer.
Parent liaisons provided advocacy for families in Virginia. In Georgia, under the Statewide Adoptive Parent Support Network that will be established in 2002, regional network advisors will be responsible for one-on-one assistance and advocacy on behalf of adoptive families. The state adoption program manager noted that experienced adoptive parents would be preferred for these positions. These advisors will be expected to be an advocate for and coordinate services to adoptive families and to be aware of adoption resources.
6.8 Support Groups
PAS providers in all five case-study states operated support groups 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 Virginia started an online support group that had approximately 250 active members and over 6,000 postings as of November 2001.
PAS providers and adoptive parents in several of the states reported a growing interest in serving the needs of older adopted children through adolescent support groups. Several providers reported plans to establish support groups for preteens and older adolescents.
| PAS providers were expanding from traditional parent support groups, adding child and adolescent support groups. |
Although providers considered support groups an essential component of PAS, recruiting and retaining families had been a continuing challenge, especially in more rural areas. Providers tried several adjustments to increase and sustain attendance, including holding child and parent groups simultaneously, offering child care for parent support groups, and providing transportation. In Virginia, parent liaisons telephoned parents to remind them about the support group meetings. As discussed earlier, adoptive parents in the focus groups expressed satisfaction with their support groups and took great comfort from participating in them.
(1) Although Oregons PAS program did not include counseling, one of the states service areas used state funding to support a Post-Adoption Family Therapy (PAFT) unit whose staff provided counseling and crisis intervention to families that adopted from the state and live in the Portland area.
Subsidies and Other Forms of Support
In addition to PAS programs, the federal Adoption Assistance Program (AAP) provides an important source of support for services needed by adoptive families through cash assistance, commonly known as subsidies. States also have the option of offering material support to adoptive families through a range of other measures that provide access to needed services. The RTI teams interviews found little evidence that PAS programs incorporated material support into their planning. Rather than compensating for limited support, strong PAS programs often were accompanied by relatively generous subsidies and other forms of support. However, adoptive families may lack adequate information about the supports available to them.
7.1 Relationship between PAS Programs and Subsidies
State adoption subsidy programs date back at least 20 years, when U.S. laws first offered a federal match for state subsidy costs. PAS programs have been planned and implemented much more recently. State adoption program mangers interviewed indicated that the choice of services to be included in PAS programs was influenced by the views of adoptive parents and by reports of successful program models implemented elsewhere. None reported that the services offered by PAS programs were chosen to complement those supported through subsidies or other service systems. However, it is clear that PAS programs are only one resource by which adoptive families can access services. Among the five case-study states, for example, only Texas included residential care in its PAS program, but other states supported residential treatment for adopted children through their Medicaid program or through another state agency. Other states may choose to adjust adoption subsidy rates to help parents purchase these services.
States have a variety of options with which to support adoptive families. |
States have considerable latitude in providing subsidies and other supports to adoptive families. Basic AAP subsidies are capped at 100% of the states foster care rate. However, the amount of support that adoptive families receive from the state depends on a range of policies that extends beyond subsidy amounts. Specific policies, such as restrictions on Medicaid access for children who are not eligible under Title IV-E or restrictions on the funding or reimbursement of respite care, will significantly affect the level of support received by some families.
Many factors limit the degree to which PAS programs and subsidies can substitute for one another. Some services offered by PAS programs, such as information and referral or support groups, cannot be purchased by individuals. Other services, such as counseling, could be accessed by families who purchase them with their own insurance or subsidy funds; however, families may be unable to find professionals with expertise in adoption-related issues except within the PAS program. In states where subsidy decisions are made at the county level, state adoption offices have little or no influence on the extent to which they can be adjusted. Substantial disparities among counties have been observed in these states (Avery, 1998). Thus even a generous subsidy program would not completely negate the need for a statewide PAS program.
It is equally true that PAS programs often will not be a satisfactory substitute for what families would purchase for themselves with subsidies. As discussed earlier, PAS programs vary substantially in terms of what services are offered, and a states program may not include the specific services needed by a family. Many families need services at a higher level of intensity or for a longer duration than available through the PAS program, or they prefer to choose their own providers and service settings.
If subsidies are to be a meaningful component of the support package offered to adoptive families, they must be sufficiently flexible to respond to families needs as their circumstances change and generous enough to meet what may be substantial needs. However, states vary significantly with respect to policies that determine the amount of subsidy support and their flexibility.
7.2 Subsidy Policy in Case-Study States
The five case-study states offered substantial flexibility in their subsidy programs. All permitted 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. Among the case-study states, Oregon appeared to be the most proactive in this way, sending an annual letter to all families receiving a subsidy to remind them to contact the state office if their circumstances have changed such that they require more (or less) support.
Adoptive parents lacked necessary information on subsidies. |
Flexibility in policy is of limited value 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. They described themselves as confused as to how subsidy levels were set and the extent to which parents can influence their provision.
