    Foster Care: Agencies Face Challenges Securing Stable Homes for Children
    of Substance Abusers (Letter Report, 09/30/1998, GAO/HEHS-98-182).

    The number of children in foster care has nearly doubled since the
    mid-1980s, and today about half a million children are in the foster
    care system. The mid-1980s also marked the onset of the crack cocaine
    epidemic. More recently, the use of other hard drugs, such as
    methamphetamines and heroin, has been on the rise in some parts of the
    country. Research suggests that the escalating use of hard drugs has
    contributed to the growth in the foster care population, but little is
    known about the effect that parental substance abuse has on how and when
    children leave the system. Members of Congress have raised concern that
    children whose parents are drug addicts or alcoholics may languish in
    foster care for years before being placed in a safe, permanent home.
    This report discusses (1) the extent and characteristics of parental
    substance abuse among foster care cases, (2) the difficulties foster
    agencies face in making timely permanency decisions for foster children
    with substance-abusing parents, and (3) initiatives to achieve timely
    permanency outcomes for foster children with substance-abusing parents.

    --------------------------- Indexing Terms -----------------------------

     REPORTNUM:  HEHS-98-182
         TITLE:  Foster Care: Agencies Face Challenges Securing Stable
    	     Homes for Children of Substance Abusers
          DATE:  09/30/1998
       SUBJECT:  Foster children
    	     Interagency relations
    	     Drug abuse
    	     Drug treatment
    	     Alcohol or drug abuse problems
    	     Child custody
    	     Child adoption
    	     Parents
    	     Alcohol abuse
    	     Rehabilitation programs
    IDENTIFIER:  Los Angeles County (CA)
    	     Cook County (IL)
    	     Orleans Parish (LA)
    	     Illinois
    	     California

    ******************************************************************
    ** This file contains an ASCII representation of the text of a  **
    ** GAO report.  Delineations within the text indicating chapter **
    ** titles, headings, and bullets are preserved.  Major          **
    ** divisions and subdivisions of the text, such as Chapters,    **
    ** Sections, and Appendixes, are identified by double and       **
    ** single lines.  The numbers on the right end of these lines   **
    ** indicate the position of each of the subsections in the      **
    ** document outline.  These numbers do NOT correspond with the  **
    ** page numbers of the printed product.                         **
    **                                                              **
    ** No attempt has been made to display graphic images, although **
    ** figure captions are reproduced.  Tables are included, but    **
    ** may not resemble those in the printed version.               **
    **                                                              **
    ** Please see the PDF (Portable Document Format) file, when     **
    ** available, for a complete electronic file of the printed     **
    ** document's contents.                                         **
    **                                                              **
    ** A printed copy of this report may be obtained from the GAO   **
    ** Document Distribution Center.  For further details, please   **
    ** send an e-mail message to:                                   **
    **                                                              **
    **                                            **
    **                                                              **
    ** with the message 'info' in the body.                         **
    ******************************************************************
    GAO/HEHS-98-182

    Cover
    ================================================================ COVER

    Report to the Chairman, Committee on Finance, U.S.  Senate

    September 1998

    FOSTER CARE - AGENCIES FACE
    CHALLENGES SECURING STABLE HOMES
    FOR CHILDREN OF SUBSTANCE ABUSERS

    GAO/HEHS-98-182

    Drug Abuse and Foster Care

    (105827)

    Abbreviations
    =============================================================== ABBREV

      AFCARS - Adoption and Foster Care Analysis and Reporting System
      CASA - Court Appointed Special Advocate
      CSAT - Center for Substance Abuse Treatment
      CWLA - Child Welfare League of America
      DATOS - Drug Abuse Treatment Outcome Study
      DRA - Delegated Relative Authority
      FAS - fetal alcohol syndrome
      GPRA - Government Performance and Results Act
      HHS - Department of Health and Human Services
      LSD - lysergic acid diethylamide
      NIDA - National Institute on Drug Abuse
      OFR - Options For Recovery
      PCP - phencyclidine hydrochloride
      ProjectSAFE - Substance and Alcohol-Free Environment Project
      SIDS - sudden infant death syndrome
      TPR - termination of parental rights

    Letter
    =============================================================== LETTER

    B-276627

    September 30, 1998

    The Honorable William V.  Roth, Jr.
    Chairman, Committee on Finance
    United States Senate

    Dear Mr.  Roth:

    Our nation's foster care population has nearly doubled since the
    mid-1980s, leading to dramatic increases in federal foster care
    expenditures.  Today, about half a million children are in foster
    care,\1 and many of them have been in the system for years.  The
    mid-1980s also marked the onset of the crack-cocaine epidemic.  More
    recently, the use of other hard drugs such as methamphetamines and
    heroin has been on the rise in some parts of the country.  Research
    suggests that the escalating use of hard drugs has contributed to the
    growth in the foster care population.  While we know that children
    often enter foster care because of neglect associated with parental
    substance abuse, little information exists on the effect parental
    substance abuse has on how and when children leave the system.
    Because of concerns about children languishing in foster care, the
    Congress recently enacted legislation that places a greater emphasis
    on adoptions for children who cannot be safely returned to their
    parents in a timely manner.\2

    Because of your concern that children whose parents abuse drugs or
    alcohol may remain in foster care for long periods of time before
    they are placed in a safe, permanent home, you asked us to provide
    information on (1) the extent and characteristics of parental
    substance abuse among foster care cases, (2) the difficulties foster
    agencies face in making timely permanency decisions for foster
    children with substance abusing parents, and (3) initiatives that
    address reunifying families or achieving other permanency outcomes in
    a timely manner for foster children whose parents are substance
    abusers.

    Data on the extent and characteristics of parental substance abuse
    among foster care cases are limited.  To obtain such information, we
    developed and administered a questionnaire that was completed by
    caseworkers for random samples of foster care cases in California and
    Illinois that were in the system as of June 1, 1997, and had been in
    continuously since at least March 1, 1997.  Together, these two
    states account for about one-quarter of the nation's foster care
    population.  To provide information about the difficulties foster
    care agencies might have making timely permanency decisions for
    foster care cases involving parental substance abuse, we conducted
    case studies of foster care programs in Los Angeles County,
    California; Cook County, Illinois; and Orleans Parish, Louisiana.  We
    focused on these three urban counties because they have large foster
    care caseloads and large populations of substance abusers.  We
    selected these particular counties because they provide a geographic
    mix and have foster care laws or initiatives that address parental
    substance abuse and permanency decisionmaking.  In each of our case
    study locations, we interviewed foster care program and policy
    officials, caseworkers, dependency court judges and attorneys, and
    drug treatment providers.  At each location, we also reviewed the
    files for a small number of foster care cases with different
    outcomes, each involving parental substance abuse.  We conducted our
    fieldwork in compliance with generally accepted government auditing
    standards between April 1997 and June 1998.  Our scope and
    methodology are discussed further in appendix I.  Appendix II
    contains the questionnaire that we used to collect data on the extent
    and characteristics of parental substance abuse among foster care
    cases, and appendix III contains the survey results.

    --------------------
    \1 The term "foster care" in this report refers to all types of
    out-of-home foster care for children to protect them from abuse and
    neglect at home.  These placements include family homes (both
    relative and nonrelative), private for-profit or nonprofit child care
    facilities, or public child care institutions.  In Illinois, all of
    these placements together are referred to as "substitute care."

    \2 The Adoption and Safe Families Act of 1997 (P.L.  105-89) was
    enacted on November 19, 1997.

       RESULTS IN BRIEF
    ------------------------------------------------------------ Letter :1

    On the basis of our survey, we estimate that about two-thirds of all
    foster children in both California and Illinois, or about 84,600
    children combined, had at least one parent who abused drugs or
    alcohol, and most had been doing so for at least 5 years.  Most of
    these parents abused one or more hard drugs such as cocaine,
    methamphetamines, and heroin.  Substance abusers often abandon or
    neglect their children because their primary focus is obtaining and
    using drugs or alcohol.  They also place their children's safety and
    well-being at risk when they buy drugs or engage in other criminal
    activity to support their drug habit.  Recovery from drug and alcohol
    addiction is generally a difficult and lifelong process that may
    involve periods of relapse.

    Parental substance abuse makes it more difficult to make timely
    decisions that protect foster children and provide them with stable
    homes.  Foster care agencies face difficulties in helping parents
    enter drug or alcohol treatment programs.  In addition, foster care
    agencies and treatment providers may not always be adequately linked,
    and as a consequence, close monitoring of parents' progress in
    treatment does not always occur.  Finally, foster care agencies also
    face several challenges when trying to quickly achieve adoption or
    guardianship in these cases after family reunification efforts have
    failed.

