Deborah Gibbs and Kristin Siebenaler
Richard P. Barth
University of North Carolina School of Social Work
Contract No. 100-99-0006
Laura Feig Radel
U.S. Department of Health and Human Services
Office of the Assistant Secretary for Planning and Evaluation
As a result of federal and state efforts, adoptions of foster children have increased sharply in recent years. Available data, while limited, indicate that most adoptions are highly successful. Disruption and dissolution(1) are relatively rare, and even adoptive families who have experienced substantial difficulties tend to report that they would adopt the same child again.
Yet many adoptions that do not experience disruption proceed under difficult circumstances. The long-term consequences of childrens early trauma and repeated disruptions may be manifested in significant functional impairments at home, in school, or in the community, which in turn creates stress for the entire family. To respond to these challenges, families draw on a variety of services. Many families would prefer that the service they use be tailored to the needs of adopted children and their families, and provided with sensitivity to the adoption-related aspects of their problems.
It is therefore not surprising that the federal government and state child welfare agencies have worked in recent years to develop strategies to support adoptive families. These supports initially consisted almost exclusively of the provision of state adoption subsidies, which now date back nearly 40 years. Post-adoption service (PAS) programs organized around the needs of adoptive families began to emerge in the 1960s, but their development accelerated in the last decade as a result of federal funding for demonstration projects, state efforts, and private agency initiatives. An infusion of federal funds from bonuses to states for increasing the number of children adopted and the Promoting Safe and Stable Families program has further facilitated both the establishment of new programs and the expansion of existing ones.
This report summarizes the findings of a project titled Assessing the Field of Post-Adoption Services, which addressed three research questions:
- What is the extent of need for PAS?
- What are the characteristics of existing PAS programs?
- How are PAS programs monitoring and assessing their effectiveness?
To address these questions, the study team engaged in four interconnected activities:
- a literature review, drawing on published reports, journal articles identified through online databases, and unpublished studies located through personal communication (Barth, Gibbs, and Siebenaler, 2001);
- case studies of five states with well-regarded PAS programs, which included interviews with state adoption managers, PAS coordinators and providers, and focus groups with adoptive parents (Gibbs, Siebenaler, Harris, and Barth, 2002);
- an examination of evaluation issues within PAS programs, based on information from the literature review and case studies (Gibbs, Siebenaler, and Barth, 2002); and
- secondary analysis of data from two states to identify indicators of need for PAS, based on adoption subsidies, disruption and dissolution (Barth, Wildfire, Lee, and Gibbs, 2002).
Methods and findings for each of these study components are described in greater detail in separate reports, cited above. These reports are available from RTI or at http://aspe.hhs.gov/hsp/post-adoption01/. This summary report presents findings from each component, with a concluding discussion of the current status of PAS and future directions for research and evaluation.
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 School of Social Work, University of North Carolina at Chapel Hill. Staff involved in the PAS programs participating in the case studies, as well as Susan Smith of the Center for Adoption Studies at Illinois State University, gave generously of their time and insights. We also appreciate the participation of the North Carolina Department of Social Services and the California Department of Social Services.
As the initial component of the assessment, the literature review describes information available from reports and professional literature, and gaps in the literature, with respect to the research questions guiding the assessment. The literature review also includes a discussion of the challenges to designing and evaluating PAS that provides guidance for subsequent activities within the assessment, including secondary data analysis and case studies of existing programs.(2)
2.1 Need for Post-Adoption Services and Supports
2.1.1 Indicators of Adoption Success
|Even with recent increases in adoptions, disruptions remain rare.|
Adoptions have generally been quite stable and successful despite the lack of PAS development. Relatively low adoption disruption rates reflect this success. This suggests that many families will not need PAS in order to keep their adoptions intact. Three federally funded studies completed in the late 1980s and one completed more recently used different methods and samples, but all arrived at similar conclusions about the approximate rates of disruption: for special needs children, somewhere between 10 and 16 percent of adoptions will disrupt (Barth and Berry, 1988; Goerge, Howard, and Yu, 1996; Partridge, Hornby, and McDonald, 1986; Urban Systems Research and Engineering Inc. [USR&E], 1985). This suggests that adoption disruptions are lower than disruptions of guardianships, which appear to occur with approximately equal frequency but within a shorter time frame, or long-term foster care placements, which occur at a greater than 20 percent rate over a 3-year time frame (Berrick, Barth, Needell, and Jonson-Reid, 1998).
As a result of federal and state efforts, adoptions of foster children have increased sharply in recent years, with an apparent growth from 24,000 in 1996 to 36,000 in 1998 (Kroll, 1999; U.S. Department of Health and Human Services [DHHS], 2000). There is currently substantial concern that this growth will increase adoption disruption rates. However, Goerge, Howard, and Yu (1996) concluded that since the passage of PL 96-272 (The Adoption Assistance and Child Welfare Reform Act [AACWA]) in 1980, the number of special needs children who were adopted increased, but the percentage of failures from adoptions and adoptive placements has declined (Goerge, Howard, and Yu, 1996, p. 6). Indeed, the proportion of adoption disruptions fell in Illinois from 21 percent prior to AACWA to 10 percent after permanency planning was implemented. This decline suggests that changes in policy that result in additional adoptions of foster children need not result in higher levels of adoption disruption.
2.1.2 Use of Adoption Subsidies for Services and Supports
|Subsidy policies vary widely, and their relation to PAS is not well understood.|
Our understanding of the relationship between adoption subsidies and other post-adoption services is limited. Several earlier studies and reviews have concluded that adoption subsidies are associated with adoption stability (Barth, 1993; Sedlak, 1991). Other assessments have indicated that the subsidies are set at least as much on the basis of geopolitical boundaries as on the familys ability to meet a childs needs (Avery and Mont, 1992). According to Bower (1995), the majority of adoption assistance administrators and adoption workers concluded that services provided through adoption assistance programs were insufficient to meet the needs of special needs children and families who adopt them (p. 25).
Adoption and Foster Care Analysis and Reporting System (AFCARS) data indicate that 88 percent of children adopted in 2000 received some form of adoption subsidy (DHHS, 2001c). Some of these children are not getting cash benefits and are receiving only deferred subsidy agreements that will allow families to obtain a cash benefit should they be able to document such a need at a later time. To our knowledge, there is no research on when and why deferred agreements are activated by families requesting a cash assistance payment.
States and localities are likely to vary in the assumptions that underlie design of their subsidy programs. Some will consider that subsidies should be set at a rate sufficient to provide general support for needed services. Others will set subsidy amounts at a level that can support only the basic care for a child, unless there are specific time-limited requests for subsidy funds to address specific problems. The range of state policies can be seen in the examples of Ohio, where the Post-Adoption Special Services Subsidy (PASSS) provides payments of up to $20,000 annually to adoptive families when there is a risk to the adoption; and Illinois, which limits its provision of cash assistance to meet exceptional needs, but offers a network of adoption preservation services.
There have been a few systematic efforts to keep track of the ways that subsidies support families. National Adoption Assistance Training, Resource and Information Network (1999/2000) survey data and a policy analysis by the North American Council on Adoptable Children (NACAC) show that states vary widely on key areas, including how special needs are defined and the provision of benefits including respite care, residential treatment, and nonrecurring adoption expenses (Bower and Laws, 2002).
More than half of the states indicate that they provide residential treatment as a post-adoptive service, according to the American Public Human Services Association (APHSA)/Interstate Compact on Adoption and Medical Assistance (ICAMA) survey (Oppenheim, Gruber, and Evans, 2000). Current IV-E regulations prohibit the use of funds for residential treatment for children receiving adoption subsidies. Although it might be possible for states to seek a waiver of this restriction, no state has yet done so. There appears to be substantial demand for this resource, yet there is no information available on its use, how it is funded in different states, and whether placements contribute to reunification.
2.2 Studies of Adoptive Families
2.2.1 Characteristics of Adoptive Families
|Adoptive families are diverse in composition, often with relatively low incomes.|
Recent studies have improved our understanding of families who adopted children from foster care. Statewide surveys of families who adopted children through the child welfare agencies in Illinois (Howard and Smith, 2000) and Oregon (Fine, 2000) offer clues about the pool of families that are, or might become, post-adoption service users. About 40 percent of the Illinois families responding to the survey were single parent.headed households a rate considerably higher than that in the Oregon samples. Similar proportions of households had one adopted child in Oregon and Illinois samples (ranging from 42 to 46 percent). In Illinois, many (42 percent) had birth children as well as adopted children. Foster children were present in 21 percent of the families, and 12.5 percent of families had other children, typically grandchildren or other relatives. About 40 percent of the children in the Illinois sample were adopted by relatives, which is a larger percentage than in the Oregon sample (18 percent). In both states, the typical age of the responding parents was about 46. The median age for adoption finalization in Illinois was 6 years.
Substantial proportions of families in both states have relatively low incomes, so that Adoption Assistance appears to be an important source of support for many families raising adopted children (Howard and Smith, 2000). These findings may indicate a substantial change in the material circumstances of adoptive families during the last decade in comparison to earlier research, which tended to describe adoptive families as more affluent than the general public (c.f., Barth and Brooks, 2000). This may be partly attributable to the growing rate of adoption by relatives who do have fewer financial resources (Magruder, 1994). Yet in Oregon, where only one in five adoptions is by relatives, 48 percent of families earned less than $40,000 a year (Fine, 2000).
School problems are consistently rated as the most significant concerns for adoptive families in both states. It is therefore not surprising that, in Illinois, support for tutoring was the reason given most often to explain the need for an increase in subsidy (by 29 percent of the families indicating the need for a higher subsidy).
Several risk factors for disruption have been identified in adoptive family characteristics. Being adopted by strangers or by families with no prior adoptive or foster care experience seems to heighten the risk for disruption (Barth, Berry, Yoshikami, Goodfield, and Carson, 1988; Berry and Barth, 1990; Partridge, Hornby, and McDonald, 1986; Smith and Howard, 1991). Several studies (Berry and Barth, 1990; Groze, 1986; USR&E, 1985) have found that younger adoptive parents are more likely to disrupt, but this conclusion is not unanimously supported. Partridge, Hornby, and McDonald (1986) did not find parental age to be a significant risk factor.
One of the more disquieting findings in the disruption literature is that adoptions by more-educated parents, particularly mothers, are more likely to disrupt (Barth et al., 1988; Brooks and Barth, 2002; Boyne, Denby, Kettenring, and Wheeler, 1984). Whereas Partridge, Hornby, and McDonald (1986) did not find education significant in predicting disruption, the studies that did find a difference theorize that this could be in part because of the heightened expectations that more educated parents may have for their children, as well as the lack of community resources equipped to handle children with special needs (Barth and Berry, 1991).
2.2.2 Satisfaction with Adoption
|Most adoptive parents report positive feelings about adoptions, even difficult ones.|
Most adoptive families have positive experiences, which vary somewhat with age, and do not use substantial amounts of services to achieve those good relationships (Brooks, Allen, and Barth, 2000). Howard and Smith (2000), in their general survey of families receiving adoption subsidies, found that 83 percent of families indicated feeling very close, 15 percent indicated feeling somewhat close, and 2 percent indicated feeling not at all close to their child. Even among families who experience an adoption disruption, 86 percent stated that they would definitely or most likely adopt again and 50 percent indicated that they would adopt the same child (but with more awareness of what adoption required of them at different stages in the adoption) (Barth and Berry, 1988).
2.2.3 Child Characteristics
Whereas most adoptions have been successful, there is a growing body of evidence that they are also unusually challenging. Concern that adopted youth are at risk for psychological disorders has persisted for several decades, although there is certainly no consensus that adopted children have unusual levels of problems (Bohman, 1981; Haugaard, 1998; Zill, 1996). The research on whether children who have been adopted are at greater risk for emotional, academic, and behavioral difficulties than nonadopted youth is widely discussed in the adoption literature (Berry, 1992; Brodzinsky, Hitt, and Smith, 1993; Haugaard, 1998; Lindholm and Touliatos, 1980; Warren, 1992; Wierzbicki, 1993).
|Age and behavioral/ emotional problems are the strongest predictors of disruption.|
Problems in adoptions whether manifested in troubled behavior or adoption disruptions are highly associated with certain characteristics of adopted children. The predominant factor influencing disruptions is the childs current age. Numerous studies have supported the conclusion that the older the child, the more likely the risk of disruption (Barth and Berry, 1991; Festinger, 1986; Goerge, Howard, and Yu, 1996; Groze, 1986; Partridge, Hornby, and McDonald, 1986; Smith and Howard, 1991; USR&E, 1985). Older children, who are more likely to have been older when separated from their biological families, may have had more exposure to maltreatment, greater ties to their biological families, and experienced more disruptions in foster care (Barth and Berry, 1991).
Families in which children display behavioral or emotional problems are also more likely to disrupt, particularly when those problems are of an externalizing nature (such as violation of family norms, sexual acting out, defiance, cruelty, or physical harm of others) (Barth and Berry, 1991; Partridge, Hornby, and McDonald, 1986; Smith and Howard, 1994; Smith, Howard, and Monroe, 1998). One survey of states about their experiences with disruption found that children with emotional problems represented 19 percent of total placements but 39 percent of disruptions. This is in sharp contrast to the findings for children with physical or mental handicaps, who accounted for 21 percent of total placements but only 13 percent of disruptions (USR&E, 1985).
2.3 Demand for Post-adoption Services and Supports in Adoptive Families
A variety of needs assessments have identified a fairly consistent set of supports and services that are desired by adoptive families and recommended by agencies supporting them.
2.3.1 Information Services
Parents in numerous studies have stressed the importance of full disclosure of information about their child, including the childs social, medical, and genetic history (Barth and Berry, 1991; Berry and Barth, 1989; Brooks, Allen, and Barth, 2000; Commonwealth of Kentucky, 1993). In addition, parents requested literature in the form of pamphlets, books, and articles to help them better understand their adopted child and deal with issues surrounding adoption. Lectures, seminars, workshops, and classes were also mentioned as helpful.
2.3.2 Clinical Services
Although many adoptive families indicated a desire for counseling for the child, couple, or family, few actually utilized these services. With the exception of the Commonwealth of Kentucky study, in which 50 percent of families reported using individual counseling for their child, only a small fraction of parents surveyed in any of several studies sought counseling for themselves or their children (Brooks, Allen, and Barth, 2000; Commonwealth of Kentucky, 1993; Howard and Smith, 1993; Walsh, 1991).
2.3.3 Respite Care
Parents often request respite care in general surveys of their needs, but they seem unsure as to how to access it in reality. Walsh (1991) found that although 26 percent of parents reported respite care as a need, only 6 percent actually used it. Findings from the Commonwealth of Kentucky (1993) can at least partially account for this discrepancy: parents either do not believe that respite care is available or cannot find someone willing or qualified to provide it. When provided, it has been lauded by parents and has reduced the experience of objective burden (Owens-Kane and Barth, 1999).