Parents in one group believed that subsidy levels were set by the state and were not negotiable. This confusion is notable because parents participating in these focus groups all were involved to some extent with the states PAS program. Thus they could be expected to be better informed, and more able to resolve questions of this sort, than other adoptive parents. One parent suggested that parents receive a bill of rights during the home study period that explains what they can ask for and do to obtain subsidies that meet their needs. The Oregon Adoption Assistance Handbook provides an example of such a document, including definitions of eligibility criteria, Title IV-E eligibility, the application process, Medicaid eligibility, and provisions for appeals.
For states to garner federal participation in a subsidy award, the award must be no higher than the states foster care rate. Some states have low foster care rates, and others have state laws that limit subsidies to the basic foster care rate rather than a higher rate paid for special-needs children or children in treatment foster care or group care. States that are constrained from offering generous subsidies could compensate by offering strong PAS programs. Or states that have flexibility around the amount of subsidies paid might allow families to use subsidies to purchase services in the marketplace.
The case-study states offered generous adoption support in addition to strong PAS programs. |
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. 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. Although strong advocates for adoptive families are likely to find a variety of ways to pursue their goals, their efforts may be moderated by the organizational and political complexity of programs, agencies, and funding streams involved.
| Items | Case-Study States | ||||
|---|---|---|---|---|---|
| Description | Georgia | Massachusetts | Oregon | Texas | Virginia |
| Provisions of special needs definitions that met or improved upon federal definition | Medical condition or handicap | Ethnicity or minority race, age, medical condition or handicap, high disability risk | Ethnicity or minority race, medical condition or handicap, need for placement with foster parents | Ethnicity or minority race, medical condition or handicap | Ethnicity or minority race, age, medical condition or handicap, need for placement with foster parents, sibling group, high disability risk |
| Basic AAP subsidy amount: | |||||
| 67% | 81% | 61% | 94% | 63% |
| 106% | 100% | 100% | 95% | 106% |
| Specialized AAP (SAAP) as a percentage of specialized foster care rate | 100% | Not available | 100% | State does not pay SAAP | State does not pay SAAP |
| Medicaid eligibility for state-subsidized children | Under certain conditions | Yes | Yes | Yes | Under certain conditions |
| Nonrecurring adoption expense amount | $2,000 | $400 | $2,000 | $1,500 | $2,000 |
| Availability of Title XX services for children receiving AAP subsidies | IV-E AAP recipients only | No | Yes | Yes | Yes |
| Special service subsidies availability | When funds available, public agency children only | Yes | Yes | Yes | Yes |
| Respite care funded or reimbursed | Yes | No | Yes | Yes | Yes |
| Residential treatment paid for | Yes | No | Yes | Yes | Yes |
| Deferred AAP agreements offered | Yes | Yes | Yes | Yes | Yes |
| Subsidized guardianships possible | No | Yes | Yes | No | No |
| Similar treatment for public and private agency adoptions | Yes | If IV-E eligible | Yes | No | Yes |
| AAP subsidies for children over 18 years | Yes | Yes | No | Yes | Yes |
| AAP administration | County | Statewide | Statewide | Statewide | Local offices |
| AAP = Adoption Assistance Program Source: Bower and Laws, 2002. | |||||
PAS Program Evaluation
The case-study states varied in the amount and kind of evaluation they were conducting with their PAS programs. All states were collecting data with which they could monitor client characteristics, service use, and client satisfaction. These data were not consistently analyzed, however. Outcome evaluations were less commonly done. Several barriers hindered evaluation, including lack of funding, design issues related to the nature of PAS programs, and lack of enthusiasm on the part of PAS program staff.
8.1 Structure of Evaluation
The organization of evaluation activities varied considerably among case-study states according to the organization of post adoption activities and whether the state used external evaluators. Regional PAS providers in Massachusetts and Oregons statewide PAS program compiled program activity data for analysis by external evaluators. These evaluators also analyzed client satisfaction surveys collected by the statewide provider in Oregon and gathered and analyzed additional data in Massachusetts. In Virginia, the statewide PAS coordinator compiled data submitted by regional PAS providers for an annual report to the state. Texas regional PAS providers used client satisfaction data at the local level and submitted activity data to the state for cost reimbursement, but the state did not analyze these data for evaluation due to a lack of funding for that purpose. In Georgia, statewide PAS providers were responsible for evaluating the specific service components that they conduct, with oversight from the state adoption program manager.
8.2 Types of Evaluation Activities
| Each PAS program monitored client characteristics and services delivered, but outcome evaluations were less common. |
The types of evaluation activities employed depended on the services being assessed and the expertise available to the PAS program for evaluation design and analysis. Among evaluation activities, needs assessment can be considered formative evaluation designed to guide program design and modify it during the early implementation period. Although states may have been guided by informal reports of adoptive families service needs from child welfare and other service providers, only Georgia and Oregon reported having conducted formal needs assessments of adoptive parents as part of their program planning processes. Needs assessments appeared to be of wide interest nationally. Excluding the five case-study states, 23 of 31 states responding to the ILSU survey reported that they were conducting needs assessment or had done so since 1990.