    To accommodate children's need for timely permanency decisions, some
    locations have launched highly collaborative initiatives, involving
    drug treatment providers and sometimes the courts and other
    organizations, to help parents obtain treatment for their addictions
    and to closely monitor their progress in treatment.  In addition to
    maximizing the prospects for reunification, these initiatives may
    produce the detailed information about parents' progress in treatment
    that judges need to make timely permanency decisions.  Some locations
    are undertaking other efforts to better enable foster care agencies
    to quickly achieve other permanency outcomes for children who cannot
    be safely returned to their parents in a timely manner.  While not
    designed specifically for foster care cases involving parental
    substance abuse, such efforts may be useful in these cases.  For
    example, concurrent planning is being used to reduce the time it
    takes to achieve permanency by simultaneously working to reunify the
    family and planning for some other permanency outcome should family
    reunification efforts fail.  Some locations are also implementing
    programs to encourage relatives of children in foster care to adopt
    or become the legal guardians of these children.

       BACKGROUND
    ------------------------------------------------------------ Letter :2

    Foster care laws and regulations have historically emphasized the
    importance of both reunifying families and achieving permanency for
    children in a timely manner.  Permanency outcomes from foster care
    include family reunification, adoption, and legal guardianship.\3 The
    Congress recently enacted legislation that places a greater emphasis
    on adoption when foster children cannot be safely returned to their
    parents in a timely manner.  Failing to secure a safe, permanent home
    for foster children before they reach age 18--sometimes referred to
    as aging out of the foster care system--can have damaging
    consequences for their emotional stability and future
    self-sufficiency.\4

    Although federal law requires states to make "reasonable efforts" to
    reunify foster children with their parents,\5 neither federal laws
    nor regulations clearly define "reasonable efforts."\6 At a minimum,
    the law does require states to develop a case plan with a permanency
    goal.  When family reunification is the goal, the case plan must
    describe the services--such as drug or alcohol treatment, counseling,
    or parenting classes--that will be provided to help parents rectify
    the problems or conditions that led to their children entering foster
    care.  In order to evaluate the progress that parents have made in
    complying with their case plan requirements, states are required to
    hold court or administrative reviews every 6 months.  They also must
    hold permanency planning hearings at which the judge must determine
    whether to continue family reunification efforts or begin to pursue
    some other permanency goal, such as adoption or guardianship.  In
    determining if and when to end efforts to reunify the family, foster
    care agencies and the courts must balance the goals of reunifying
    children with their parents and meeting children's need for timely
    permanency.

    The Adoption and Safe Families Act of 1997 (P.L.  105-89) emphasizes
    that a child's health and safety are of paramount concern by
    specifying situations in which states do not have to make reasonable
    efforts to reunify the family before parental rights can be
    terminated.\7 This law also stresses the importance of securing safe,
    permanent homes for children in a timely manner by (1) requiring
    states to file a petition to terminate parental rights (TPR) if the
    child has been in foster care for at least 15 of the most recent 22
    months,\8 (2) shortening from 18 to 12 months the time period within
    which a permanency planning hearing must be held,\9 and (3) providing
    incentive payments to states for increasing the number of foster
    children who are adopted.  This law also authorizes funds for
    time-limited family reunification efforts.\10

    Currently, data on foster care outcomes--including family
    reunification rates--and length of stay in foster care are
    limited.\11 A longitudinal study of foster care outcomes in
    California found that, while 44 percent of children who entered
    foster care in 1990 as infants were reunified with their families
    within 4 years, 37 percent were still in care after 4 years.\12 This
    study also showed that foster care outcomes vary by placement type,
    age at entry, and ethnicity.  Data on how parental substance abuse
    may affect the length of time children spend in foster care and their
    outcomes are particularly limited.  However, Illinois reported that
    the percentage of foster children who were reunified with their
    families dropped between 1990 and 1995, which foster care agency
    officials attribute to the "epidemic level of parental drug
    abuse."\13 Parental substance abuse may also result in children
    re-entering foster care.  The California study cited above found that
    among those who were reunified with their families, 28 percent
    re-entered foster care within 3 years.  This study found that
    parental substance abuse was particularly common among cases in which
    children had re-entered foster care.

