Child Welfare: Better Data and Evaluations Could Improve	 
Processes and Programs for Adopting Children with Special Needs  
(13-JUN-05, GAO-05-292).					 
                                                                 
On September 30, 2002, the most recent date for which Department 
of Health and Human Services (HHS) data were available, about	 
126,000 foster children were waiting to be adopted. Estimates	 
suggest that a significant portion of these children had one or  
more special needs, such as a medical condition or membership in 
a minority group, that may discourage or delay their adoption.	 
Federal support in the form of adoption subsidies and incentive  
payments to states is available to promote special needs	 
adoption. This report (1) identifies the major challenges to	 
placing and keeping special needs children in adoptive homes, (2)
examines what states and HHS have done to facilitate special	 
needs adoptions, and (3) assesses how well the Adoption 	 
Assistance Program and the Adoption Incentives Program have	 
worked to facilitate special needs adoptions, and determines if  
changes might be needed.					 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-05-292 					        
    ACCNO:   A26397						        
  TITLE:     Child Welfare: Better Data and Evaluations Could Improve 
Processes and Programs for Adopting Children with Special Needs  
     DATE:   06/13/2005 
  SUBJECT:   Child adoption					 
	     Children with disabilities 			 
	     Disadvantaged persons				 
	     Federal aid to states				 
	     Federal/state relations				 
	     Foster children					 
	     Program evaluation 				 
	     Subsidies						 
	     Surveys						 
	     Public assistance programs 			 
	     Eligibility criteria				 
	     Strategic planning 				 
	     Block grants					 
	     Child welfare					 
	     Timeliness 					 
	     Adoption Assistance Program			 
	     Adoption Incentives Program			 
	     HHS Adoption and Foster Care Analysis		 
	     and Reporting System				 
                                                                 
	     HHS Aid to Families with Dependent 		 
	     Children Program					 
                                                                 
	     HHS Temporary Assistance for Needy 		 
	     Families Program					 
                                                                 
	     Social Services Block Grant			 

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GAO-05-292

United States Government Accountability Office

GAO

                       Report to Congressional Requesters

June 2005

CHILD WELFARE

 Better Data and Evaluations Could Improve Processes and Programs for Adopting
                          Children with Special Needs

GAO-05-292

[IMG]

June 2005

CHILD WELFARE

Better Data and Evaluations Could Improve Processes and Programs for Adopting
Children with Special Needs

                                 What GAO Found

According to state child welfare officials, limited resources, court
processes, and delays in completing interstate placements challenged the
adoption of children with special needs by hindering recruitment of
adoptive families and delaying the adoption process. In particular,
adoptive parents in many states received lower subsidies and fewer
services than foster parents. In addition, child welfare officials, court
staff, and judges said that the adoption process can take months to
complete because hearings to terminate parents' rights are hard to
schedule and may involve appeals. Further, officials said that interstate
placements are often hampered by delays in completing home studies of
prospective families, although no data exist to assess the timeliness of
such placements.

States and HHS have developed and implemented strategies and programs to
promote special needs adoptions, but few evaluations measure their
effectiveness. Four of the 5 states we visited sponsored post adoption
resource centers. However, only 9 of 49 states responding to a relevant
question in our survey indicated that they had evaluated the effectiveness
of their services. At the federal level, HHS supported and promoted local
innovation, provided technical assistance, and disseminated information,
but the agency has done little to assess the effectiveness of the programs
it has funded. When HHS has taken steps to have states assess funded
projects, the agency has not ensured sufficient rigor to assess
effectiveness.

The Adoption Assistance and Adoption Incentives Programs have provided
support for special needs adoptions, but data are lacking to determine if
changes are needed to better facilitate adoption. The former uses an
income eligibility threshold that is more restrictive than other cash
assistance programs' standards of need and may not include all who might
otherwise qualify. Since 1998, the Adoption Incentives Program has
provided financial awards to almost all states for increasing adoptions,
but does not provide a specific inducement for interstate placements. Data
to track and credit states for collaborating on interstate placements are
not available.

Flowchart of a Typical Adoption Process United States Government Accountability
                                     Office

Contents

  Letter

Results in Brief
Background
States Reported That Limited Resources, Court-Related Processes,

and Interstate Placement Delays Impede the Adoption of Special
Needs Children
States and HHS Have Promoted Special Needs Adoption, but Few
Evaluations Measure Program Effectiveness

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

Conclusions
Recommendations for Executive Action
Agency Comments

                                       1

                                      3 5

11

20

31 37 38 38

  Appendix I Objectives, Scope, and Methodology 41

Objectives 41
Scope and Methodology 41
Survey 41
Site Visits 42
Interviews and Discussion Groups 43
Review of States' Reports, Federal Laws, and HHS Regulations 43
Review of Studies and Evaluations 44

Appendix II 	Comments from the Department of Health and Human Services

Appendix III GAO Contact and Acknowledgments

Related GAO Products 50

  Tables

Table 1: Characteristics of Post Adoption Resources Available in
Five States 22

  Figures

Figure 1: Flowchart of a Typical Adoption Process 7 Figure 2: Types of
Support Provided to Families Caring for Children with Special Needs 13
Figure 3: Frequency of States' Attainment of the Adoption

Incentive Award, 1998-2003 34 Figure 4: Number of States Claiming Award,
by Earning Year 35 Figure 5: Illustration of the Difficulty in Claiming an
Award under

the Adoption Incentives Program 36

Abbreviations

AFCARS Adoption and Foster Care Analysis and Reporting System
AFDC Aid to Families with Dependent Children
APHSA American Public Human Services Association
ASFA Adoption and Safe Families Act of 1997
CFSR Child and Family Services Review
HHS Department of Health and Human Services
ICPC Interstate Compact on the Placement of Children
NCANDS National Child Abuse and Neglect Data System
SSBG Social Services Block Grant
SSI Supplemental Security Income
TANF Temporary Assistance for Needy Families
TPR Termination of Parental Rights

This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
its entirety without further permission from GAO. However, because this
work may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this material
separately.

United States Government Accountability Office Washington, DC 20548

June 13, 2005

The Honorable Charles E. Grassley
Chairman
Committee on Finance
United States Senate

The Honorable Hillary R. Clinton
United States Senate

On September 30, 2002, the most recent date for which these data were
available, about 126,000 foster children were reported by the Department
of Health and Human Services (HHS) to be waiting for adoption. These
children, on average, were 8 years old, had been in foster care for nearly
half their lives, and 55 percent were living with an unrelated foster care
provider. According to federal program officials, a significant portion of
these children had at least one special need, such as a medical condition
or membership in a minority group that might make adoptive placements
challenging. Further, in some cases, the most appropriate adoptive
families reside in one state while waiting children reside in another.
Therefore, interstate placements, which require child welfare agencies in
both states to work together, are critical to finalizing their adoption.

In an effort to promote the adoption of children with special needs,
Congress authorized the Adoption Assistance Program in 1980 under Title
IV-E of the Social Security Act. Through this program, the federal
government partially reimburses states for subsidies they provide to
adoptive parents of eligible special needs children to assist them with
related caretaking expenses. The act defines children as having special
needs if the state has determined that the child should not or could not
be
returned to the home of his or her parents, and certain factors, such as
age; membership in a sibling unit or minority group; or emotional, mental,
or physical conditions would make finding an appropriate adoptive home
difficult.

In order to qualify for the federal subsidy reimbursement, children must
meet the special needs definition and one of several eligibility criteria.
These criteria include having been removed from the home pursuant to a
judicial determination and being eligible for the Aid to Families with
Dependent Children (AFDC) program, as it existed in 1996. In each of the
fiscal years 2001 through 2003, the federal adoption assistance subsidy

reimbursement, including related administrative and training expenses,
exceeded $1 billion. In fiscal year 2002, the latest year for which HHS
could provide figures, the federal government partially reimbursed states
for adoptive families' subsidies for about 66 percent of foster children
adopted.

In addition to the adoption subsidy reimbursement, the Adoption Incentives
Program, created by the Adoption and Safe Families Act of 1997 (ASFA) and
amended in 2003, provides rewards for states that increase the number of
foster care adoptions, special needs adoptions, or adoptions of children
age 9 and older. Since the program's inception through 2003, the most
recent year for which data are available, the federal government has
awarded nearly $178 million to states in adoption incentive payments.

To better understand the issues related to the placement and adoption of
special needs children, we (1) identified the major challenges to placing
and keeping special needs children in adoptive homes, (2) examined what
states and the Department of Health and Human Services have done to
facilitate special needs adoptions, and (3) assessed how well the Adoption
Assistance Program and the Adoption Incentives Program have worked to
facilitate special needs adoptions and what changes, if any, might be
needed to further facilitate adoptions.

To conduct our work, we gathered and analyzed data from several sources.
We developed and conducted a nationwide survey of adoption directors in
all 50 states, as well as those in Washington, D.C., and Puerto Rico, and
we received 50 responses.1 We visited 5 states -Georgia, Massachusetts,
Michigan, New Mexico, and Oregon-where we spoke with child welfare agency
officials, caseworkers, parents, court personnel, and private adoption
agency officials to better understand states' strategies for placing
children with appropriate adoptive families.2 We selected these states for
diversity in the size of their foster care populations, location, and
program administration, and for the different degree of success they have
had in finalizing adoptions. In addition, we selected and reviewed 10
states' Child and Family Services Plans and Annual Progress and Services
Reports-documents that HHS requires as part of its ongoing child welfare
oversight-in order to obtain information

1We did not receive responses from Alabama and Nevada.

