Improving the Oddsfor the Healthy Development

of Young Children in Foster CareSheryl DickerElysa GordonJane Knitzer

PROMOTING THE EMOTIONAL WELL-BEING OF CHILDREN AND FAMILIES

NATIONAL CENTER FOR CHILDREN IN POVERTYMAILMAN SCHOOL OF PUBLIC HEALTH, COLUMBIA UNIVERSITY

2 Improving the Odds National Center for Children in Poverty

Improving the Odds for the Healthy Development of Young Children in Foster Care

Copyright © 2001 by the National Center for Children in Poverty

Copies of this publication are available prepaid for $5.00 from the National Center for Children inPoverty, 154 Haven Avenue, New York, NY 10032; Tel: (212) 304-7100; Fax: (212) 544-4200 or544-4201; E-mail: nccp@columbia.edu; Web site: www.nccp.org. Checks should be made payable toColumbia University.

The Authors

Sheryl Dicker, J.D., is the executive director of the New York State Permanent JudicialCommission on Justice for Children. She has a long history as an advocate on behalf ofpoor and disabled children.

Elysa Gordon, J.D., M.S.W., is the senior policy analyst at the New York State PermanentJudicial Commission on Justice for Children.

Jane Knitzer, Ed.D., is deputy director of the National Center for Children in Poverty.She also directs research on vulnerable families experiencing multiple stresses and onchildren’s mental health.

Acknowledgments

The authors are indebted to the many people involved in the projects described here whogenerously shared their time and their fax machines, responding to all our repeated queriesfor information. We are also very grateful to those who reviewed earlier drafts of the manu-script: Nancy Dubler, J.D., of Montefiore Medical Center; Rutledge Hutson, J.D., of theCenter for Law and Social Policy (CLASP); Dr. Peter Pecora of the Casey Family Program;Dr. Judith Silver, at the Children’s Hospital of Philadelphia; Dr. Sheila Smith of New YorkUniversity; and Dr. Carol Williams of the University of Pennsylvania. Any errors of fact oremphasis, however, are ours. We are also grateful to the NCCP communications and pro-duction team led by Julian Palmer: Carole Oshinsky, Telly Valdellon, Martha Garvey, andElvis Delahoz, as well as to Shari Richardson in the Program and Policy Unit and GinaRhodes who copyedited the manuscript.

This policy paper would not have been possible without the generous support of the CaseyFamily Program.

National Center for Children in Poverty Improving the Odds 3

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Executive Summary

Overview

Very young children are the fastest growing segment ofthe child welfare population. Over the past decade, thenumber of children under age five has increased by 110percent in contrast to a 50 percent increase for all chil-dren. Over 30 percent of all children in foster care areunder age five. Infants comprise the largest cohort ofthe young child foster care population, accounting forone in five admissions, and they remain in care twiceas long as older children. Ensuring healthy develop-ment and permanency for these young children, giventhe range of risks they face, is a complex challenge thatrequires a unique mix of resources and strategies.

Yet, there has been relatively little attention focusedon linking child welfare practice with health care, earlyintervention, and other strategies that could effectivelyaddress the risks that these young children face andstrengthen their families. This policy paper is intendedto be a wake-up call—to challenge communities all overthe country to attend to the needs of children in or atrisk of foster care placement. It is about what child wel-fare agencies, courts, and other partners can do to im-prove the physical, developmental, and emotionalhealth of young children in foster care. It highlightsthe special risks these children face and identifies strat-egies that service providers, courts, policymakers, andadvocates can use to enhance the healthy developmentof young children in foster care and promote their pros-pects for permanency—whether that means reunifica-tion with their families or adoption.

Key Findings from Research: Young Children inFoster Care Are Among the Most VulnerableChildren in the Country

n Nearly 80 percent of these young children are at-risk for a wide range of medical and developmentalproblems related to prenatal exposure to maternalsubstance abuse.

n More than 40 percent of them are born low birth-weight and/or premature, two factors which increasetheir likelihood of medical problems and develop-mental delay.

n More than half suffer from serious physical healthproblems.

n Over half experience developmental delays, whichis four to five times the rate found among childrenin the general population.

n Despite their vulnerability, a significant percentageof these young children do not receive basic healthcare such as immunizations, and specialized needsresulting from developmental delays and emotionaland behavioral conditions are even less likely to beaddressed.

Promising Strategies to Promote the HealthyDevelopment of Young Children in Foster Care

n Provide developmentally appropriate health care toyoung children in the context of comprehensivehealth care for all children in foster care.

n Design and implement specialized developmentaland mental health assessments and services for youngchildren in foster care.

n Create monitoring and tracking mechanisms to en-sure that needed health, developmental, and men-tal health services are provided.

n Ensure that young children in foster care have ac-cess to quality early care and learning experiences.

n Use the oversight authority of the courts to ensurethat children in foster care receive needed health,developmental, and mental health services as a partof permanency planning.

This policy paper is intended to be a wake-up call—to challenge communities all over the country

to attend to the needs of children in orat risk of foster care placement.

4 Improving the Odds National Center for Children in Poverty

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Action Steps and Key Recommendations

n Use federal laws, programs, and dollars provided un-der the Adoption and Safe Families Act, Medicaid,Early and Periodic Screening, Diagnosis and Treat-ment, the Early Intervention Program (Part C of theIndividuals with Disabilities Education Act), andTemporary Assistance for Needy Families to developspecialized attention to young children in foster care.

n Harness the power of the courts, which review theplacement of all children in foster care, to enhancetheir healthy development.

n Build collaborative partnerships between the courtsand child welfare, health care, early intervention,and early childhood agencies to enhance develop-mental outcomes for young children in foster care.

n Ensure that court personnel, child welfare workers,biological and foster parents, and other caregivershave the training and information that they need tohelp young children in foster care.

n Develop explicit state and community-based strate-gies to ensure that young children in foster care haveaccess to developmental health services, high-qual-ity child care including Early Head Start, and pre-school and family support programs.

n Develop formal mechanisms to track and monitorthe delivery of health, mental health, and relatedservices to children in foster care.

n Use professional and state best-practice standards andrelevant federal guidelines that call for the deliveryof comprehensive, coordinated, continuous, and fam-ily supportive care as a framework to develop im-proved approaches to promote healthy early devel-opment for young children in foster care.

n Weave together multiple approaches to enhance thewell-being of young children in foster care, buildingon community strengths.

n Pay special attention to young children at risk ofplacement in foster care and those being dischargedfrom the child welfare system. These children needaccess to all the benefits to which they are entitled(such as continuation of Medicaid) as well as accessto comprehensive and multidisciplinary services thatcan both enhance their healthy development andtheir prospects for permanency.

n Promote a federal agenda that provides incentivesto states and communities to build partnerships withhealth care and early childhood agencies to enhancethe healthy development of young children in or atrisk of foster care placement.

Young children at risk of placement in foster care andthose being discharged from the child welfare system

need access to all the benefits to which they are entitled(such as continuation of Medicaid) as well as access

to comprehensive and multidisciplinary servicesthat can both enhance their healthy development

and their prospects for permanency.

Ensuring healthy development and permanencyfor these young children, given the range

of risks they face, is a multifaceted challengethat requires a unique mix of resources and strategies.

National Center for Children in Poverty Improving the Odds 5

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Introduction

Very young children are the fastest growing segment ofthe child welfare population. Each year, about 150,000children under age five are placed in foster care by courtorder, representing about 30 percent of all children infoster care. Over the past decade, the number of chil-dren under age five in foster care has increased by 110percent, in contrast to a 50 percent increase for all-aged children.1 Ensuring healthy development andpermanency for these young children, given the rangeof risks they face, is a complex challenge that requiresa unique mix of resources and strategies.

These infants, toddlers, and preschoolers enter the childwelfare system already exposed to poverty, substance abuse,and parental neglect and abuse.2 Compared to other chil-dren living in poverty, young children in foster care arefar more likely to have fragile health and disabilities andfar less likely to receive services that address their needs.Yet, there has been relatively little attention focused onlinking child welfare practice with health care, early in-tervention, and other strategies that could effectively ad-dress the risks that these young children face. Ignoringtheir needs and failing to provide their parents with sup-port compromises the well-being of these children andcan undermine the family-building efforts of the childwelfare system. Connecting young children in foster careto health and early intervention services provides an im-portant opportunity to enhance the child’s developmentand strengthen the child’s family.

This issue brief is about what child welfare agencies,courts, and other partners can do to improve the physi-cal, developmental, and emotional health of young chil-dren in foster care. It is organized into four sections. Thefirst section highlights the special risks that these chil-dren face. The second section highlights the major rea-sons why it is important to focus deliberate, strategicpolicy and practice attention on improving the physi-cal, developmental, and emotional well-being of youngchildren in foster care. The third section identifies fivestrategies that pioneering service providers, courts, andtheir partners are using to improve the emotional anddevelopmental status of young children, providing ex-amples of each strategy in action. The final section iden-tifies action steps that child welfare professionals, judges,

attorneys and other court personnel, service providers,policymakers, and advocates can take to enhance thehealthy development of young children in foster careand promote their prospects for permanency.

Portrait of Young Children in Foster Care

Young children in foster care are among the most vul-nerable children in the country. Nearly 40 percent ofthem are born low birthweight and/or premature, twofactors which increase the likelihood of medical prob-lems and developmental delay.3 These infants and tod-dlers are involved in over one-third of all substanti-ated neglect reports and more than half of all substan-tiated medical neglect reports.4 More than half sufferfrom serious physical health problems, includingchronic health conditions, elevated lead blood-levels,and diseases such as asthma.5 Dental problems are wide-spread: one-third to one-half of young children in fos-ter care are reported to have dental decay.6 Over halfexperience developmental delays, which is four to fivetimes the rate found among children in the generalpopulation.7 For example, one recent study found thatmore than half of over 200 children in foster care un-der the age of 31 months had language delays, com-pared to the general population of preschoolers in whichonly 2 to 3 percent experience language disorders and10 to 12 percent have speech disorders.8

The risks to healthy development are especially pro-nounced for infants. Infants comprise the largest cohortof the young child foster care population, accounting forone in five admissions to foster care and remaining incare longer than older children. Infants placed withinthree months of birth are those most likely to enter careand spend the longest time in care—twice as long asolder children. One-third of all infants discharged fromfoster care reenter the child welfare system, further un-dermining the likelihood of their healthy development.9

Connecting young children in foster care to healthand early intervention services provides an important

opportunity to enhance the child’s developmentand strengthen the child’s family.

6 Improving the Odds National Center for Children in Poverty

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In the recent past, most of these young children—nearly80 percent—have been at risk for a wide range of medi-cal and developmental health problems related to pre-natal exposure to maternal substance abuse.10

All young children in foster care also face heightenedrisk of emotional and behavioral problems. The incon-sistent and unresponsive caregiving to which they areoften exposed sets the stage for potentially serious emo-tional and behavioral difficulties, often involving dif-ficulty in forming close relationships and managingemotions.11 As infants and toddlers, the children mayshow signs of attachment disorders. As preschoolers,their behavior may be especially challenging and pro-vocative, or they may show signs of anxiety and de-pression. These problems not only affect the children,but often cause great stress for those who care for them:relatives, foster parents, and child care providers, as wellas their biological parents. If severe enough, these is-sues can disrupt the placement of the children in fosterhomes and prevent successful permanency outcomes.