2.3.4 Material Services
Parents also want material services for their children, such as adoption subsidies, medical care, and special education options. Adoptive families often struggle under the financial burden of another child in the house and request assistance to offset that childs expenses (Berry and Barth, 1990; Brooks, Allen, and Barth, 2000; Commonwealth of Kentucky, 1993; Frey, 1986; Rosenthal, Groze, and Morgan, 1996). Berry and Barth (1990) compared stable to disrupted placements and found that the amount of the monthly subsidy check differed, with stable placements receiving greater subsidies. They also found that families who did not receive subsidies had a higher likelihood of disruption than other factors would predict. Children who are adopted often enter placement with special medical and/or education problems that require additional care and, by extension, additional money (Brooks, Allen, and Barth, 2000; Commonwealth of Kentucky, 1993; Howard and Smith, 1993; Howard and Smith, 1997; Kramer and Houston, 1998; Partridge, Hornby, and McDonald, 1986; Walsh, 1991).
2.3.5 Support Networks
Many adoptive parents utilize available support groups or rely on a more experienced adoptive parent as a mentor (Barth and Berry, 1991; Berry and Barth, 1989; Brooks, Allen, and Barth, 2000; Daly and Sobol, 1994). A growing number of support groups are available to adoptive families. Parent groups typically provide support in dealing with the variety of issues facing adoptive parents, including intercountry adoptions; special needs adoptions; future reunification with birth parents; and emotional, social, and educational assistance pre- and post-adoption. Parent support groups can be organized by parents or through support networks sponsored by community, state, and national-level public and private agencies. There does not appear to be any research that specifically evaluates the effectiveness of these support groups.
2.4 Post-adoption Services and Supports Programs in Operation or Development
2.4.1 Public Agency-Supported Services
|PAS may be provided directly by child welfare agencies or contracted out.|
In some areas (e.g., California), the adoption program includes an appropriation for post-adoption services as part of the reimbursement to the public agency for the completion of the adoption. In other states (e.g., North Carolina), Temporary Assistance to Needy Families (TANF) or Title IV-B Subpart 2 (Promoting Safe and Stable Families program [PSSF]) funds are provided to the public agency to underwrite post-adoption services activities. An apparent benefit of this approach is that a worker who knows the family and was involved in the original placement will provide the services in many cases. However, the worker might not still be with the agency when post-adoption services are needed, and he or she may not be a specialist in providing such services.
A second approach is to develop specialized post-adoption services units within the public agency to which cases can be referred. An apparent advantage of this approach is that these public PASS workers can collaborate closely with the adoption worker, have excellent access to the case history information, and have access to public agency resources (e.g., referral to intensive in-home services or temporary foster or group home care). Oregons Post-Adoption Family Therapy (PAFT) model and Californias Santa Clara County post-adoption services unit are examples of this model in action.
A third, and increasingly widely used, model is to develop interdisciplinary teams or provide training to other public and private agency personnel to improve the level of community response. These models typically involve contracting with service providers outside the public agency. El Paso County, Colorado, has developed more interdisciplinary support for adoptive families by engaging public community mental health programs and hiring a highly qualified adoption specialist, located in the DSS office, to serve as a single point of contact. In 2.5 years, only one of El Paso Countys 500 placements has disrupted before finalization, and only one completed adoption has not worked out after legalization (Berns, 2000).
The Arizona State Adoption Programs Post-Adoption Services Project began a 3-year agenda in 1992 to address the problems of special needs adoption placement (Morse and Lussier, 1995). Training programs for mental health professionals and adoptive parents, as well as crisis prevention services, were developed and offered to adoptive families. Pre- and post-assessments of adoptive families satisfaction with support services indicated a modest improvement in satisfaction, although a low response rate at post-test complicates the interpretation of the findings.
In 1991, the Rocky Mountain Adoption Exchange received federal demonstration grant funding for a 2-year project to develop a collaborative model of interdisciplinary teamwork for serving families who had adopted children with special needs (Naylor, 1993). Teams were formed in Colorado, New Mexico, Nevada, and South Dakota. Mental health, social service, developmental disabilities/education professionals, and adoptive parents were incorporated into each team. A total of 168 families were served over the 2-year period.
Spencer (1999) describes what she considers to be an optimum approach to post-adoption services, involving comprehensive Post-Adoption Service Centers. The centers should be triad focused and equally address the long-term needs of all adopted children. The proposed centers would have enough service volume to support the delivery of quality services by trained staff. The centers would also provide training and technical assistance in remote areas of the state.
Alabamas Department of Human Resources (DHR) has developed an approach to post-adoption services that involves the establishment of a system of family resource centers for adoptive families (NACAC, 2000). The project was developed during 1999 by examining other states post-adoption models and programs and by surveying Alabama families who had adopted foster children. The focus of the Alabama program is twofold: family support and family education and empowerment. A request for proposal was issued to locate a licensed child-placing agency to operate a statewide resource center and to manage a statewide network of post-adoption support services.
Other states implementing this model include Oregon, where a post-adoption resource center provides information and referral, library resources, and parent and professional training, Minnesota, where a post-adoption resource center is run by NACAC and the Minnesota Adoption Resource Network, and Louisiana, where services have included case management and subcontracted centers but now focus on respite (Karl Ensign, personal communication, February 12, 2001).
2.4.2 Impact of Federal Legislative Changes
PAS programs have gained increased support in recent years by three federal legislative measures. The Promoting Safe and Stable Families (PSSF) program addresses a broad array of goals, including preventing unnecessary separations of children from their families, improving the quality of services, and increasing reunification and successful adoptions for children in out-of-home care (DHHS, 2001a). Under the terms of the PSSF, states are allowed to use Title IV-B, Subpart 2 funds for adoption support and preservation. A recent review shows that 15 percent of these funds have been used for this purpose nationally, with state allocations ranging from 0 to 25 percent of the funds received. This categorization does not allow identification of the extent to which funds were used specifically for post-adoption support (James Bell Associates, 2001).
|The Promoting Safe and Stable Families program and other recent federal initiatives have expanded funding for PAS.|
The Adoption 2002 Initiative set a national goal of doubling the number of children adopted or placed in permanent homes each year. Among the measures taken in response to this challenge was a system of cash bonuses for states increasing the number of children adopted from the public child welfare system. States may use their bonus funds to increase services, including post-adoption services (DHHS, 1996).
Finally, the Adoption Opportunities program, which amends Section 205 of the Child Abuse Prevention and Treatment and Adoption Reform Act of 1978, awards grants and contracts to public and private nonprofit agencies that improve permanency for children who would benefit from adoption (particularly children with special needs). The seven major program areas include post-legal adoption services for families who have adopted children with special needs (DHHS, 2001b).
2.4.3 Private and International Adoptions
|Advocates support PAS availability for all adoptive families, not only those adopting from foster care.|
At the December 2000 National Conference on Post-Adoption Services, there were repeated affirmations of the concept that post-adoption services should be universally available to all adopted children, regardless of any past involvement with the U.S. foster care system. Article 9 of the recently ratified Hague Convention on International Adoption requires participating countries to promote the development of adoption counseling and post-adoption services in their States. In this country, the Hague Convention is implemented by the Intercountry Adoption Act of 2000 (http://www.jcics.org/haguetop.html). New Child Welfare League of America standards will include provision of post-adoption services among its criteria for accreditation of private adoption agencies (including those providing international adoptions).
2.5 Evaluation of Post-Adoption Services and Supports Programs
Only five projects, described below, were identified as having formally assessed the performance of post-adoption services to prevent adoption disruption and dissolution. The small sample sizes and nonrandom sampling for several of these projects serves as a warning that the results should not be considered generalizable. The diversity of populations, services and evaluation methods represented by these evaluations makes it impossible to generalize any assessments except to note that while not all adoptions can be preserved, well-designed and evaluated programs can demonstrate positive effects.
|Few PAS programs have been formally evaluated.|
Although the available evaluation research is unable to offer precise estimates of the effectiveness of post-adoption services, some approaches have consistently been found to be more helpful than others. Contact with self-help groups or other adoptive parents who can provide respite and support is reported to be helpful (Commonwealth of Kentucky, 1993; Frey, 1986; Nelson, 1985; Walsh, 1991). In contrast, the disappointing results from the evaluations of brief, intensive adoption preservation services models suggests that they do not generally fit the needs of adoptive families (Barth, 1995; Howard and Smith, 1995). A less time-limited and more family-focused approach appears more suitable (Howard and Smith, 1995; Prew, Suter, and Carrington, 1990).
Illinois: Adoption/Guardianship Preservation Project. Beginning in the early 1990s, Illinois attempted to reduce disruptions to both adoptions and subsidized guardianships through its statewide adoption preservation program, which offers in-depth assessment, on-call support, therapy, support groups, and advocacy. The program currently serves approximately 600 families annually. The average case involves a total of 72 hours of work, including travel time and collateral contacts, and lasts for 9.7 months. Thirteen percent of children were out of their homes at the end of service, although nearly half of the parents of these children remained committed to their parental relationship. Satisfaction with the program was high; 92 percent of parents described themselves as satisfied or very satisfied with the services received. Childrens behavior was reported as improved by 74 percent of families and 70 percent of workers (Howard and Smith, 2001).
Oregon: Post-Adoption Family Therapy Project. In Oregons PAFT Project, an adoption worker and a family therapist (both of whom were licensed clinical social workers) teamed up to provide services to families struggling with post-adoption issues. Sessions were often conducted in the familys home and focused on helping parents develop better ways of relating to their adopted childs confused belief system, which may be the cause of the childs inappropriate behavior (Prew, 1990). Only 8 percent of the 50 families served by PAFT disrupted by the end of the service period, the median of which was 3.5 months. Among 34 families referred to the program but not receiving services, 6 adoptions (18 percent) disrupted. There is no assessment of the comparability of these groups, however (Prew, Suter, and Carrington, 1990). The authors attribute PAFTs success to the idea of co-therapists, as well as helping parents better understand their childs behavior (Prew, 1990; Prew, Suter, and Carrington, 1990).
|Family-focused services and contact with other adoptive families are associated with effectiveness.|
Washington: Medina Childrens Services. In a collaboration between Medina Childrens Services (a well-established special needs adoption agency) and HOMEBUILDERS of Tacoma, Washington, 22 children and their adoptive families received 4 weeks of intensive in-home therapy (three to five sessions of 2 hours or more). Each full-time therapist handled a caseload of two families, allowing them to devote the necessary time to provide these services. One year after these special services were initiated, nine children remained with their adoptive families, nine petitioned for disruption, and four children were not living in the home (either in a group home or living on their own) but had not experienced disruptions. The disruption rate for this project ranged from 41 percent to 59 percent, depending on the status of the youth in transition (unpublished program documents).
Iowa: PARTNERS. Iowas Post-Adoption Resources for Training, Networking, and Evaluation Services (PARTNERS) program, piloted by Groze and colleagues, provided a continuum of services to adoptive families, including support groups, sustained adoption counseling, and intensive services (Barth, 1991; Groze, Young, and Corcran-Rumppe, 1991). Of the 39 families who participated in PARTNERS, 29 percent of the children were in out-of-home placements at the end of the service period. Groza cautions not to equate displacement with disruption and states that the children needed more intensive treatment than could be provided in the home at that time (Victor Groza, personal communication, May 18, 1999).
New England: Casey Family Services Program. CFS, based in Connecticut, offers post-adoption services in several New England states. Although structure and focus vary among the CFS divisions, the programs offer a broad array of services typically including adoption information and education, counseling, advocacy, workshops, and facilitated support groups open to any adoptive family. Services are generally short-term, with a median length of case opening of 5 months and a median of three sessions for families receiving family systems counseling. Based on a counselors assessment of family gains, strongest improvements were found in child behavior, understanding of adoptive issues, and effective communication, with less change in child-family attachment. Gains appear to be greatest among cases with longer duration and more counseling sessions received (Gibbs, Barth, and Lenerz, 2000).
|PAS programs have yet to develop consistent service classifications or a research base for program effectiveness.|
The purposes and processes of PAS vary widely. There is no centralized source of information about which post-adoption service programs are operating with which populations and procedures. A classification scheme for PAS interventions must be established before significant strides can be made in studying the most efficacious approaches. This must then be joined with a consistent means to describe presenting problems of families who might benefit from post-adoptive services.
Families seek post-adoption services for many reasons, including crises that threaten the stability of the adoption; gathering general information about an adoption issue (e.g., open adoption or transracial adoption); normalizing the adoption experience; and searching for biological parents in closed adoptions. Families also bring many differing experiences to post-adoption services. PAS providers seem to have taken an approach to PAS that embraces this diversity and welcomes all comers. Whereas there is some evidence that adoptive families created from different circumstances are more alike than different (Groza and Rosenberg, 1998), there is also evidence that the problems of children adopted from foster care are the most substantial (Smith and Howard, 2001).
Child welfare administrative data is not likely to provide information about the impact of PAS. Assessment of post-adoption services will require more intensive and costly methods, involving direct assessments of the well being of children and families. Parent reports on their childrens well-being are insufficient because of the data indicating that adoptive parents have high standards for their children (Barth and Miller, 2000). Randomized clinical trials will be necessary and seem feasible, although they will not be easily achieved because the numbers of similarly situated cases served by most agencies is small and because the culture of PASS is generally distant from such rigorous research methods.
These trials would also need to be based on new developments in interventions on behalf of adoptive families. The adoption field has long been dominated by psychodynamic approaches like attachment theory, which has not received substantial empirical support as the basis for interventions with troubled children and families (Burns, Hoagwood, and Mrazek, 1999; Weisz and Hawley, 1998). Interventions that have demonstrated efficacy with other troubled families (e.g., Huey, Henggeler, Brondino, and Pickrel, 2000) also deserve testing with adoptive families.
(1) Disruption refers to the breakup of an adoption prior to finalization; dissolution refers to the legal abolishment of the adoption. Displacements refer to out-of-home care with continued involvement of the adoptive family.
(2) See Appendix for a complete list of references. (Note: Not all materials in the bibliography are cited in this condensed version of the literature review prepared for this summary report.)
The case study component of this project used interviews with state adoption program managers and post-adoption service (PAS) providers as well as focus groups with adoptive parents across five states. The case study report focuses on services that fall within each 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 the case-study states are discussed in the summary of the Evaluation Issues Report, Section 4.
|Case studies drew on information from adoption managers, program coordinators, providers, and parents.|
The RTI team selected candidate sites for the case study based on interviews conducted with state adoption managers by the Center for Adoption Studies at Illinois State University (ILSU) and expert opinion.(3) Using this information, ASPE selected five well-regarded state programs for the case study: Georgia, Massachusetts, Oregon, Texas, and Virginia. Data for the case study included semistructured interviews with staff from PAS programs and public adoption agencies, informal focus groups with adoptive parents, and PAS program documents. The RTI team conducted the five 2- or 3-day site visits between October and December 2001.
Site interviews were semistructured, collecting information on client needs, existing services, and program evaluation efforts. The team interviewed a broad range of service-based stakeholders with direct involvement in post-adoption programs and services. Specific questions asked of each interviewee varied, according to the circumstances of the program and the role and expertise of the individual. Topics discussed in the focus groups with adoptive parents included services desired, level of program satisfaction, utilization of services and subsidies, and areas for improvement.(4)Although findings from these focus groups cannot be generalized to the larger population of PAS recipients, the diverse opinions expressed suggest that participation was not unduly biased toward parents who were highly satisfied with the services they had received.