    Research suggests that children who spend long periods of time in
    foster care, or age out of the system before a permanency outcome has
    been achieved, may have emotional, behavioral, or educational
    problems that can adversely affect their future well-being and
    self-sufficiency.  A study of the title IV-E foster care independent
    living program, which assists children in their transition from
    foster care to self-sufficiency, found that about 2-1/2 to 4 years
    after aging out of the system, 46 percent of foster children had not
    completed high school; 38 percent had not held a job for longer than
    1 year; 25 percent had been homeless for at least 1 night; and 60
    percent of those who were female had given birth to a child.
    Furthermore, 40 percent had been on public assistance, incarcerated,
    or a cost to the community in some other way.\14

    The Department of Health and Human Services (HHS) is responsible for
    the management and oversight of federal programs providing services
    to foster children.  HHS issues federal foster care regulations,
    monitors states' compliance with them, and administers federal
    funding.  Federal foster care funds are authorized under title IV-E
    of the Social Security Act of 1935.  Title IV-E is an uncapped
    entitlement program that reimburses states for a portion of the
    maintenance cost for foster children whose parents meet federal
    eligibility criteria related to their income level.  Federal
    expenditures for the administration and maintenance of children
    eligible for title IV-E funding increased from about $546 million in
    1985 to an estimated $3.3 billion in 1997.  States and counties must
    bear the full cost for maintaining foster children who are not
    eligible for title IV-E funding.\15

    Children are exiting foster care at a slower rate than they are
    entering.  As a result, the foster care population nationwide has
    nearly doubled since the mid-1980s, increasing from about 276,000 in
    1985 to about 500,000 in 1997.  Following the advent of crack-cocaine
    in the mid-1980s, cocaine use increased dramatically and reached
    alarming proportions by the end of the 1980s.  Research indicates
    that the "crack epidemic" may have contributed to the increase in
    foster care caseloads.  We reported that, in 1991, nearly two-thirds
    of foster children 36 months of age or younger in Los Angeles County,
    New York City, and Philadelphia County combined were known to have
    been prenatally exposed to drugs or alcohol.  Most of them were
    exposed to cocaine.\16 Although research indicates that the number of
    new crack-cocaine users is declining, chronic use among parents of
    foster children is still common.

    While crack-cocaine use is declining, the use of other hard drugs is
    on the rise.  Methamphetamine use has been growing, particularly in
    the West and Southwest, and there is a resurgence of heroin use
    throughout much of the country.  Heroin's growing popularity may stem
    from its sharply increased availability; decreased cost; and higher
    purity level, in a form that does not need to be injected.  Both
    crystallized methamphetamines and crack-cocaine are inexpensive,
    smokable drugs that produce immediate and intense highs and increased
    alertness.

    In March 1998, we reported that major studies have shown that drug
    treatment is beneficial, although concerns about the validity of
    self-reported data suggest that the degree of success may be
    overstated.\17 Nonetheless, substantial numbers of clients do report
    reductions in drug use and criminal activity following treatment.
    Research also indicates that those who remain in treatment for longer
    periods generally have better treatment outcomes.  Methadone
    maintenance has been shown to be the most effective approach for
    treating heroin abuse.  Research on the best treatment approach or
    setting for other groups of drug abusers, however, is less
    definitive.  To date, there is no effective pharmacological treatment
    for cocaine abuse, but studies have shown that several
    cognitive-behavioral treatment approaches show promise for treating
    cocaine addiction.  Little is known about the effectiveness of
    treating methamphetamine addiction.

    --------------------
    \3 A legal guardian is someone who assumes legal responsibility for
    the care of a child.  Parental rights do not have to be terminated in
    order to establish a legal guardianship.

    \4 Services to help these young adults become self-sufficient are
    sometimes provided until they are 21 years of age.

    \5 The Adoption Assistance and Child Welfare Act of 1980 (P.L.
    96-272).

    \6 The lack of a specific definition of "reasonable efforts" has been
    a source of controversy, and allegations that the state has failed to
    meet the reasonable efforts requirement have been used as grounds for
    contesting permanency decisions.

    \7 These include cases in which a parent has committed murder or
    voluntary manslaughter or in which parental rights for another child
    have already been involuntarily terminated.  This provision may also
    apply, at the state's discretion, in cases of abandonment, torture,
    chronic abuse, or sexual abuse.

    \8 Exemptions from this requirement are allowed if (1) the child is
    placed with a relative; (2) reasonable efforts to reunite the family
    have not been made; or (3) there is a compelling reason, documented
    in the case file, indicating why it would not be in the best interest
    of the child to terminate parental rights at that time.