2This report uses the word "states" to refer to the 50 states, the
District of Columbia, and Puerto Rico.

  Results in Brief

on how states were using the adoption incentive funds. Further, we
reviewed federal adoption assistance and adoption incentive laws and
regulations, as well as additional adoption-related research and
evaluations conducted by HHS, the states, and nongovernmental
organizations. We also interviewed HHS officials and staff from
independent child welfare organizations, and we conducted discussion
groups with adoptive parents and adoption program managers from around the
country at two national conferences. We conducted our work between May
2004 and April 2005 in accordance with generally accepted government
auditing standards. A more detailed discussion of our scope and
methodology appears in appendix I.

According to state officials, limited resources, court processes, and
delays in completing interstate placements were the major challenges to
successful special needs adoptions. These challenges hindered efforts to
recruit families and delayed the adoption process. According to state
officials in 4 of the 5 states we visited, budget issues in their states
have caused reductions in or elimination of adoption services. In part
because of these resource limitations, adoptive parents in many states
received lower subsidies and fewer services than foster parents. Our
survey asked states about 13 types of services or support. For 9 of the 13
services, fewer states reported providing them to adopted children than to
foster children. In addition to reporting limited resources, child welfare
officials, court staff, and judges from our site visit states said that
the adoption process can take many months to complete because hearings to
terminate parental rights are hard to schedule, and appeals by parents and
other relatives may add months to the process. Further, although federal
law requires states to facilitate the timely adoptive placement of
children through the effective use of cross-jurisdictional resources,
interstate placements can be delayed, in part, by the slow completion of
home studies to determine the qualifications of prospective families. HHS
officials said that there are no data to assess the timeliness of such
placements. However, they are in the process of updating their central
data system and informed us that they are considering many revisions to
improve data collection.

States and HHS have developed and implemented both general and targeted
strategies to promote special needs adoptions, but few evaluations measure
their effectiveness. All 5 of the states we visited partner with adoption
exchanges-information and referral services for adoptive families-to
operate electronic registries of children awaiting adoption, and all 5
states worked with private agencies to promote adoption. In addition to
these general activities, many states used targeted

recruitment strategies. For example, states hosted adoption promotion
events geared toward matching prospective families with certain children,
such as those who have been waiting the longest for placements. Four of
the 5 states we visited sponsored formal post adoption resource centers.
However, only 9 of 49 states responding to a relevant question in our
survey indicated that they had evaluated the effectiveness of their post
adoption services. At the federal level, HHS has supported and promoted
local innovation through its programs, provided technical assistance, and
disseminated information to increase public awareness about the need for
adoptive families. However, the agency has done little to assess the
effectiveness of its programs. Moreover, when HHS has taken steps to have
participating states assess specific projects, few of the evaluations
produced reliable data. We found that five of the seven evaluations we
reviewed lacked sufficient rigor to determine whether the projects had met
their intended goals. HHS officials acknowledged the need for more
rigorous evaluation. However, they informed us that once they approve the
projects, they have very little control over how the evaluations are
actually conducted because states manage the evaluations.

While the adoption assistance and adoption incentive programs have
supported special needs adoption, data are lacking to determine if changes
are needed to better facilitate adoptions. For example, the Adoption
Assistance Program uses an income threshold or need standard from the
expired Aid to Families with Dependent Children program, which is more
restrictive than other cash assistance programs and therefore limits
eligibility. HHS does not separately collect data on the characteristics
of children who do not meet IV-E eligibility, so the number of children
with special needs from low-income families is unknown, and we cannot
determine the extent to which this population is being underserved. With
regard to the Adoption Incentives Program, all states have received
financial awards for adoption achievements at least once since 1998.
However, the program is not currently designed to provide a specific
inducement for interstate placements. Data to track and give credit to
states for collaborating on interstate placements are not available.

Given the challenges states face with respect to special needs adoptions,
the limited assessments available to determine best practices, and the
lack of data available to determine if changes to federal adoption
programs are needed, we recommend that HHS (1) assist states in collecting
and reporting data related to interstate placements and analyze this data
to provide a basis for facilitating timelier placements, (2) facilitate
the evaluation of federal and state strategies and programs that promote
special needs adoption, and (3) gather data on the economic

Background

circumstances of special needs children who do not currently qualify for
the Adoption Assistance Program and assess the impact of expanding
eligibility on federal cost.

HHS provided written comments on a draft of this report but did not
explicitly agree or disagree with the recommendations. In its comments,
HHS stated that changes to address the recommendations designed to improve
data collection were being considered in conjunction with efforts to
revise its central data system. While HHS said that our recommendation to
improve evaluations was unnecessary because the agency has taken steps to
strengthen evaluations, it acknowledged that projects have sometimes not
yielded useful results, because of problems adhering to evaluation
protocols. Also, HHS stated that it will continue to work with states to
identify rigorous, administratively feasible evaluation strategies. We
continue to recommend that HHS develop additional guidance to improve
evaluations. Such guidance is needed to help assess the effectiveness of
funded projects.

Most children enter foster care when the state's child welfare agency
determines that they have been subjected to abuse or neglect and it is not
in their best interest to immediately return home. On September 30,
2002-the latest date for which HHS figures were available for our review,
532,000 children were in foster care in the United States.3 Generally,
after investigating the circumstances that contributed to the abuse or
neglect, state child welfare agency staff develop a plan to help the
parent make improvements and create a safe and stable family environment.
ASFA requires that states hold a permanency planning hearing at least once
every 12 months to determine, among other things, when and if
reunification with the child's family is a safe and practical option. HHS
estimated that just over 50 percent of the 281,000 children who exited
foster care during fiscal year 2002 were reunified with a parent or
principal caretaker.

If the parent has not followed child welfare agency plans or has failed to
change behaviors to make reunification safe, the state may identify an
alternative goal to establish a permanent home for the child. These goals
include adoption, independence, or legal guardianship. Independent living
arrangements may be attained once children reach the age of 18-or 21 in

3Data were preliminary fiscal year 2002 estimates as of August 2004.

some jurisdictions-and have not been reunified with their families or
adopted and for whom federal reimbursement for foster care expenditures is
no longer available. Legal guardianship is a judicially created
relationship between a child and a caretaker whereby the caretaker is
awarded custody and decision-making rights with respect to the child. An
October 2004 report indicated that 35 states and the District of Columbia
had established subsidized guardianship programs to help ensure permanent
families for children.4 The federal government typically does not
reimburse states for costs associated with subsidized guardianship.
However, 7 states have operated or are currently operating federally
funded guardianship projects through their participation in the Title IV-E
waiver program. HHS data show that 4 percent of children exited foster
care through guardianship in fiscal year 2002.

HHS reports that in fiscal year 2002, 17 percent of children exited foster
care through adoption. Unless a parent voluntarily relinquishes his or her
rights, states must petition the court for a termination of parental
rights (TPR) before a foster child can be adopted. ASFA requires, with few
exceptions, that states file a TPR petition when a child has been in
foster care for 15 of the most recent 22 months, but ASFA does not address
the length of time needed to grant the petition to terminate. Before the
termination is completed, states can begin to recruit for an adoptive
family and even place a child in a pre-adoptive home with an interested
family after this family has been approved. The adoptive family approval
process generally involves background checks and a home study-a detailed
examination of a family's circumstances, including its employment and
finances and family medical history-to ensure that the family will provide
a safe and suitable placement. The key steps in the process for adopting
children from state child welfare agencies are summarized in figure 1.

4Children's Defense Fund. "States' Subsidized Guardianship Laws at a
Glance." Washington, D.C., October 2004.

Figure 1: Flowchart of a Typical Adoption Process

In order to be eligible to receive federal funding, ASFA requires that
states

do not delay or deny the placement of a child for adoption when an

approved family is available outside the jurisdiction that currently
handles

the child's case5 and requires states to facilitate the timely adoptive

placement of children through the effective use of cross jurisdictional

resources.6 States govern the placement of children across state lines

through a compact known as the Interstate Compact on the Placement of

Children (ICPC). At the time of publication, the compact was being

rewritten to improve the process of placing children across state lines.

Families who adopt children with special needs can receive monthly
subsidies. The Adoption Assistance Program, under Title IV-E of the Social
Security Act, authorizes the federal government to partially reimburse the
states for the subsidies they provide to families who adopt special needs
children. Payments to the parents of an eligible child with special needs
can include both one-time adoption assistance for expenses such as
attorney fees and ongoing monthly assistance, which is used for any

542 U.S.C. S:671(a)(23)(A). 642 U.S.C. S:622(b)(12).

identifiable needs of the child. Special needs children must meet at least
one criterion from the following list: (1) the child is a dependent child
who would have been eligible for AFDC, as it existed in 1996;7 (2) the
child is eligible for Supplemental Security Income (SSI);8 (3) the child
is a child of a minor parent who is in foster care already and receiving
foster care maintenance payments under Title IV-E; or (4) the child
received adoption assistance previously, but the adoption dissolved or the
adoptive parents died. If the child does not meet these eligibility
criteria, but still meets the state's definition of special needs, the
state can provide a subsidy to the child's adoptive family, but cannot
claim federal reimbursement.