But despite their vulnerability, too many young chil-dren in foster care do not receive services that can ad-dress and ameliorate these risks. A significant percent-age do not even receive basic health care, such as im-munizations, dental services, hearing and vision screen-ing, and testing for exposure to lead and communicablediseases (see box below). Specialized needs such as de-velopmental delays and emotional and behavioral con-ditions are even less likely to be addressed.12

Why It Is Important to Promotethe Healthy Developmentof Young Children in Foster Care

There are three compelling reasons to develop deliber-ate strategies to promote the healthy development ofyoung children in foster care:

1. New scientific knowledge shows the importanceof the earliest years.

Emerging research makes it very clear that stable,nurturing early relationships are key to a child’ssocial and emotional development. All children areborn wired for feelings and ready to learn, but earlyexperiences and/or exposure to risk factors can dis-rupt these processes.13 Indeed, a compelling bodyof cumulative science indicates that the more riskschildren experience, the more likely they are tohave serious negative consequences that are re-flected in their behavior and development. Sinceresearch shows that children in foster care experi-ence many risk factors, this is a very troubling pic-ture.14 However, research also suggests that inten-sive and early interventions can help reduce theharm that young children in foster care face due totheir experiences with multiple risk factors.15

2. Children in foster care are the state’s children.

All children in foster care are placed by court orderin the custody of the state. The court order vests thestate with powers typically exercised by parents forall other children. The state determines where andwith whom a child will live, the nature of any medi-cal care, and whether the child receives early child-hood services or other services to address his or herneeds. Neither the biological parent nor a fosterparent who may know the child best has authorityto make all vital decisions on a child’s behalf. Thus,unlike most other young children, many childrenin foster care often lack the most fundamental re-source to ensure their healthy development—astable relationship with an adult who can observetheir development over time, advocate on theirbehalf, and provide consent to services.

FOSTER CARE IN THREE URBAN AREAS

Findings from a U.S. General Accounting Office report about how youngchildren in foster care fared in three urban areas (serving 50 percent ofall young children in foster care)

n 12 percent received no routine health care.

n 34 percent received no immunizations.

n 32 percent continued to have at least one unmet health need after placement.

n 78 percent of the children were at high risk for HIV, but only 9 percent hadbeen tested for the virus.

n Less than 10 percent received services for developmental delays.

n Children placed with relatives received fewer health-related services ofall kinds than children placed with nonrelative foster parents.

Source: U.S. General Accounting Office. (1995). Foster care: Health needs of many young children are unknownand unmet (GAO/HEHS 95-114). Washington, DC: U.S. General Accounting Office.

National Center for Children in Poverty Improving the Odds 7

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Because of these enormous powers, the state hasan enhanced responsibility to children in foster careabove and beyond its responsibility to all otherchildren—it has a responsibility to improve theirwell-being and to strengthen their families. Con-sistent with that enhanced responsibility, federaland state law mandates that state child welfarepolicy and practice ensure a child’s safety and well-being and promote permanence.16 Ignoring theirneeds and failing to provide parents and foster par-ents with support compromises the well-being ofthese children and can undermine the child wel-fare system’s family-building efforts.

One way to meet these obligations is for states toensure that young children receive appropriate andtimely services, their caregivers receive respite andsupport, and caseworkers and court personnel un-derstand the connections between reducing the de-velopmental risks to young children in foster careand achieving permanency. For example, ensuringreunification, adoption, or a stable foster or kin-ship care placement for a young child with severedisabilities, chronic health problems, or emotion-ally challenging behavior is likely to be much easierif the caregivers receive respite care as well as train-ing to manage their child’s special needs.

3. It is in society’s economic and social interest topromote positive outcomes for young children infoster care.

The third reason to promote strategic attention tointerventions targeted to young children in fostercare is that this nation has a vested interest in pro-moting the healthy development of all of its youngchildren. In fact, more and more states are craftingpolicies to promote sound developmental and fam-ily support services for their young children.17 Con-gress, too, has weighed in. Recognizing the linksamong early development, school readiness, andlater school performance, this nation has set fortha national goal that “all children shall enter schoolready to learn.”18 All children, of course, includesyoung children in foster care. But given the levelof risk so many children in foster care face, pro-moting their healthy development and schoolreadiness requires more than business as usual. In-

deed, failing to address these young children’s needshas costly consequences for society. Children whohave spent part of their childhood in foster careare more likely than other children to suffer ad-verse outcomes such as dropping out of school, teenpregnancy, homelessness, or incarceration.19

Five Strategies to Promotethe Healthy Developmentof Young Children in Foster Care

Given the range of risks they face, ensuring the healthydevelopment of young children in foster care is a many-sided challenge. This section highlights five corestrategies that, either singly or in combination, canchange the manner in which the needs of young chil-dren in the foster care system are addressed. Each strat-egy is illustrated with examples of the ways it is beingimplemented.

Children who have spent part of their childhoodin foster care are more likely than other children

to suffer adverse outcomes such as droppingout of school, teen pregnancy, homelessness,

or incarceration.

STRATEGIES TO PROMOTE THE HEALTHY DEVELOPMENTOF YOUNG CHILDREN IN FOSTER CARE

n Provide developmentally appropriate health care to young children in thecontext of comprehensive health care for all children in foster care.

n Design and implement specialized developmental and mental healthassessments and services for young children in foster care.

n Create monitoring and tracking mechanisms to ensure needed health,developmental, and mental health services are provided.

n Ensure that young children in foster care have access to quality early careand learning experiences.

n Use the oversight authority of the courts to ensure that children in fostercare receive needed health, developmental, and mental health services as apart of permanency planning.

8 Improving the Odds National Center for Children in Poverty

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STRATEGY 1Provide developmentally appropriate health careto young children in the context of comprehensivehealth care for all children in foster care.

Every child involved in the child welfare system shouldhave access to continuous health and developmentalservices. The following examples highlight how youngchildren can receive these services in the context ofcomprehensive health-related strategies for all-agedchildren. They embody best practice principles as de-fined by standards developed by the American Acad-emy of Pediatrics and the Child Welfare League ofAmerica, which require that services for children infoster care be comprehensive, coordinated, continuous,and family-supportive. (See box on page 9 for defini-tions).

Excellence in Health Care to Abused andNeglected Children (ENHANCE)Syracuse, New York

ENHANCE is a comprehensive, multidisciplinary pro-gram providing pediatric health care, child develop-ment, and mental health services twenty-four hours aday, seven days a week, to over 600 children in fostercare in Onondaga County. The program is a collabora-tive effort between the State University of New YorkUpstate Medical Center in Syracuse, New York, andthe Onondaga County Department of Social Services(DSS).

Staff includes two pediatricians, a clinical child psycholo-gist, a child development specialist, two pediatric nursepractitioners, two registered nurses, and access to spe-cialists at the university hospital. The psychologist pro-vides mental health assessments, clinical interventionand referral, and consultation to ENHANCE staff, DSScaseworkers, and foster parents. A DSS caseworkerfunctions as a liaison between ENHANCE and DSS.A typed summary of each ENHANCE visit is given toDSS and made available to foster parents. When chil-dren are discharged from foster placement, their guard-ian attends a discharge visit at ENHANCE. The pur-pose is to ensure that the guardian is fully aware of thechild’s medical history, to facilitate the transfer of careto a new physician, and to be sure that the guardianhas an opportunity to address all concerns. Half of these

MAJOR FEDERAL PROGRAMS TO HELP FOSTER CHILDREN

The following federal programs are being used to promote the physical,developmental, and emotional well-being of young children in foster care:

Adoption and Safe Families Act (ASFA): This legislation and its predecessor,the Adoption Assistance and Child Welfare Act, establish the framework forchild welfare policy and practice. ASFA focuses on ensuring permanence, in-cluding adoption, for all children in foster care as well as ensuring their safetyand well-being. Under ASFA, the health and safety of children in foster care areto be “paramount concerns” in every child protective proceeding. It also strength-ens the court’s role in monitoring cases and tightens timeframes for makingdecisions about permanency.

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Provisionsof Medicaid: EPSDT sets forth clear regulations relating to the delivery of compre-hensive health-related services to all children eligible for Medicaid, which includesall children in foster care.20 As the title suggests, it requires ongoing and peri-odic screening, diagnosis, and treatment of conditions affecting the health sta-tus of children. It also permits states to use Medicaid to finance an array ofEPSDT-required services that might otherwise be ineligible for Medicaid reim-bursement, including early intervention services and developmental screening.

Early Intervention Program for Infants and Toddlers (Part C of the Indi-viduals with Disabilities Education Act): The Early Intervention Program pro-vides an entitlement to services for infants and toddlers who experience devel-opmental disabilities and delays or physical or mental conditions with a highprobability of resulting in delay. States set specific eligibility criteria. The lawpermits “parents,” which includes biological and adoptive parents, a relativewith whom a child is living, a legal guardian, and, in some instances, a fosterparent and other caregivers, to receive services. These may include parenttraining and counseling, parental support groups, home visits, and respite careto enhance the development of their children, based on an Individualized Fam-ily Service Plan (IFSP) that is developed with family input to guide services.

Temporary Assistance for Needy Families (TANF) provision of the Per-sonal Responsibility and Work Opportunity Reconciliation Act: TANF, thecurrent welfare law, requires recipients of cash assistance to work and setslifetime limits on the receipt of cash assistance (up to five years in federal law,but shorter at state option). The law, through a block grant to the states,makes funds available for a wide array of services and supports consistent withthe four purposes of the law. These are to: provide assistance to needy familiesso that children may be cared for in their own homes or in the homes ofrelatives; end the dependence of needy parents on government benefits bypromoting job preparation, work, and marriage; prevent and reduce the inci-dence of out-of-wedlock pregnancies; and encourage the formation of two-parent families.

For sources and more information, see Appendix A.

National Center for Children in Poverty Improving the Odds 9

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children elect to continue their care at the UpstateMedical University after they leave foster care. Recog-nizing the special importance of ensuring the well-be-ing of young children in foster care, children ages birthto 18 months are visited in their foster homes by anENHANCE nurse practitioner, who conducts a devel-opmental assessment.

Center for the Vulnerable Child (CVC)/Services to Enhance Early Development (SEED)Oakland, California

The Center for the Vulnerable Child focuses on at-riskchildren and their families. Located within theChildren’s Hospital of Oakland, the CVC program is aprivate, nonprofit, regional pediatric medical centerserving the San Francisco Bay area and northern Cali-fornia that offers comprehensive health, developmen-tal, and mental assessment; treatment; and referralsthrough a series of clinics. There is a special CVC pro-gram for children in foster care that now includes SEED,a pilot project in conjunction with a county child wel-fare office to provide services to infants and toddlers infoster care.

The CVC foster care program, targeted both to chil-dren and their biological and foster families, providesan array of family-focused services including intake as-sessments, foster parent support groups, home andclinic-based mental health consultation, and case man-agement. The staff works with an interdisciplinary teamof physicians, nurses, psychologists, social workers/casemanagers, and addiction specialists. Intensive casemanagement is used to provide and monitor neededservices and develop strong collaborative relationshipswith both the county caseworkers and foster parents.Primary health care is provided by the foster care medi-cal clinic during two half-day medical clinics each week.Additionally, CVC psychologists or child developmentspecialists screen children for early indicators of men-tal health and behavioral problems. Children in theprogram can receive intensive short-term mental healthservices at the clinic or be referred to appropriate com-munity mental health resources. Health-related activi-ties are supplemented by a rich program of supports tofamilies, foster parents, and child welfare workers. Forexample, foster parents (including those whose chil-dren are not served by CVC) can participate in a sup-

port program that addresses issues of child developmentand parenting. The sessions are also open to profes-sionals from local child welfare and foster family agen-cies. The CVC foster care program also works with asmall group of children who are newly reunified withtheir biological parents.