3.2 Need for PAS
|Parents and PAS coordinators generally agreed on the type of services needed.|
Respite care. Most coordinators/providers mentioned respite as being a major need. Many also felt that, in addition to payment for respite care providers, families needed group respite activities such as camps, trips, and fun days. Respite care was also mentioned most often as a major need of families, across all states visited. Many adoptive parents described a dearth of available respite providers and lack of respite providers qualified to deal with special needs children. Parents also expressed a need for more group activities that would provide adopted children with opportunities to interact with one another.
Information. Adoptive parents reported that they were unclear about what PAS services were available to them and needed more information about services that they could access. They wanted to be knowledgeable about services before crises developed.
Parent training. Several coordinators/providers said that parents needed more training about adoption issues before the adoption occurred. Adoptive parents also felt that training about adoption issues was a critical need. Although some parents mentioned that parent training currently was offered, they often had found that it did not meet their needs. Parents often stated that the training was offered too soon after adoption, before they had enough experience with the issues to understand the training content.
Professional training. Coordinators/providers and adoptive parents mentioned the need for professionals competent in adoption issues, especially in the educational and mental health areas. Adoptive parents repeatedly reported having trouble finding qualified therapists who were knowledgeable about adoption issues. Parents reported that their children were stigmatized by schools when it was discovered that they were adopted. They wanted staff training as well as advocacy to help them deal with schools on their childs behalf.
Mental health services. Another need coordinators/providers and adoptive parents often expressed was mental health services for adoptive families. Parents were concerned about finding a provider as well as being able to pay for the services when they did find a provider with whom they felt comfortable. They noted that although these services were funded through Medicaid, many mental health providers did not accept Medicaid or were not available through private insurance plans.
Child assessments and evaluations. Adoptive parents wanted more comprehensive assessments and evaluations conducted on their adoptive child when they were placed and before finalization. They also wanted to know more about the childs and birth parents background, and about potential physical and mental problems before adoption finalization. Parents mentioned needing assistance in interpreting the records.
Other needs mentioned by coordinators/providers included advocacy, residential treatment, case management, support groups, and assistance with adoption subsidies.
Adoptive parents were generally satisfied with the services available to them by their states PAS programs, but many felt that additional funding was needed. Parents in several states expressed strong satisfaction with how effectively and quickly program staff handled crises (e.g., suicidal behavior, hospitalizations, aggressive behavior), with receipt of appropriate information about adoption issues and referrals to adoption-competent therapists and other service providers. Many parents expressed satisfaction with respite options, but they also very clearly expressed a desire for more funding for those services.
3.3 PAS Program Structure
|Each state contracted out its PAS program, although program structures varied.|
Formal PAS programs were instituted during the 1990s in all five case-study states. Adoption program managers reported that the development of PAS resulted from a combination of factors, including adoptive parent advocacy movements, state legislative action, and state executive initiative. In each of these states, PAS are contracted out rather than provided by state child welfare staff. State adoption program managers mentioned a variety of reasons for this approach. These reasons included cost effectiveness, the difficulties of hiring additional state staff and protecting their positions against budget cuts, and the belief that using external contractors fostered creativity and facilitated statewide service delivery in county-administered systems.
Adoption program managers and PAS coordinators described four PAS program structures:
- A central PAS provider with staff who serve all regions (Oregon)
- A central PAS coordinator who funds regional PAS providers (Massachusetts and Virginia)(5)
- Regional PAS providers operating without a central PAS coordinator (Texas)
- Separate statewide PAS providers for specific services (Georgia)
Most of the PAS providers selected by the states have extensive experience in providing services to children and families, including adoption services and child placement. Regional PAS providers were expected to offer the full array of services for their region.
Services such as information and referral, parent training, and support groups were provided at no cost to families. However, in some cases, funding did not cover the full cost of a service that families sought through other community providers (e.g., respite, camps).
3.4 Program Goals and Objectives
Program managers in case-study states identified several common program goals.
Preserving adoptive families. State adoption program managers shared the belief that the primary purpose of PAS programs was to help adoptive families stay together and to prevent out-of-home placements among adopted children.
Statewide access. Adoption program managers in all five states stressed the importance of offering services to adoptive families throughout the state. Regardless of program structure, adoption program managers reported that delivering services to rural areas was a particular challenge due to clustering of services around larger communities and demands of staff travel.
Family-centered services. Several adoption program managers reported that another explicit objective was to allow families to decide their level of involvement with PAS and to identify the types of services they felt they needed.
Adoptive family recruitment. In only one state did the adoption program manager expressly identify the PAS program as a tool for recruiting adoptive families. However, PAS providers in other states noted this connection, reporting that they often presented their PAS programs at pre-adoption parent trainings.
Across the case-study states, adoption program managers reported that eligibility for PAS was determined largely by adoption type and receipt of subsidy (i.e., presence of special needs). Adoption program managers in Virginia and Massachusetts reported that any adoptive family residing in the state was eligible for PAS. In Massachusetts, eligibility for services is extended to families in legalized guardianship arrangements. In Virginia, the state also opened up PAS to families prior to adoption finalization. Adoption program managers in the remaining three states primarily served families who adopted from the child welfare system in their state. Two of these states offered some lower cost services to all adoptive families.
|Funding levels varied widely, with state funds and Title IV-B Subpart 2 most commonly used.|
Two distinct patterns of funding PAS programs were seen among the five states visited, use of state funding and use of Title IV-B Subpart 2 (Promoting Safe and Stable Families program) funds. Virginia required its lead PAS contractor to contribute a 10 percent match toward the cost of the program. None of the five states reported using funding from the Adoption Incentive Program for PAS.
Annual funding for PAS in 2001 varied widely across states, ranging from $500,000 in Oregon to between $8 million and $9 million in Georgia. Given the variations in population size and program eligibility among the five states, it is difficult to compare funding levels across states, but funding levels clearly varied with the provision of higher cost services such as crisis intervention (in Georgia) and residential care (in Texas).
Adoption program managers and other officials in several states were concerned that the dramatic increase in adoption the past several years will increase future needs for PAS and require additional funds to support it. Among services providers, concern was widespread regarding the current levels of funding. Although no states reported waiting lists for PAS services, some had to restrict availability of higher cost services such as crisis intervention and residential treatment.
3.7 Outreach and Referral
|Despite energetic outreach, many adoptive families are unaware of available services.|
State adoption managers and providers in the five case-study states reported a variety of strategies by which they inform families about the availability of PAS. Activities included sending letters about the program to families receiving subsidies, disseminating printed materials, meeting with local or state government social services and other community organizations, establishing community boards on post-adoption services, operating local or statewide information and referral telephone lines, and presenting the PAS program at pre-adoption parent training classes. None of the adoption program managers expressed concern that increased publicity would lead to waiting lists for services. In spite of these extensive efforts, adoptive families across the five case-study states reported that they still needed more information about the types of services offered and how to access them. This was true even for parents who had accessed the states PAS program.
Many families heard of PAS programs through referrals from the child welfare agency or other service providers. In several states, however, PAS coordinators/providers and adoptive families reported that child welfare intake staff and adoption subsidy workers failed to refer families to PAS programs. In spite of extensive outreach efforts, providers reported that many adoptive families came to them for the first time in crisis situations, rather than receiving support in a preventive manner. Adoptive families in the focus groups confirmed that they often were unaware of the PAS program prior to a crisis situation.
3.8 Services Offered
|Common PAS include I&R, counseling, respite, training, advocacy, and support groups.|
Across the five states, the services most widely offered by PAS programs included information and referral, counseling, crisis intervention, respite, case management, training for parents and professionals, advocacy, and support groups. Some variation existed among the states. Texas was the only state to offer residential treatment within the PAS program; Georgia was the only state to offer tutoring; and Oregon was the only state that did not include counseling, crisis intervention, and respite.(6)
Information and referral (I&R). States used diverse strategies for information and referral services: 24-hour phone lines, websites, lending libraries, databases of adoption-competent professionals, printed materials (both about the program and about specific resources for families), and newsletters. Two states operated lending libraries (including books and videos), which were said to be well used, and one state was preparing to place regional advisors around the state.
As part of their response teams, the Virginia and Massachusetts programs used parent liaisons, who were themselves adoptive parents, to provide information and referrals. Parent liaisons in both states talked with the families who had contacted their agencies, identified their needs, and worked to locate needed resources.
PAS programs in the five states provided families with referrals to community mental health and other service providers. In Massachusetts, a subcontractor to the lead service agency provided families with free access to its extensive provider database.
Counseling and crisis intervention. In four of the case-study states, counseling and crisis intervention was available directly from the PAS providers or through referrals to community mental health agencies that were reimbursed by the PAS provider. A variety of approaches was used in delivering counseling and crisis intervention services, including multidisciplinary teams and in-home services. Providers did not expressly mention conducting comprehensive clinical assessments and testing, a need expressed by adoptive parents.
Respite. In four of the case-study states, respite was provided through the PAS program in several forms, including reimbursement or vouchers for a caregiver, sending a child to camp or on an outing, holding special events (e.g., annual parties), or art therapy. In Virginia, the Client Fund gave PAS providers the flexibility to fund an array of services identified by clients, including respite. Due to the high demand for caregiver respite, many programs limited the availability of respite funding. Finding respite providers who were acceptable both to families and to the state often was challenging. Only one state allowed adoptive families to use other family members to provide respite.
Virginia funded an effort to increase respite resources for adoptive families through the Virginia Institute for Developmental Disabilities (VIDD), an organization affiliated with Virginia Commonwealth University. The VIDD coordinator visited each region to discuss resource development and developed a resource guide for adoptive parents based on her experiences with respite for families with developmentally delayed children.
Case management. PAS providers in the five states engaged in varying levels of case management in conjunction with providing crisis intervention, counseling services, and/or information and referral. All of the states used client-tracking systems to assist staff in case management activities. Events that were tracked included incoming referrals, case openings, service use, and case status.
Parent training. State adoption program managers and PAS coordinators/providers reported providing training not only on adoption-specific issues (e.g., grief and loss) but also on child development issues relevant to adoptive families (e.g., fetal alcohol syndrome). While many of the trainings were one-session events, providers also reported offering workshops and a series of sessions on a particular topic. Providers also sent families to adoption conferences.
Professional training. In all five case-study states, state adoption program managers and PAS coordinators/providers also reported offering professional training on adoption-specific issues and child development issues. Training audiences included child welfare workers, mental health professionals, teachers and other school staff, court system staff, and medical practitioners. Topics offered to professionals included cross-cultural competency, transracial adoption, attachment in adoption, respite care for adoptive families, education law and advocacy, and openness in adoption. In several case-study states, PAS providers themselves also received training.
Advocacy. PAS providers described accompanying client families to meetings and conferences with schools and community service providers. Staff in one Texas region attended community review board meetings for cases where the childs needs extended to several state agencies. Parent liaisons provided advocacy for families in Virginia.
Support groups. PAS providers operated support groups for parents and/or children, either by leading them or through more limited assistance (e.g., offering a location, providing refreshments, mailing flyers). In addition to PAS staff, counselors, parent liaisons, and graduate students helped facilitate the support groups. Most often, providers formed support groups according to age and level of need (e.g., therapeutic support group). A regional PAS provider in rural Virginia started an online support group. Although providers considered support groups an essential component of PAS, recruiting and retaining families had been a continuing challenge. Many tried to increase and sustain attendance by, for example, holding child and parent groups simultaneously, offering child care for parent support groups, and providing transportation.
3.9 Subsidies and Other Forms of Supports
Families who have adopted children from public child welfare systems generally have access to adoption subsidies in addition to whatever PAS program may be available to them. The five case-study states offered substantial flexibility in their subsidy programs. All allowed establishment of deferred subsidies, which allowed families who did not require a subsidy at the time of adoption to request one at a later date if circumstances changed. In addition, all five states noted that subsidies could be renegotiated as family circumstances changed. Flexibility in policy is of limited value, however, unless adoptive families understand what resources may be available to them and how they can be accessed. In four of the five states, adoptive parents participating in focus groups expressed considerable frustration and confusion related to subsidies.
Data on state adoption support policies compiled by the North American Council on Adoptable Children (NACAC) suggest that in the five case-study states, strong PAS programs are accompanied by relatively generous subsidies and other supports (Bower and Laws, 2002). However, case study data did not reveal any suggestion of a planned effort to coordinate the various forms of support to which families have access.
3.10.1 Need for PAS
Better data needed for planning. High-quality data on families needs are needed to support improved planning for PAS. While many states have conducted needs assessments, their usefulness is often limited by modest response rates. In addition, these surveys rarely provide enough detail to establish when services are most likely to be needed, in terms of childrens ages or elapsed time since adoption. A national probability-based sample of adoptive families would help to provide a picture of underlying needs among those families that have, and have not, obtained PAS from state sources. At the state or program level, needs assessments should be conducted with enough rigor and detail to inform ongoing planning and program adaptation.
Services appreciated, but unmet needs remain. PAS representatives and adoptive parents identified similar priorities for service to adoptive families. Adoptive parents confirmed the usefulness of services offered by the PAS programs, especially information and referral, respite, advocacy, crisis intervention, and counseling. They also identified additional needs beyond the boundaries of typical PAS programs, including more usable information about their children, better information about supports available to them, and improved access to service providers of their choice.
Satisfaction with PAS generally high. Many states collect data on satisfaction with PAS programs, which, like needs assessments, may be biased by low response rates. Available data suggest that most families are very satisfied with services offered, and focus group participants confirmed this impression. Of particular value to adoptive parents was the level of insight and sensitivity to adoption issues that were inherent in the services they received from the PAS program. The only major source of dissatisfaction was the desire for additional services not currently offered by the PAS program.
3.10.2 Characteristics of Programs
Federal funds necessary but not sufficient for PAS development. There is no doubt that the growth in PAS programs has been encouraged by the recent availability of federal funding for this purpose. In the case-study states, however, advocacy by adoptive parents and program champions within state agencies or legislatures appeared to have been even more influential than the influx of federal funds. The experience for this limited set of states suggests that while federal funding may be necessary for PAS programs development, these resources did not by themselves lead to program development.
Adoptive families face disparities based on residence. Available research strongly suggests that some adoptive families need specialized supports for part or all of their childs development. However, the availability of both PAS programs and support to families through adoption subsidies varies widely among states. It does not appear that states with strong PAS programs provide less generous subsidies, or vice versa. Disparities in subsidies and services mean that childrens long-term outcomes may vary according to their state and county of residence/adoption.
Common goals, diverse strategies. All of the programs studied shared the common goal of keeping adoptive families intact, although the services they delivered in working toward this goal varied across states. More variation was seen in the ways in which programs worked to influence the service delivery environment. Most programs offered training for mental health, education, and legal professionals likely to serve adoptive families. These efforts to change delivery systems also are necessary to increase the extent to which other service delivery systems can meet the needs of adoptive families.