All five states collected the kinds of data normally used for process evaluation: characteristics of clients served and services delivered. Oregon and Massachusetts were far more sophisticated in their collection and use of process evaluation data than were the other three states. Both states developed databases of client contacts and other events and used external evaluation providers to analyze the resulting data. Both of these databases were detailed, including information on the nature, content, and client characteristics of every service delivery event, although Oregon did not record contacts that were handled in a single telephone call. The Massachusetts database was web-based to allow direct access by regional providers. These two states used their event tracking databases to support analyses of training audiences, specific types of services provided, hours of service provided in various service categories, and household composition of client families.
Assessments of client satisfaction also were used in each state, again with varying approaches and levels of rigor. Across the five states, client satisfaction surveys were used for most services, including information and referral, tutoring programs, respite care, family support group, training, and counseling. However, response rates for these surveys were low enoughranging from 36% to 86%to raise concerns about the validity of resulting data. Interviewees mentioned using the surveys, even if not aggregated, to inform their sense of how they were doing and what services might be added. Massachusetts also used group interviews and focus groups in its assessment of client satisfaction.
Formal outcome evaluations are conducted less frequently than process and client satisfaction measures. Georgia and Virginia used clinical instruments administered pre- and post-services to assess counseling services. Georgias crisis intervention program, which provided intensive case management to families in crisis, administered the Child and Adolescent Functional Assessment Scale at intake, three months, and exit as well as monitoring disruption rates among its clients. Regional PAS providers in Virginia reported using the Achenbach Child Behavior Checklist, Current Feelings About Relationship with Child, and Cline/Helding Adopted and Foster Child Assessment at intake and closing, although not all providers used all of these instruments.
Other forms of outcome assessment were mentioned. Massachusetts evaluators reported using data from their information system to analyze the degree to which goals identified in the course of information and referral calls actually were attained. Virginia planned to monitor the extent to which disruptions occurred among families served by the PAS program. PAS program staff in three states mentioned reviewing their own treatment narratives to assess how families were doing, if they were looking better. This informal assessment is worth noting because staff appeared to be implementing it without any direction from above. This suggests that they may have been more comfortable with individual clinical assessment than with program evaluation activities, perhaps reflecting the emphasis of their own professional training or their limited faith in the usefulness of other evaluation activities.
8.3 Barriers to Evaluation
Several barriers to evaluation, or to more extensive evaluation, were identified in the course of interviews. Some of these may have been inherent in the ethos of PAS or in services for children and families. Others were specifically related to program structure.
| Barriers to evaluation included insufficient funding, lack of expertise, and staff concerns. |
Funding was the barrier mentioned most frequently by both state adoption program managers and PAS coordinators/providers. Funding represented either staff time to conduct evaluations or the ability to contract with external evaluators. Although evaluation was among the activities described in either the RFP or the providers proposals in each state, it generally was not specified by allocation of specific staff members or budget line items. Massachusetts, the only state with a line item specific to evaluation, spent approximately 5% of its budget on evaluation. Although clearly more extensive than in other states, these efforts represent a relatively small proportion of funds to allocate to evaluation. Interviewees were committed to evaluation, and in some cases their efforts had gone beyond what was required by the state. However, providers noted the burden of evaluation on limited staff time.
Evaluation expertise is strongly related to funding. Contracting with an external evaluator requires a greater commitment of program funds but provides access to a higher level of expertise. Although program coordinators frequently have some experience and training in evaluation, it is unlikely to be at the same level as for someone whose primary role is evaluation. Similarly, local staff generally are chosen according to their service delivery skills and may have limited qualifications in the collection and management of evaluation data.
PAS program staff expressed concerns about evaluation in terms of its impact on their interactions with clients. One PAS provider noted that the worlds of social workers and evaluators are very different, and service providers did not naturally embrace evaluation. Program staff also expressed concern about the amount of client time spent completing assessment instruments, especially if this did not provide any direct benefit to the client. Families that come to me are under a lot of stress, said one service provider, and asking them to fill out something with 140 questions just adds to that. Program staff feared that adoptive parents would be put off by clinical instruments that seemed to focus on child and family problems.
| PAS programs presented specific challenges to evaluation design. |
The very structure of these PAS programs creates inherent challenges for rigorous evaluation design. With the exception of one intensive crisis management intervention that used a defined intervention model, the PAS programs described in this report were intended to be extremely flexible in their delivery, responding to the varied needs of individual families rather than offering a predefined bundle of services for a set period of time. PAS coordinators/
providers considered this tailoring to be a strength of the programs, allowing them to respond to clients specific needs in a way that empowers families. Unfortunately, this tailoring was at odds with several assumptions of evaluation design, particularly with respect to outcome evaluation:
- Because families use the service on an as needed basis, discontinuing and reentering as their concerns change, it is difficult to identify points at which pre- and post-measures should be administered. Measuring at standard intervals (e.g., three months after first contact) would be an alternative, but if families are not in touch with the program at that point, data collection will be more difficult.