The SEED pilot program provides therapeutic inter-ventions and care coordination services for childrenunder age three in foster care. It is being implementedin the Alameda County Department of Social Services.Four child welfare workers and a public health nurseare following 100 randomly assigned children from birthto age three. Once a child is assigned to SEED, a fosterparent is contacted and a visit is scheduled for either aclinic or home visit. At the initial visit, SEED staffcomplete a family needs assessment. Within twomonths of entry into SEED, a psychologist administersa developmental assessment for each child. A publichealth nurse gathers the child’s medical history, whichmay include interviews with the biological family and

STANDARDS FOR FOSTER CARE SERVICES

The American Academy of Pediatrics and the Child Welfare League ofAmerica have defined best practice standards for comprehensive healthand related services to children in foster care to require that care be:

n Comprehensive: Children in foster care should receive a package of healthservices including preventive health care, care for acute and chronic illness,developmental and mental health screening and services if indicated, den-tal care, ongoing evaluation for abuse and neglect, and referrals to earlyintervention and early childhood programs.

n Coordinated: One person should be identified as responsible for overseeingthe child’s care and sharing information about the child’s needs across sys-tems— child welfare, early childhood, early intervention, education, medi-cal, and mental health. Establishing formal mechanisms to ensure that neededservices are provided and monitoring the child’s health and access to careare essential components of care coordination.

n Continuous: Information about the child’s health history, services, and healthinsurance coverage accompany the child as the child enters care, changesplacement, and is discharged from care.

n Family-supportive: Information about the child’s health should be sharedwith the child’s caregivers and should provide support to families in theirongoing care of the child.

Sources: American Academy of Pediatrics, Committee on Early Childhood, Adoption, and Dependent Care. (1994).Health care of children in foster care. Pediatrics, 93(2), 335, and Child Welfare League of America. (1988).Standards for health care services for children in out-of-home care. Washington, DC: Child Welfare League ofAmerica.

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the child. Biological families are invited to participatewhere reunification is the permanency goal. This in-formation and other health-related data are entered intoa statewide computer system. Alameda County and theCVC have just begun SEED II, a refinement and ex-pansion of SEED, for 60 children aged birth to five,within a second special unit of the child welfare agency.

Reflections

Comprehensive health care collaborations are “one-stop shopping.” They provide multidisciplinary healthservices to children in foster care and their caregiversat a centralized site. Each involves a partnership be-tween a local social service/child welfare agency and ahealth care agency—in these examples either univer-sity based or hospital based. In other examples aroundthe country, they may be based in primary care facili-ties21 or involve a managed care organization. Althoughthe specifics of the staffing patterns and the collabora-tive partners vary, all use Medicaid and Early and Peri-odic Screening, Diagnosis, and Treatment (EPSDT) asthe starting point and are guided by standards of besthealth care practice for children in foster care. Becausethese “one-stop” models often see the vast majority ofchildren in foster care in a region, staff can developexpertise in issues related to the health of children infoster care and become a repository of information aboutthe child’s health status. Moreover, whatever their scopeand structure, a special focus on young children can beaccommodated easily, for example, by using publichealth nurses to assess and facilitate early interventionand other specialized services for them in the contextof broader services to all-aged children.

STRATEGY 2Ensure Access to Early Intervention Services forInfant and Toddlers in Foster Care.

Young children in foster care need not only access tohealth services, but sometimes to specialized early in-terventions. For this, federal law provides an impor-tant building block to ensure that young children getsome of the specialized early intervention services theyneed—the Early Intervention Program of the federalIndividuals with Disabilities Education Act (IDEA).22

Part C, as it is known, requires services to infants andtoddlers with developmental delays, a high probabilityof delay, or, in some states, young children who are atrisk of developing delays. (See box on page 8.) Of par-ticular relevance in the context of foster care, the lawpermits services to be provided to foster parents andrelatives as well as to biological and adoptive parents.23

(Some states, such as New York, also permit services toother caregivers, such as early childhood providers.)24

Yet, despite these provisions, accessing these serviceson behalf of young children in foster care presents spe-cial challenges. Typically, referrals to Part C programsare made by parents or physicians. But children in fos-ter care are less likely to receive consistent parentingand medical care. Requirements for parental consentat every juncture also complicates access—parents maybe unavailable and foster parents lack legal authority.The two program examples described below reflect ef-forts to ensure that infants and toddlers in foster careare connected to Part C services, one through acountywide strategy, the other at a program level.

Attention to the emotional development of young chil-dren in foster care is also crucial—both through ser-vices that help the children directly, and, equally im-portant, through services that help parents and fosterparents promote healthy relationships and repair dam-aged relationships where necessary. The third programin this section is structured to do just this.25

The Starting Young ProgramThe Children’s Hospital of PhiladelphiaPhiladelphia, Pennsylvania

The Starting Young Program is a pediatric, multidisci-plinary developmental diagnostic and referral servicethat is designed exclusively for infants and toddlers who

Every child involved in the child welfare systemshould have access to continuous health

and developmental services.

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receive foster care or in-home child welfare servicesfrom the Philadelphia Department of Human Services(DHS). Its aim is to link these children to early inter-vention services through Part C and to ensure that theyreceive appropriate health care and social services.

Starting Young evaluates approximately 10 percent ofPhiladelphia County’s 1,163 foster children under 31months of age annually, accepting referrals from over40 agencies under contract with the DHS or directlyfrom DHS caseworkers. The program is based at theChildren’s Hospital of Philadelphia. The multidisci-plinary assessment team includes a pediatrician, childpsychologist, speech-language pathologist, and physi-cal therapist who provide developmental evaluationsof infants and toddlers. A pediatric social worker con-ducts intake interviews and facilitates referrals, while aproject manager schedules appointments and maintainsthe information database. The team includes an intakeworker from the county agency that coordinates theearly intervention program. This makes it easier to ex-plain the program to the child’s caregiver, complete thecounty intake for eligible children, and facilitate timelyand smooth admission to the program. The assessmentteam collaborates with the child welfare social workerto develop recommendations for the child’s service plan.Biological parents are encouraged to attend sessions,and training and support to help caregivers enhancetheir relationship with their child is a key tenet of theprogram.

Once authorization is obtained for the release of infor-mation, typed reports are sent to the child’s socialworker from the private child welfare agency, the DHScaseworker, and the caregiver (foster parent and/or bio-logical parent). The child’s attorney also receives thereport in cases where the Starting Young team deter-mines that additional advocacy is warranted. Thecaregiver is encouraged to share the report with thechild’s primary health care provider. Starting Young’ssocial worker follows up with the caregiver 8–12 weeksafter the evaluation to ensure that the child receivesrecommended services. Children are reevaluated ev-ery six months until 30 months of age regardless of fos-ter care placement or discharge.

Although Starting Young does not provide primary medi-cal care, it serves as a resource to professionals and

caregivers of young children in foster care throughoutthe metropolitan area, including training child welfareprofessionals on children’s health and development.

Leake and WattsYonkers, New York

Leake and Watts is one of the oldest child welfare andcommunity service agencies in the country. Its Medi-cal and Mental Health Services Department includespediatricians, advanced practice nurses, and psycholo-gists operating out of two community clinics and linkedto major medical centers in the region. All foster chil-dren receive ongoing medical care and are assigned anurse case manager in addition to a caseworker. It alsohas a special commitment to improving the develop-mental status of young children, providing on-site as-sessment, early intervention, and early childhood pro-grams. Thus, all children under age five receive a de-velopmental and behavioral screening from a NurseDevelopmental Specialist. These screenings occur onadmission and then at regular intervals of 2–6 monthsand include a discussion with the foster parent to iden-tify any concerns about the child’s behavior and devel-opment. Children under three years identified as need-ing further evaluation are referred to their Early Inter-vention Unit where a service coordinator shepherdsthe child through the process of creating an Individu-alized Family Service Plan (IFSP) and works with boththe foster and biological family. Children between agesthree and five are referred for evaluation by agency staffthrough the preschool special education process.

Parents and Children Together Birth-to-FiveInitiativeDetroit, Michigan

The Birth-to-Five Initiative is part of the Parents andChildren Together (PACT) program. PACT is a jointeffort between Wayne State University and the Michi-

Children in foster care are less likely to receiveconsistent parenting and medical care.

Further complicating access are requirementsfor parental consent at every juncture in the process.

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A number of jurisdictions are developingspecialized monitoring and tracking mechanisms

that strengthen accountability to children infoster care, sometimes in response to litigation.

gan Family Independence Agency. Its major purpose isto provide year-long training internships to post-bach-elor professionals in order to enhance their skills inworking with families involved in the child welfare sys-tem. All children served by the PACT program are infoster care or protective or prevention services, andrange from birth to age 17. PACT interns work closelywith the child’s caseworker and relevant systems, pro-viding reports to the courts and schools.

PACT created the Birth-to-Five Services Unit to meetthe specialized needs of children in foster care under agefive. Program staff includes three infant mental healthspecialists, university interns, and an early interventionservice coordinator. All children receive a developmen-tal screening, and those identified with risks for delay ordisability receive a comprehensive developmental assess-ment. Children under age three with developmentaldelays are referred to the state early intervention pro-gram. PACT staff meet with biological and foster par-ents, make home visits, and provide individual and fam-ily counseling, parent education groups, and parent-childinteraction activities. Through the visitation program,a PACT counselor coaches parents to recognize andrespond to their child’s needs. PACT also assists fami-lies with transportation and food vouchers. WhilePACT does not provide primary health care, it willensure that a child has a medical provider and will checkimmunization records. Meals and snacks are served atthe center to provide parents with an opportunity tospend time meeting the basic needs of their child.Wayne State University has provided funding for datacollection, including the impact of the program on re-unification. An evaluation of the program is in progress.

Reflections

Specialized programs for young children in foster caremeet many needs. Most include careful assessment andappropriate referrals to other community-based services,including early intervention and family support services.Some focus on assessment and early detection of de-velopmental and emotional distress; others provide arange of direct services for the children and their fosterand biological parents, helping to model and promotestrong relationships for both. To maximize the impactof these kinds of interventions, they also include for-mal mechanisms to share and interpret information

about the child’s need for services with caseworkers andcourt actors responsible for making permanency deci-sions. In some instances, the strategy of choice iscountywide; in others, specific intervention strategiesare developed by foster care agencies or early child-hood programs.

STRATEGY 3Create monitoring and tracking mechanisms toensure that needed health, developmental, andmental health services are provided.

Ensuring that children in foster care actually get thehealth and developmental services that they need isproblematic. Caseworkers and attorneys change, chil-dren move from placement to placement, often mov-ing to different jurisdictions, and many programs suchas Early Intervention are premised on active parentalinvolvement. To address these challenges, a number ofjurisdictions are developing specialized monitoring andtracking mechanisms that strengthen accountability tochildren in foster care, sometimes in response to litiga-tion. The first strategy described below is a countywideinitiative.26 The other two efforts are statewide initia-tives to develop health passports to ensure that infor-mation about the child’s health status is available tothose who need and are entitled to it.

The Foster Care ProjectSuffolk County, New York

In Suffolk County, New York, the Foster Care Projectrepresents a collaborative effort between the SuffolkCounty Departments of Health Services and SocialServices to provide home visits by public health nursestwice a year to children age birth to 13 years in fostercare to ensure their health and well-being. During thevisit, a public health nurse from the county’s Bureau ofPublic Health Nursing, located in the local Departmentof Health Services, conducts a complete physical; ob-

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tains the child’s health history, immunization, and den-tal care status; and identifies the child’s primary careprovider. The nurse also assesses the foster parent’s abil-ity to oversee the health needs of the child and pro-vides education to the foster family as indicated. If theassessment of the child identifies a health or medicalproblem, the nurse will make a referral to the child’sprimary care provider for follow-up. The nurse will com-municate with the provider regarding the referral andany subsequent interventions.

For children under age six, the nurse conducts a devel-opmental screening and refers eligible children underage three to the county Part C Early Intervention Pro-gram. In addition, for infants new to foster care, visitsare made immediately, rather than in alphabetical or-der of the foster parents’ names. Reports of the visit aresent to the foster care division of the county Depart-ment of Social Services. All the visits are billed toMedicaid. The Bureau of Public Health Nursing re-ceives approximately 100 referrals each month.