Eligibility restrictions limit program impact. Three of the five states in this study restricted eligibility for at least some of their services to families who had adopted from their states child welfare system. Although restrictions may be necessary to conserve scarce program resources, this policy raises two concerns. First, the effort to increase the rate of adoptions from foster care will be hampered to some degree if families who subsequently move across state lines know they will have limited access to PAS. Second, limiting services for families who have adopted privately or from other states may increase their eventual risk of needing high-cost services. PAS programs may be more effective in both preserving adoptive families and encouraging adoptions from foster care if they are able to serve all adoptive families. Only one of the case-study states offered PAS to families prior to legal adoption, although many providers and parents identified this as a need.
Most programs contracted out by states. Each of the states in the case study contracted out its PAS program to providers who delivered services either statewide or regionally, and the ILSU survey suggests that this is the dominant model nationally. State adoption program managers identified several advantages to this model, including better protection against fluctuations in state agency budgets, the ability to standardize services throughout the state, and the avoidance of the stigma many adoptive parents feel in approaching the child welfare agency for PAS.
Serving rural families remains challenging. States consciously worked to make their PAS programs consumer-driven, providing families with an array of services from which to choose. Although adoptive parents did not specifically mention these consumer-driven efforts, it was clear that they had taken advantage of the flexibility. Although PAS programs shared the goal of making services available statewide, coordinators reported difficulty in making services truly accessible in rural areas. Barriers to delivery of services in rural areas include the scarcity of mental health services, difficulty in gathering participants for trainings or support groups, and increased travel time for program staff. New communication technologies, such as the online support group in Virginia, may be a useful strategy.
Support needed from child welfare system as well as PAS providers. While many states choose to contract out PAS services, some level of post-adoption support should be maintained within public child welfare agencies. Adoption workers typically remain accessible to adoptive families for some time after finalization, and many families will turn to adoption workers as the first responders. However, adoptive families reported that adoption workers often lacked interest in their ongoing welfare or expressed surprisingly negative attitudes toward families who returned with difficulties. Some PAS programs in the case-study states were addressing this issue by offering training in adoption issues to public agency workers. If families are to feel confident about support from the system, system support should be consistently communicated to them at any point of entry to PAS, even if the content of the interaction consists only of a referral to the PAS program.
Services adapted to local conditions. The case-study states were fairly consistent in offering a core set of services (information and referral, education and training, support groups, respite, and counseling). Within this core, the variety with which states addressed these core services reflects considerable creativity in program design and commitment to adapting service delivery to local conditions. It also suggests the potential usefulness of systematic program evaluation in shedding light on which service delivery approaches work best under various circumstances.
Respite care highly valued but difficult to provide. Respite care appears to be a particularly challenging need to address. Families consistently reported it as a need in the literature, in state needs assessments, and in these focus groups and states have tried a variety of approaches in providing respite. Two states offered respite in congregate settings, but this model may not meet the needs of many children whose parents were most in need of respite. States struggled with the challenges of finding or training providers who were acceptable both to parents and funding agencies. For the most part, limitations on funding meant that only a very limited level of relief was available for parents who were dealing with extremely challenging children.
PAS often used in crisis mode. Both PAS providers and focus group participants reported that PAS programs are more often used during times of crisis than as a preventive measure. A better understanding of the type of need and extent of need for both preventive and crisis services could improve service planning and provide impetus for better coordination and referral systems between adoption workers and PAS providers.
PAS planning must encompass subsidies and existing services. Adoptive parents often face a patchwork of services and supports, from which essential pieces may be missing. A comprehensive approach to serving adoptive families would encompass subsidies and existing service delivery systems, as well as PAS programs. Such a network would be challenging to develop, requiring coordination among agencies involved in health, mental health, education, and child welfare. However, comprehensive planning eventually could offer states more efficient use of their resources while improving the delivery of services to adoptive families.
(3) RTI spoke with Susan Smith, faculty and co-director, Center for Adoption Studies, ILSU; Jane Morgan, adoption specialist, U.S. DHHS, Administration for Children and Families; and Kathy Ledesma, Oregon state adoption coordinator and chair, National Association of State Adoption Programs.
(4) The 32 adoptive families represented in the focus groups had adopted 76 children, 66 of whom were from the public child welfare system.
(5) Virginia did contract separately with two providers for PAS in addition to funding a network of providers. One provider offered professional training, and the other developed respite resources.
(6) Although 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 who adopted from the state and live in the Portland area.
Available research on post-adoption services and supports is largely descriptive and based on only a few of the programs implemented in this rapidly developing field. Two groups of evaluations are discussed: (1) those identified by our literature review and (2) ongoing evaluations in the case-study states. While the former group is generally more fully developed, the latter group represents ongoing and recent efforts by well-respected programs.
4.1 Current and Recent PAS Evaluations
4.1.1 Types of Evaluations Conducted
Needs assessments. Needs assessments are commonly done, although rarely published for circulation outside the sponsoring state. They describe the kinds of services most needed by families, in terms of recent needs, anticipated needs, priorities, or unmet needs. These studies can be used to document the need for a PAS program and support planning of services to be provided. State-sponsored needs assessments in the field of adoption have generally gathered information from surveys of families who adopted from a states public welfare system and were receiving an adoption subsidy. Contacting these families is facilitated by the fact that states keep contact information for subsidy payment purposes.
|Needs assessments and program documentation are more common than outcome evaluations.|
Characteristics of children and families served. Regularly collecting data on the characteristics of children and families served is common practice by case managers providing health and social services, often at intake and assessment. In the case of PAS programs, evaluators have used the data gathered by case managers and program staff as part of a process evaluation, yielding a range of potentially useful information to guide PAS program direction and service delivery. Data on families and children served include basic demographic information, history prior to adoption, risk to adoption, family problems and strengths, and family functioning. Clinical instruments are sometimes used to describe child and family functioning, as well as to provide a baseline for outcome evaluations.
|Needs assessments and program documentation are more common than outcome evaluations.|
Services delivered. The collection of data on service delivery and usage is also fairly common for PAS programs; these data have been used in several PAS evaluations. These data are also critically important to planning PAS programs and funding. Data on services delivered may serve as mediating variables in outcome evaluations, establishing the effect of specific types of services or a threshold service level necessary for effect. If used as part of an outcome evaluation, services need to be documented as they are delivered rather than summarized at case closing. PAS program records are also unlikely to capture services that the family may have received from private providers or other sources not affiliated with the PAS program, which may influence outcomes.
Client satisfaction. An assessment of family satisfaction with services received is a common evaluation approach to improving PAS program staffing and programmatic planning. Most client satisfaction surveys involve the adoptive parent. In several of the case-study states, program staff and evaluators used client satisfaction surveys to guide service delivery. As with needs assessments, the validity of client satisfaction survey data is often limited by poor response rates. Nevertheless, these efforts serve as a useful barometer for program staff and offer an opportunity to maintain communication with adoptive families regarding their needs and preferences.
Outcomes. Outcome evaluations are the least common of all evaluation types. Among challenges inherent in outcome evaluations are the difficulty of demonstrating effects, particularly for less intensive interventions, and the lack of a clear point at which outcomes are to be measured. While outcome evaluations are not necessarily appropriate for all interventions, there is likely to be increasing pressure on PAS programs to document their effectiveness, and increasing interest within the field in comparing alternative service delivery approaches. A variety of measures have been used for outcome assessment, including clinical assessments, changing incidence of events such as adoption disruption or out-of-home placements, goal attainment, or subjective assessments by workers or parents. Child and family clinical assessments offer detailed measures of child and family outcomes for more intensive interventions, with the opportunity for pre/post comparison. There is no consensus yet on which measures are best suited to the needs of adoptive families and most appropriate for different program models.
4.1.2 Services and Programs Evaluated
|Intensive interventions are more amenable to evaluation than comprehensive PAS programs.|
Crisis intervention and counseling. Evaluations of crisis intervention and counseling services are more likely than other interventions to include outcome evaluations, using either subjective ratings by parents or workers, events such as out-of-home placement, or clinical assessments. If services are offered on a flexible rather than time-limited schedule, evaluators must grapple with the problem of defining an endpoint at which outcomes are to be measured. The evaluations reviewed had widely varying study populations, ranging from 22 children and families (Medina) to 1,162 children and families (Illinois). Evaluations with very small populations will lack the statistical power needed to demonstrate significant differences in outcomes.
Information and referral services. Because of the low intensity of these services, evaluations are generally limited to descriptions of the families and children served and service utilization. Measures of client satisfaction may be the most appropriate outcome measure. Given the brief nature of the interaction, evaluations that require collecting additional information from the client (other than that collected within the information and referral request) are unlikely to be feasible. One case-study state, however, used data from its web-based case management system to document the degree to which problems identified in the information and referral service were eventually resolved.
Evaluations of comprehensive PAS programs. Evaluations of comprehensive PAS programs tend to follow the pattern of evaluations of counseling and crisis intervention by compiling data on child and family characteristics, clinical assessments, risks to adoption, service usage, client satisfaction, and case outcomes. Evaluation methods are also similar and include clinical assessments, case records, and parent feedback forms. Evaluations that attempt to assess the entire program rather than specific components will inevitably be limited in their ability to link services to outcomes. The nearly limitless combinations of amount and type of services that may be used, compounded by the diversity of adoptive families, make it difficult to unravel the threads of what services are effective for which families.
4.1.3 Data Collection Methods
Evaluations of PAS interventions and PAS programs have employed a variety of data collection methods. Choice of method is influenced by several factors, including the type of evaluation, type of PAS offered, type of respondent (e.g., program staff or adoptive family), type of case management system (e.g., paper or computerized), evaluation goals, and level of evaluation funding. For example, an evaluation of a support group for adoptive parents might use focus groups with members of the group. A linked computerized case management system could allow for analysis of aggregate data on child and family characteristics, service usage, and case outcomes entered by caseworkers. If ensuring high-quality service delivery is a primary goal, conducting a client satisfaction survey might be an appropriate method. If funding allows, an evaluator could conduct an outcome evaluation using clinical assessments and even a comparison group. Among evaluations reviewed, some general patterns were observed:
- Needs assessments and client satisfaction most often relied on surveys;
- Descriptions of children and families served and services provided use program records, either paper or electronic; and
- Outcome evaluations used diverse methods, including clinical instruments, and assessments by both workers and parents.
4.2 Evaluation Barriers and Facilitators
Observations on factors influencing PAS evaluation are drawn largely from case-study interviews. Although we cannot assume that they are generalizable, the differences encountered by these well-regarded programs are likely to be present in other states as well.
4.2.1 Common Barriers to Evaluation
|As in many programs, a lack of funding and expertise, and interference with program activities are barriers to evaluation.|
Funding. Funding was the evaluation barrier most frequently mentioned by state adoption program managers and PAS coordinators and providers. Evaluation requires substantial resources, and program coordinators frequently place higher priority on meeting service needs than on evaluation. Funding agencies contribute to this situation if they require evaluation without specifying the level at which it is to be done or do not allocate adequate resources for both service delivery and evaluation. Among the case-study states, the one with the most sophisticated evaluation allocated approximately 5 percent of its budget to evaluation, hardly adequate for a new program area in which service delivery models and evaluation methods are not well established.
Evaluation expertise. Contracting with an external evaluator requires a greater commitment of program funds but provides access to a higher level of expertise than is likely to be found among program coordinators or staff. Even if a PAS program is willing to commit the resources to contracting with an external evaluator, however, finding an evaluator with adequate understanding of adoption issues may be difficult. Given the recent development of PAS programs, there is neither a large base of published research nor an extensive network of experienced researchers.
Interference with program activities. PAS program staff were concerned that the time required for evaluation activities added to their workload and impinged on their interactions with families, without necessarily providing any direct benefit to the family. Program staff were also concerned that evaluation activities introduced a clinical tone to their interaction that was at odds with their efforts to normalize the adoption experience, especially when instruments focused on child and family problems.
Limited value to program. PAS coordinators or providers rarely found evaluation findings to be useful in their practice. While data were used to quantify the volume of services delivered or families satisfaction with the program, evaluation was not seen as a source of new and useful input on substantive questions of program design. If evaluation findings do not inform program development, staff are less likely to be willing participants in evaluation activities.
4.2.2 Barriers Specific to PAS
|Some evaluation barriers are related to the clients, structure, and context of PAS programs.|
Limited statistical power. Adoptive families are relatively few in number, and not all adoptive families require PAS, so the total number of families served may be fairly small. PAS programs will thus be limited in the extent to which they can describe patterns of needs and services for specific subgroups, and they will have difficulty demonstrating statistically significant differences in service use or outcomes. Compounding the problem of small numbers is the fact that outcomes achieved may be relatively modest. Outcomes such as adoption disruption or dissolution that may be prevented by PAS are relatively rare; however, the pervasive effect of early trauma suggests that they will occur in some families no matter what supportive services are provided. Improvements in problem behavior and family relationships may also be confounded by developmental changes as children move toward adolescence and its typical disturbances.
Diverse goals and services. The client-driven approach typical of PAS programs creates several limitations to evaluation. First, variations in services received make data on satisfaction or other outcomes more difficult to interpret. Second, the outcomes of interest will vary according to family needs. Evaluators must choose between tailoring outcome measures to the specific issues of the family (that is, having greater specificity but smaller groups) and measuring outcomes more broadly (increasing statistical power but with less informative measures). Third, 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. Finally, in family-focused programs, evaluators must choose between collecting data from all family members, which increases respondent burden and may obscure outcomes, and limiting measurement to family members with the most acute needs, which raises concerns about stigmatizing problem children.
Limited program data. To date, program data have been of little help in evaluating PAS programs. PAS programs may not be incorporated into Statewide Automated Child Welfare Information System (SACWIS) data because services are contracted out, or because of concerns about confidentiality. Data about services are often limited by the lack of standard nomenclature for characterizing PAS components. Administrative data systems are further handicapped by the lack of data on adoption subsidies, which are used by families to purchase services they need. Yet subsidy data are often not linked with case records, and are not always captured in a longitudinal format that allows capture of subsidy history and changes.
Rapid program evolution. The rapid and recent growth of PAS programs has allowed limited opportunities for program maturation and stability. Among the PAS programs described in the literature review and case studies, nearly all were less than 10 years old, allowing few opportunities for service delivery models to be refined, outcomes to be tracked, or findings to be shared across sites. Evolving program models can wreak havoc on evaluation if program objectives, participants, or interventions are redefined in mid-course. Newer programs have little shared knowledge to build on, forcing their staff to reinvent the evaluation wheel.
Interventions vs. programs. In considering evaluation, the distinction between PAS interventions clearly defined sets of services delivered to families with similar needs and PAS programs arrays of interventions with different objectives and activities to serve a broad range of adoptive families has important ramifications for evaluation. Interventions with specific populations, activities, and outcomes are far more amenable to systematic evaluation, and the majority of published evaluations are of specific interventions. PAS programs that do not structure data collection so that families can be grouped by services received will have difficulty identifying outcomes from their work, although descriptions of children and families served and services used over time may offer valuable lessons for ongoing program development. Outcome evaluations of such programs (rather than their component interventions) may not, however, be sufficiently informative to justify the resources they require. Programs like Multi-Systemic Therapy (MST) and Assertive Community Treatment (ACT) may offer a middle ground, being flexible and open-ended but with enough structure to be evaluable.