The amount of the subsidy is determined through negotiations between the
adoptive parents and a representative of the state agency based on the
needs of the child and circumstances of the adoptive family. The subsidies
are intended to help adoptive families manage the cost of caring for their
special needs children. Adopted children often have difficulties with
issues of loss, attachment, and identity formation that can lead to
behavioral and developmental problems and require professional treatment.
In addition, special needs children with physical and other mental
disabilities may require specialized care and treatment. Adoption
subsidies are available to families until children reach age 18 but may be
extended to age 21 if a mental or physical disability necessitates
continuation.

In addition to reimbursing states for the adoption subsidies, the federal
government pays adoption incentive funds to qualifying states. Under the
Adoption Promotion Act of 2003, (Pub. L. No. 108-145), which amended the
Adoption Incentives Program, a state is eligible for an award if the
number of adoptions from the foster care system for the fiscal year under
review exceeds the state's baseline year, the highest number of adoptions
in any previous year, beginning with fiscal year 2002. States may also
receive an incentive payment based on the adoptions of children having

7To be eligible for AFDC, a child (defined as a dependent child under the
AFDC statute) has to be a needy child who (1) has been deprived of
parental support due to the death or absence, or physical or mental
incapacity, of a parent; or (2) has been deprived of parental support due
to the unemployment of the parent who is the principal earner; and (3) is
living with one of a number of specified relatives; and (4) is generally
under the age of 18.

8To be eligible for SSI benefits, a child must be either blind or have
other impairments. An individual is eligible if he or she has a medically
determinable physical or mental impairment, which results in marked and
severe functional limitations and can be expected to result in death, or
has lasted or can be expected to last for a continuous period of not less
than 12 months. In addition, the child or his or her family must have
limited income and resources.

special needs or children older than age 9. Specifically, when a state
exceeds its baseline year in each category, it will receive an incentive
payment of $4,000 for each child adopted from foster care, $2,000 for the
adoption of each special needs child younger than age 9, and $4,000 for
the adoption of each child aged 9 or older. Thus, the program encourages
adoption generally while emphasizing the adoption of children with special
needs. In fiscal year 2003, the federal government paid states more than
$17 million in incentive payments through this program.

Title IV-E adoption subsidies and adoption incentive awards are not the
only federal assistance available to support adoption. Funds authorized
under Title IV-B of the Social Security Act, the Temporary Assistance for
Needy Families program (TANF), and the Social Services Block Grant (SSBG)
have also been used to facilitate and sustain adoptions.9 We reported that
in fiscal year 2002 states used more than $5 million in Title IV-B funds
on adoption subsidy payments, more than $9 million on recruitment and
training for foster and adoptive parents, and nearly $29 million on
adoption support and preservation services.10 A recent survey on states'
fiscal year 2002 allocations of federal funds for child welfare found that
states reported spending $56 million in TANF funds, $44 million in Title
IV-B funds, and $22 million in SSBG funds on adoption and support services
for adopted children.11

HHS's Children's Bureau administers and oversees federal funding to states
for child welfare services under Titles IV-B and IV-E of the Social
Security Act, and states provide these child welfare services, either
directly or indirectly through contracts with private agencies. Among
other activities, HHS staff are responsible for developing appropriate

9Title IV-B of the Social Security Act, consisting of two subparts, is the
primary source of federal funding for services to help families address
problems that lead to child abuse and neglect and to prevent the
unnecessary separation of children from their families. TANF was created
by the Personal Responsibility and Work Opportunity Reconciliation Act of
1996 to provide assistance and work opportunities for a limited time to
individuals and families. SSBG is authorized under Title XX of the Social
Security Act as a block grant to states for the provision of social
services for adults and children.

10See GAO, Child Welfare: Enhanced Federal Oversight of Title IV-B Could
Provide States
Additional Information to Improve Services, GAO-03-956 (Washington, D.C.:
September 12, 2003).

11The Urban Institute received survey responses from 50 states, including
the District of Columbia, but some states were unable to provide all of
the information requested so spending amounts may underestimate true
spending. The Urban Institute. The Cost of Protecting Vulnerable Children,
IV. December 2004.

policies and procedures for states to follow and conducting administrative
reviews to ensure that states are in compliance with established policies.
HHS staff from its 10 regional offices provide technical assistance to
states, review state planning documents, assist with state data system
reviews, and assess states' use of funds for foster care maintenance
payments. Between 2001 and 2004, HHS completed its first round of Child
and Family Services Reviews (CFSR), which assessed child welfare outcomes
in all 50 states, the District of Columbia, and Puerto Rico. These reviews
assessed states' progress and achievement in many areas and found
weaknesses related to adoption. For example, HHS reported that at least 27
states experienced challenges seeking terminations of parental rights in
accordance with ASFA. In addition, HHS also reported that 37 of the 52
states failed to meet the national standard of finalizing adoptions within
24 months of the child's most recent entry into foster care.

To evaluate states' performance on child welfare indicators, such as
timely adoptions, HHS relies, in part, on its Adoption and Foster Care
Analysis and Reporting System (AFCARS) to capture, report, and analyze
information collected by the states. In addition, AFCARS is used to
generate annual reports on foster care and adoption programs nationwide,
and it is the primary source of data for the Adoption Incentives Program.
We reported that the AFCARS data were not reliable and recommended that
HHS make improvements. HHS officials agreed with our findings and stated
that several data definitions in AFCARS would be updated and revised.12 In
June 2004, HHS officials stated that the regulations related to making
these changes were being drafted. As of April 2005, the regulations had
not been issued, and HHS officials said they did not have a specific
planned release date.

12See GAO, Child Welfare: Most States Are Developing Statewide Information
Systems, but the Reliability of Child Welfare Data Could Be Improved,
GAO-03-809. (Washington, D.C.: July 31, 2003).

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

States we visited reported that limited resources, court-related
processes, and delays in completing interstate placements were the major
challenges to special needs adoption. The limited resources impeded state
agencies' efforts to recruit adoptive families. Additionally, officials
said that difficulties scheduling cases and the time involved with other
court proceedings delayed finalizing adoptions. Officials also reported
that delays in completing home studies hindered adoptions that involved
interstate placements.

    State Adoption Officials Report That Limited Resources Impede Adoptions

In part because of resource limitations, adoptive parents in many states
received lower subsidies and fewer services than foster parents. Officials
in 4 of the 5 states we visited told us that budget issues in their states
have caused reductions in or eliminations of adoption services. States are
prohibited by statute from providing monthly adoption assistance payments
that exceed the foster care maintenance payments that would have been paid
if the child had been in a foster home. Officials in 4 of the states we
visited said that most special needs children are adopted by their foster
parents, and a 2002 report found that nearly two-thirds of children
adopted from the child welfare system are adopted by their foster
parents.13 In responding to a question in our survey, 31 of 49 states
reported that adoption assistance payments were lower than foster care
maintenance payments in those states, and more than half of the 31 states
viewed lower adoption payments as a moderate to very great hindrance to
the adoption of special needs children. According to an official in one of
the states we visited, adoption subsidies are critical to helping families
who adopt special needs children pay for the care and services these
children need. Families adopting special needs children may face
substantial costs for medical care and mental health services, and several
of the experts we interviewed explained that prospective adoptive families
may hesitate to adopt special needs children because they are concerned
about the costs of providing services to meet their needs. In addition,
services, such as respite care, provided by the state for foster children
may be provided to a lesser degree or not at all to adopted children or to

13American Public Human Services Association. "Understanding Delays in the
Interstate Home Study Process." September 2002.

children being cared for by legal guardians. Our survey asked states about
13 types of services. For 9 of the 13 services, fewer states reported
providing the services to adopted children than to foster children; for
every service, the fewest number of states extended these services to
children in guardianship arrangements. (See fig. 2.) Further, officials in
4 of the 5 states we visited confirmed that subsidies and services
declined when foster parents became adoptive parents.

                       THIS PAGE INTENTIONALLY LEFT BLANK

Figure 2: Types of Support Provided to Families Caring for Children with
Special Needs

Number of states 50 49 49

40

30

20

10

0

Maintenance Clothing payments allowance

Services provided

Foster families

Adoptive families

Guardians

Source: GAO survey.

Agency Medical Daily Residential caseworker supplies childcare treatment

48 47 47

                                     48 48

Respite Substance Crisis Individual/ Family Tutoring Post service abuse
intervention group therapy therapy secondary treatment waivers

Notes: Data based on survey responses from 47 states, the District of
Columbia, and Puerto Rico.

Maintenance payments are payments to foster parents to reimburse them for
the costs associated with caring for foster children. Analogous payments
can be made to adoptive parents in the form of adoption subsidies.

Agency caseworker services are ongoing case management services, provided
by trained agency staff that can include, among other things, information
and referral services that adoptive or foster families might need.

Medical supplies can include reimbursement for physical therapy or medical
equipment, such as wheelchairs.

Residential treatment is a therapeutic intervention process for children
who cannot or do not function satisfactorily in their own home
environments.

Respite service is temporary care for foster or adoptive children so that
foster or adoptive parents can be relieved of the responsibility for the
children's daily care for a period of time (several hours or several
days).

Crisis intervention is provided on an emergency basis and can include
mental health treatment or family counseling in response to severe
emotional or health issues that threaten the stability of a foster care or
adoptive placement.