The Fostering Healthy Children ProjectUtah

The Fostering Healthy Children project is a collabora-tion among Utah’s Child Welfare, Medicaid, and Men-tal Health agencies as well as health care providers. Itwas designed as a response to litigation. Thirteen pub-lic health nurses and nine support staff, funded by theUtah Health Department, are colocated at child wel-fare agencies throughout the state. The nurses serve ascase managers to ensure that children in foster care re-ceive screening, treatment, and follow-up services. Theyattend a multidisciplinary meeting that is convenedwithin 24 hours of the child’s entry to develop a medi-cal history and health needs assessment, and they areresponsible for sharing information with the child’sprimary health care provider and working with fosterparents to ensure that the child receives services. Ad-ditionally, the nurses collaborate with and provide train-ing for child welfare caseworkers, serve as medical casemanagers for children with complex needs, and ensurehealth care continuity during placement changes. Theyare also responsible for maintaining a computerized datasystem based on the health visit forms completed byhealth care providers. The database is part of the state’sautomated child welfare information system that con-

tains all child welfare data. Reports are availablethrough the Internet to users having special securityclearances. Although this does not now include fosterparents, the plan is that it will in the future.

The Health and Education PassportCalifornia

Under the California Health and Education Passportprogram, California employs public health nurses toprovide an array of supportive services to children infoster care or other out-of-home placements. The nursesare hired by county child welfare departments and byChild Health and Disability Prevention Programs.27

Each county develops the initiative differently:

n In San Diego, the county has formed a consortiumthat includes Children’s Hospital of San Diego andthe newly created San Diego County Health and Hu-man Services Agency (HHSA). It has also priori-tized the development of passports for children un-der age five. The program is managed by the HHSAusing funds from the EPSDT program. The passportsinclude immunization records, information aboutmedical and dental problems, laboratory test results,results of hearing, vision, and developmental screen-ing, and recommendations for follow-up care. Infor-mation gathered during the child’s initial medicalexam (required within 30 days of care entry) is for-warded to the Health and Education Passport Unit.Located in the county HHSA, the unit consists ofpublic health nurses and clerks. Unit staff send formsto biological and foster parents to obtain contact in-formation for the child’s health care providers andthen gather information on the child’s needs fromthese providers. The public health nurses are respon-sible for interpreting the health information receivedfrom the provider, summarizing the information, andentering the data into the unit’s database. The nursesalso train child welfare workers on medical issues andEPSDT follow-up and provide consultation on indi-vidual cases.

n In Santa Clara county, as described below, the pass-port system is actively used by Judge LeonardEdwards, Supervising Judge of the Dependency Di-vision, Santa Clara Superior Court, to identify prob-lems and gaps in services and to guide case planning.

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Reflections

These tracking and monitoring efforts are potentiallyvery significant. They combine computer-based mecha-nisms and efficiencies with a people-based approach,often involving the use of public health nurses. Typi-cally, public health nurses are viewed as nonthreaten-ing by families, have knowledge about children’s healthand development, are trained to educate other profes-sionals and clients about health issues, and can workeasily with other health care providers. All involvedreport challenges in making tracking and passport sys-tems work efficiently for all children in foster care. Butall also recognize the importance of such tracking strat-egies in enabling child welfare workers, foster parents,and the courts to monitor the health, emotional, anddevelopmental status of the children, especially whetherthey are receiving EPSDT and other services to whichthey are entitled.

STRATEGY 4Ensure that young children in foster care haveaccess to quality early care and learningexperiences.

In many ways, the first line of defense for young chil-dren in foster care ought to be ensuring that they haveaccess to high quality early care and education pro-grams. For young children in foster care, these programscreate an opportunity for the child to experience anurturing, stimulating environment. For families, theyoffer information, connection to other resources, and,sometimes, direct services to help address challengingproblems.28 Early care and education programs also cansupport many foster and kinship parents, who, like allother parents, must hold a job as well as be a parent.

States are increasingly investing in early childhoodprograms and family support programs such as HeadStart, Early Head Start, Healthy Families, and Parentsas Teachers. Typically, the goals of these programs areto promote healthy child development and provide fam-ily support and to help ensure that, consistent with GoalOne of the Educate America Act, all children enterschool ready to succeed. Yet, for the most part, youngchildren in foster care are not deliberately enrolled inhigh-quality, developmentally-enriching child care andearly learning experiences. Highlighted below are two

approaches, one focused at the program level and theother at the state level, that ensure children in fostercare and their families are included in these programs.29

West Boone Early Head StartSpokane, Washington

The West Boone Early Head Start provides early child-hood and parent-child support services to young chil-dren in foster care. It is a partnership among the Spo-kane County Early Head Start, the Casey Family Pro-gram, which operates a network of family foster careprograms, and the Marycliff Institute, a group of men-tal health therapists and researchers. Early Head Startoperates a full-day program serving eight infants andtoddlers in out-of-home placement and their biologi-cal parents. The goal is to enhance the child’s develop-ment and promote reunification of the child with thebiological parent. (For that reason, foster parents donot participate in the program. However, foster fami-lies are encouraged to participate in all other HeadStart/Early Head Start program options.)

A plan is individualized for each family, balancing pro-gram expectations and Child Protective Services (CPS)requirements for the family. Most families spend fivedays each week in the program where they learn aboutchild development, health, nutrition, and safety whilestrengthening the bond with their child. Most also par-ticipate in the attachment and bonding program, Circleof Security, that was developed by therapists at theMarycliff Institute. The program includes mental healthconsultations for the parent and child, clinical super-vision, and home visits. Referrals were initially madethrough the Casey Family Program, but the programnow receives direct referrals from CPS. Reports are gen-erated through regular team meetings, and the programstaff have contact with Court Appointed Special Ad-vocate (CASA) volunteers and CPS workers. The Spo-kane County Head Start/Early Head Start program is

In many ways, the first line of defense for youngchildren in foster care ought to be ensuring thatthey have access to high quality early care and

education programs.

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currently collaborating with CASA and CPS to pro-mote more adequate screening of families prior to re-ferral and to educate CPS and CASA both about pro-gram requirements and early childhood development.The program views CASA as a vital link to sharinginformation about the children and their families withthe courts.

The Birth to Three Services Program, IllinoisDepartment of Children and Family ServicesIllinois

The Birth to Three Services Program is a recent initia-tive undertaken by the Illinois Department of Childand Family Services (IDCFS). It is an effort by the de-partment to take the implications of research on earlychildhood to scale. The program has two overarchinggoals: to ensure that young children in foster care en-ter school ready to succeed and to reduce the risks ofmultiple placement changes. The state now requiresthat every young child in foster care receive a develop-mental screening by a trained developmental special-ist in order to identify any behavioral and developmen-tal needs and provide appropriate services. Foster par-ents, and occasionally biological parents, play a role indetermining services but are not permitted to declineservices altogether. To date, some 7,000 children havebeen screened.

The program began as a public-private partnership andreceived half of its funding for the first two years fromlocal foundations. It is now fully funded through de-partmental appropriation for staff, equipment, andscreening activities. To provide enrichment services forat-risk children, the IDCFS also has appropriated $2million of day care funds to cover the costs of privateearly childhood programs for children in foster care.The program is administered by a newly created unitfor early childhood in the IDCFS.

The initiative has led to new partnerships between thechild welfare agency and the early childhood commu-nity that involve Head Start, Early Head Start, ChildCare Resource and Referral Networks, Early Interven-tion (Part C), and child care. For example, the IDCFScontracts for three full-time positions with the Chi-cago Public Schools Cradle-to-Classroom program forparaprofessionals trained as home visitors. In exchange,

the Cradle program expanded its service area to includeyoung children in foster care. The IDCFS also con-tracts with the Daycare Action Council of Illinois(DCACI) to provide an enhanced referral service foryoung children in foster care. State funding enables theDCACI to work with other agencies to develop ser-vices to meet the needs of each family.

Reflections

The deliberate inclusion of young children in foster carein high quality early childhood programs is a vitallyimportant strategy that needs to be expanded acrossthe country. This, coupled with parallel efforts withinthe early childhood community to strengthen its ca-pacity to better meet the needs of high-risk young chil-dren and families, is a very encouraging development.It means that the early childhood community will bebetter able to respond to the needs of young childrenin foster care as well as children in their own familiesfacing risks to their early healthy development. It alsomeans that this is an opportune moment for makingchild welfare and early childhood connections, as policyand practice interest in promoting the well-being ofyoung children takes on new momentum.

STRATEGY 5Use the oversight authority of the courts to ensurethat children in foster care receive needed health,developmental/early intervention, and mentalhealth services as a part of permanency planning.

Under federal child welfare law, each of over half a mil-lion children in foster care in the United States has acourt order approving placement in foster care. The courtis the central decisionmaker in every child protectiveproceeding, and at every hearing the court must reviewthe child’s needs and the parent’s ability to meet thoseneeds. This critical role was established by Congress in1980 by the passage of the Adoption Assistance andChild Welfare Act30 and reinforced by the Adoptionand Safe Families Act of 1997 (ASFA).31 ASFA makesclear that a child’s health and safety are paramount con-siderations in child protective proceedings. Thus, everycourt hearing is an opportunity to raise questions abouta child’s developmental status. In most states, courts havebroad powers to review individual case plans and to or-der services to ensure a child’s health and well-being.32

16 Improving the Odds National Center for Children in Poverty

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Newly issued federal regulations for the AFSA reinforcethis. They specifically hold states accountable for pro-viding services to address the safety, permanency, andwell-being of children and families; require families tohave enhanced capacity to provide for their children’sneeds; and require children to receive appropriate ser-vices to meet their educational needs as well as adequateservices to meet their physical and mental health needs.33

Those responsible for children in foster care need topay attention to the different types of services that arenecessary for children at particular ages, including in-fants, toddlers, and preschoolers. Yet, in practice, thereis very little strategic use of the power and potential ofthe court to address children’s developmental needs.The five examples below focus on the well-being ofyoung children in foster care. They illustrate the im-portance of judicial leadership to identify the needs ofchildren in foster care, to ensure that the court receivescritical information for permanency decisionmaking, andto bring together parties and professionals to help de-termine services needed by children and their families.

The Healthy Development Checklist: A Projectof the New York State Permanent JudicialCommission on Justice for Children’s HealthyDevelopment for Foster Children InitiativeNew York State

In New York State, the Permanent Judicial Commis-sion on Justice for Children, a multidisciplinary com-mission chaired by New York State Chief Judge JudithKaye, has developed an initiative designed to help thecourts augment their role in ensuring the healthy de-velopment of children in foster care. The initiative grewout of findings from research the commission conductedwith support from the federally-funded State Court Im-provement Project. That research found few court or-ders for services for young children, little indication incourt records or proceedings that services were beingprovided to young children, and only rare inquiriesabout the condition of young children in foster care ortheir needs for services.34 Alarmed by these findings,the commission developed the Healthy DevelopmentChecklist to raise awareness about the health, devel-opmental, and emotional needs of children in fostercare and to ensure that these needs are addressed bythose involved in the court process.

The commission’s booklet, Ensuring the Healthy Devel-opment of Foster Children: A Guide for Judges, Advocates,and Child Welfare Professionals, contains a checklist—10basic questions to identify the health, developmental,and emotional needs of children in foster care and gapsin services (see box on this page). It also provides a ra-tionale for each of these questions, as well as referencesto expert sources. Each question in the booklet is con-sistent with the national standards for health care as rec-ommended by the American Academy of Pediatrics andthe Child Welfare League of America, and by the Earlyand Periodic Screening, Diagnosis, and Treatment pro-visions of Medicaid (see box on page 8).