State vs. local programs. Like other child welfare services, adoption and post-adoption services are administered at either the state or local level. PAS programs that are developed at the local or regional level will encounter several barriers to evaluation. These include small numbers of families served, with corresponding loss of statistical power; limited access to evaluation expertise; and proportionally higher burden of evaluation start-up costs. Statewide models, in which a single program model is delivered statewide or regionally, are far more amenable to evaluation.
Lack of demand from funding agencies. A final barrier to evaluation among PAS programs is the apparent lack of demand from funding agencies. Among the case-study states, there was little indication that program sponsors are setting clear standards for evaluation or are actively advocating for stronger evaluations. More basically, funders are not requiring that programs be evidence-based, building on rigorously evaluated work with troubled children and families. It may be that PAS programs are currently being funded based on the high visibility of foster care adoptions and the common sense appeal of supporting adoptive families. However, higher standards of accountability for requested funding are likely at some point in the future, particularly as many states face budget shortages. The relatively meteoric rise and fall of intensive family preservation services demonstrated that family testimony and anecdote do not help a field reach its potential. Strong theory- and evidence-based interventions that are adapted to adoption and rigorously tested are the best strategy for ensuring the future of PAS.
4.2.3 Evaluation Facilitators
|PAS program evaluations may be facilitated by staff dedication and lessons learned from other family service programs.|
Although outweighed by barriers to evaluation, some facilitators were noted in case study interviews. First, the rapid evolution of the PAS field has given rise to a ferment of new approaches, and those involved in these programs tend to share a genuine curiosity about what works? and is this an improvement on other approaches? Evaluations that respond to this appetite for program improvement could garner substantial cooperation in spite of the evaluation barriers described above. Second, adoptive parents (a major source of data for such evaluations) have an enormous investment in adoption-related topics and will often be ready participants in evaluation. Although PAS program staff are appropriately protective of parents time and desire to normalize family life, the study teams experience suggests that many adoptive parents are very willing to participate in activities that can improve PAS programs. Finally, although PAS programs are relatively new, they can draw upon evaluation experiences in other areas of child and family services and on the existence of psychometrically tested instruments for both children and families. Use of these instruments allows considerable streamlining of evaluation design, as well as the opportunity for comparability across evaluations.
4.3 Future Directions in PAS Evaluation
A substantial boost in our knowledge of PAS will require many steps, building from two general strategies. First, evaluators should collaborate with PAS leaders to develop fundamental evaluation tools that will reduce the start-up costs for programs and will increase comparability of evaluations across programs. Second, funding agencies can consider strategies to reduce barriers to evaluation by making them more useful to program staff, ensuring that evaluation activities do not impinge upon service delivery, and providing adequate resources in the form of both funds and expertise. This section provides specific recommendations to address each of these agendas.
4.3.1 Fundamental Evaluation Tools
Develop consistent service classifications. The spectrum of PAS has now been identified in several descriptive efforts (e.g., Smith and Howard, 1997). Yet these have not been carefully described so that different raters would consistently categorize the kind of service received that is, the difference between classifying a service as therapy, advocacy, or case management may not be readily distinguished. If the field is going to describe post-adoption activities and eventually link these to case characteristics, consumer satisfaction, and client outcomes then a more precise nomenclature is needed. In addition, we need basic research to determine the overlap between a variety of services to understand whether these interventions can be separated out (and monitored or tested separately) or combined into clusters of services.
|Basic evaluation tools can reduce evaluation burden and increase data comparability.|
Identify best practice models with recommended evaluation strategies. The field of PAS has been dramatically strengthened by the high level of innovation evidenced during the past decade. As discussed earlier, the fast pace of program development has to some extent come at the cost of evaluation. With the emerging recognition of promising models, it should now be possible to propose a core set of interventions with associated evaluation strategies. Such an effort could be led by an expert panel, working in consultation with program coordinators in the field. For each intervention component, the panel would characterize intended participants, objectives, program activities, process and outcome measures and recommended instruments. While not all programs would follow the strategies, identification of recommended measures and instruments could considerably reduce evaluation design costs and facilitate cross-site comparisons.
Develop a model data set. Program data are rarely used to evaluate PAS, although most programs collect information on family characteristics and services provided. A model data set, offered to PAS providers in a basic database format, would facilitate consistent data collection across programs and jurisdictions, and speed the development of a broad understanding of who uses PAS and how. A contractor and Technical Work Group should determine whether this basic data collection format would also include measures of services provided, child or family functioning, or satisfaction with services.
Improve data on adoption subsidies. Improved administrative data about subsidies could provide a variety of insights that would help shape the future of post-adoption services and supports. Given such data elements as subsidy amounts, their basis, and reasons for changes; duration of subsidy; basis for subsidy amounts at the time of adoption and later; prior foster care payments to the family; linkages to vendor payment files, and reasons for subsidy termination, it would be possible to determine the duration of subsidies; the total amount of a childs subsidy; and the reasons that subsidies stop, start, or change. In addition, subsidy data should be stored in ways that ensure confidentiality but allow for retrieval for purposes of managing the program, with linkages to the childs foster care record and detailed information on vendor payment. Information should be stored in a format that maintains historical data to support longitudinal analysis.
Develop programmed child and family assessments. Use of child and family assessments that have been programmed into computers, which can be linked to a computerized case management system, could benefit both case workers and evaluators. Such a system could notify the case manager when a follow-up assessment is needed, allowing assessments during home visits (using a laptop). Data could be transmitted into the database system at the office, where it would be aggregated for evaluation purposes.
Conduct rigorous evaluations. Enhanced information resources should expand the possibilities for a multisite experimental design. Rigorous evaluation would start the long process of determining whether PAS are effectively helping families. Several possible approaches should be considered:
- applying well-tested family-based interventions (e.g., multisystemic therapy) that have shown promise with other difficult populations;
- finding clinical interventions with enough similarities to group them into a set of smaller intervention studies; and/or
- locating some larger jurisdictions that can support a single experimental study that may be of interest.
4.3.2 Strategies to Facilitate Evaluation
Promote evaluation as a tool for program improvement. Pattons (1997) utilization-focused evaluation approach stresses the importance of engaging the primary users of evaluation in every step of the process in order to build support for its use. Stakeholders include not only representatives of funding agencies and program coordinators, but front-line staff who implement the program. Focusing the evaluation on the questions they consider critical will improve both its relevance and implementation. Program staff can play a vital role in identifying questions that will complement standard designs and increase the relevance of evaluation to practice.
|Strategic funding and evaluation design can reduce barriers and create incentives for evaluation.|
Structure evaluation processes so that they are useful to programs and families. A related recommendation is to ensure that evaluation processes provide useful feedback to participants. A major barrier to evaluation among PAS program staff was the belief that families were being asked to spend time completing instruments without receiving any direct benefit in return. The choice of instruments should favor those that can provide useful feedback to program staff and families. This will also help mitigate the sense among program staff that evaluations compete with program activities for scarce resources. As noted in the case study, many adoptive families have difficulty obtaining assessment services and interpretation of clinical data. Although evaluation instruments would not substitute for a comprehensive assessment, feedback on the information collected is likely to be perceived as valuable information by many families.
Earmark funds for evaluation. PAS programs need funding that is specifically designated for evaluation and related activities. Without separate evaluation funds, many program leaders will choose to use all, or nearly all, of their resources for services to families and children. Earmarking funds for evaluation will convey the fact that funding agencies (at both the federal and state levels) view evaluation as essential. Designating funds will also help mitigate concerns by program coordinators that evaluation takes resources away from needed services. Program leaders would then be held accountable for allocating those resources for evaluation.
Fund programs for multiple years. Short funding cycles make it difficult to plan, implement, and evaluate programs in the time allotted, so that managers are unlikely to invest in evaluation staff and activities. Funding programs for four years or longer ensures that they have sufficient time to develop, implement, learn from their evaluations, and incorporate those lessons into ongoing practice. Extended funding also provides opportunities for PAS programs to conduct follow-up activities, producing more substantive evaluations and facilitating assessment of outcomes.
Provide evaluation technical assistance. Accessible, culturally appropriate technical assistance can be used to supplement PAS programs evaluation skills, or to build long-term evaluation capacity within the organization. Depending on the programs needs, technical assistance may emphasize support (where the provider conducts some of the evaluation activities with input from the program) or capacity building (where the provider trains and coaches program staff who carry out the evaluation). Technical assistance should be tailored to the particular needs and interests of the program, and may include evaluation design, development or selection of data collection tools, data management and analysis, and application of findings to program development.
Secondary Data Analysis
This portion of the study explored whether administrative data could be used to better understand the use of subsidies for purchase of services and to describe the disruption, dissolution, and displacement of adoptions. The highly confidential nature of adoption data posed a major challenge to this effort, because states and agencies are often unable or unwilling to share data about adopted children of families. After extensive negotiation, we were able to obtain relevant data from two states: California and North Carolina. The analyses described in this section demonstrate what could be done in other states with similar data and suggest how modifications to administrative data systems could enhance our understanding of adoptions.
5.1 Administrative Data on Adoptions
Our understanding of the relationship between adoption subsidies and other post-adoption services is limited. Administrative data and surveys indicate that adoption subsidies are commonly used. As noted earlier, data from the Adoption and Foster Care Analysis and Reporting System (AFCARS) indicate that 88 percent of children adopted in 2000 were receiving subsidies (DHHS, 2001c). Preliminary AFCARS data from 2001 suggest that the number of children receiving subsidies is rising in tandem with the number of adoptions (Penelope Maza, personal communication, August 26, 2002). Many families that could qualify for subsidies, however, do not receive them (Sedlak and Broadhurst, 1993).
Little is known about pathways on and off subsidies or the reasons for, or timing of, changes in subsidy levels. Given the many children now receiving subsidies, there is a need to examine these transitions. A key issue is the transition from a deferred (or very low) subsidy to a higher subsidy, suggesting that the family has developed the need for additional services.
|States and localities vary in their subsidy policies and provisions, and in the organization of administrative data.|
States and localities are likely to vary in the assumptions that underlie the design of their subsidy programs (Bower and Laws, 2002). Some consider that subsidies should be set at a rate sufficient to provide general support for needed services. Others set subsidy amounts at a level that can only support the basic care for a child, unless there are time-limited requests for subsidy funds to address specific problems. States also vary in terms of Medicaid access for state eligible children, payments for special services, augmented rates for particularly challenging children, and payment for respite or residential care.
There is no consistency in the organization and maintenance of adoption subsidy data. Depending on the system, data may be maintained at the county level or state level; data may be integrated with the financial system used to make foster care payments or maintained in a stand-alone system; and reasons for subsidy changes may be documented well or not at all.
Administrative data do not expressly address disruption, dissolution, or displacement of adoption. Most studies of these events have relied on case record reviews and interviews labor intensive, costly approaches that are difficult to replicate for comparison over time. An exception is the Illinois study in which Goerge, Howard, and Yu (1996) were able to match children entering foster care to children who had previously exited foster care to adoption. They identified both previously adopted children experiencing a dissolution (about 4 percent) and those placed for adoption but reentering foster care without ever having completed the adoption (about 14 percent). This effort provided a prototype for our work with North Carolina data.
5.2 Adoption Disruption, Dissolution, and Supports in North Carolina
5.2.1 Data Resources and Study Population
Our analysis used North Carolina data from three sources: (1) summary information on each child receiving adoption assistance, (2) vendor payments made in the name of adopted children, and (3) records of adoption subsidy checks. Because payment data were not available prior to January 1, 1990, the study population was restricted to the 8,647 children adopted after that date. Foster care placement records were then used to identify children who either had records of adoption assistance payments or who were identified as having been adopted prior to the foster care placement. These matches were complicated by the use of different ID numbers at the time of initial out-of-home placement, at adoption, and at the time of any subsequent out-of-home placement.
Children in the study population were approximately evenly divided by gender; more than half were members of minority groups. Only 12 percent of the children were older than 11 at the time of the final decree of adoption. The vast majority (90 percent) were currently receiving some form of adoption assistance. Virtually all of the children (99.8 percent) were identified as emotionally disturbed, which meets the adoption assistance eligibility requirement for special needs. Seventy percent had been adopted in the past five years.
5.2.2 Adoption Dissolution
|North Carolina data on adoption subsidies and foster care were merged to identify adoption dissolutions.|
North Carolina does not identify adopted children within its foster care files; however, by combining adoption subsidy and foster care placement data, we can establish a cohort of adopted children to be followed. Data on termination of parental rights (TPR) was not available in the records used for analysis.
We utilized two lines of analyses to examine adoption dissolution in North Carolina. First, we tried to track our cohort of adopted children to see if they experienced an out-of-home placement after the final decree. Second, we looked at all children who had entered out-of-home placement since July 1, 1998, to determine whether a child was previously adopted. Although neither line of analysis was entirely satisfactory, both provided information about possibilities for further research.
Cohort analysis. Three conditions were used to define dissolution: (1) date of entry into out-of-home placement occurred at least 90 days after final adoption decree date, (2) adoption assistance was no longer being received after this placement, and (3) if permanency was achieved at end of this placement, it was achieved with someone other than primary caregiver at time of placement. Of the 8,647 children in the adoption assistance data file, only 70 of these met the dissolution criteria. Using Cox Proportional Hazards Models, we estimated the risk of adoption dissolution, by age at adoption, race, gender, and year of adoption. Older children (current age) are significantly more likely to experience dissolution than younger children. Black children are twice as likely as white children to return to placement after an adoption, and about 50 percent of these dissolutions occur within three years of adoption.
|Dissolution is most likely among older children and black children usually within 3 years of adoption.|
The finding of a less than 1 percent dissolution rate in North Carolina must be viewed cautiously. Three interpretations are possible. First, these analyses exclude families not receiving cash assistance payments, who may represent less stable adoptive relationships. This seems unlikely, based on conversations with state officials who believe that most adopted children in the state receive cash assistance payments and comparisons between the number of children adopted in North Carolina over the past several years and the number of children receiving cash assistance payments. Second, it is possible that these data and our linking algorithms do not validly link adoption assistance records to children who reentered placement under a different ID number, either the foster care number or a newly assigned number. A third possibility is that these data actually represent events in North Carolina; given the states relatively low rate of reentry to foster care, a low rate of adoption dissolution may also be plausible.
This line of analyses did not produce the certain results that we expected. However, if new ID numbers were systematically and consistently assigned to all children in the state who were adopted, analyses of this type could produce results that would be useful in understanding the course of an adoption that ultimately fails.
Entry into foster care. The North Carolina longitudinal placement data files provided the source of data for the second line of adoption dissolution analyses. It uses a data element added in July 1997 as part of the AFCARS enhancement that recorded whether a child who was entering out-of-home placement had been previously adopted. Of the children entering placement between July 1997 and December 2001, 318 had been adopted previously. Over half were teenagers; 58 percent were white; and 51 percent were female. Compared to the characteristics of all children who initially entered placement during the last 10 years, legally adopted children entering placement were more likely to be white (56 percent versus 47 percent) and teenagers (66 percent versus 26 percent). About one-third of the children were reunified with their primary caretaker or exited placement to a nonremoval parent, a guardian, or a court-appointed caretaker; 17 percent left for unknown or miscellaneous other reasons; 16 percent were adopted; 10 percent were emancipated; leaving slightly more than one-fourth still in placement in April 2002. Although these analyses do not provide sufficient data to calculate a dissolution rate, they suggest a higher rate of dissolution than seen in the cohort analysis. The analyses provide some insight into the number of adoption dissolutions that occur per year and the characteristics of children who are reentering placement following an adoption.