    \9 While a permanency decision is not required at the time of the
    initial permanency planning hearing, states are expected to submit a
    permanency plan for the child at this hearing, for the judge's
    approval.  The plan should reflect whether the permanency goal for
    this child is family reunification or some other permanency outcome,
    such as adoption or guardianship.

    \10 These monies are available only during the 15-month period that
    begins on the date the child is considered to have entered foster
    care.

    \11 The Department of Health and Human Services' (HHS) Adoption and
    Foster Care Analysis and Reporting System (AFCARS), which is in the
    early stages of implementation, requires states to report detailed,
    case-specific information.  In the future, information on how
    parental substance abuse affects the length of time children remain
    in foster care and case outcomes may be available through this
    database.  HHS will be using AFCARS data to track foster care
    agencies' progress in meeting HHS program goals under the Government
    Performance and Results Act (GPRA).

    \12 Barbara Needell, Ph.D., "Permanence for Children Entering Foster
    Care as Infants." Family Welfare Research Group, Child Welfare
    Research Center, School of Social Welfare, University of California
    at Berkeley.

    \13 Child Protective and Child Welfare Services Fact Book, FY 1995,
    Illinois Department of Children and Family Services, December 1996.

    \14 A National Evaluation of Title IV-E Foster Care Independent
    Living Program for Youth:  Phase II Final Report, Vols.  I and II
    (Rockville, Md.:  Westat, Inc., 1991).

    \15 The proportion of foster children who are eligible for federal
    IV-E funding has increased from about 40 percent in 1985 to about 50
    percent in 1997.

    \16 Foster Care:  Parental Drug Abuse Has Alarming Impact on Young
    Children (GAO/HEHS-94-89, Apr.  4, 1994).

    \17 Drug Abuse:  Research Shows Treatment Is Effective, but Benefits
    May Be Overstated (GAO/HEHS-98-72, Mar.  27, 1998).

       PARENTAL SUBSTANCE ABUSE IS
       PREVALENT AMONG FOSTER CARE
       CASES AND MAKES REUNIFYING
       FAMILIES EXTREMELY DIFFICULT
    ------------------------------------------------------------ Letter :3

    According to our survey, most children in foster care in California
    and Illinois had at least one parent with a serious and long-standing
    substance abuse problem that makes recovery extremely difficult.
    Most of these parents had been abusing drugs or alcohol for 5 years
    or more.  About two-thirds of these parents had used one or more hard
    drugs such as cocaine, heroin, or methamphetamines.  These hard drugs
    are highly addictive and debilitating and can greatly diminish the
    ability to parent.  These substance-abusing parents often neglect
    their children because their primary focus is obtaining and using
    drugs.  In addition, substance abusers often engage in criminal
    activity that can threaten the safety and well-being of their
    children.  Recovery from drug and alcohol addiction depends on many
    factors, such as the substance abuser's readiness for recovery, and
    relapse is common.

          PARENTAL SUBSTANCE ABUSE IS
          INVOLVED IN MOST FOSTER CARE
          CASES
    ---------------------------------------------------------- Letter :3.1

    On the basis of the results of our survey, we estimate that about 65
    percent of the foster children in California and 74 percent in
    Illinois, or about 84,600 children combined, had at least one parent
    who was required to undergo drug or alcohol treatment as part of the
    case plan for family reunification.  (See fig.  1.) In about 40
    percent of these cases in each state the father was required to
    undergo drug or alcohol treatment, while the mother was required to
    undergo treatment in over 90 percent of these cases in each state.
    In about one-third of the cases involving parental substance abuse in
    each state, either the father was deceased or his whereabouts were
    unknown.  As a result, the mother was usually the focus of the foster
    care agency's family reunification efforts.  Caseworkers in our case
    study locations explained that fathers whose whereabouts are unknown
    may not even be aware they have children in the foster care system;
    and even if they are aware, they may never have been involved in the
    care of their children.

       Figure 1:  Foster Care Cases in
       Which a Parent Was Required to
       Undergo Treatment for Drug or
       Alcohol Abuse

       (See figure in printed
       edition.)

    Notes:  Percentages may not total 100 because of rounding.  About 30
    percent of the fathers and less than 4 percent of the mothers in each
    state were deceased or their whereabouts were unknown.  See also
    tables III.1 and III.2 in app.  III.

    Source:  GAO survey of open foster care cases in California and
    Illinois.