The commission is now conducting a major effort toeducate all those involved in the court process aboutthe health and developmental needs of children in fos-ter care and how to use the Healthy DevelopmentChecklist to promote children’s well-being. This ini-tiative is part of the commission’s goal to ensure that atleast one person involved in a child welfare case willask questions about the basic health needs of a child infoster care. The outreach has been both national andwithin New York State. Nationally, the commission hasshared the checklist with the Court Improvement

HEALTHY FOSTER CARE CHECKLIST

This checklist for the healthy development of foster children was devel-oped by the Permanent Judicial Commission on Justice for Children.

U Has the child received a comprehensive health assessment since enteringfoster care?

U Are the child’s immunizations up-to-date and complete for his orher age?

U Has the child received hearing and vision screening?

U Has the child received screening for lead exposure?

U Has the child received regular dental services?

U Has the child received screening for communicable diseases?

U Has the child received a developmental screening by a provider withexperience in child development?

U Has the child received mental health screening?

U Is the child enrolled in an early childhood program?

U Has the adolescent child received information about healthy development?

Source: Permanent Judicial Commission on Justice for Children. (1999). Ensuring the Healthy Development ofFoster Children: A Guide for Judges, Advocates, and Child Welfare Professionals. New York, NY: PermanentJudicial Commission on Justice for Children.

National Center for Children in Poverty Improving the Odds 17

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Projects in all states and all model courts of the Na-tional Council of Juvenile and Family Court Judges.

In New York State, the training effort has involved fam-ily court judges, law guardians, social services and healthadministrators, selected state legislators, Early Interven-tion officials (Part C), public health nurse directors,advocates, parents’ attorneys, child and family servicesproviders, and CASA directors and volunteers. CourtAppointed Special Advocates are specially trained com-munity volunteers appointed by a family court judgeto assist in finding safe and permanent homes for chil-dren in the child welfare system. Once appointed bythe judge, the CASA becomes an official part of thejudicial proceedings, working alongside the judge, at-torneys, and social workers as an appointed officer ofthe court for a particular case to identify the child’sbest interests.

As a result of these training efforts, judges, lawyers, andCASAs throughout New York State are using the check-list at the earliest possible point, even in abandonmentproceedings, to identify the needs of young foster chil-dren and to shape permanency planning. Some FamilyCourt judges in New York State now routinely order thatevery foster child under age three be screened for devel-opmental delays through Part C. In two New York Statecounties, Erie and Westchester, CASAs have been spe-cifically assigned to cases of children in foster care underage five. With over 900 CASA programs nationwide,if the checklist were implemented on a more widespreadbasis, it could have significant impact.33

The Dependency Division, Superior CourtSanta Clara County, California

Judge Leonard Edwards, supervising judge of the Juve-nile Dependency Court in San Jose, California, hasbeen one of the principal architects of a new judicialrole for juvenile and family court judges—a more ac-tivist, problem-solving role, both on and off the bench.The core of this new role is judicial leadership. JudgeEdwards keeps a tight rein on individual cases, holdingfrequent, sometimes weekly, hearings, inquiring aboutchildren’s health and developmental needs, orderingservices to address those needs, and monitoring theprovision of those services. He requires all court re-ports to contain health, education, and developmental

information about the child (drawing on the Califor-nia Health and Education Passport program, a recordthat follows all children in the foster care system thatis described more fully above) and for any problems tobe addressed in case plans prepared by social workers.Judge Edwards is able to do all of this within an exist-ing judicial budget. Off the bench, he exercises judi-cial leadership in the community by working to createthe services needed by the children and their familiesappearing in court. He has served as a convenor, bring-ing together government agencies and service provid-ers to address children’s needs, as well as acting as apublic spokesperson for those concerns. He meets withpublic agency and private service providers to ensurethat they work together on behalf of children.

The Dependency Court Intervention Programfor Family ViolenceDade County, Florida

In Miami, Judge Cindy Lederman, the administrativejudge of the Juvenile Court, has spearheaded a pioneer-ing effort to address the well-being of young childreninvolved in Dade County’s Dependency Court throughthe Dependency Court Intervention Program for Fam-ily Violence (DCIPFV). The DCIPFV is a court-initi-ated demonstration project awarded to the EleventhJudicial Circuit of Florida by the U.S. Department ofJustice. Led by Judge Lederman, the program representsa court-based, collaborative effort to develop and evalu-ate a comprehensive intervention program for womenand children from homes with co-occurring domesticviolence and child maltreatment. The PREVENT (Pre-vention and Evaluation of Early Neglect and Trauma)initiative of the DCIPFV evaluates infants, toddlers,and preschoolers who are adjudicated dependent by thecourt. Each child aged one to five referred from thecourt receives a comprehensive assessment of his or hercognitive, language, social, and emotional develop-ment. This is very important since almost 70 percent

A child’s health and safety are paramountconsiderations in child protective proceedings.Every court hearing is an opportunity to raise

questions about a child’s developmental status.

18 Improving the Odds National Center for Children in Poverty

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suffer from significantly delayed language and cogni-tive development and many from impaired emotionaldevelopment. Additionally, the quality of the relation-ship between the child and the parent or parents is as-sessed through a comprehensive videotaped play-and-teaching instruction situation. Written evaluations areprovided to the court and all parties to assist in perma-nency and treatment planning.36

The 2000 Florida Legislature has designated the DadeCounty Juvenile Court, Eleventh Judicial Circuit ofFlorida, as one of three Infant and Young Children’sMental Health Pilot Project sites in the state. Theevaluation and treatment practices of PREVENT havebeen selected to act as a model for all three of Florida’sInfant and Young Children’s Mental Health Pilot sites.The pilot project in Miami-Dade Juvenile Court offerscomprehensive evaluation and intensive preventionand intervention services to high-risk infants and youngchildren to enhance the quality of the parent-child at-tachment and bonding relationship.

In addition to the above initiatives, Judge Ledermanwrites court orders for all children to receive EPSDTand, if appropriate, referrals to Early Intervention (PartC) as well as to other child developmental and familysupport programs such as Florida Healthy Start (a homevisiting program) and Head Start. She also organizes anearly childhood lecture series for attorneys, guardiansad litems (i.e., children’s advocates), and caseworkers.

The Family Drug Treatment CourtsSuffolk County, New York

Throughout the country, drug treatment courts haveenabled substance abusers accused of crimes to receivetreatment rather than be incarcerated. Family DrugTreatment Courts have emerged as a variation of thisapproach. These courts focus on the core reason manychildren are placed in foster care: parental drug addic-tion. There are now 10 Family Drug Treatment Courtsthroughout the country, each tapping into an array offunding streams, including earmarked federal funds,Medicaid, and TANF. Early indications demonstratetheir success in keeping parents sober and reducingchildren’s time in foster care.37 In order to participatein these courts, parents must admit to both substanceabuse and child neglect as well as consent to treatment.

The cases are tightly monitored with frequent courtappearances. Attention is also beginning to be paid tothe needs of the children. All of these courts make con-certed efforts to develop greater coordination amongthe court, treatment providers, community organiza-tions, public health agencies, and schools in respond-ing to the needs of the child and the family.

Under the leadership of Family Court Judge NicolettePach, the Suffolk County Family Drug Treatment Courthas incorporated elements of the Checklist for theHealthy Development of Foster Children (see box onpage 16) into its court order and treatment plan forms.Addressing the public health needs of participating chil-dren, including assessment, treatment, and preventionof health problems, is a critical part of the family drugcourt process. Additionally, through a collaboration in-stituted by the court, the Suffolk County Bureau of Pub-lic Health Nursing (highlighted earlier) performs in-home assessments of all young children under age fiveassigned to that court. The Family Drug TreatmentCourt team provides the nurses with a copy of the courtorder and a psychosocial assessment for each referral.The public health nurses meet with the Family DrugTreatment Court team assigned to each case on amonthly basis and the nurses’ involvement has resultedin more referrals to Early Intervention (Part C) for thesechildren.

Kathryn A. McDonald Education Advocacy Project,Legal Aid Society, Juvenile Rights DivisionNew York, New York

In New York City, the Juvenile Rights Division (JRD)of the Legal Aid Society, which represents over 90 per-cent of the children in the city, employs a designatedattorney to address the early intervention and specialeducation needs of children involved with the courtsbecause of abuse and neglect. The attorney worksclosely with other attorneys, caseworkers, biological andfoster parents, and coordinators from the New York City

Addressing the public health needs of participatingchildren, including assessment, treatment, andprevention of health problems, is a critical part

of the family drug court process.

National Center for Children in Poverty Improving the Odds 19

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Early Intervention program to ensure that appropriatereferrals to the Early Intervention program are madeand that children receive evaluations and services in atimely fashion. The attorney also provides training andongoing consultation on the Early Intervention pro-gram to the interdisciplinary staff of the Legal Aid So-ciety as well as to New York City child welfare case-workers and CASAs. This initiative draws on a modelof expert consultation long available in legal servicesprograms for specialized legal issues such as health, hous-ing, or consumer law.

The JRD is seeking to expand the project over the nextthree to five years by creating education units in eachborough in New York City that will consist of an attor-ney, social worker, and paralegal worker. These unitswill focus on addressing the early intervention and spe-cial education needs of JRD clients and on collaborat-ing with other parties involved in the Family Court tosecure services to enhance their development. Otherprograms providing representation to children canadopt this model in two ways: (1) by using an attorneywith specialized knowledge about child development,early intervention, special education, and relevant ser-vices and programs as a consultant to other lawyers; or(2) by encouraging bar associations and other localmechanisms to provide training to lawyers.

Reflections

Courts can be a powerful gateway to health and devel-opmental services for young children. The initiativesdescribed here harness the power of the court to ensurethat young children and families get the services theyneed. They educate participants about the importanceof these services and convene those responsible in or-der to ensure that the children and their caregivers ac-tually receive the services. They create concrete court-linked mechanisms that promote a steady focus on thehealth, developmental, and emotional needs of youngchildren. The means vary—a checklist to gather infor-mation, drive queries, and identify services; an attor-ney with specialized knowledge about services for youngchildren to serve as a consultant to the court and otherattorneys; a seminar series for those involved with thecourt. The initiatives bring the expertise of criticalentities that exist in most communities—CASA, pub-lic health nurses, and early intervention programs—to

the courts to build the local capacity to address youngchildren’s needs. But most importantly, they are markedby pioneering judicial leadership.

Moving Forward: Summary andAction Steps

This issue brief has highlighted five core strategies toenhance the health and emotional well-being and pros-pects for permanency of young children in foster care:

n Provide developmentally appropriate health care toyoung children in the context of comprehensivehealth care for all children in foster care.

n Design and implement specialized developmentaland mental health assessments and services for youngchildren in foster care.

n Create monitoring and tracking mechanisms to en-sure that needed health, developmental, and men-tal health services are provided.

n Ensure that young children in foster care have ac-cess to quality early care and learning experiences.

n Use the oversight authority of the courts to ensurethat children in foster care receive needed health,developmental, and mental health services as partof permanency planning.

Based on the lessons from the programs and initiativesdescribed in this issue brief, states and communities facetwo interrelated challenges. The first is to make surethat issues related to early development are addressedfor each and every young child in foster care. The sec-ond is to improve the array of community resourcesand the service delivery system to make possible thesegoals. In addition, this report implicitly underscores theneed for more research on the most effective strategiesand interventions for this vulnerable young populationand a clearer accounting of the costs and benefits ofeach program, especially as the children enter school.Below are 10 ways to promote better attention not onlyto the developmental and emotional needs of youngchildren in foster care, but also to the needs of theirparents and foster parents.