5.2.3 Adoption Disruption
Using the foster care placement files, we next examined the question of how many children experienced an adoption disruption, that is, had placements coded as an adoptive home but ultimately were not adopted. Among the 54,747 children entering care for the first time between July 1, 1989 and June 30, 2001, 463 had a first placement recorded as an adoptive home. A full 77 percent of these children subsequently exited placement to adoption; 5 percent remained in care. A larger group of children (2,657) entered foster care for reasons other than adoption but were subsequently placed in an adoptive home. The majority of these children (59 percent) exited placement to adoption; 10 percent remained in care. The remaining children (18 percent of initial placements and 31 percent of subsequent placements in adoptive homes) may have experienced disruptions or had changes in their adoption plans for other reasons, including reunification, emancipation, running away, or a conversion to a guardianship. At this time, we cannot determine the ultimate case status of these children who had an adoption plan, but these data will be available in future years.
Although these analyses offer some insights, note that the majority of children (65 percent) who achieve permanency through adoption are never placed in an identified adoptive home. These are most likely foster children who are adopted by foster parents without ever having been identified in the data system as changing status from foster to adoptive homes. Considering all adopted children, then, the data do not support an effort to precisely estimate adoption disruption rates in North Carolina. They do indicate, however, that this will become more possible in the future.
5.2.4 Adoption Subsidies
|Nearly all adopted children receive subsidies, with subsidy amounts generally stable over time.|
These analyses use data that record payments to adopted children (subsidies) or for services received by adopted children (vendor payments). Because adopted children in North Carolina receive a new client ID number after the adoption decree is final, these analyses are limited to post-finalization assistance, beginning in 1990. Almost all (94 percent) children with adoption assistance received cash payments, and close to two-thirds (61 percent) also received additional assistance in the form of payments to vendors for therapeutic or medical services or nonrecurring costs of adoption. Half of the children started receiving cash payments almost immediately after the final decree. Within 6 months of the decree, 96 percent had received their first cash assistance check. The average cash payment amount during this time period was $346 per month received for an average of 42 months. However, because most of these cases are still open, these averages may change over time since there are some increases in payments as children age. Very young children received average cash assistance payments equal to $315; the average payment for children between 6 and 12 years old was $364; for children older than 12, the average payment increased to $409.
Slightly over half (51 percent) of children had no change in their subsidy amounts over the course of their assistance period. For the remaining children the increases were not substantial. The average number of days between the first cash payment and the initial increase was almost 2 years (22 months); however, this varied by age and race of adopted child. Older children were less likely to receive subsidy increases, although this was in part because older children actually had less time in which they were eligible to receive assistance. Using survival analysis to control for this effect, we found the probability of having received an increase ranged from 20 percent of children during the first year of assistance, to 50 percent by 2.5 years. Children under 5 years of age were the most likely to have subsidy increases and to incur them more quickly.
Because many factors are related to the length of time before an increase occurs, survival analysis was used to analyze the likelihood that a subsidy increase will occur, while controlling for characteristics of adopted children and length of eligibility time. Race and age at initial payment are significantly related to the likelihood of a subsidy increase. Even though the model controls for the number of months of assistance, children who begin receiving adoption assistance before age five are much more likely to receive increased subsidy payments than older children. Other minority children are less likely to receive an increased subsidy than either white or black children.
Analysis of vendor payments indicated that half of the children with a vendor payment had the first payment within two months of the adoption decree, and three-quarters had first payment within six months of the decree. The average number of vendor payments per child was four, with amounts ranging up to $2,000. The analysis of these payments is complicated by the fact that children could receive these payments before and after the final decree, and so payments for one child could be recorded under different ID numbers. Thus, it is likely that these numbers actually underestimate the amount of vendor payments incurred by an individual child.
5.3 Adoption Subsidies in California
5.3.1 Data Resources and Study Populations
Analysis of adoption subsidies drew on two sources: survey data and administrative records. Participants in the California Long-Range Adoption Study (CLAS) completed questionnaires in three waves (1990, 1992, and 1996) following adoption of children from foster care in 198889. Data from the CLAS study include information on a broad range of psychological, social, economic, and relational characteristics of adoptive families in California, some of which has been previously reported (Brooks, Allen, and Barth, 2002).
|California administrative data were combined with those of a survey of adopted families.|
California state data include case records completed at the time of adoption placement for children placed for adoption in 1988-89, and matching Adoption Assistance Program (AAP) records through December 2000. Data were available for 1,172 cases with AAP changes during that time, of whom 771 had available case record information. A total of 401 cases were excluded because children were over age 18, cases did not match, or cases had substantial missing data. Approximately half of children were female. Birth mothers race was most often white not Hispanic (61 percent), followed by 23 percent of Hispanic origin and 14 percent of African-American. Most of the adopting mothers were high school graduates (29 percent) or had some college or trade school (35 percent); just over half (51 percent) of adopting mothers worked outside the home prior to the adoption.
The AAP is theoretically updated with each biannual recertification or any time when the AAP amount changes; as with most administrative databases, some information is incomplete or missing. Children with many subsidy changes or those who have been in group care may be overrepresented in the database because workers have more opportunities to update their records.
5.3.2 CLAS Data on Services and Subsidies
|Youth receiving subsidies were more likely than others to have behavior problems in the clinical range.|
Additional analyses on subsidy use were conducted for this report to examine whether childrens behavior is associated with early changes in AAP payments. Of the 288 adopted foster children in this sample, there were exactly equal numbers (144) of those who received and those who did not receive AAP funds within 2 years of placement in their adoptive homes. AAP receipt or nonreceipt tended to remain stable over the subsequent 6 years of data collection. Youth receiving AAP throughout the study period were much more likely to have Behavior Problem Index (BPI) scores in the clinical range than those who did not receive AAP. Among those families that initiated AAP between Waves 1 and 2, the proportion with high BPI scores was 21 percent at Wave 1 and 73 percent at Wave 2.
Although limited by the small numbers of cases, these data suggest that while some families do manage to care for children with high levels of behavior problems without subsidies, the likelihood of having a subsidy and maintaining it is greater for those families with children who score in the problem behavior range. Families are more likely to transition from no subsidy to subsidy because behavior problems increase, although the reasons that families stop their subsidy use are less clear.
5.3.3 Amount and Direction of Payment Changes
AAP changes may occur following required biannual recertifications, reflecting routine age-related increases; or they may result from special requests for needed services. Nearly three-fourths (73 percent) of cases had one or two payment changes to recertify or change AAP amounts during the 11-year period covered by the AAP data. The vast majority of changes filed were a result of recertifications. Further, the greatest proportion of those who had any changes had only one change during this 10-year period. Clearly adoption subsidy payments in California are, on the whole, quite stable.
|Subsidy changes tend to occur in conjunction with required recertifications.|
Additional analyses addressed the direction and size of subsidy changes. These analyses excluded payment changes that occurred when the child aged out of the adoption subsidy program at age 18. We divided the amounts of payment changes into payment increases and payment decreases, and also looked into the total average amount of each payment change.
The first monthly payment was $404, on average. The average size of the payment changes grew from the first payment change to the fifth payment change. The average amount of each payment change was just $95 monthly. Of all payment changes, 26 percent were reductions in payments, which appear to have been made to correct increases that were too high or meant to be temporary. The average payment change increases in size as the number of payment changes grows: among all first payment changes, 68 percent were gains or losses of less than $100. This proportion dropped only slightly (to 64 percent) by the third payment change, but by the fifth payment change, only 38 percent of payment changes were of that size.
5.3.4 Reasons for Payment Changes
Reasons for AAP changes were recoded into four categories of rate changes: (1) basic care, (2) basic and special care, (3) special care, and (4) residential care, which account for 98 percent of all rate changes.
We examined reasons for payment change during each payment change. The percentage of AAP recipients needing special care and residential care changes consistently increased from the first payment change to the fifth payment change. These data suggest it is unusual for children to have high payment changes ($500 or more) as their first payment change. Most children entering residential care do so after several payment changes requested by families to help them provide services to their children. This makes the provision of residential care seem somewhat less costly than it would be if this was a common first payment change.
5.3.5 Multivariate Analysis of Payment Changes
Multivariate analyses were based on the subset of 771 children for whom adoption case record data were available. This subset was similar to the larger population in the proportion receiving subsidy changes, the amount and direction of change, and reasons for change. Unlike in North Carolina, most AAP recipients experience periodic payment changes, probably coinciding with recertification.
|Family income and maternal education were associated with subsidy increases.|
Bivariate relationships between case characteristics and payment changes. Analyses of bivariate associations between changes in subsidy level and adoptive families demographic characteristics focused on positive amount of payment changes because the negative payment changes were often in response to the positive changes. These analyses examine payment changes as events that signal needs (of varying magnitude) within the adoptive family, rather than focusing on the amount of subsidies received over time. We compared demographic differences in smaller ($0 to $300) and larger ($301 or more) amounts of monthly subsidy increases. Children adopted by a well-educated adopting mother or in higher-income families were significantly more likely to receive large amount of subsidy increase. Associations between payment change and childrens race and age were statistically insignificant. If the association between education and income holds up in the multivariate analysis, this would suggest a need for a more equitable adoption subsidy program.
Multivariate analysis: logistic regression results. We performed logistic regression analysis in order to test associations between individual demographic characteristics after controlling for their association with other case characteristics and the amount of payment changes. We ran three slightly different models, each one including a somewhat different combination of variables, because all variables could not be tested simultaneously and because we wanted to see whether removing education or income which are highly correlated affected the results. Model 1 includes the childs race, age, and adopting mothers educational level; model 2 includes childs race, age, and adoptive familys income; and model 3 includes childrens race, age, the adopting mothers educational level, and family income. All three logistic models appeared to be significant with acceptable, but not impressive, goodness-of-fit results. However, results should be carefully considered because pseudo R² values are very small across all models, that is, the model did not explain a sizable proportion of the difference in subsidy changes. These models do not include data on child disability, which should be strongly related to subsidy amount.
Event history analysis. These analyses examine the timing of payment changes in order to understand patterns of post-adoptive services need. Many AAP recipients experienced payment change every two years because families must recertify their AAP status every two years. Only 25 percent of AAP recipients have experienced a payment change before the required two-year subsidy change. However, people who have experienced more payment changes are likely to more quickly experience other payment changes before two years. About 41 percent of AAP recipients who have experienced a fifth payment change experienced their fifth payment change before two years from the date of fourth payment change.
The probability of payment change varies by family income and race. Confirming the logistic analysis, families with incomes between $26,443 and $36,000 are significantly more likely to experience an payment change within three years after placement. Children who are of other races have a greater likelihood of experiencing a payment change than do white, black, and Hispanic children.
|Transition to residential care is often preceded by multiple subsidy increases.|
Transitions to residential care. Residential treatment has particular policy relevance because the federal government will not reimburse for this, but 19 states will cover some or all of its cost. Only 34 children in this sample entered residential care during the study time frame. California does not pay for for-profit residential treatment, so some children may have entered residential treatment but not be included in these data. The small group makes it impossible to estimate medians for individual variables; however, a Cox proportional hazards model could be computed. The model shows a higher likelihood of payment changes associated with residential placement for children adopted when older than three years. The number of payment changes was also significantly related to a payment change for residential treatment. Most children who entered residential treatment had three or more prior payment changes. Families with income between $36,001 and $48,761 were more likely to receive a payment change for residential treatment. Neither race nor the education of the mother was significantly related to the use of subsidies for residential treatment.
Information relevant to understanding post-adoption dynamics, post-adoption services, and subsidy use is routinely collected and underused. Because there has been so little attention to these data, we have found substantial confusion about them. This is indicative of how foster care data were kept prior to SACWIS and other innovations in foster care data use. We believe that adoption subsidy data continue to be written over in some states, so that only the current subsidy shows there is no history, therefore, of subsidy changes. These kinds of procedures greatly weaken our chances of showing how the pattern of subsidy changes is related to adoption outcomes. Demonstrating possible uses of subsidy data is important to motivating states to do a better job of collection, storage, retrieval, and analysis.
Taken together, the analyses in this document serve several purposes. They offer a sample of the kinds of administrative data that are available to better understand post-adoption services and supports. They offer some ideas about the kinds of analyses that can be done to bring meaning to these data. They offer some substantive findings about adoption subsidies and how they are used. Finally, they offer some ideas about modifications to administrative data systems that could improve their information yield about adoption.
5.4.1 Substantive Findings
Differences in data availability and structure between North Carolina and California limit our ability to assess the generalizability of our findings. Yet some clear similarities and differences have emerged. Almost all (94 percent) of the children adopted from foster care in North Carolina received cash assistance subsidy payments. The amount of the cash assistance payment remained unchanged for slightly more than half of the children (51 percent). For the rest there were gradual increases in the amount of cash payment that appear to occur as the child grows older.
|Though inconclusive, these analyses suggest possible uses of administrative data for adoption research.|
These stable subsidy amounts appear to differ from those in California, where only 17 percent of the children for whom we had data had never had a payment change. Many of these payment changes are routine subsidy increases resulting from biannual recertification requirements but there also appear to be fewer cases in which there are no changes. The probability of a payment change is associated with the prior number of payment changes. As prior payment changes occur, the rapidity of subsequent changes increases. Thus the number of payment changes provided could be used as a marker for outreach to families who may need additional guidance or assistance.
Relatively large subsidy increases in California are also associated with a few family characteristics specifically, the childs age at the time of adoption and family income. Families at middle income levels are the most likely to obtain larger subsidy increases. Also, families that have more-educated mothers obtain larger subsidies. CLAS data suggest that subsidy increases are associated with the worsening of childrens behavior; we also see that they are strongly associated with parental characteristics. The equitability of adoption subsidy adjustments needs to be better understood.
Data in North Carolina support previous findings of low dissolution rates. Although the results suggest that the risk of adoption dissolution in North Carolina is lower than that seen elsewhere, further analyses show that the risk is greater for older children and for minority children compared with infants and white children in the state. We were unable to study disruption or displacement rates in North Carolina.
In California, we could study the transition from home to residential/group treatment for the relatively small proportion of children who used this option. Event history analysis indicates that age at placement, the number of prior payment changes, and to a lesser extent family income are associated with state-funded residential care.
5.4.2 Data System Issues
Adoption data are highly confidential and fragmented. Data about foster care histories and foster care payment amounts, adoption home studies (or their electronic summaries), adoption subsidy amounts, payments for special services (i.e., vendor payments), and disruptions, dissolutions, or displacements are often collected and stored in unrelated data systems, if at all. Record matching is often required because common identifiers do not exist.
|Confidentiality concerns, incompatible data systems, and incomplete data limit analysis.|
Data on adoption assistance in North Carolina provide a clear estimate of the payment amount and length of time that children receive cash subsidy payments. The picture of vendor payments is less clear because the overall summary data maintains year-to-date estimates rather than career estimates of payments for each child. No reasons for subsidy changes or vendor payments are included in the data that we used. Nevertheless, even with these identified data constraints, these analyses do provide an important first look at these critical issues and begin to identify ways in which administrative data files might be modified to support future analyses.