- The array of services provided depends on the level and type of needs identified by the family and often changes over time. This diversity of interventions makes variations in satisfaction or other outcomes more difficult to interpret.
- Family needs and concerns are diverse. Evaluators must choose between tailoring their outcome measures to the specific issues of the family (creating greater specificity but smaller groups) or measuring outcomes more broadly (increasing statistical power but with less informative measures).
- Programs generally are family focused in philosophy and service delivery, but outcomes might be specific to one family member. Evaluators must choose how many family members to include in outcomes (e.g., whether to measure all children, all adopted children, or those children presenting the greatest problems). A narrow focus might increase the power to detect outcomes, but it raises concerns about stigmatizing and scapegoating. More inclusive data collection increases respondent burden and might dilute outcomes by including family members who are less involved in services.
The challenges described here are not unique to PAS programs. In HIV-prevention programs, for example (Napp, Gibbs, Jolly, Westover, and Uhl, 2002), limited funding, lack of staff expertise and interest in evaluation, and lack of fit between program models and standard evaluation methods all have been noted as barriers to evaluation. Though few would argue that program models should be radically altered to meet the requirements of rigorous evaluation, several measures could enhance the quality and usefulness of evaluations for PAS programs. A discussion of these measures is the subject of the PAS Evaluation Issues Report.
Discussion
9.1 Need for Post-Adoption Services
9.1.1 Projecting PAS Needs
Needs assessments, which many states performed recently or were in the process of conducting, are designed to describe the kinds of services most needed among the families surveyed, generally families receiving adoption subsidies. Without the persistent follow-up efforts needed to achieve high survey response, however, these assessments may not adequately represent the population of adoptive families.
Available data on the needs of adoptive families were not adequate to guide current PAS programs, nor to plan for future needs. |
High-quality data on families needs would support a strong planning process. Needs assessments do not allow estimates of the number of adoptive families needing services, because it is not known how families responding to the survey differ from those who do not respond. Nor does this approach establish when, in terms of childrens ages or elapsed time since adoption, the various services are most likely to be needed. This information will be all the more valuable as the population of adopted children (and young adults) continues to expand, so that states can plan for adequate service availability. A national probability-based sample of adoptive families that are receiving subsidies would help to provide a picture of underlying needs among those families that have, and have not, obtained PAS from state sources.
The needs assessment process is ongoing. The needs of adoptive families are likely to evolve as PAS programs influence service delivery systems, as families mature, and as the characteristics of children being adopted change. As PAS programs increase their visibility within states and communities, they are becoming better situated to monitor these needs by compiling information on client characteristics and services needed. These data can become a valuable tool for ongoing planning and program adaptation.
9.1.2 Service Needs Identified by Adoptive Parents
The adoptive parents participating in the focus groups were vocal self-advocates. Although the single focus group held in each case-study state does not support generalizations about adoptive families in those sites, several themes about needed services emerged consistently across sites. These themes tended to converge with those identified in previous reviews of programs and related literature, although the emphasis on respite care was particularly keen in this study. This may reflect a change in the needs of adoptive families or a finding unique to the states or parents selected.
PAS programs offered valuable services to adoptive families, but unmet needs remained. |
The parents who participated in focus groups in the case-study sites 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, including more usable information about their children, better information about supports available to them, and improved access to service providers of their choice. Although these needs might lie outside the boundaries of typical PAS programs, state adoption program offices could potentially address them.
Parents stated that having better information about their childs pre-adoption history and, consequently, a better understanding of the childs strengths and limitations, could have considerably lessened the difficulties the families had experienced. Two issues are involved in this assertion. First is the well-documented desire among adoptive parents to be provided with as much information on their child as is available at the child welfare agency. Although states have increased their commitment to preadoptive disclosure in recent years, parents in the focus groups might not have benefited from this change. It also is possible that parents eager to move forward with adoption listen selectively to what is disclosed. They need to hear it about three times, according to one adoption worker. In either case, parents indicated that they thought they would have benefited from the opportunity to review their childs history with an adoption worker as needed over the course of the adoption.
Parents needed assistance in understanding their childrens history and needs. |
Information on the childs history is of limited value without interpretation of its implications for educational, perceptual, emotional, and behavioral functioning and future needs. Thus adoptive parents expressed a need for help in understanding and interpreting the information given them. They wanted access to cognitive, social, behavioral, and educational assessments for their child. They reported that this information would have helped them access needed services but that comprehensive assessments were expensive and difficult to obtain. As with needs assessment, review of this information must be an ongoing process, rather than a single prelegalization event, that can be revisited as the child matures.