20 Improving the Odds National Center for Children in Poverty

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1. Use federal programs and dollars creatively. TheAdoption and Safe Families Act, Medicaid,EPSDT, the Early Intervention program, and, po-tentially, TANF, provide an important frameworkto develop specialized attention to young childrenin foster care. ASFA requires states and localitiesto address the well-being of children in foster care.Medicaid can support a wide range of needed ser-vices, including administrative case managementand the services of public health nurses. EPSDTprovides reimbursement and an entitlement to earlyand periodic screening, diagnosis, and treatment.The Early Intervention program entitles eligibleyoung children in foster care to developmentalscreenings, assessments, and services along with thepossibility of supports to caregivers. TANF can fundprograms to provide a wide array of child develop-

ment and prevention services as long as they areconsistent with the four purposes of the act. States,communities, and agencies that use these federalbuilding blocks creatively can go a long way to-ward promoting better access to services for youngchildren in the child welfare system and even forchildren at risk of foster care placement.38

2. Harness the power of the courts to enhance thehealthy development of children in foster care.Each of the over 150,000 young children who en-ter the child welfare system nationwide appear be-fore specific judges, in specific communities. Thusevery court appearance is an opportunity for at leastone person in the court process—one judge, onelawyer, one caseworker, one CASA volunteer—toask questions about a young child’s health and de-velopmental status, access to services, and generalemotional development. Judges play a crucial rolein shaping community expectations. In most cases,they can order needed services.39 Where there aregaps in resources, they can use their role to helpspur new initiatives to ensure the healthy develop-ment of every young child in foster care.

3. Build collaborative partnerships between thecourts and child welfare, health care, and earlychildhood agencies. New formal partnershipsamong child welfare agencies; those involved inthe court process (for example, Court AppointedSpecial Advocates); health professionals operatingout of university-based health departments or othersettings; state, city and county early interventionagencies; and the broader early childhood commu-nity should all be part of the effort to enhance de-velopmental outcomes for young children in fostercare. Collaborative formal partnerships (with writ-ten protocols, memoranda of understanding, andthe out-stationing of professionals serving young

WAYS TO PROMOTE THE DEVELOPMENTALAND EMOTIONAL NEEDS OF YOUNG CHILDRENIN FOSTER CARE AND TO HELP THEIR PARENTS

AND FOSTER PARENTS

n Use federal programs and dollars creatively.

n Harness the power of the courts to enhance the healthy development ofchildren in foster care.

n Build collaborative partnerships between the courts and child welfare, healthcare, and early childhood agencies.

n Ensure that court personnel, child welfare workers, biological and fosterparents, and other caregivers have information that they need to help youngchildren in foster care.

n Develop explicit state and community-based strategies to ensure that youngchildren in foster care have access to developmental health services, high-quality child care, preschool, and family support programs.

n Develop formal mechanisms to track and monitor the delivery of health,mental health, and related services.

n Use professional and state best-practice-standards and relevant federal guide-lines to develop improved approaches to promote healthy early develop-ment.

n Weave together multiple approaches to enhance the well-being of youngchildren in foster care, building on community strengths.

n Pay special attention not just to young children in foster care, but to those atrisk of placement in foster care and those being discharged from the childwelfare system.

n Promote a federal agenda that provides incentives to states and communi-ties to build partnerships with health care and early childhood agencies toenhance the healthy development of young children in or at risk of fostercare placement.

States, communities, and agencies that use thesefederal building blocks creatively can go a long way

toward promoting better access to services foryoung children in the child welfare system and even

for children at risk of foster care placement.

National Center for Children in Poverty Improving the Odds 21

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children in the child welfare and court systems),designed to ensure access for young children in fos-ter care or to develop specialized approaches, canassist in meeting the safety, well-being, and per-manence goals of the child welfare system in addi-tion to national school readiness goals.

4. Ensure that court personnel, child welfare work-ers, biological and foster parents, and othercaregivers have information that they need to helpyoung children in foster care. For court and childwelfare personnel, this often means making surethat the connections between services to addresshealth, developmental, and emotional challengesand achieving permanency are clear. It also meansmaking sure that court and child welfare workersknow about child development, appropriate com-munity resources, and how to ensure access for thechildren for whom they bear responsibility. In manyof the initiatives highlighted here, liaison workersare on-site to provide information, although otherstrategies are also being used involving checklistsand, most importantly, judicial leadership.37

5. Develop explicit state and community-based strat-egies to ensure that young children in foster carehave access to developmental health services, high-quality child care, preschool, and family supportprograms. In most communities there are networksof early care and education providers and advocateswho supply leadership to local efforts to enhanceand expand early childhood and family support pro-grams. Child welfare leaders, foster parents, andjudges can connect with these efforts to make surethey include and are responsive to young childrenin foster care and their families. Advocates for youngchildren and community programs also need to placeyoung children in foster care on their radar screen.They can work with Early Intervention officials totarget children in foster care and develop an auto-matic referral for all children in foster care underage three as part of their outreach efforts to ensurethat all young children eligible for early interven-tion services have access to them. (Often these arereferred to as Child Find activities.) They can workwith Head Start programs to identify these childrenand their families for recruitment and designate pri-ority slots for enrollment.

6. Develop formal mechanisms to track and moni-tor the delivery of health, mental health, and re-lated services. The monitoring and tracking effortsdescribed here define clear responsibility for assess-ing and coordinating a child’s health, developmen-tal, and mental health services. Some approachesuse public health nurses to directly assess a child’shealth and developmental needs. Others designatestaff to coordinate the child’s care across systemsand ensure that information is shared with thechild’s caseworker and the court through writtenreports. The emphasis in AFSA on monitoringstates’ attention to educational, developmental,and other needs of children in foster care providesan additional impetus to continue to develop andstrengthen such efforts.

7. Use professional and state best-practice standardsand relevant federal guidelines to develop im-proved approaches to promote healthy early de-velopment. Standards of best practices, most ofwhich call for the delivery of comprehensive, co-ordinated, continuous, and family-supportive care,provide a framework for action and accountability.They mean that no community has to start fromscratch. Instead, the challenge is to incorporatethese standards in a meaningful way into new col-laborations and partnerships.

8. Weave together multiple approaches to enhancethe well-being of young children in foster care,building on community strengths. There are manyways to achieve the basic objective of enhancingthe medical, developmental, and emotional well-being of young children in foster care. But in themost compelling examples cited here, multiplestrategies are woven together to create a criticalthreshold for change. They involve strategies tomaximize the power and authority of the court, to

Standards of best practices, most of whichcall for the delivery of comprehensive, coordinated,

continuous, and family-supportive care, providea framework for action and accountability.

22 Improving the Odds National Center for Children in Poverty

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develop new partnerships to ensure that young chil-dren in foster care have access to comprehensivehealth care and specialized services for them andtheir caregivers, and to engage the broader earlychildhood community in efforts to improve theiroutcomes and opportunities. None are exactly alikeand all build on local strengths—the nature of ju-dicial leadership, the constellation of services, thewillingness of the child welfare system to try newways of doing business. The challenge is for morecommunities to start the process.

9. Pay special attention not just to young childrenin foster care, but to those at risk of placement infoster care and those being discharged from thechild welfare system. This issue brief has focusedprimarily on young children in foster care. But thesame strategies need to be in place as part of a con-certed effort to prevent needless placement and toensure family stability when children leave fostercare. Young children in foster care or at risk of fos-ter care placement need access to all the benefitsto which they are entitled (such as continuation ofMedicaid coverage)40 as well as access to compre-hensive and multidisciplinary services that can bothenhance their health and development and theirparent’s ability to respond to their complex needs.

10. Promote a federal agenda that provides incentivesto states and communities to build partnershipswith health care and early childhood agencies toenhance the healthy development of young chil-dren in or at risk of foster care placement. Thefederal government can encourage states, throughresearch, demonstration, training, and other inno-vative efforts, to link child welfare agencies andthe courts with health care, early intervention, andchild development and family support agencies andnetworks. Efforts should also be made to help statesidentify ways to use child welfare, TANF, and otherfederal funds creatively on behalf of young chil-dren in foster care. Similarly, states should be en-couraged to use the broad language in Part C ofIDEA to promote targeted Child Find activities andprioritize Early Head Start and Head Start slots inevery county in America, in order to ensure qual-ity child care experiences to young children in fos-ter care. Federal initiatives should also support a

research agenda to develop better knowledge aboutthe most effective intervention strategies, theircosts, and their benefits.

Conclusion

This issue brief is intended to be a wake-up call—tochallenge communities all over the country to attendto the needs of young children in or at risk of fostercare placement. The building blocks are judicial lead-ership; the creative use of federal programs; new ap-proaches to ensuring access to health, developmental,and mental health services for young children in fostercare; and linking all of these elements to the networkof early childhood and family support programs withina community. The innovations and collaborations high-lighted here can be used strategically in ways that fitcommunity needs and strengths. Improving outcomesfor young children in foster care is a doable task. It isalso an investment in the future that can help achievethe goals this society wants for all its young children—that they be safe, that they grow up in a loving home,and that they develop to their full potential.

The innovations and collaborations highlightedhere can be used strategically in ways that

fit community needs and strengths.

National Center for Children in Poverty Improving the Odds 23

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APPENDIX A

Federal Building Blocks to Improve theDevelopment of Young Children in Foster Care

Adoption and Safe Families Act of 199741

n Emphasizes permanency and adoption

n Makes child’s “health and safety” a “paramount concern” inevery child protective proceeding

n Identifies situations where “reasonable efforts” toward reuni-fication are not required, such as where the parent has sub-jected the child to aggravated circumstances, including aban-donment, torture, chronic abuse, and sexual abuse; where theparent has committed murder, voluntary manslaughter, or afelony assault that resulted in serious injury to the child; or ifparental rights have been terminated voluntarily for a sibling

n Strengthens court role in monitoring cases

n Allows concurrent planning by child welfare agency

n Tightens time frames for decisionmaking

n Requires permanency planning hearings 12 months afterplacement

n Requires permanency planning hearings within 30 days afterplacement where the court has determined reasonable effortsto reunify are not required

n Requires that Termination of Parental Rights petitions be filedwhen a child is in care for 15 out of the most recent 22 monthsunless compelling reasons exist not to do so

n Requires states to provide health insurance coverage for anychild with special needs who cannot be adopted withoutmedical assistance

n Provides fiscal incentives for states to increase adoptions

n Monitors states on their compliance in providing services toenhance the capacity of families to provide for their children’sneeds and to meet the educational, physical, and mentalhealth needs of children in foster care

Early and Periodic Screening, Diagnosis, and Treatment(EPSDT) Provisions of Medicaid42

n Applies to children in foster care

n Requires medical, vision, hearing, and dental screenings tobe performed at distinct intervals as determined by “period-icity schedules” that meet standards of pediatric and adoles-cent medical and dental practice

n Requires that a medical screening include at least five com-ponents:

1. A comprehensive health and developmental history as-sessing both physical and mental health.

2. A comprehensive unclothed physical exam.

3. Immunizations.

4. Laboratory tests including lead blood testing at 12 and 24months and otherwise according to age and risk.

5. Health education.

n Requires hearing and vision screenings to include diagnosisand treatment for defects, including hearing aids and eyeglasses

n Requires dental screening to include assessments for relief ofpain and infection, restoration of teeth, and maintenance ofdental health

n Requires state Medicaid agencies to assure the provision ofnecessary treatment for both physical and mental health con-ditions to the extent required by the needs of an individualchild

n Permits states to finance, through Medicaid, an array of ser-vices that might otherwise be ineligible for Medicaid reim-bursement, including early intervention services and devel-opmental screening