The California analyses also provide important information about data issues. First, the subsidy data are not as complete as could be hoped some children who have subsidy changes are not included in the database, as this information does not always get sent from the counties to the state. Second, there is no field in the AAP database that indicates the starting subsidy amount all that can be gleaned from these data are the subsidy amounts upon the first payment change. Third, these data cannot be readily linked back to the foster care data, so critical information about foster care histories is not available for explaining subsequent subsidy use.
Conclusions and Future Directions
Considering the rapid and ongoing development of the field of post-adoption services, none of the inquiries conducted within this study can be considered definitive. Many promising programs have yet to be documented in the literature, and our case studies included only a few of the well-regarded programs currently in operation. Much work remains to be done before program and administrative data achieve their potential for describing the experience of adoptive families.
Based on this incomplete evidence, we can nevertheless make some early observations on what is known with respect to the studys research questions:
- What is the extent of need for PAS?
- What are the characteristics of existing PAS programs?
- How are PAS programs assessing their effectiveness?
From this base, we suggest a framework of strategies to move the field forward. These represent research, policy, and practice directions for consideration at the federal, state, and program levels.
A general caveat to these observations is that available data have rarely addressed the experiences of families with subsidized guardianship arrangements. As states expand their use of subsidized guardianship, these families will become an important part of the population of adoptive families. To the extent that their needs differ from other adoptive families, PAS programs may need to develop new approaches to reaching and serving these families.
6.1 What Is the Extent of Need for PAS?
6.1.1 Indicators of Need for PAS
|What patterns of disruption, dissolution, and displacement indicate potential need for PAS?|
What we know: Disruptions, dissolutions, and displacement are extreme indicators of difficulties within adoptions, suggesting the existence of many more families in less dire need who could use PAS. There is little published data in this area, but more could potentially be mined from state administrative data systems. Concerns about confidentiality, as well as data system inadequacies, have hindered progress to date in this area.
Four studies using different methods and samples estimate the rate of disruptions for special needs children at between 10 and 16 percent of adoptions (Barth and Berry, 1988; Goerge, Howard, and Yu, 1996; Partridge, Hornby, and McDonald, 1986; Urban Systems Research and Engineering Inc. [USR&E], 1985). Several published studies agree that older children, and those with behavioral or emotional problems, are more likely to disrupt (Barth and Berry, 1991; Partridge, Hornby, and McDonald, 1986; Smith and Howard, 1994; Smith, Howard, and Monroe, 1998). In addition, better-educated parents, particularly mothers, are more likely to have troubled placements and are more likely to disrupt (Barth et al., 1988; Barth and Brooks, in press; Boyne et al., 1984).
Two prior studies (Goerge, Howard, and Yu, 1996; Festinger, 2002) have arrived at similar adoption dissolution rates of between 2 and 6 percent figures consistent with those generated in our analysis of North Carolina data. Analysis of administrative data from North Carolina indicates that half of the dissolutions identified occurred within the first three years of adoption, and that the risk of dissolution was higher for minority children and those adopted after age five.
Patterns of out-of-home care for adopted children are doubtless affected by variations among states in how residential treatment, a common form of care, is funded. Although data are again sparse, a recent analysis of adopted families in California found about 6 percent of children adopted between 1988 and 1989 had used residential care (Allphin, 2000). Our analysis of California administrative data found that transition to residential care was typically preceded by three or more changes in adoption subsidies, suggesting that families had increased their use of services prior to out-of-home care. Increased age at time of adoption was associated with greater use of residential care, as was moderate family income.
Moving forward: Better information about patterns of disruption, dissolution, and displacement could help PAS programs reach out to, and tailor their services for, those families in which the adoption may be at risk. Of particular interest would be questions such as the following:
- What characteristics of adoptive parents and children are most associated with disruptions and dissolution?
- When in the adoption process are disruptions most likely to occur?
- When do dissolutions and displacements occur in relation to adoption finalization?
- What kinds of services have families used prior to dissolution and displacement, and what services would they have liked to have available?
- What are the impacts of state policies about residential treatment on rates of dissolution and disruption?
6.1.2 Demand for PAS
|Which adoptive families are most likely to want PAS?|
What we know: Data on families seeking PAS in New England, Massachusetts, Illinois, and Oregon indicate that PAS programs serve a variety of adoptive families, including those formed by guardianship, adoptions from public child welfare agencies, and private and international adoptions; and many have more than one adopted child. Median age of the focus child at the time of case opening was noted between 10 and 11 in two studies, and children are roughly evenly divided by gender. Families often perceived their needs to be acute at the time that services were sought: 21 percent of families in Massachusetts reported a severe or extreme risk to the adoption. Behavioral problems were reported by more than half of families in both Illinois and Oregon. In Illinois, 55 percent of children served have one or more diagnosed disability, and 27 percent had been placed out of the home for some time since adoption (Gibbs, Barth, and Lenerz, 2000; Hudson et al., 2002; Fine, 2000; Howard and Smith, 2001). In the absence of population-based data on adoptive families, we cannot specify the ways in which families seeking services differ from other adoptive families.
Moving forward: Most PAS programs report collecting data on the children and families they serve. If this information were compiled in a way that captured comparable data where possible, a picture might emerge. Development of a minimum program data set would facilitate both the data collection start-up and data consistency. Questions of particular relevance to PAS program planning include:
- How do the strengths and needs of guardianship families differ from those of adoptive families?
- What are the most useful measures of child characteristics, adoption history, child well-being, child behavior, and family functioning with which to describe the families who seek out PAS?
- Which adoptive families have been finding needed services within the community, and which need services that are specifically tailored to adoptive families?
6.1.3 Service Needs
|What services are most needed by different types of adoptive families?|
What we know: Assessments of needs among adoptive families are commonly conducted by states. Approximately half of the states responding to the ILSU survey reported they were currently conducting a needs assessment or had done so within the past 10 years. Although their usefulness is often limited by low response rates and inconsistent methods, these surveys offer a general picture of services desired by adoptive families. These include educational and information resources, clinical services, material help in the form of subsidies and help with child care, and support networks. A sizeable minority of families 30 percent in an Oregon needs assessment report that no services are needed at this time. When families receive service, they prefer working with providers who understand the long-term impact of early trauma and the unique dynamic of adoptive families.
These surveys typically use the most complete sampling frame available, the list of families receiving adoption subsidies, but one that is only a portion of all eligible families. We know less about the service needs and experiences of those families who do not receive subsidies. Although it is possible that they do not pursue subsidies because they have few service needs, they may also be underserved by the subsidy program, with fewer resources with which to address their needs. Most needs assessments also exclude families who have adopted privately or from other countries.
Moving forward: Our understanding of the needs of adoptive families could be substantially improved by two measures. First, development of a standardized needs assessment instrument for states voluntary use could reduce design costs, increase the comparability of data over time and across states, and in some cases improve data quality. Second, a population-based survey of adoptive families, with adequate follow-up to ensure high response rates, would provide needed data on topics such as
- How do the needs of adoptive families vary across states and between rural and urban families?
- Are states with active PAS programs demonstrating a reduction in unmet need among adoptive families?
- Who are the families currently not being served by PAS programs?
- How do the needs of adoptive families vary by child characteristics and adoption history?
- How do needs vary among families receiving no subsidy and those receiving varying levels of subsidy?
- If private and international adoptions are included, how do their needs differ from those of families who adopt from the public child welfare system? Which families are at risk of needing high-cost services?
6.1.4 Role of Adoption Subsidies
|What part do adoption subsidies play in supporting post-adoption services?|
What we know: Adoption subsidies are a sizable and growing federal and state expenditure. We know only the broad outlines of subsidy distribution. Nationally, 88 percent of children adopted in 2000 received subsidies (DHHS, 2001c). The number of children receiving subsidies appears to be rising in tandem with increases in the number of adoptions; preliminary AFCARS data showed a 3 percent increase between 1998 and 2001 (Penelope Maza, personal communication, August 26, 2002). The proportion of adoptive families receiving subsidies may be lower for adoptions in the programs earlier years. A 1993 analysis found that substantial numbers of families who could have qualified for subsidies did not receive them (Sedlak and Broadhurst, 1993). This is significant in light of data indicating that families receiving subsidies are less likely to experience disruption (Berry and Barth, 1990).
State and county subsidy policies vary widely. A review by the North American Council on Adoptable Children found that states varied in both the generosity and flexibility of their subsidy policies. The review documented differences in the definition of special needs, basic and specialized subsidy rates, availability of deferred subsidy agreements and subsidized guardianships, and payment for residential and respite care (Bower and Law, 2002). Although there is not yet data with which to rigorously evaluate the relationship between adoption subsidy provision and the success of adoptions, the authors may be correct in asserting that the underuse and misuse of subsidies may discourage would-be adoptive parents and contribute to the incidence of disruptions. Even when state policies govern subsidy provision, variation in implementation may produce vastly different results. Between-county variability in subsidy provision may be nearly as great as state-to-state variability (Avery, 1998), and have similar consequences.
Very little has been done to examine changes in subsidies over time. These changes may be essential purchase post-adoption services and supports that help them respond to changing needs. Our analysis of administrative data from California and North Carolina found large differences between the two states in the likelihood that families will experience a change in subsidy amount at some point. Although most subsidy increases appear to be associated with periodic reviews or with administrative cost-of-living adjustments, an important proportion of changes are unrelated to review schedule. These changes appear to be associated, in part, with changes in childrens behavioral problems. A pattern of increasing frequency of subsidy changes often preceded initiation of residential care, suggesting that these changes could serve as a marker for families in need of supportive services. The likelihood and amount of subsidy changes were also found to be associated with parental characteristics (income and maternal education) as well as child characteristics. Higher income and more educated households received a disproportionate share of larger increases. This suggests that families ability to negotiate needed increases may play as substantial a part in subsidy determinations as financial need.
Moving forward: Better understanding is needed of both the determinants of state policy and their role within adoptive families. The substantial variations among states with respect to subsidy policies suggest that impacts on the adoption of children from foster care and the level of services available to them must certainly exist. More needs to be understood about which factors influence state policies on subsidies and other supports, and how federal reimbursement policies shape state decision-making. Given better administrative data, it would also be possible to more fully examine the relationship between subsidy levels and changes and time to permanency, adoption disruption, and displacement.
A variety of changes in adoption subsidy policies have been proposed in recent years, such as allowing subsidies to be higher than foster care payments or allowing subsidies to be used to pay for temporary residential treatment. These would be challenging to assess because they are governed by state statutory requirements. Waivers from standard Title IV-E funding schemes could be granted to test other cost-neutral approaches to delivering subsidies, but this would be very difficult to achieve, and the outcomes would probably be quite subtle.
At the family level, we can work to understand how subsidy increases are being used, whether they are being adjusted in ways that appear to be appropriate to family circumstances, the implications of current approaches to subsidy determination and re-authorization, and the interface between subsidies and PAS programs. Among the questions to be answered:
- What combination of subsidies and family resources are used to meet the needs of special needs children in different families?
- What kinds of events trigger activation of deferred subsidy agreements?
- Are subsidy increases for purchase of PAS, sufficiently timely and flexible to help families address pressing needs?
- To what extent could services purchased by subsidies be provided through PAS programs? When are subsidies more effective than PAS, and when are PAS more useful?
6.1.5 Satisfaction with Existing Services
|How satisfied are adoptive parents with the services they have received?|
What we know: Adoptive parents satisfaction with services available to them either from PAS programs or other community resources is a subjective indicator of the need for new or additional PAS. Many programs assess the extent to which participating families are satisfied with services provided by the PAS program (see, for example, Fine, 2000 and Hudson et al., 2002). Client satisfaction studies appear to generally indicate strong satisfaction with PAS program offerings. However, there are several concerns about the quality of their data. Studies vary widely in design sophistication, ranging from simple ratings to detailed assessments. Unless substantial effort is invested in follow-up, response rates may be so low as to compromise data validity. Response bias is also likely, particularly because few PAS programs contract with external evaluators, and much PAS evaluation data is collected by agency staff who may be associated with PAS delivery.
Several barriers may limit the usefulness of community services, including limited availability, cost, restricted access and poor match with family needs (Fine, 2000). Adoptive parents participating in focus groups as part of Casey Family Services evaluation described community providers as often lacking the necessary understanding and skills to address their families issues (Gibbs, Barth, and Lenerz, 2000). Taken together, these findings suggest that families may be unable to access the specific services they need in their communities, and that services available to them may fall short of being adoption-competent.
Moving forward: Satisfaction studies ideally should address the universe of services used by adoptive families in the community and through PAS programs. In this way, programs would not only know how satisfied families were with the PAS program services they received, but also whether they were providing the services needed. Such studies would also identify areas in which the PAS program could work toward advocacy and system change by increasing awareness of adoption issues within schools, or training mental health providers in adoption issues. Research in a limited number of communities with varying PAS availability, conducted by independent researchers, using both qualitative and quantitative methods, could illuminate such questions as the following:
- Which services can effectively be provided by existing resources, and which should be provided by PAS programs?
- In what areas is there a need to increase the adoption competence of service providers in health, mental health, and education systems?
- What other barriers to services need to be addressed for them to be accessible to adoptive families?
- What are the particular strengths of PAS programs, and in what areas could their service delivery be improved?
6.2 What Are the Characteristics of Existing PAS Programs?
6.2.1 Program Models
|What program models are being used to provide PAS?|
What we know: In recent years, states have established new statewide PAS programs and expanded existing smaller scale projects. Most of these programs go beyond provision of a clearly defined intervention to families with similar needs, instead offering an array of interventions with different objectives and activities to serve a broad range of adoptive families. PAS programs in the five case-study states are similar in three fundamental ways. First, the PAS programs are contracted out rather than provided by state child welfare staff, to control costs and increase administrative flexibility. Second, these programs offer services statewide, using various organizational structures. Finally, the programs share goals of keeping adoptive families together and creating a consumer-driven program.
These states did not report drawing on proven models or documented best practices to develop their PAS programs. Instead, they relied primarily on related experience and advocates input. Only one state reported using a publication about post-adoption services (Spaulding for Children, 1996) to help design their PAS program.
Better understanding of mix of subsidies, agency contracts, or private providers to be used for post-adoption services is certainly feasible. The relationship between this payment strategy and program outcomes, however, will be far more difficult to test, until we have methods to gauge the effectiveness of the purchased services.
Moving forward: The experience of the five states participating in the case studies is not sufficient to provide guidance to others considering developing or expanding programs. The ILSU interviews provide limited information about service availability, but lack detail and do not differentiate time-limited services provided by child welfare agencies from PAS programs. As more states consider establishing PAS programs, the availability of well-documented and evaluated program models will be useful in garnering support for funding and implementation. Specific questions include the following:
- What has been the experience of states that provide PAS directly, rather than contracting them out?