Individual/group therapy and family therapy include psychological and
emotional counseling for children in the care or their adoptive or foster
parents.

Post secondary waivers provide free or reduced tuition for adoptive or
foster children in statesupported post secondary educational programs.

In addition, many states reported that it was difficult to recruit
families and limited resources affected their efforts. Nearly half of the
49 states responding to a relevant question in our survey indicated that
difficulty recruiting families was a great or very great challenge to the
adoption of special needs children. In 4 of the 5 states we visited, child
welfare staff we interviewed told us that high caseloads limited the time
caseworkers could spend recruiting families and placing children. In some
cases, tight budgets led officials to make personnel decisions that made
fewer experienced staff available to recruit adoptive parents. In Georgia,
officials explained that because of budget and staffing constraints,
instead of having workers who could specialize in various processes, such
as recruiting adoptive parents, child welfare workers had to handle
multiple aspects of each case. Further, in Michigan, officials explained
that a budget saving plan to encourage early retirement led many
experienced child welfare staff to retire. While the child welfare agency
hired new workers, nearly all of them were inexperienced and needed both
formal and on-the-job training. As a result, according to the foster and
adoptive parents we interviewed in that state, these inexperienced workers
were less effective than experienced workers at meeting families' needs.

Additionally, in part because of staffing and resource constraints, there
are concerns about how long it takes to place children with families. Both
a home study and a background check are required for adoptive families,
but according to adoptive and waiting parents in one state, high caseloads
limited the time caseworkers could spend completing these studies, and
frequently it was several months from the time families indicated interest
in adopting until their home studies were completed. In addition, states
typically provide adoptive families with an orientation to the adoption
process and relevant training, but caseworkers in one of the states we
visited told us that because of resource constraints, training of
prospective adoptive parents is limited, particularly in the rural areas.

After home studies are completed and the families have been approved,
families often wait for suitable placements. One study found that the
matching and placement phase involved more uncertainty and
misunderstanding for prospective adoptive families than any other step in
the adoption process.14 The same study also found that one-quarter of
potential adoptive parents felt that they were not given an accurate

14Geen, Rob, Karin Malm, and Jeff Katz, "A Study to Inform the Recruitment
and Retention of General Applicant Adoptive Parents." Adoption Quarterly,
7 (4).

estimate of the time it would take for a placement. Another report noted
that infrequent contact between caregivers-foster parents and
guardians-and case managers resulted in caregivers leaving the foster care
system and not pursuing adoption.15 In 3 of the states we visited, foster,
adoptive, and pre-adoptive parents told us that because of staff
shortages, high caseloads, and other duties, caseworkers did not give them
the attention they needed. As a result, some adoptive and pre-adoptive
parents who were trained lost interest or sought children through other
means, such as private placements. In New Mexico, almost all of the
potential adoptive families we talked with in one rural area had been
waiting for more than a year to adopt. They expressed frustration over the
lack of contact from the child welfare agency while they knew that there
were many children waiting for placements. Correspondingly, 20 of 46
states responding to an open-ended question in our survey reported that
high caseloads or insufficient staff were among the three greatest
challenges to facilitating or finalizing the adoption of special needs
children.

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

Court-related delays were also cited as a challenge to the adoption of
special needs children. Twenty-two of the 46 states responding to a
relevant question in our survey indicated that court-related delays were
among the three greatest challenges to the adoption of special needs
children. In 3 of the states we visited, judges told us that it was hard
to schedule termination of parental rights hearings because court dockets
were full and because of the many parties involved in some hearings. In
some cases, the participants include the judge, biological parents, foster
parents, the caseworker, and multiple attorneys-one for each child in a
sibling group, one for each biological parent, and one for the caseworker
or child welfare department. Scheduling a hearing date that fits
everyone's schedule and allows all parties to attend can be difficult.

In addition to difficulties in scheduling hearings, termination
proceedings can last months. Many judges want to be sure that the
biological parents have had sufficient opportunity to remedy the problems
that led to their children being removed. If a parent seems to be making
progress, even if the parent is not yet ready to resume custody of his or
her child, the judge

15Lutz, Lorrie, "Achieving Permanency for Children in the Child Welfare
System: Pioneering Possibilities Amidst Daunting Challenges." National
Resource Center for Foster Care and Permanency Planning. New York.
November 2003.

may postpone a decision. Even in cases in which the likelihood for
reunification is low, attorneys in 3 of the 5 states we visited told us
that some courts hesitate to terminate parental rights until adoptive
families are found for children. According to HHS's analysis of its Child
and Family Services Reviews, in over half of the states reviewed between
2002 and 2004, many judges were reluctant to terminate parental rights
either because adequate services had not been provided to parents or
because an adoptive family had not been identified.16 Yet while some
judges may not want to create a legal orphan before an adoptive placement
is identified, judges we spoke with in 3 of the 5 states we visited said
that the identification of prospective adoptive families did not play a
role in their decision to terminate parental rights. Furthermore, the
termination process can be delayed if an appeal is filed by a biological
parent or a relative raises an objection. In Michigan, court officials
told us that children's relatives may come forward to protest when such a
decision is imminent. Relatives' objections can create delays because the
child welfare agency must determine whether the relatives can be involved
in the children's care, and the court may also schedule further hearings
concerning the details of their objections.

    Delays Completing Home Studies Have Hindered Some Interstate Adoptive
    Placements

Delays in completing home studies impeded the interstate placement of
children and therefore delayed the adoption process. Of the 49 states
responding to our survey, 26 cited the lengthy process to place children
across state lines as a moderate to very great hindrance to the adoption
of special needs children. In the course of seeking an adoptive placement,
sometimes a child welfare agency in the state where the child resides
finds a suitable family in another state. The agency in the state with the
child, known as the sending state, seeks a placement in the state where a
potential adoptive family lives-the receiving state. Generally,
caseworkers from the sending state request that a receiving state complete
a home study of the prospective family. However, caseworkers in the
receiving state may assign this request a low priority because conducting
the home study would take time away from their own caseloads. According to
a survey of state officials conducted by the American Public Human
Services Association (APHSA), 32 of the 45 respondents cited staffing and
workload issues as the leading cause for delay in completing home studies
requested by other states. Another frequently cited cause of

16U.S. Department of Health and Human Services. "General Findings from the
Federal Child and Family Services Review." No date.

delay was the low priority assigned to interstate placements by local
workers.17 According to current interstate compact guidelines, 6 weeks or
30 working days is the recommended processing time from the date the
receiving state gets notice from the sending state until the placement
request is approved or denied. However, APHSA notes that sometimes the
receiving state does not complete home studies for many months. In some
cases, therefore, children linger in foster care when interstate
placements are delayed.

While the Adoption and Safe Families Act includes a provision that directs
states to develop plans to facilitate the timely adoptive placement of
children through the effective use of cross-jurisdictional resources,
there are no national data to assess the timeliness of these placements.
Data from AFCARS can show whether or not children were adopted outside
their home state, and they also can be used to track the length of time
from entry into foster care to termination of parental rights and
adoption. However the system does not capture which states were involved
or when placement requests were made or completed. Without such specific
data, HHS does not know the extent to which states are cooperating, which
states may need to improve their processes, or whether certain states are
burdened by high numbers of requests for home studies in support of
interstate placement. APHSA has developed a database for tracking
interstate adoptions. Unlike HHS's system, this database tracks the total
number of children any participating state sent out of state or received
for adoption and the total number of finalized adoptions a state made
after receiving requests from other states. Participation in the
association's database is voluntary, and as of November 2004, 16 state
agencies had provided their information.

17American Public Human Services Association. Understanding Delays in the
Interstate Home Study Process. September 2002

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

States and HHS have developed strategies and implemented programs to
promote special needs adoptions, but few evaluations measure their
effectiveness. States used both general and targeted recruitment efforts
to help identify adoptive homes for special needs children. States have
also provided special services and programs to help sustain adoptions. To
assist states in their adoption efforts, HHS has supported many
demonstration programs over the years. Although HHS has disseminated
information and summaries about some of the programs and services, little
has been done to assess the effectiveness of such programs, and as a
result, neither HHS nor the states know which approaches have been most
successful.

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

States have used various methods to recruit adoptive families. They have
placed ads on billboards; distributed or posted flyers and posters at
booths during public events or in special locations, such as shopping
malls, libraries, churches, and businesses; sent caseworkers to community
fairs and parades; and used special public service announcements and media
campaigns to generally recruit adoptive families. Many states have
observed and participated in National Adoption Awareness Month each
November, and some states have promoted adoptions by designating other
special days.18 For example, officials in Massachusetts told us that they
finalized 32 adoptions on a single day in May 2004. According to the
National Adoption Day organization, more than 3,100 adoptions were
finalized during National Adoption Awareness Month in 2003.

To help facilitate adoption, states have contracted with private adoption
agencies to recruit and train prospective families, developed Web sites,
and partnered with adoption exchanges. Of the 49 states responding to our
survey, 40 indicated that contracts with private agencies were an
essential or very important recruitment method. In addition, all 5 of our
site visit states, as well as others, operated Web sites that include
photo listings of children awaiting adoption as well as information on
adoption procedures and resources for prospective adoptive families. Also,
4 of the 5 states we visited, as well as other states, partnered with
adoption exchanges- information and referral services for prospective
adoptive families-to operate electronic registries of waiting children.
For example, Michigan's

18November was proclaimed National Adoption Month in 1990. Its purpose is
to promote adoption, support adoptive families, and increase the awareness
of children in foster care nationwide who need permanent families.

adoption resource exchange operates a Web site containing a calendar of
training opportunities and events, a searchable database of children
awaiting adoptive families, and general information on the adoption
process.