Early Intervention Law for Infants and Toddlers (Part C ofthe Individuals with Disabilities Education Act)43

n Provides an entitlement for eligible infants and toddlers (birthto third birthday) with developmental disabilities and delaysor a high probability of developing them as a result of condi-tions such as Down’s Syndrome, cerebral palsy, severe attach-ment disorders, and fetal alcohol syndrome

n Permits states to include children at risk of developmentaldelays due to biological conditions, such as low birthweight,environmental conditions, such as teen parents, or a historyof abuse and neglect

n Requires an Individualized Family Service Plan (IFSP) tospecify needed services for children and families

n Permits a broad range of services that include traditional thera-pies, such as occupational, speech, and physical therapies, aswell as special instruction, social work, transportation, andassistive technology devices, such as wheelchairs and hearingaides. Service coordination or case management is mandatory.

n Permits parents and other caregivers to receive services toenhance the development of their children, pursuant to anIFSP. Services can include parent training, parent counsel-ing, parent support groups, home visits, and respite care. (Thedefinition of a “parent” includes a legal parent, whether bio-logical or adoptive, a relative with whom the child is living,a legal guardian and, in some instances, a foster parent. Forthose without a “parent” broadly defined, the law requiresappointment of a surrogate parent who can be a foster par-ent, relative, or advocate.)

n Provides money to the states for coordinating activities, but,for the most part, services must be paid for through othersources, such as Medicaid

Special Education Laws for Preschool-Aged Children(The Preschool Special Education Grants Program of theIndividuals with Disabilities Education Act)44

n Provides an entitlement for children aged three through fiveto special education and related services

n Allows states to choose to continue eligibility standards ofPart C—otherwise eligibility for children aged three throughfive must meet the standards of disability under special edu-cation law (i.e., must have a specific, diagnosed disability thataffects their ability to learn)

24 Improving the Odds National Center for Children in Poverty

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APPENDIX B

Program Contact Information

Center for the Vulnerable Child and SEED ProgramDiana Kronstadt, Ed.D.747 52nd StreetOakland, CA 94609Phone: 510-428-3156Fax: 510-601-3913E-mail: dkronstadt@mail.cho.org

The Dependency Court Intervention Program forFamily ViolenceJuvenile Justice CenterHon. Cindy Lederman3300 NW 27th Avenue, Room 201Miami, FL 33142Phone: 305-638-6087Fax: 305-634-9921E-mail: hclausell@judll.flcourts.org

The Dependency DivisionSanta Clara County Superior CourtHon. Leonard Edwards115 Terraine StreetSan Jose, CA 95113Phone: 408-299-3949Fax: 408-293-9408E-mail: ledwards@sct.co.santa-clara.ca.us

ENHANCE ProgramSteven Blatt, M.D.Department of PediatricsSUNY Health Science Center90 Presidential PlazaSyracuse, NY 13202Phone: 315-464-7250Fax: 315-464-2051E-mail: Blatts@upstate.edu

The Fostering Healthy Children Project, UtahSalt Lake City Health DepartmentChris Thytraus, R.N., B.S.N.49 North Medical DriveSalt Lake City, Utah 84114Phone: 801-584-8598Fax: 801-584-8488E-mail: cthytrau@doh.state.ut.us

The Health and Education Passport, CaliforniaSan Diego County Health and Human Services AgencyNancy Kail, Social Services Admin. III1700 Pacific HighwaySan Diego, CA 92101Phone: 619-685-2420Fax: 619-685-2447E-mail: kailna@cws.state.ca.us

n Permits state discretion in defining a child with a disabilityto include a child experiencing developmental delays in oneor more areas of physical, cognitive, communicational, so-cial, emotional, or adaptive development who is in need ofspecial education and related services by reason of this delay

n Allows states to avoid unnecessary labeling by permittingthem to find a child to have a developmental delay withoutfurther specification

Temporary Assistance for Needy Families (TANF)Provisions of the Personal Responsibility and WorkOpportunity Reconciliation Act of 199645

n Eliminates the Aid to Families with Dependent Children pro-gram and its individual entitlement to cash assistance andreplaces this system of aid with block grants to states. The newlaw provides states with a lump sum payment for each of theyears 1997–200246 and requires that states spend a certainamount of state money for assistance benefits and services forneedy families with children.47 Assistance is payment to meetongoing basic needs for families that are not employed.48 Anumber of services and benefits are excluded from the defini-tion of “assistance” including: nonrecurrent, short-term (nomore than four months) benefits designed to address a spe-cific crisis; supportive services for employed families; and ser-vices (e.g., counseling, case management, peer support) thatdo not provide basic income support. The distinction betweenassistance and nonassistance is critical because many of thefederal requirements associated with TANF (e.g., time lim-its, work requirements, child support cooperation) apply onlyto families receiving “assistance,” not to families receivingother benefits and services funded under the block grant.Therefore, many services can be provided to families withoutstarting the TANF time clock or creating work requirementsfor families that are not already receiving assistance.

n Makes funds available for a wide array of services and sup-ports. Unless otherwise prohibited, TANF funds (federal blockgrant monies) and MOE monies (the state’s required mainte-nance-of-effort funding)49 can be spent in any way reason-ably calculated to accomplish any of the four purposes of thelaw.50 These purposes are to:

1. Provide assistance to needy families so that children may becared for in their own homes or in the homes of relatives.

2. End the dependence of needy parents on government ben-efits by promoting job preparation, work, and marriage.

3. Prevent and reduce the incidence of out-of-wedlock preg-nancies and establish annual numerical goals for prevent-ing and reducing the incidence of these pregnancies.

4. Encourage the formation and maintenance of two-parentfamilies.

n A state may also transfer up to 30 percent of its TANF fundsto the Child Care and Development Block Grant or to theSocial Services Block Grant (Title XX), subject to certainlimits.51 Many services that could benefit young children infoster care can be funded under one of the TANF purposes,through a transfer to Title XX, or under the grandfather clause,and thereby become subject to Title XX rules rather thanTANF restrictions.

National Center for Children in Poverty Improving the Odds 25

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Endnotes

1. For current estimates as of January 2000 see: U.S. Depart-ment of Health and Human Services, Children’s Bureau. (1999).The AFCARS report. <http://www.acf.dhhs.gov/programs/cb>This report found 547,000 children in foster care. For othersources discussing the increasing number of young children en-tering foster care see Wulczyn, F. & Hislop, K. B. (2000). Theplacement of infants in foster care. Chicago, IL: Chapin Hall Cen-ter for Children, University of Chicago; Goerge, R. & Wulczyn,F. (December 1998/January 1999). Placement experiences ofthe youngest foster care population: Findings from the MultistateFoster Care Data Archive. Zero to Three, 19(3), 8–14; U.S. Gen-eral Accounting Office. (1995). Foster care: Health needs of manyyoung children are unknown and unmet (GAO/HEHS-95-114).Washington DC: U.S. General Accounting Office.

2. See Goerge & Wulczyn in endnote 1.

3. Halfon, N.; Mendonca, A.; & Berkowitz, G. (1995) Healthstatus of children in foster care: The experience of the Center for theVulnerable Child. Archives of Pediatric and Adolescent Medi-cine, 149(4), 386–392. For a discussion of the impact of prema-turity and low birthweight on a child’s development as well as acomprehensive analysis of the medical, developmental, andemotional concerns related to young children in foster care seeSilver, J. A.; Amster, B. J.; & Haecker, T. (Eds.). (1999). Youngchildren and foster care. Baltimore, MD: Paul H. Brookes Pub-lishing Co.

4. The most recent child abuse and neglect data reveal thatamong victims of substantiated child maltreatment, infants rep-resent the largest subpopulation, accounting for about 7 per-cent of all substantiated reports in 1997. Children between birthand age three were involved in 34 percent of all substantiatedneglect reports, the largest category of substantiated maltreat-ment reports. Additionally, children under age three accountedfor more than half of children entering care due to medical ne-glect. See Wulczyn & Hislop in endnote 1.

IDCFS Birth to Three Services ProjectAndria GossIllinois Department of Child and Family Services100 W. Randolph St., Suite 6-200Chicago, IL 60601Phone: 312-814-5988Fax: 312-814-8945E-mail: agoss@idfcs.state.il.us Agoss@idfcs.state.il.us

Kathryn A. McDonald Education Advocacy ProjectKatherine Locker60 Lafayette StreetNew York, NY 10013Phone: 212-312-2277Fax: 212-349-0874E-mail: krlocker@legal-aid.org

Leake and Watts Service, Inc.Wendy Kamaiko-Solano463 Hawthorne AvenueYonkers, NY 10705Phone: 914-375-8500 or 718-794-8213Fax: 718-794-8201E-mail: wkamaiko@leakeandwatts.org

Parents and Children Together (PACT)Kathleen Baltman, Executive Director87 E. Ferry, 45 Knapp BuildingDetroit, MI 48202Phone: 313-577-3519Fax: 313-873-2300Web address: www.cla.wayne.edu/pact/index/htm

Permanent Judicial Commission on Justice for Childrenof New York StateSheryl Dicker, Executive Director140 Grand StreetWhite Plains, NY 10601Phone: 914-948-7568Fax: 914-948-7584E-mail: : sdicker@court.state.ny.us

Starting Young ProgramJudith Silver, Ph.D.P.O. Box 31945Philadelphia, PA 19104Phone: 215-590-7723Fax: 215-590-9339E-mail: silverj@email.chop.edu

Suffolk County Family Drug Treatment CenterChristine Olsen400 Carelton AvenueP.O. Box 9076Central Islip, NY 11722-9076Phone: 631-853-4482Fax: 631-853-7616E-mail: colsen@courts.state.ny.us

The Suffolk County Foster Care ProjectMary Lou Boyle225 Rabro DriveHauppauge, NY 11788Phone: 631-853-3069Fax: 631-853-3069E-mail: marylou.boyle@co.suffolk.ny.us

West Boone Early Head StartCommunity Colleges of SpokaneSandra Turner, Social Services SpecialistSpokane County Head Start/Early Head Start/ECEAP4410 N. Market StreetSpokane, WA 99207Phone: 509-533-8544Fax: 509-533-8599E-mail: sturner@iel.spokane.cc.wa.us

26 Improving the Odds National Center for Children in Poverty

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5. Studies demonstrating the serious health and developmentalproblems of children in foster care are consistent nationwide.For Baltimore see Chernoff, M. D.; Combs-Orme, T.; Risley-Curtiss, C.; & Heisler, A. (1994). Assessing the health status ofchildren entering foster care. Pediatrics, 93(4), 594–601; for Cali-fornia see Halfon, Mendonca, & Berkowitz in endnote 3; forIllinois see Hochstadt, N.; Jaudes, P.; Zimo, D.; & Schachter, J.(1987). The medical and psychosocial needs of children enter-ing foster care. Child Abuse & Neglect, 11(1), 53–62; for NewYork see Blatt, S. D.; Saletsky, R. D.; & Meguid, V. (1997). Acomprehensive, multidisciplinary approach to providing healthcare for children in out-of-home care. Child Welfare, 76(2), 331–349; for Philadelphia, Pennsylvania, see Silver, J.; DiLorenzo,P.; Zukoski, M.; Ross, P. E.; Amster, B. J.; & Schlegel, D. (1999).Starting young: Improving the health and developmental out-comes of infants and toddlers in the child welfare system. In K.Barbell & L. Wright, (Eds.). Special edition: Family foster carein the next century. Child Welfare, 78(1), 148–165; for Wash-ington see Takayama, J. I.; Bergman, A. B.; & Connell, F. A.(1994). Children in foster care in the state of Washington:Health care utilization and expenditures. JAMA, 271(23), 1850–1855. Approximately 80 percent of all foster children have atleast one chronic medical condition, with nearly one-quarterof these children having three or more chronic problems. Forexample, numerous studies document the prevalence of seriousrespiratory illness among foster children. One study of fosterchildren from Oakland, California, revealed that 16 percenthad asthma—about three times the national average for asthma.See Halfon, Mendonca, & Berkowitz in endnote 3.