Adoptive families needed information about available services before they were in crisis. |
Parents also wanted better information about the services and supports available to them. Recruited for the focus groups by the PAS programs, these parents might have been expected to be highly aware of available resources. However, many were confused about what could be supported through adoption subsidies and how subsidies were adjusted. Only one state described a proactive effort to provide this information to adoptive families on a regular basis. Parents also maintained that they lacked information about supportive and preventive services and were directed to resources only after their needs had reached crisis proportions. Although all states made efforts to publicize the existence of their PAS program, it does not appear that information reached families with mild to moderate needs.
Access to professionals who understand adoption issues was particularly needed. |
Finally, parents stressed the need for easier access to adoption-competent service providers. Some PAS programs were addressing this issue by offering training in adoption issues to mental health practitioners and other professionals. However, families access to these providers, or to those who already had the desired expertise and attitudes, may have been limited. Many providers, especially those with specialized expertise, did not participate in state Medicaid program or Medicaid managed care plans. Therefore, they were not available to parents who were unable to pay for their services out of pocket. States efforts to train professionals will not benefit adoptive families without efforts to allow families to access services outside their managed care provider or to reimburse services through subsidies.
9.2 Program Structure and Services
9.2.1 Impetus for PAS Program Development
Federal funding was essential in encouraging PAS programs in states that were motivated to develop them. |
The federal government has long invested in adoption subsidies and, since the late 1990s, has invested in PAS. Assessing the extent to which the federal funding support has encouraged development of PAS programs is challenging, but there is no doubt that the growth in PAS has been encouraged by the availability of adoption bonuses and Promoting Safe and Stable Families Program funding under Title IV-B, Subpart 2. Although four of the five case-study states used Title IV-B, Subpart 2 funds for their PAS programs, the availability of this support did not seem to have been critical in these states decision to develop PAS programs. Instead, adoption program managers described the importance of advocacy by adoptive parents and champions within state agencies or legislatures. The experience for this limited set of states suggests that while federal funding may be necessary for PAS program development, these resources did not in themselves lead to program development. Of course, these states were selected because they are considered well developed in the area of PAS. States with weak or nonexistent PAS programs might be more readily influenced in initiating services as a result of federal initiatives.
Adoptive families may face substantial disparities according to their state of residence. |
The field of PAS has not yet produced a conclusive research base, but strong evidence suggests that some adoptive families need specialized supports for part or all of their childs development and that PAS programs are providing these supports effectively. Some of these needs could also be supported through adoption subsidies; however, the RTI teams review of data on subsidy policies does not suggest that any states are increasing subsidy support to compensate for a lack of PAS. To the extent that PAS programs and subsidies do meet the needs of adoptive families, disparities in their availability will mean that childrens long-term outcomes will vary by their state and county of residence/adoption. This research, in the context of work reported in an earlier literature review, suggests that it is timely for the federal government to take stronger measures to encourage all states to make more extensive post-adoption supports available.
9.2.2 Program Goals and Eligibility
Program developers make several decisions in the design process, based on their assessment of how best to balance needs and available resources. Two fundamental choices are the specification of program goals and which families will be eligible. Although based on pragmatic considerations, these decisions have potentially far-reaching policy implications.
The PAS programs studied shared a goal of preserving adoptive families, but varied in the strategies chosen to reach this goal. |
All of the programs studied shared a 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 extent to which programs worked to influence the service delivery environment. Only one program identified an explicit goal of changing service delivery systems through the efforts of its PAS providers to develop service networks. However, four of five programs offered training for mental health, education, and legal professionals likely to serve adoptive families. Considering systems change from a different perspective, Oregon chose not to offer counseling through its PAS program to maintain pressure on the county mental health system to provide the level of services needed by adoptive and other families. Although providing adoptive families with the services they currently need is a logical priority for PAS programs, systems change efforts also are necessary to increase the extent to which other service delivery systems can meet the needs of adoptive families.
Restrictions on the type of adoptive families served limited the potential impact of PAS programs. |
Three of the five states in this study restricted eligibility for at least some of their services to families that had adopted from their states child welfare system. Although adoption program managers defended this as a means of conserving scarce program resources, it raises two concerns. First, the effort to increase the rate of adoptions from foster care will be hampered if families that subsequently move across state lines have limited access to PAS. Second, if PAS programs are believed to reduce the likelihood of out-of-home placements or adoption dissolutions, restricting access for families that have adopted privately or from other states might increase the eventual risk of needing high-cost services for these families. PAS programs might be more effective in both preserving adoptive families and encouraging adoptions from foster care if they are able to serve all adoptive families.
9.2.3 Program Structure
Each of the states in the case study contracted out its PAS program to providers who delivered services either statewide or regionally. Data from the ILSU survey suggest that most other states providing PAS contracted out some or all of the services. 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 (especially in states where services are administered at the county level), and the avoidance of the stigma many adoptive parents feel in approaching the child welfare agency for PAS.