In addition, most states used targeted recruitment strategies that focused
on a specific group of children. Of the 49 states responding to a question
in our survey on methods for recruiting adoptive families for special
needs children, 37 reported that television advertisements and stories
were essential or very important, 35 states reported that advertisements
in magazines and other periodicals were essential or very important, and
22 responded similarly regarding mass mailings or flyer distribution. For
example, Kentucky officials noted in our survey that they created a
special television public service announcement to recruit adoptive
families for special needs children. The advertisement was filmed at the
Governor's home and included children with special needs. Another state,
Georgia, issued a photo listing book, entitled "My Turn Now," that
includes those children who have been awaiting adoption for the longest
period of time.

Many states also hosted adoption promotion events throughout the year that
targeted certain children, such as minorities or those in sibling groups.
In Massachusetts, for example, the state agency has partnered with a local
furniture store to host several adoption parties. The goal of the event is
to help match prospective families with those children in attendance.
State officials credit this business partnership with a number of
successful adoptive matches. Another targeted strategy, known as the Heart
Gallery, has been under way in New Mexico since 2001 and has also been
implemented by a number of other states. This event has showcased
professional photographs of children waiting to be adopted. Though the
organizers in New Mexico have not collected data to track matches
resulting from participation in the gallery event, one organizing official
told us that several children who were showcased at the events have been
adopted. Further, a Massachusetts official stated that within 2 months of
implementing the Heart Gallery in that state, placements were found for
half of the children showcased. In addition, some states are working with
local community organizations and churches to help recruit and place
particular children in adoptive homes. According to a National Governor's
Association report, 30 states and the District of Columbia have
participated in an adoption program called One Church One Child, since
1980. The program seeks to recruit one family from each African-American
church to adopt an African-American child.

    States Provided Some Services and Resources to Help Sustain Adoptions

As indicated earlier in figure 2, states are providing some post-adoption
services and resources, which many experts have said are critical to
helping families sustain adoptions. Generally, post-adoption services are
provided with the recognition that parents adopting children often face
challenges they did not anticipate and for which they are not fully
prepared, especially when the children have special needs. These services
are intended to help reduce the number of adoptions that are dissolved.19
As previously noted, states generally provide fewer services to adoptive
families than to foster families. However, 4 of the 5 states we visited
have established centers to assist families after their adoptions were
finalized- see table 1.

  Table 1: Characteristics of Post Adoption Resources Available in Five States

State resource Key features of post adoption service Eligibility
regulations

Georgia

Georgia Center for Adoption Resources and Support-a Toll-free number
Services provided through statewide service center located in Atlanta,
Georgia. The Connects families with the resource the Georgia Center for
center became operational in 2002 and is part of Georgia's center, lending
library, and Resource Adoption Resources and Office of Adoptions. Resource
Advisors are located in each Advisors Support are available to all of the
regions of the Department of Human Resources adoptive families residing in
throughout the state. Post adoption advisors Georgia.

Assist families in locating resources

Newsletter

Provides articles of interest to adoptive families

Adoptive Family Network

Matches adoptive families with "buddy" families who adopted children with
similar needs

Web site

Provides current information on resources and special events

Lending library

Contains a collection of books, magazines, and videotapes covering a
variety of adoption, parenting, and child development issues

19Dissolutions occur when a child is returned to foster care after the
adoption has been finalized.

  State resource Key features of post adoption service Eligibility regulations

Georgia's Office of Adoptions-created to develop, promote, and support
quality adoptive placements and services.

A TEAM mentoring program

Provides mentoring for adopted teens in grades 6-12

Intervention team

Provides early intervention to improve the family's well being, and to
decrease adoption disruption and dissolution

Tutorial services

Provides educational support services for children who need tutorial
intervention

Camp Promise

Provides an opportunity for adopted children to attend a summer camp
program with other adopted children

Respite care

Provides short-term, time-limited care for adopted children With the
exception of services provided by the Georgia Center for Adoption
Resources and Support, services provided by the Office of Adoptions are
available only to families who have adopted children from the state's
public child welfare agency.

  State resource Key features of post adoption service Eligibility regulations

Massachusetts Adoption Journeys (formerly known as Adoption Crossroads)-a
statewide program founded in 1997. Services are administered and
coordinated by the Child and Family Services Agency for the state, and are
provided through a network of five affiliate agencies located in different
geographic regions of the state. Toll-free number

Connects families and professionals to a 24-hour toll-free phone line that
offers information, joint problem solving, and immediate emotional support

Family support groups

Meet on a weekly basis in all regions of the state

Regional response teams

Work with families to address a range of problems that could jeopardize
the longterm success of the adoption

Advocacy and coordination

Empowers families and enhances their self-advocacy skills

Training for mental health and social service professionals

Provides consultation and training

Respite care

Provides short-term, time-limited care for adopted children Services are
available to all state residents who have adopted children or legalized
guardianships, including those originating from state, private, or
international sources.

  State resource Key features of post adoption service Eligibility regulations

Michigan Regional Resource Centers for Post Adoption Services- established
in 2001. At the time of our site visit, there were seven centers serving
specific counties in the state. 20 Toll-free number

Connects families to a toll-free line to obtain information on free and
low-cost services that are available around the state

Parent support groups

Allow parents to meet and connect with others facing similar situations

Family support events

Allow adoptive families to connect while taking the time to relax and
enjoy activities

Parent training

Provides training for adoptive parents to become educated on issues that
affect their families Services are available to families who have adopted
children from the state's foster care system. The child must be under 18
years of age, receive an adoption subsidy, and reside in the county in
which the center provides services.

20In commenting on a draft of this report, a Michigan official noted that
the state had discontinued contracts with the regional post adoption
service providers due to budget constraints. Six of the contracts expired
on March 31, 2005, and were not renewed, and the seventh contract will
expire on September 30, 2005, and will not be renewed.

  State resource Key features of post adoption service Eligibility regulations

New Mexico According to state officials, no formal post adoption program
exists in the state. Families needing assistance can call their
caseworkers for information and referral and may be linked to training and
support groups that private agencies provide. Oregon Oregon Post Adoption
Resource Center-a statewide service founded in 1999. The center, a program
of the Oregon Department of Human Services, is federally funded. Parent
support groups

Provide on-site assistance, training, and technical support for adoptive
parent support groups

Parent training

Provides formal on-site training twice a year in each of the state's four
regions

Directory

Lists local, regional, and statewide resources for parents in need of
therapists, respite care, support groups, camps, public school programs,
special educational facilities, and other services

Lending library

Includes videos, books, self-study courses, and information packets

Respite care

Develops and maintains systems that help families connect with respite
resources Services are available to families who have adopted children
from the state's foster care system.

Source: GAO summary of resources, as described by state resource centers.

However, according to state adoption officials, caseworkers, and adoptive
parents we met during our site visits, better post adoptive mental health
services are needed. In addition, several of the experts we interviewed
expressed the opinion that many mental heath providers needed to develop
and improve their competencies in adoption-related topics such as trust,
abandonment, and attachment. Some states have established programs to do
just this. For example, New Jersey's Adoption Certificate Program, in
coordination with Rutgers University School of Social Work and Continuing
Education Department, developed a 45-hour postgraduate training program
leading to an adoption certificate for mental health clinicians. The
certificate program is intended to increase the knowledge of mental health
practitioners regarding the core issues facing adoptive families, and to
expand their clinical skills in attachment-based, familyfocused
therapeutic interventions. Oregon's efforts present another example.
Portland State University, in collaboration with Oregon's Department of
Human Services and Oregon's Post Adoption Resource Center, has also
developed a postgraduate training certificate program for

mental health providers working with adoptive families. The training
program includes hands-on strategies for coaching and working with
adoptive parents to address their children's challenging behaviors.
According to program officials, the program has trained 27 therapists, and
15 more are expected to complete the program by June of 2005. The names of
these therapists have been or will be forwarded to Oregon's adoptions
resource center to be included in referral information sent to adoptive
families in need of mental health therapists.

Most states have not conducted evaluations of their post adoption
services. In responding to our survey, 9 states indicated that they have
completed evaluations of post adoption services; 8 states said that they
had evaluations under way, and 30 informed us that they had not conducted
any evaluations prior to their completion of our survey. Evaluations play
an important role in improving program operations. They can identify which
services are most important to families, as well as help managers
determine whether the services are achieving desired goals and if they can
be provided more efficiently. Evaluation results can help individual
states improve their programs and, if shared, can provide other states
with valuable information to help avoid costly mistakes.

    HHS Has Administered Many Programs to Help States' Adoption Efforts

Various HHS activities have helped states' adoption efforts. Over the
years, HHS has administered programs, sponsored campaigns, funded a
resource center, and taken steps to disseminate information about
adoptions. According to HHS officials, special needs children constitute
the majority of children waiting for adoptive homes, and as such, they are
the beneficiaries of the agency's efforts to support adoption.