- How do state program leaders assess the relative advantages and disadvantages of various funding streams that may be used to support PAS?
- What is the relationship between PAS programs and services provided by child welfare agencies during the pre-finalization and immediate post-finalization period?
- What resources would state adoption managers find most useful in helping them to develop new PAS programs or refine existing ones?
- How have states dealt with the challenge of providing services to families in rural areas?
|Which adoptive families are eligible to be served by PAS programs?|
What we know: Most programs identified in the literature review provided PAS to families that have completed adoptions from the public child welfare system. The ILSU interviews suggest that these families remain the priority population for state-sponsored PAS programs. Children adopted internationally or privately may be excluded from receiving PAS. Among the five case-study states, however, two served all adoptive families regardless of adoption type. We do not know how likely it is that families with children adopted privately or from overseas will require services. However, data suggest that the needs they identify when they do seek services are similar to those of families who adopted from public child welfare systems (Gibbs, Barth, and Lenerz, 2000). One of the case-study states reported that its PAS program was open to pre-finalization adoptive families as well, an important target population given the challenges that families often face in the early phases of adoption (Pinderhughes, 1996).
Moving forward: State adoption agencies naturally place priority on services to children adopted from their foster care population. However, if PAS programs are effective in preserving adoptive families, removing eligibility restrictions could reduce displacement and dissolution among children adopted privately or internationally, and reduce disruptions among children from public child welfare agencies. Even modest achievements of either goal might make broader eligibility cost effective. Evaluation data from programs serving these families could answer questions including:
- How do the frequency, type, and intensity of service needs differ among pre- and post-legalization families, and those who have adopted from public, private, and international agencies?
- How do the needs and service utilization of adoptive families with subsidized kinship guardianship agreements differ from those of adoptive families?
- Are there differences among types of families in service utilization and outcomes?
- What is the most effective interface between support from child welfare adoption workers and PAS programs for families prior to adoption finalization?
|Which funding streams are being used to provide PAS?|
What we know: PAS programs have been funded by a variety of sources, including foundations, Adoption Opportunities grants, state general revenue, Adoption Incentive Program bonuses, and, more recently, Title IV-B Subpart 2 funds (Promoting Safe and Stable Families program). A recent review shows that 15 percent of Title IV-B Subpart 2 funds were used for adoption support and preservation, with state allocations for those purposes ranging from 0 to 25 percent of the funds received. However, it is not possible to identify the extent to which those funds were spent on post-adoption services rather than facilitating adoptions (James Bell Associates, 2001). The five case-study states used a mix of state and Title IV-B Subpart 2 funds for their PAS programs.
Moving forward: Little is known about states decision-making process when it comes to funding PAS. Specifically, we do not know how the availability of federal funding support influences states consideration of developing PAS programs, how states choose among available funding streams. Given states recent achievements in increasing adoptions, expansion and sustainability may become critical issues in PAS funding.
Specific questions related to PAS funding include:
- How do states choose among available funding streams when implementing PAS programs?
- How do states determine what proportion of Title IV-B Subpart 2 funding will be allocated for post-adoption rather than pre-adoption services?
- How will increases in the number of children on adoption subsidy affect states capacity to fund PAS?
- What funding provisions would provide effective incentives for states to develop or expand PAS?
6.2.4 Services Offered
|What services are being offered by PAS programs?|
What we know: Although the field has proposed an optimal continuum of care for adoptive families (Howard and Smith, 1997), the provision of post-adoption services can best be described as patchy rather than comprehensive. Services offered range from information and referral networks to support for residential treatment. Yet there is little uniformity in provision of services across, and sometimes within, states.
Although each of the states responding to the ILSU interviews reported providing a range of PAS, open-ended descriptions of these services revealed that many states relied on adoption subsidy workers to provide limited information and referral services and/or had one-time grants or time-limited programs designed to provide various PAS. Some states considered adoption subsidies to be a PAS, since families can use these funds to purchase needed services.
Our case studies and available written descriptions of state-level programs suggest that information and referral, parent and professional training, advocacy, and support groups are the most commonly offered post-adoption services. Adoption-sensitive counselors were frequently offered as well. Although respite care was commonly mentioned by families as a significant service need, funding for, or provision of, respite care was relatively uncommon.
Many sites do not offer one or more of these basic elements, and available services are often not linked to each other. In a few places (e.g., Minnesota, Oregon, Massachusetts), we did find statewide information and referral resource interfaces that identify adoption support groups that operated in local communities. In some places, training of clinicians about adoption was paired with information mechanisms to inform adoptive families about which professionals were trained, but this pairing was more the exception than the rule.
Moving forward: At a basic level, we can identify effective strategies for putting families in touch with the resources that exist in local communities. Web-based resources may be of value, including interactive systems that enable parents to search for adoption-competent therapists and websites with information on services provided, eligibility, support group locations, and links to other resources.
PAS program developers have to date drawn on a patchwork of professional recommendations, state-level needs assessment and practice wisdom to design their service menu. Absent from this mix is systematic compilation of the experience of states that have developed programs, at a level of detail that could offer practical guidance for other states, particularly those at earlier stages of program development. Useful information would answer the following questions:
- What services are offered, either locally or statewide?
- How have other states resolved questions of which services to offer through PAS programs rather than through existing service delivery and payment systems?
- Which services have been used by most families, including those with less severe needs?
- Which have been used by families in crisis, and are there preventive services that might have averted the crisis?
- What are the relative costs involved in providing different services?
6.2.5 Service Delivery Approaches
|What treatment models are most effective in meeting the needs of adoptive families?|
What we know: Among the many interventions offered to adoptive families, there is no accumulated evidence regarding which approaches are useful, at what dose or desirable duration, and for which types of families. Disappointing results from early efforts to apply short-term, intensive family preservation models (Barth, 1991) suggest that service systems designed for biological families may not be effective with adoptive families. Only a few evidence-based interventions, such as parent-mediated training approaches (e.g., Fischer and Stormshak, 2000) and clinical models (Hoagwood et al., 2001; Weersing and Weisz, 2002), have been adapted for adoptive families.
Developing evidence-based approaches to treatment of adoptive families is fraught with unknowns (Schoenwald and Hoagwood, 2001). The greatest unknown is how adoptive families differ from other families that have benefited from evidence-based clinical approaches. Although the adoption field has long concluded that adoptive families are quite different from those formed by birth (Kirk, 1981), the importance of these differences to effective service delivery needs to be better understood. Although there is also much diversity among adoptive families, some have argued (e.g., Groza and Rosenberg, 2001) that adoptive families whether created via international, independent, or public agency adoptions are more clinically alike than different.
Moving forward: We need to develop a disciplined and strategic approach to advancing the quality and effectiveness of post-adoption counseling services. Promising approaches to development and dissemination of treatment innovations that begin with intensive training and supervision of homogeneous adoption populations and moves toward more naturalistic conditions of intervention with more heterogeneous adoption populations (Schoenwald and Hoagwood, 2001). Burns and Hoagwood (2002) have provided an important resource with their description of child and family services at various stages of testing. Yet we do not know how effective these efficacious interventions would be in the PAS context.
Questions that could be addressed by an expert panel and through an intensive review of existing research include:
- What interventions now being used with adoptive families are the strongest candidates for systematic assessment?
- Which evidence-based child and family mental health treatment approaches have the greatest promise for testing with adoptive families?
- What kind of adaptation might be needed to best assist adopted children and their families?
- Which subgroups of adoptive families should be the focus of initial assessments of treatment approaches in homogeneous populations?
6.2.6 Influencing the Service System
|How are PAS programs working to change the larger service delivery system?|
What we know: In addition to services provided by PAS programs, families may be involved with contract agencies, private clinicians contracting with the public agency, mental health clinics, or private-sector providers. Many PAS programs are attempting to improve the adoption competence of community providers who interact with or treat adoptive families.
Training may be designed to increase the sensitivity of professionals such as school or medical personnel who come into contact with adopted children and families. More intensive efforts involve training mental health workers to increase their competence in working with adoptive families. The University of Washington, in collaboration with the state, offers a postgraduate certificate for mental health professionals working with adoptive families, and Casey Family Services provides extensive training to professionals in New England states. Other states offer training in specific therapeutic approaches, such as Georgias training for mental health professionals in attachment therapy. However, public agencies may hesitate to train private providers whose fees are not reimbursable by Medicaid. Some may also question whether turnover in county mental health agencies limits the impact of staff training.
States may also influence the service delivery system by their choice of which services are delivered through the PAS program. Oregon has elected not to provide counseling through its PAS program, in part because county mental health offices are intended to be the point of entry for mental health services.
Moving forward: To inform system change efforts, information is needed on how families experience services they receive from community resources, in general, and from clinicians with experience and training in adoption issues. Understanding the stability of efforts to sensitize communities and mental health systems will be necessary in assessing the impact of training efforts. Questions in this area include the following:
- Do professionals being trained find the effort useful?
- Can the impact of training be quantified in terms of increases in referrals or families served over time?
- Do families perceive a difference in their treatment when working with practitioners who have received training in adoption issues?
- Does training reduce the need for PAS programs to provide certain services, such as advocacy on behalf of parents at schools or adoption-specific therapy?
6.3 How Are PAS Programs Assessing Their Effectiveness?
Evaluations of PAS programs are fairly rare in the published literature, and many well-regarded programs are strikingly limited in their evaluation activities. Among the reasons for this deficit are the relative newness of the field, the ongoing evolution of treatment models and service classifications, program models that tailor services to family needs rather than following predefined protocols, and a lack of evaluation experience among program staff. Three basic strategies could substantially advance evaluation development.
6.3.1 Evidence-Based Treatment Models
|How can the field begin to build a foundation of evidence-based practice for PAS?|
Moving forward: PAS programs have not yet developed an evidence base for treatment of adoptive families. They are proceeding down the path of other services e.g., family preservation and SAMHSAs child and adolescent services system program (CASSP) which became well-established before they were evaluated and are now struggling to document their effectiveness (Schoenwald and Hoagwood, 2001). The field needs a systematic approach to rigorously analyzing PAS.
A systematic approach can support development of clinical treatment models for use with adoptive families. There are existing paradigms that may guide this process well (e.g., Hoagwood, Burns, and Weisz, 2002; Rothman and Thomas, 1994). These approaches could be adapted to the current context of the PAS field to plan a long-term approach for the development of evidence-based services. A 10-year plan for the development of post-adoption service research could address selection of interventions to be tested, identification of the subpopulations of adoptive families for initial trials, dissemination of promising approaches, and subsequent program refinement.
6.3.2 Facilitating Evaluation
|What strategies can improve evaluation quality and reduce its burden for PAS programs?|
Moving forward: We know that the diversity and complexity of the PAS program offerings make it extremely challenging to evaluate post-adoption services. While the field works to determine which programs are most effective for those families who need substantial amounts of clinical services, evaluation efforts are needed to document and assess other commonly delivered services, and their delivery as part of multifaceted PAS programs. Although it may not be feasible to precisely quantify the specific impact of less intensive services such as information and referral and support groups, there is much to be learned about issues such as which families use these services, in what quantities and patterns, and how they work together to address the needs that families identify.
Because the staff time required is a major barrier to evaluation, providing a ready resource of PAS evaluation tools and strategies would substantially facilitate the process. A minimum data set along with electronic data collection and scoring tools would help make the evaluation enterprise less onerous. Technical assistance in evaluation could build capacity among service providers with little or no experience in evaluation.
6.3.3 Evaluation Incentives
|What incentives could be used to encourage evaluation of PAS programs?|
Moving forward: Incentives can facilitate evaluation by addressing both the resource and goodwill costs of evaluation activities. We do not know what kind of incentives would open the doors to using evaluation approaches with adoptive families. Some PAS providers have concerns about asking families to participate in evaluations, feeling that data collection activities are at odds with their effort to move from a clinical atmosphere to one of support. The introduction of random assignment to services, on top of rigorous data collection, is likely to be met with still greater levels of concern.
It is not clear what mix of incentives and technical assistance might be the most powerful accelerant for evaluation efforts. Because funding for post-adoption services is so diverse, incentivizing evaluations will be difficult. Funds to pay for additional services and not just for evaluation activities would be needed in order to gain the commitment of the necessary number of PAS program sites.
For providers to commit to evaluation, evaluation must be sensitive to their concerns about family sensitivities. Families may in fact be quite receptive to participating in evaluations that can help secure funding for services.
Funding agencies can promote evaluation as a tool for program improvement, building on the amply demonstrated commitment of PAS coordinators and providers to delivering the best possible support to adoptive families. This will involve structuring evaluation methods that can actually provide timely and useful input on questions of interest to program staff, and providing technical assistance to enable staff to interpret and apply evaluation findings.
Promoting Safe and Stable Families funds are often used for post-adoption services and could be used for evaluation. However, some states use these funds for recruitment of families and purchase of services to expedite adoptions; they use adoption bonuses or state funds to purchase post-adoption services. The Adoption Opportunity program could serve as a vehicle for soliciting competitive proposals for rigorous evaluations. State agencies funding PAS can also increase their support for evaluation. Such approaches may be needed but not sufficient to increase the level of evaluation activity. The field also needs to examine ways to add new resources for both evaluation and services. Just paying the ticket for evaluation without a companion ticket for additional services is unlikely to entice states and counties to attend the evaluation dance.
6.4 Research Agenda for PAS
PAS has been something of a handcrafted field, in which dedicated advocates and managers developed creative approaches to families needs. Sustaining these programs over the long term, however, would require a solid knowledge base that complements the dedication and creativity that have fueled it to date. The questions and tasks outlined in the previous sections, while ambitious and broad-ranging, could be addressed with a fairly modest set of interrelated research and evaluation activities:
- Conduct a population-based survey of adoptive families. Such a survey would include information on adoption history, family and child functioning, service and subsidy experience, and current needs. It should include kinship adoptive families, and ideally would include families formed by private and international adoptions.
- Create an evaluation tool kit. An expert committee working with experienced evaluators could identify standardized service classifications, a model data set for compilation of data on families served and services provided, and a recommended set of measures for assessment and outcome evaluations. This would reduce the burden of program evaluation and create a common language allowing programs and jurisdictions to share and compare experience.
- Develop evidence-based models. Models for clinical interventions with adoptive families could build on approaches that have proved effective with similar populations. Use of a systematic approach to research and development would ensure both credibility of the field and wise investment of future program resources.
- Sponsor in-depth evaluations. Evaluations of well-regarded PAS programs should include qualitative and quantitative approaches and analysis of program organization, cost, and effectiveness. Intensive study of a developed program will build understanding of interactions between program and context and will identify lessons for development and implementation in other jurisdictions.
- Provide evaluation incentives and technical assistance. Managers and providers dedicated to serving families are unlikely to engage in evaluation without funds earmarked for that purpose. Use the standardized measures and data set described above to reduce the burden of evaluation while building staff capacity to collect, analyze, and use data for program improvement.
- Established a web-based compendium of PAS activities. A simple interface could facilitate compilation of information on activities across states and jurisdictions, tracking services provided, program models, funding streams used, and promising developments. This will facilitate rapid sharing of knowledge among programs with common goals and challenges.
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