States developed a variety of structures by which they offered consumer-driven services and statewide coverage, but serving rural areas remained challenging. |
Several of the case-study states consciously worked to make their PAS program consumer-driven, providing families with an array of services from which to choose. Adoptive parents did not specifically mention these consumer-driven efforts, but it was clear that they had taken advantage of the flexibility. Parents in focus groups cited using varying types of PAS.
Although PAS programs shared the goal of making services available statewide, each coordinator reported frustration in the programs ability to make services truly accessible in rural areas. Barriers included the scarcity of mental health services (adoption-competent or not), difficulty in gathering adequate participation for a training or support group, and increased travel time for program staff. Because online support groups appear to be effective with social workers (Meier, in press), PAS programs might want to consider new communication technologies for parent support and perhaps for training. The reported success of the online support group in Virginia lends credence to the potential effectiveness of using new technologies to support adoptive families. At least one state has attempted an online approach to training, although with limited success.
Support for adoptive families must be communicated by the child welfare system as well as PAS providers. |
Although many states choose to contract out PAS services, focus groups with adoptive parents suggest that some level of post-adoption support should be maintained within public child welfare agencies. Most states expect adoption workers to be accessible to adoptive families for at least a limited time, and because of their association with the child, adoption workers are likely to be the ones that families in need of PAS will turn to as the first responders. However, families participating in focus groups reported that adoption workers often lacked interest in their ongoing welfare. Worse, the families reported encountering surprisingly negative attitudes from some adoption workers and intake workers when seeking residential care or other services. 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 must 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.
9.2.4 Services Offered
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 was highly valued by families 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, through camps and weekend outings. In addition to offering parents a break, this model provided beneficial opportunities for adopted children to interact with one another. However, adoptive parents noted that this model did not meet the needs of very young children, those with attachment issues, and those with the most severe behavioral difficultiesin other words, the children whose parents were most in need of respite. In-home respite models might help to provide younger children with a more familiar setting, which would be less likely to raise concerns about being placed again. Such models have been tried successfully with adoptive families (Owens and Barth, 1999). Other models might be needed for families with adolescents.
The two states that assisted parents in finding and paying for family-specific respite care struggled with the challenges of finding or training providers acceptable to parents and funding agencies. Restrictions on using family members as respite providers, even though these may have been most acceptable to the child and parents, suggest a concern with the appearance of misuse of funds or providing babysitting rather than professional services. 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.
Both PAS providers and focus group participants reported that PAS is more often used during times of crisis than as a preventive measure. Moreover, while state and provider interviewees mentioned sending information on PAS to families receiving adoption subsidies, they also noted a lack of coordination between adoption workers and PAS providers. 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.
Expanding eligibility to all adoptive and pre-adoptive families could substantially extend the impact of PAS programs. |
None of the case-study states offered eligibility to families in which children had been placed from the state child welfare system but whose adoptions were not yet finalized. Outreach to these families by PAS providers was limited to discussing PAS at adoptive parent classes. However, providers in several of the states expressed a strong interest in providing some of their core PAS to these families, whom they felt were facing some of the same challenges as families with finalized adoptions. Because many PAS providers also were child-placing agencies, they might have been already serving these pre-finalization families. As just described, adoptive parents also felt that greater pre-finalization assistance beyond required adoption classes and home visits were warranted. States using Title IV-B, Subpart 2 funds were not precluded from using the funds to serve these families; however, there did not appear to be any state-initiated movement in that direction.
9.3 Other Supports and Services
In this study and many others, states assessed the nature of service needs using surveys of adoptive families, most often those receiving federal Adoption Assistance Program subsidies. The variation in service offerings and program structure among the five states described here is evidence that states tailor their programs to family needs and existing service delivery systems. However, other than acknowledging that not all desired services could be funded, state adoption program managers provided little explicit information as to how they had made these choices.
Comprehensive planning that encompasses subsidies and existing service resources, as well as PAS programs, could increase support for adoptive families. |
Adoptive families needs could be addressed in several ways other than delivery through a PAS program: (1) by making services available through existing health, mental health, or social service systems; (2) providing resources directly to adoptive families so that they can purchase services; or (3) modifying existing service systems to reduce the need for the service among adoptive families. Although these three strategies are not interchangeable, alternative routes may exist for at least some services. States that are constrained in their ability to offer increased subsidies (because basic subsidies are capped at the states foster care rate) may be able to facilitate access to other services through Medicaid programs. Services such as case advocacy within schools might be addressed in the long run through systems changes that improve understanding of adoption issues among guidance counselors. Although case advocacy is necessary to respond to families immediate needs, changing school systems could improve school interactions for all adoptive families.
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.