HHS has promoted innovation for many years through the Adoption
Opportunities Program and the Title IV-E Child Welfare Demonstration
Program. The Adoption Opportunities Program, authorized by the Child Abuse
Prevention and Treatment and Adoption Reform Act of 1978, as amended,
generally provides 3-to 5-year grants and contracts to public and private
adoption agencies. These grants and contracts have been used to support
states' efforts, such as increasing placement of minority children,
recruiting minority adoptive families, and providing post adoption
services for families with special needs children. Since the program's
inception, Congress has obligated more than $300 million for the Adoption
Opportunities Program. In 2003, HHS administered about $7.3 million in
first-year funding for 20 projects and in 2004 awarded $4.4 million in
firstyear funding for 13 projects. Also, to promote innovation, HHS has
administered the Title IV-E Child Welfare Demonstration Program since

1994. Among other things, this program allows states to waive certain
restrictions on the use of Title IV-E funds that heretofore have prevented
states from providing support to guardians. Since 1996, 7 states have
operated or are currently operating waiver projects that have provided
monthly payments to relatives and other caregivers who agree to become a
child's legal guardian. The objective is to test whether providing monthly
support to guardians, which is generally less than payments made to foster
parents, can help reduce a state's overall foster care costs and improve
permanency outcomes for children.

Since 2002, HHS has supported local efforts to recruit and support
adoptive families and increase public awareness about adoption by
sponsoring AdoptUSKids-a national initiative promoting adoption that is
operated by a coalition under contract with HHS. AdoptUSKids has partnered
with the Ad Council-a provider of public service announcements to raise
awareness about social issues-to develop a national campaign to recruit
adoptive families, and HHS has contributed more than $4.1 million to the
effort. The campaign is expected to run for 3 years and feature a variety
of public service announcements on television and radio, and in print
media. Of this amount, AdoptUSKids has allocated $2 million to support
state recruitment response teams to handle the anticipated interest the
campaign is designed to generate. Members of these state-based teams are
expected to respond to calls and e-mails from prospective parents, link
them with the appropriate state agencies, keep prospective parents engaged
in the adoption process by providing a point of contact, and help parents
overcome the barriers they may face in pursuing adoption. Response teams
are also expected to encourage local media stations to run AdoptUSKids ads
and to network with local politicians and community leaders.

The AdoptUSKids initiative also helps fund adoptive parent organizations
around the country to recruit prospective adoptive families and support
existing ones. As of October 2004, AdoptUSKids had awarded a total of
$420,000 to 105 parent groups in 44 states. To recruit prospective
adoptive parents, AdoptUSKids operates a national database of children
waiting to be adopted and has established a Web site that includes photos;
demographic profiles; and brief descriptions of interests, special needs,
and the types of adoptive families that would be the most appropriate for
the children. The site is available to the public, although prospective
adoptive families can inquire about specific children only after their
state has approved them for adoption. According to AdoptUSKids, as of
April 2005, about 41 percent of the children featured on the Web site had
been placed with families in pre-adoptive homes.

Further, HHS has also dedicated the resources of one of its seven
federally funded national resource centers to specifically address special
needs adoption.21 Based in Michigan, the National Child Welfare Resource
Center for Adoption provides training and technical assistance to states
to help them achieve timely adoptions and develop program improvement
plans to correct weaknesses identified through federal reviews. HHS has
provided about $1 million annually to support this resource center.

HHS also has acknowledged the work of others to promote adoption and has
disseminated adoption-related information. HHS established the Adoption
Excellence Awards in 1997 and since then has presented the award to public
and private organizations, courts, and individuals. In 2004, HHS
acknowledged the efforts of 17 groups and individuals who had a role in
increasing the number of foster children placed in permanent homes.
According to agency officials, the nonmonetary awards aim to raise
awareness about adoption and publicly acknowledge best practices. To
disseminate information about its programs and other activities concerning
adoption, HHS has sponsored conferences devoted to adoption issues and
sends a monthly electronic newsletter, the Children's Bureau Express, to
more than 9,700 readers. This newsletter highlights new developments in
the adoption field, as well as provides readers information on conferences
and funding opportunities. The agency also maintains an e-mail
distribution list of states' adoption and foster care program managers to
help disseminate information on policies, procedures, and practices to the
states and also maintains a Web site, operated by the National Adoption
Information Clearinghouse, which collects and disseminates information
concerning all aspects of adoption.

    HHS Has Done Little to Assess the Effectiveness of Its Programs

Although HHS has administered demonstration programs for many years, the
agency has done little to evaluate the projects funded through these
programs and therefore does not know which ones have been most successful.
For example, the Adoption Opportunities Program has been under way since
the late 1970s, but HHS did not require evaluations from the grantees
until 2002. In the absence of evaluations, the agency has published
summaries of grantees' final reports. For example, a document provided by
HHS staff in 2002 and disseminated by the Clearinghouse

21HHS's other resource centers also provide some technical assistance to
states regarding adoption matters, but they primarily focus on other
topics, such as organizational improvement and data and technology.

synthesized the findings from 8 of 19 projects funded under this program.
The document contains some information on the projects' challenges,
lessons learned, and accomplishments, as well as recommendations from the
grantees. However, HHS has prefaced this material with a disclaimer,
noting that it does not represent the official views of the agency.
Although evaluations have been required for the last several years, HHS's
program staff told us they were still in the early stages of identifying
criteria to help ensure that future evaluations from grantees will be done
with sufficient rigor to help assess effectiveness.

HHS has also required evaluations from Title IV-E waiver recipients, but
little is known about the effectiveness of these projects, even though HHS
has provided staff and technical assistance to help state grantees design,
implement, and evaluate their projects. Rigorous design is an essential
component to incorporate when evaluations are intended to develop
conclusions about the effectiveness of a project. Such design could
include random assignment or controlled quasi-experimental design.22 Of
the seven state evaluations submitted between 2002 and 2004 that addressed
guardianship, two were designed in a manner that allowed for comparisons
between experimental and control groups. For example, the evaluation in
selected regions of Illinois was the most methodologically rigorous of the
seven, and its design incorporated random assignment, which allowed for
reliable comparison between the control and experimental groups. The
Illinois evaluation's findings suggest that children for whom subsidized
guardianship was an option experienced a 6 percent higher permanency rate
than those in the control group and guardianship was also comparable with
adoption in terms of safety and ensuring a child's well being. The
evaluations from the other 5 states were less rigorous in their design or
implementation. For example, comparison groups used to evaluate
guardianships in Oregon and New Mexico were not necessarily comparable in
composition or makeup with the guardianship population supported by the
project. Consequently, the difference in outcomes for those in
guardianships could be due to internal differences or characteristics,
rather than to the treatment (i.e., guardianship) itself. Other project
evaluations were limited by reliance on

22Experimental evaluations involve random assignment of participants to
one group or the other in order to increase the likelihood that the two
groups are roughly equivalent on all characteristics that could affect
outcomes. In a quasi-experimental design, a comparison group is composed
of individuals who share characteristics with program participants but who
have not been randomly assigned. With this design, statistical controls
are needed to isolate the program from other factors that could influence
outcomes.

group numbers too small for generalization and by poor response rates to
assessment surveys and interviews. While the size of the project and the
costs associated with measuring outcomes and collecting data should be
considered in conducting evaluations, HHS officials acknowledged the
weaknesses of the current work conducted by grantees and said they have
learned more about the need for greater rigor as evaluations have been
submitted. They also indicated that evaluations are managed by the states
and HHS has very little control over how they are completed. Meanwhile,
HHS has posted summaries of projects undertaken through the waiver
program, and according to agency officials, they have drafted a synthesis
of findings reported by grantees.

The adoption assistance and adoption incentive programs have supported the
adoption of special needs children, but data are lacking to determine if
changes are needed to better facilitate adoption. The Title IV-E Adoption
Assistance Program uses an income threshold for eligibility that is
outdated and more restrictive than other cash assistance programs'
standards of needs and therefore limits eligibility. With regard to
adoption incentives, all states have increased their annual number of
adoptions enough to receive financial awards for doing so at least once
but data are lacking to assess interstate placement challenges and credit
states for collaborating.

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

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

The Title IV-E Adoption Assistance Program was designed to help support
the adoption of economically disadvantaged children with special needs.
However, the income measure used to assess the standards of need in the
AFDC program, as it existed in 1996, is outdated and in many states more
restrictive than other programs' standards of need, such as the measure
used for TANF cash assistance eligibility.23 For example, in
Massachusetts, a family of three could earn up to $633 per month and
qualify for TANF, but this family would not qualify for AFDC unless the
earnings were no

23Under the AFDC program, states set eligibility criteria within federal
guidelines and the federal government and states shared the costs of
providing benefits to eligible families. Under TANF, the federal
government provides states a fixed amount of funds each year- through a
block grant-and the states have much more flexibility in determining
eligibility criteria and services provided. With this increased
flexibility and in keeping with the TANF program goals of promoting work,
many states have increased the amount of earnings a parent may make while
still receiving cash benefits. However, states also have the flexibility
to impose a less generous standard of need for TANF.

more than $579-a difference of $54 per month. According to an HHS
official, eligibility for AFDC and TANF is governed by complex rules,
which therefore complicate comparison. Nonetheless, more than one-third of
the 39 states responding to an open-ended question in our survey, as well
as officials in 4 of the 5 states we visited, expressed the view that
Title IV-E income eligibility criteria-based on AFDC eligibility-should be
less restrictive.

Further, making the income determinations has presented problems for some
states. We asked officials in each of our 5 site visit states to comment
on the administrative burden associated with the income eligibility
criteria. Officials in 4 states said that determining whether children met
the income requirements, by virtue of the parents' income, was
time-consuming and challenging, particularly if their incomes were not
readily available through a state-maintained database. Between fiscal
years 2000 and 2004, HHS found that nearly all states had made errors in
applying the income criteria and determining the income eligibility for
foster care maintenance determinations. Since states must also base
adoption assistance income eligibility on parents' income, similar
mistakes are likely. HHS fined 50 of the 52 states it reviewed between
2000 and 2004 more than $14 million for claiming foster care maintenance
payments for ineligible cases, and one of the most frequent reasons for
fines, according to HHS officials, was the inappropriate application of
the AFDC income criteria.24

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

While members of Congress, the Administration, and others have proposed
changing or eliminating income requirements, HHS lacks data to assess the
likely cost to the federal government of doing so. Nevertheless, state
officials and adoption subsidy managers from 4 of the 5 states we visited
recommended that Title IV-E not be tied to criteria once used for the old
AFDC program. The Pew Commission on Children in Foster Care-a national
nonpartisan group formed in 2003 and composed of legislators, judges,
child welfare administrators, and others-has estimated that eliminating
the AFDC criteria from the foster care and adoption programs would cost
the federal government $1.6 billion annually. The commission based its
figure on fiscal year 2002 expenditure

24Other reasons were complications associated with obtaining required
judicial determinations, lapsed foster family licenses, and limited
resources to adequately monitor and relicense families whose licenses had
expired.

data as well as estimated projections of the percentage of children who
qualify under current regulations. A more reliable estimate cannot be made
because HHS does not maintain critical data on those children and their
families who are not eligible. Specifically, for those children deemed
ineligible, HHS does not maintain family income data or data on the
presence or absence of special needs. As a result, no one can determine
how many families just missed the eligibility criteria and how many of
these children had special needs. According to an HHS official, the agency
has not done a formal cost estimate of expanding Title IV-E eligibility
criteria, but it has been developing an approach in support of proposals
that the administration has made since 2004. According to one agency
official, these proposals would eliminate income eligibility
determinations for foster care. However, without critical data and a cost
estimate, the extent to which expanding eligibility for the Adoption
Assistance Program would contribute to the nation's growing fiscal
imbalance is unknown.

All States Have Claimed With regard to the Adoption Incentives Program, as
figure 3 indicates, all Adoption Incentive Funds states have been able to
increase their annual number of adoptions enough at Least Once to receive
financial awards at least once since 1998.

Figure 3: Frequency of States' Attainment of the Adoption Incentive Award,
19982003

From 1998 to 2003, only South Dakota and Texas claimed the award each
year, and 42 states earned it at least three times. The number of states
receiving the award has fluctuated from year to year, however, as figure 4
illustrates. In 1999, 44 states earned the award-a reflection, perhaps, of
states' implementation of ASFA and their pursuit of permanency through
adoption. By 2001, though, the number of states receiving the award
dropped to 24, which may have been due to states' inability to sustain
high levels of adoptions. Since 2001, the number of states receiving the
award has been on the rise. However, fewer states received the award in
2003 than in 1998, when the program began.

Figure 4: Number of States Claiming Award, by Earning Year

Adoption incentive award amounts have varied, and states have used the
funds to support an array of activities. For example, award amounts Texas
earned ranged from $68,000 to nearly $3 million. States participating in a
2000 study reported using these awards to fund a variety of onetime
activities, such as investing in post adoption services and making
performance-based awards to local offices or counties.25 Our review of
Child and Family Services Plans and Annual Progress and Services Reports
from 5 states that received the award in 2002, found that these states
used the funds to develop ad campaigns to recruit adoptive families,
provide free legal services for adoption, and support child care for
adoptive families.

The Adoption Incentives Program rewards states for exceeding baselines.
Some states reported that they focused on adoption prior to the
implementation of the program but have since seen declines in the rate at
which children enter foster care, and thus have been unable to finalize
enough adoptions to claim the reward. According to officials from

25Cornerstone Consulting Group, Inc. A Carrot among the Sticks: The
Adoption Incentive Bonus. 2001.

Massachusetts, while the state has continued to focus on adoption, it does
not perceive the program to be an appropriate incentive because it simply
rewards states for exceeding baselines rather than for other improvements
such as placing children who have been in care the longest. As figure 5
indicates, a state theoretically could increase adoptions in the years
subsequent to the establishment of its baseline and still not be in a
position to claim the reward, especially if its baseline had been
calibrated at a level it might not reach again.

Figure 5: Illustration of the Difficulty in Claiming an Award under the
Adoption Incentives Program

According to our survey, respondents had mixed opinions about the extent
to which the program served as an incentive to promote special needs
adoption. Twenty-two of the 49 states responding to a relevant survey
question said the program was a great or very great incentive, while 24
responded that the program was a moderate or weak motivator. In addition,
several of these respondents suggested that HHS further modify its
baseline calculations. For example, states suggested adding a category to
reward states for the adoption of children who have been in foster care
for long periods of time, or altering the baseline to reflect increases
yearto-year rather than rewarding states for exceeding historic baselines.

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

  Conclusions

In addition, the program does not provide a specific inducement for
interstate placements. Under the program's authorizing statute, the
sending state can count the finalized adoption in its totals, but the
receiving state does not get any credit for facilitating a placement, even
though the receiving state must conduct the home study-a critical step in
the adoption process. We do not have estimates of the costs incurred by
states for conducting a home study, but officials in 1 state told us that
prospective adoptive families who adopt through private agencies may pay
as much as $3,000 to complete home studies. HHS officials noted that it
would be difficult to track which states should be receiving the credit
for facilitating interstate placements, given the limitations in the data
collected in AFCARS. Furthermore, officials informed us that they do not
have the authority to split the incentive award. Nevertheless, they
acknowledged the challenges states face with regard to interstate
placement and expressed the view that changes that would provide an
incentive to facilitate interstate adoptions could help.

While many states have increased the adoption of children with special
needs, data and evaluations are lacking to assess the degree to which
federal and state programs have promoted special needs adoptions.
Interstate placements have delayed adoptions, but data to assess the
timeliness of these placements are not available. Without such data, HHS
cannot identify those states that may need to improve their processes or
those burdened by requests for assistance. As a result, delays associated
with interstate placements will likely persist, and some special needs
children may linger in foster care. Although states and HHS have developed
strategies and innovative programs to promote and support special needs
adoptions, HHS has done little to assess the effectiveness of its programs
and funded projects. As a consequence, HHS does not know which projects
have been most successful and cannot be assured that federal funds used to
support state projects have been used wisely. While Title IV-E Adoption
Assistance has supported special needs adoption, it is unclear how many
more children would qualify for the program if income standards were
adjusted to today's income standards of need. Further, without critical
data and a cost estimate of expanding eligibility, the extent to which
increasing the number of qualified children would contribute to the
nation's growing fiscal imbalance is unclear. As for the Adoption
Incentives Program, it does not encourage states to collaborate on
interstate placements, therefore failing to support an area that already
presents barriers.

Recommendations for 	We are making three recommendations to further
improve the process and programs related to special needs adoption.

  Executive Action

o  	To better understand delays associated with interstate placements, the
Secretary of HHS should assist states in collecting and reporting data
related to the interstate placement processes, especially the time needed
to complete home studies and the sending and receiving state for each
child placed across state lines. Such assistance could include modifying
HHS's central data system, AFCARS, in conjunction with the agency's
ongoing efforts to update and revise this system. HHS should analyze the
data to assess the extent to which home studies cause delays or impede
interstate adoptions and to identify which states are facilitating timely
interstate placements. If supported by its findings, HHS should consider
proposing legislation to amend existing law so that both sending and
receiving states could claim an interstate adoption for purposes of
determining award eligibility.

o  	To improve HHS's ability to assess the effectiveness of its funded
projects, the Secretary of HHS should develop guidance to ensure that
rigorous design elements are incorporated into projects and related
evaluations. Such guidance could consider the nature and structure of the
projects and include measures to control costs.

o  To assess the extent to which Title IV-E adoption assistance
eligibility

  Agency Comments

criteria exclude some economically disadvantaged children with special
needs, the Secretary of HHS should (1) gather data on the economic
circumstances of special needs children who do not currently qualify for
IV-E and (2) develop a model to estimate the federal cost of expanding
eligibility.

We received written comments on a draft of this report from HHS. These
comments are reproduced in appendix II. HHS also provided technical
comments, which we incorporated when appropriate.

HHS did not explicitly agree or disagree with the recommendations, but
stated that two of our recommendations were being considered as part of a
process to determine what, if any, revisions would be made to the agency's
central data system, AFCARS. Specifically, HHS stated that the
recommendation to collect data related to interstate placements and the
recommendation to gather data on disadvantaged children with special needs
would be considered as part of its AFCARS review.

With regard to our recommendation that HHS develop guidance to improve
project evaluations and help assess the effectiveness of funded projects,
HHS stated that such actions were unnecessary and noted that it had taken
steps to strengthen evaluation requirements and provided technical
assistance. Nevertheless, HHS acknowledged that a number of demonstration
projects have sometimes yielded results of limited utility because of
problems adhering to negotiated evaluation protocols. Also, HHS stated
that it is committed to continuing to improve the quality of information
generated by funded projects and it will continue to work with states to
identify rigorous, administratively feasible evaluation strategies. We
continue to recommend that HHS develop additional guidance to improve
evaluations. Such guidance is needed to improve the quality of the results
from funded projects which will enable managers to assess their
effectiveness.