9.4 Evaluation
Evaluation activities in the five case-study sites varied considerably in their focus and degree of sophistication. States conducted formative research to guide program design, developed systems for monitoring client characteristics and services delivered, and identified outcome measures. However, the usefulness of evaluations in some states was limited by inconsistent implementation, insufficient resources to achieve adequate response rates, and limited data analysis. Considering that these five are among the countrys most highly regarded programs, the relatively limited emphasis on evaluation is noteworthy.(1)
Evaluations of PAS implementation and outcomes are needed to support program development and document the value of continued funding. |
None of these programs is more than 10 years old, and the field of post-adoption services is not much older than that. The newness of PAS as a service delivery model is itself a barrier to evaluation. In a new arena, program models, service offerings, and service delivery strategies are subject to ongoing adaptation based on experience; tailoring the program takes precedence over maintaining consistent implementation. Under these circumstances, programs rely on immediate field experience rather than waiting for evaluation findings.
As the field matures, however, the potential usefulness of evaluation increases. The variety of approaches with which states have implemented core services like information and referral suggests the need for evaluation to assess which strategies work best under various conditions. Data from strong evaluations could enable the experience of these five states to provide needed guidance to other jurisdictions currently considering or developing PAS programs. If existing programs are to continue improving and to inform the development of others, their evaluation components will need to be strengthened. This strengthening would include design enhancement in the form of outcome indicators and robust evaluation designs, as well as strategies to minimize respondent burden and engage program staff in the process. Substantially more resources than are currently being dedicated to evaluation will be needed.
The impetus for what evaluation is being done comes from state adoption program managers and PAS program coordinators, in varying combinations. Notably absent is any evidence of pressure from the larger funding agency or calls for accountability from legislators involved in budget negotiations. This absence might reflect the considerable persuasiveness of adoptive parents advocating these programs or a sense of urgency attached to increasing the rate of foster care adoptions. Because these influences might be inadequate to sustain program resources in the face of state budget crises and competing needs, evaluations that can document program implementation and effectiveness must become a priority among leaders in PAS programs. The continued acceleration in the rate of adoptions and the number of adoptive families underscores the need for a scientifically robust base of evaluation research to guide program development.
9.5 Conclusion
The field of PAS is young and evolving rapidly as states implement creative responses to the perceived needs of adoptive families. Although adoption program managers have recognized the importance of these services for years, recent access to federal resources has greatly expanded availability. The five programs described in this report (as well as many in other states) have developed services that did not exist previously and have provided adoptive families with services that most had never had access to before.
Evaluation and comprehensive planning could extend the effectiveness of PAS programs. |
As the value of PAS gains recognition, the need for stronger evaluation and more comprehensive planning becomes more pressing. States need better data with which to estimate the number and characteristics of families needing services and how this population is likely to change in coming years. Adoption program managers are called on both to meet the current needs of adoptive families and to work for system changes that increase the responsiveness of service delivery systems. To respond to these sometimes conflicting priorities, they will need to plan their PAS programs in the context of other service systems and other supports available to adoptive families.
Evaluation of PAS programs is hampered by the ongoing evolution of the field and the premium placed on tailoring services to family needs. As the field matures, however, evaluation information is increasingly essential. Careful analysis of families use of and satisfaction with existing PAS programs can help states tailor their programs to changing populations of adoptive families. Finally, it is particularly incumbent on the well-established PAS programs to invest in outcome evaluations. Findings from these evaluations will be essential in documenting the value of PAS programs, improving accountability among providers and public agencies, and expanding the knowledge base about best practices.
(1) Among the PAS programs considered for the case study, Maine had begun and Illinois had completed extensive evaluations (they appear to be unusual in this way).
References
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Barth, R. P., Gibbs, D. A., and Siebenaler, K. 2001. Literature Review: Assessing the Field of Post Adoption Service: Family Needs, Program Models, and Evaluation Issues. Research Triangle Park, NC: Research Triangle Institute.
Bower, J. W., and Laws, R. (2002). A policy analysis of adoption subsidy programs in the United States: Support for families of children with special needs. North American Council on Adoptable Children.
Fine, D. N. 2000. Adoptive Family Needs Assessment: Final Report. Portland: Oregon Post Adoption Resource Center.
Hudson, C. G., Cedeno-Zamor, P., Rosenthal, M., Springer, C., Hudson, B., Ford, D. A., and Kowal, L. W. 2001. Adoption Crossroads: The Third Year Evaluation. Salem, Mass.: Salem State College.
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Napp, D., Gibbs, D., Jolly, D., Westover, B., and Uhl, G. (2002). Evaluation barriers and facilitators among community-based HIV prevention programs. AIDS Education and Prevention 14, Supplement A, 3848.
Oregon Post Adoption Resource Center (ORPARC). 2001. Oregon Post Adoption Resource Center, a program of Northwest Resource Associates: Semi-Annual report. Portland, OR: ORPARC.