HHS also commented on our findings related to the evaluations conducted
under the Title IV-E waiver program. HHS stated that our summary of these
evaluations was somewhat misleading. It noted that several states in which
guardianship is a focus of the demonstration have used experimental
design. Also HHS said that the Oregon demonstration was focused primarily
on testing the use of flexible funding, and therefore the evaluation of
the guardianship components used other methods and focused on descriptive
data. We modified the report to clarify the aspects of rigorous design.
However, we did not change our description of the Oregon evaluation
because it accurately portrayed the evaluation, which included information
on the impact and effectiveness of the guardianship component of the
project.

We also provided a copy of our draft report to child welfare officials in
the 5 states we visited and received technical comments from Georgia,
Massachusetts, Michigan, and Oregon. We incorporated these comments when
appropriate.

As arranged with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days from
its issue date. At that time we will send copies of this report to the
Secretary of Health and Human Services, state child welfare directors, and
other interested parties. In addition, we will make copies available to
others on request. Also, this report will be available at no charge on
GAO's Web site at http://www.gao.gov. If you or your staff have any
questions about this report, please contact me at (202) 512-8403 or
[email protected]. Contact points for our Offices of Congressional Relations
and Public Affairs may

be found on the last page of this report. GAO staff who made major
contributions to this report are listed in appendix III.

Cornelia M. Ashby, Director Education, Workforce, and Income Security
Issues

Appendix I: Objectives, Scope, and Methodology

Objectives 	The objectives of our study were to (1) identify the major
challenges to placing and keeping special needs children in adoptive
homes, (2) examine what states and the Department of Health and Human
Services (HHS) have done to facilitate special needs adoptions, and (3)
assess how well the Adoption Assistance Program and the Adoption
Incentives Program have worked to facilitate special needs adoptions and
what changes, if any might be needed to further facilitate adoptions.

Scope and 	To gather information about these objectives, we utilized
multiple methodologies: (1) a Web-based survey to state child welfare
agencies;

Methodology 	(2) site visits to 5 states; (3) interviews with HHS
officials, staff from key National Resource Centers, and child welfare
researchers and practitioners, as well as discussion groups with adoptive
parents and state adoption program managers; (4) a review of 10 selected
states' 5-year reports and 5-year plans that HHS requires as part of its
ongoing child welfare oversight, as well as a review of federal adoption
assistance and promotion laws and HHS regulations; and (5) a review of
adoption-related studies and evaluations conducted by HHS, the states, and
nongovernmental organizations. We conducted our work between May 2004 and
April 2005 in accordance with generally accepted government auditing
standards.

  Survey

To gather information about states' experiences with special needs
adoption, we distributed a Web-based survey to the adoption program
managers in all 50 states, the District of Columbia, and Puerto Rico on
September 17, 2004. The survey contained a number of both closed- and
open-ended questions. To determine whether the survey questions were
clear, unbiased, and used appropriate language, we pretested the survey
instrument with officials in Delaware, Pennsylvania, Maryland, New York,
Virginia, Ohio, and the District of Columbia prior to distribution. After
an appropriate period of time had passed after initial survey
distribution, we conducted an extensive follow-up process that included
e-mails and phone calls to states that had not yet completed the survey.
At the culmination of this process, we received and analyzed responses
from 50 states.1

Because this was not a sample survey, there are no sampling errors.
However, the practical difficulties of conducting any survey may introduce

1We did not receive responses from Alabama and Nevada.

Appendix I: Objectives, Scope, and Methodology

errors, commonly referred to as nonsampling errors. For example,
difficulties in how a particular question is interpreted, in the sources
of information that are available to respondents, or in how the data are
entered into a database or were analyzed can introduce unwanted
variability into the survey results. We took steps in the development of
the questionnaire, the data collection, and the data analysis to minimize
these nonsampling errors. For example, social science survey specialists
designed the questionnaire in collaboration with GAO staff with subject
matter expertise. Then, the draft questionnaire was pretested with a
number of state officials to ensure that the questions were relevant,
clearly stated, and easy to comprehend. When the data were analyzed, a
second, independent analyst checked all computer programs. Since this was
a Web-based survey, respondents entered their answers directly into the
electronic questionnaire. This eliminated the need to have the data keyed
into a database, thus removing an additional source of error.

We took several steps to assess the reliability of the data obtained
through our survey. During our pretests, we asked state officials
questions to determine the reliability of the data they could provide,
such as how accurate their data entry systems were and how confident they
would be estimating the data we requested. On the basis of these
responses, we decided to include an open-ended question in the survey
instrument that would give states an opportunity to discuss any
limitations in the data they sent us. After receiving final surveys from
50 states, we examined the responses to that particular open-ended
question, along with all the closed-ended data questions, and made
decisions about which to report on. We then examined the output to test
for inconsistencies, took steps to resolve these inconsistencies with the
relevant states, and determined that the data were sufficient and reliable
for the purposes of our report.

                                  Site Visits

To gather more detailed information about the challenges states face
promoting and sustaining adoption, as well as some of the practices
they've implemented to overcome challenges, we selected 5 states to
visit-Georgia, Massachusetts, Michigan, New Mexico, and Oregon- based on
differences in their success achieving adoption incentive awards, along
with their differences in location, size of child welfare population,
degree of privatization of services, and whether they had state or locally
administered systems. In preparation for the visits and to understand the
unique circumstances in each state, we talked with HHS's regional office
staff and field experts and obtained and reviewed relevant literature from
each of the 5 states, such as studies of adoption efforts and promising
practices. During our visits to each state, we talked with officials from
the

Appendix I: Objectives, Scope, and Methodology

  Interviews and Discussion Groups

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

state child welfare agency, along with officials and staff from at least
one local agency office. Specifically, in each state we spoke with the
adoption program manager; caseworkers and supervisors; foster and adoptive
parents; judges, attorneys, and other court personnel, such as guardians
and advocates; and private agency officials under contract with the state.

To gather information about HHS's role in promoting special needs adoption
and generating related research and evaluation, we interviewed HHS
officials from Central Office and all the Regional Offices. We also spoke
with staff from National Resource Centers involved in special needs
adoption and permanency issues and interviewed nearly 20 child welfare
experts and researchers to learn additional information about challenges
confronting states' promotion and maintenance of special needs adoption.

We also conducted separate discussion groups with adoptive parents and
state adoption program managers. We conducted a discussion with 11
adoptive parents from 8 states who were attending the annual conference of
the North American Council on Adoptable Children to learn their
perspectives on the adoption process, subsidy rates, and post-adoption
services. We also held a discussion group with adoption program managers
from 18 states during the annual meeting of the National Association of
State Adoption Programs. During this discussion, we learned more about the
federal role in promoting and sustaining adoption and obtained managers'
perspectives on Title IV-E funding and the provision of subsidies to
adoptive parents.

To learn more about how states were spending the adoption incentives funds
they had received and what their plans were to recruit and retain adoptive
families using federal funds, we reviewed 10 states' 2005-2009 Child and
Family Services Plans and 2004 Annual Progress and Services
Reports-documents required by HHS as part of federal funding
participation. We selected 10 states-half of which received an adoption
incentive award in 2002-the latest date for which figures were available
at the time of our selection and analysis-and half of which did not. Since
we wanted to include documents from our 5 site visit states in the sample,
we collected the plans and reports from another 5 states, selected
randomly based on their receipt or nonreceipt of the award. Among the 10
states whose documents we reviewed, Georgia, Kentucky, New Hampshire,
Oregon, and Pennsylvania received an award in 2002, and Alaska,
Massachusetts, Michigan, Mississippi, and New Mexico did not. We
summarized the plans and reports that HHS's regional offices provided to

Appendix I: Objectives, Scope, and Methodology

  Review of Studies and Evaluations

us for these states, including excerpts from unapproved plans, and
included this information where appropriate. We also reviewed relevant
laws and regulations describing the Adoption Assistance and Adoption
Incentives Programs.

During the course of the work, we reviewed more than 20 adoption studies
that had been conducted by states, university professors, and independent
child welfare researchers. We also reviewed 14 evaluations, including
those required under the federal Title IV-E waiver program, that were
designed to assess the effectiveness of adoption, permanency, and post
adoption projects. For each of the selected studies that are used in this
report, we determined whether the study's findings were generally
reliable. To do so, two GAO social science analysts evaluated the
methodological soundness of the studies using common social science and
statistical practices. For example, they examined each study's
methodology, including its limitations, data sources, analyses, and
conclusions.

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

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

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

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

Appendix III: GAO Contact and Acknowledgments

GAO Contact Cornelia M. Ashby (202) 512-8403

Staff 	In addition to those named above, Joy Gambino, Joah Iannotta, Kopp
Michelotti, Vernette Shaw, and Carolyn M. Taylor made key

Acknowledgments 	contributions to this report. Susan Bernstein, Karen
Burke, Michele Fejfar, Catherine Hurley, Kevin Jackson, Stuart Kaufman,
Jason Kelly, Luann Moy, and Jay Smale also provided key technical
assistance.

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