Owens-Kane, S., and Barth, R. P. 1999. Evaluating a family support service: An empirical study of respite care outcomes. Unpublished manuscript available from the University of California at Berkeley: An empirical study of respite care outcomes.
Appendix: Persons Interviewed
States
- Georgia
- Massachusetts
- Oregon
- Texas
- Washington
| Lauren Anderson | Executive Director The Attachment Network of GA, Inc. Athens |
| Peggy Baird | Director of Adoption Program Families First Atlanta |
| Rhonda Fishbein | Executive Director Adoption Planning, Inc. Atlanta |
| Gail Greer | Program Manager Department of Human Resources Atlanta |
| Lyn Liphart | State Coordinator, Adoption Intervention Team Mentor Network Marietta |
| Cindi Maxwell | Social Services Case Manager Cobb County Dept. of Family and Children Services Marietta |
| Linda Price | Executive Director Georgia Council on Adoptable Children Atlanta |
| Jacqueline Campos | Post Adoption Social Worker Child and Family Services, Inc. Fall River |
| Patricia Cedeno-Zamor | Evaluation Team Salem State College School of Social Work Salem |
| Joan Clark | Executive Director ODS Adoption Community of New England, Inc. Holliston |
| Doug Delaney | Staff Clinician Center for Family Connections Cambridge |
| Leo Farley | Adoption Program Manager Massachusetts Department of Social Services Boston |
| Mary Gambon | Assistant Director Massachusetts Department of Social Services Boston |
| Christopher Garcia | Post Adoption Social Worker Child and Family Services, Inc. Fall River |
| Christopher Hudson | Evaluation Team Leader Salem State College School of Social Work Salem |
| Susan Norton | Regional Director Catholic Charities Lawrence |
| Nora O'Farell | Assistant Director Adoptive Families Together Boston |
| Angelina Ojimba | Program Staff Children's Services of Roxbury Roxbury |
| Kathy Roche- Goggins | Program Staff Children's Friend Worcester |
| Marguerite Roser | Evaluation Team Salem State College School of Social Work Salem |
| Sharon Silvia | Program Director Child and Family Services, Inc. Fall River |
| Cheryl Springer | Evaluation Team Salem State College School of Social Work Salem Program Staff |
| Jan Coleman | Adoption Worker Department of Human Services Portland |
| Chito Cuanzon | Independent Adoptions Specialist Department of Human Services Salem |
| Gladys Hedgmon | Adoption Worker Department of Human Resources Portland |
| Claudia Hutchison | Project Manager Oregon Post Adoption Resource Center Portland |
| Mary Ickes | Adoption Consultant Department of Human Resources Salem |
| Shelley Jones | Financial Resources Manager Department of Human Services Salem |
| Barry Kirvin-Quamme | Administrative Co-Director Kinship House Portland |
| Kathy Ledesma | State Adoption Coordinator Department of Human Services Portland |
| Vicki Lopez | Post-Adoption Family Therapist Department of Human Services Salem |
| Iris Lyman | Adoption Unit Supervisor Post Adoption Family Therapy Portland |
| Marylyn Moe | Social Service Specialist Oregon Department of Human Resources Portland |
| Connie Pollard | Training Specialist Portland State University Portland |
| Malcolm Tabor | Assistant Manager Department of Human Services Salem |
| Beth Vaagen | System of Care Manager Department of Human Services Salem |
| Marilyn Webb | Director of Training Portland State University Portland |
| Karalyn Heimlich | Executive Director of Adoption and Adoption Relate Lutheran Services of the South Austin |
| Susan Klickman | Adoption Program Manager Department of Protective and Regulatory Services Austin |
| Pat Simms | Post Adoption Program Manager DePelchin Children's Center Houston |
| Bill Taube | Manager of Post Adoption Services Spaulding for Children Houston |
| Jackie Burgeson | Director of Child Placing Services United Methodist Family Services of Virginia Richmond |
| Jodi Charmoy | Program Manager and Adoptive Family Counselor Coordinators/2, Inc. Richmond |
| Lauren DeFrese | Adoption Supervisor United Methodist Family Services of VA Alexandria |
| Cynthia Evans | Regional Director United Methodist Family Services of VA Harrisonburg |
| Patricia Gonet | Post-Legal Adoption Coordinator Department of Social Services Richmond |
| Brenda Kerr | Adoption Program Manager Department of Social Services Richmond |
| Barbara Pedrotty | Regional Training Coordinator Coordinators/2, Inc. Richmond |
| Debbie Riley | Executive Director The Center for Adoption Support and Education, Inc. Falls Church |
| Sara Rodriguez-Story | Regional Family Counselor United Methodist Family Services of VA Alexandria |
| Marilyn Schoettle | Director of Education and Publications The Center for Adoption Support and Education, Inc. Falls Church |
| Monica Uhl | Director of Respite Resource Project Virginia Commonwealth University Richmond |
| Barbara Pearson | Director Northwest Adoption Exchange Seattle |