6. See Swire, M. R. & Kavaler, F. (1997). The health status offoster children. Child Welfare, 56(10), 635–653 (one-third ofthe preschool children studied had dental decay) and Chernoff,Combs-Orme, Risley-Curtiss, & Heisler in endnote 5 (almosthalf of the children studied needed to see a dentist). The U.S.General Accounting Office reports that dental disease is one ofthe most prevalent chronic illnesses impacting children’s over-all health. See U.S. General Accounting Office. (2000). Oralhealth: Dental disease is a chronic problem among low-income popu-lations (GAO/HEHS-00-72). Washington, DC: U.S. GeneralAccounting Office.

7. See Silver, DiLorenzo, Zukoski, & Ross in endnote 5, andSilver, Amster, & Haecker in endnote 3. See also Silver, J.(2000). Integrating advances in infant research with child wel-fare policy and practice. Protecting Children, 16(5), 12–21 andKlee, L.; Kronstadt, D.; & Zlotnick, C. (1997). Foster care’syoungest: A preliminary report. American Journal of Orthopsy-chiatry, 67(2), 290–299.

8. Amster, B.; Greis, S. M.; & Silver, J. (1997). Feeding and lan-guage disorders in young children in foster care. Paper presentedat the American Speech Language Hearing Association AnnualConvention, November 22, Boston, Massachusetts. (On file atthe Permanent Judicial Commission on Justice for Children)

9. See Wulczyn & Hislop in endnote 1.

10. Research reveals that more than half, and some studies re-port as many as 80 percent, of children in foster care have beenexposed to maternal substance abuse. See U.S. General Account-ing Office. (1994). Foster care: Parental drug abuse has an alarmingimpact on young children (GAO/HEHS-94-89). Washington DC:

U.S. General Accounting Office. The Multistate Foster Care DataArchive, a database that contains foster care histories for all chil-dren who have been placed in foster care between 1983–1994 insix states: California, Illinois, Michigan, New York, Texas, andMissouri reports the increasing number of substance-exposed in-fants entering foster care. See Goerge & Wulczyn in endnote 1.

For more information contact Karen Mulitalo, South MainPublic Health Center, University of Utah, 3195 South MainStreet, Salt Lake City, Utah 84115; phone: 801-483-5451; fax:801-464-8935; e-mail: kmulitalo@hotmail.com.

11. For an overview of the impact of foster care on the emotionaldevelopment of young children see: Morrison, J. A.; Frank, S.J.; Holland, C. C.; & Kates, W. R. (1999). Emotional develop-ment and disorders in young children in the child welfare sys-tem. In Silver, Amster, & Haecker in endnote 3; and Katz, L. L.(1987). An overview of current clinical issues in separation andplacement. Child and Adolescent Social Work, 4(3–4), 61–77.

12. Despite their level of need, less than one-third of childrenin foster care nationwide receive mental health services. SeeRosenfeld, A. A. (1997). Foster care: An update. Journal of theAmerican Academy of Child and Adolescent Psychology, 36(4),448–457. Most of these services focus on older children; men-tal health services for young children are underdeveloped. SeeKnitzer, J. (2000). Early childhood mental health services: Apolicy and systems development perspective. In J. P. Shonkoff& S. J. Meisels. Handbook of early childhood intervention. NewYork, NY: Cambridge University Press.

13. See Shonkoff, J. & Phillips, D. (Eds.). (2000). NationalAcademy of Science and Institute of Medicine. From neurons toneighborhoods: The science of early childhood development. Wash-ington, DC: National Academy Press and Shore, R. (1997).Rethinking the brain: New insights into early development. New York,NY: Families and Work Institute.

14. Research on risk factors shows that the more risk factorschildren experience, the more likely they are to develop learn-ing disabilities, behavioral problems and/or mental illness. Onaverage, studies reveal that children in foster care have morethan 14 risk factors. See Werner, E. & Smith, R. (1992). Over-coming the odds: High-risk children from birth to adulthood. Ithaca,NY: Cornell University Press; Thorpe, M. & Swart, G. T. (1992).Risk and protective factors affecting children in foster care: Apilot study on the role of siblings. Canadian Journal of Psychia-try, 37(9), 616.

15. See Gross, R. T.; Spiker, D.; & Haynes, C. W. (Eds.). (1997).Helping low birth weight, premature babies: The Infant and HealthDevelopment Program. Stanford, CA: Stanford University Pressand Zeanah, C. H. & Larrieu, J. A. (1998). Intensive interven-tion for maltreated infants and toddlers in foster care. Child andAdolescent Psychiatric Clinics of North America, 7(2), 357–371.

16. The Omnibus Budget Reconciliation Act of 1989 (P.L. 101-239) requires states to maintain up-to-date health records, suchas immunization records and a child’s health conditions, forchildren in foster care.

17. Cauthen, N. K.; Knitzer, J.; & Ripple, C. (2000). Map andtrack: State initiatives for young children and families. New York,NY: National Center for Children in Poverty, Mailman Schoolof Public Health, Columbia University.

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18. Goals 2000: Educate America Act, P.L. 103-227, enactedMarch, 1994. The concept of school readiness addressed in thisgoal is broad, including attention to the emotional, cognitive,physical, and social aspects of child development.

19. Courtney, M. E. & Piliavan, I. (1999). Foster care transitionsto adulthood: Outcomes 12 to 18 months after leaving care. Madi-son, WI: University of Wisconsin-Madison School of SocialWork and Institute for Research on Poverty.

20. Medicaid eligibility is based on provisions that vary acrossthe states. Children in foster care automatically are eligible forMedicaid coverage if they receive Title IV-E foster care assis-tance. Foster children who do not receive IV-E assistance canqualify for Medicaid through one of the other mandatory eligi-bility categories or through one of the optional categories.Rosenbach, M.; Lewis, K.; & Quinn, B. (2000). Health condi-tions, utilization, and expenditures of children on foster care: Finalreport. Cambridge: MA: Mathematica Policy Research Inc.<http://aspe.hhs.gov/hsp/fostercare-health00/index.htm>. Seealso English, A. & Freundlich M. (1997). Medicaid: A key tohealth care for foster children and adopted children with spe-cial needs. Clearinghouse Review, 31(3-4), 109–131.

21. For example, in Monroe County, New York, New York FosterCare Pediatrics (FCP) is a full-service primary care pediatricoffice with limited on-site developmental and mental health services.FCP averages 3,600 visits annually and operates under the auspicesof the Monroe County Health Department in collaboration withMonroe County Department of Social Services. For moreinformation contact Moira Szilapyi, M.D.; phone: 716-274-6149;fax: 716-292-3942; e-mail: mszilapyi@mcls.rochester.lib.ny.us.

22. 20 U.S.C. § 1432 (5)(A)(I)(ii)(2000).

23. See 34 C.F.R. 303.19 for definition of parent under Part C.

24. New York State Law, Public Health Law, article 25, title II-A.

25. See also Burns, S.; Stagg, V.; & Bennermon, B. (1999). Put-ting it together: Providing mental health services in early interven-tion. Harrisburg, PA: Pennsylvania CASSP Training and Tech-nical Assistance Institute.

26. Class action lawsuits in numerous states have lead to con-sent decrees that have created catalysts for system change in-cluding increasing quality and documentation of health careprovided to children in foster care. See Dicker, S. & Gordon, E.(2000). Safeguarding foster children’s rights to health services:The right to health care. Children’s Legal Rights Journal, 20(2),45–53. Lutz. L. L. & Horvath, J. (1997). Health care of childrenin foster care: Who’s keeping track? Portland, OR: National Acad-emy for State Health Policy.

27. The California Department of Health Services has producedstatewide guidelines for public health nursing in child welfareservices. See California statewide guidelines for public healthnursing in child welfare services. (1999). In J. Rawlings-Sekunda.Opening the toolbox: Resources for states seeking to improve healthcare for children in foster care. Portland, OR: National Academyfor State Health Policy.

28. See Yoshikawa, H. & Knitzer, J. (1997). Lessons from thefield: Head Start mental health strategies to meet changing needs.New York, NY: National Center for Children in Poverty, Mail-man School of Public Health, Columbia University and Ameri-

can Orthopsychiatric Association; Knitzer, J. (2000). Using men-tal health strategies to move the early childhood agenda and promoteschool readiness. New York, NY: The Carnegie Corporation ofNew York and the National Center for Children in Poverty,Mailman School of Health, Columbia University; Donahue, P.J.; Falk, B.; & Provet, A. G. (2000). Mental health consultation inearly childhood. Baltimore, MD: Paul H. Brookes Publishing Co.;and Cohen, E. & Kaufmann, R. (2000). Early childhood mentalhealth consultation. Washington, DC: U.S. Department of Healthand Human Services, Center for Mental Health Services(CMHS), Substance Abuse and Mental Health Services Ad-ministration (SAMHSA).

29. Another strategy provides early intervention and early child-hood services in the context of a foster care agency. In Brook-lyn, New York, the Early Childhood and Family Center, a divi-sion of foster care agency Brookwood Child Care, is a therapeu-tic nursery that provides services to children birth to age threewho have emotional and developmental difficulties. Approxi-mately 60 percent of the children are in foster care. Most chil-dren are referred by the agency’s on-site medical clinic or bycaseworkers. Working with both biological and foster parents,center staff serve as coaches and models in a classroom settingto assist parents in learning strategies for engaging their chil-dren, addressing their child’s developmental and emotionalneeds, and managing the child’s behavior. Every child referredto the center receives a comprehensive evaluation by a psy-chologist, and a treatment plan is developed collaboratively withthe caregivers. The center offers a special education classroom,early intervention services, parent support groups for biologicaland foster parents, parent-child therapy, and individual therapyfor child and parent. The classroom sessions are two and one-half hours daily and provide a range of supervised early child-hood activities for the child. When children leave the program,a service coordinator helps transition them to other programssuch as special education or Head Start. For more informationcontact Faith Sheiber; phone: 718-596-5555, ext. 454; fax: 718-596-0985.

30. The Adoption Assistance and Child Welfare Act of 1980, Pu-bic Law No. 96-272, Social Security Act Titles IV-B, IV-E, 42U.S.C. §§620 et seq., 670 et seq.

31. The Adoption and Safe Families Act of 1997, Pubic Law No.105-89, 111 Statute 2115–2135.

32. 45 C.F.R. § 1355.34 (b) (1) (iii).

33. Ibid.

34. See Armstrong, M. L.; Conger, D.; & Finck, K. (1997).New York State Family Court improvement study. Washing-ton, DC: Vera Institute for Justice, unpublished paper (on fileat the Permanent Judicial Commission on Justice for Children)and Heidt, J. (1996). Survey of key child welfare actors in thecourt. Unpublished paper (on file at the Permanent JudicialCommission on Justice for Children).

35. For more information about the CASA program see: <http://www.casanet.org>.

36. Lederman, C. S.; Malik, N. M.; & Aaron, S. M. (2000).The nexus between child maltreatment and domestic violence:A view from the court. Journal of the Center for Families, Chil-dren, and the Courts, 2, 129–135.

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37. These courts are using TANF funds to provide supportiveservices to parents. For more information about DependencyDrug Treatment Courts see the U.S. Office of Justice ProgramsDrug Court Clearinghouse and Technical Assistance Project(DCCTAP) at <http://www.ojp.usdoj.gov/dcpo>.

38. Some states and counties are using TANF funding to pro-mote the well-being of children and their families. The New YorkState Office of Children and Family Services (OCFS) developeda Request for Proposals (RFP) for prevention programs to useTANF funding to create new community-based services for vul-nerable children and families to reduce the need for out-of-homeplacement. The RFP is a collaborative effort between OCFS andthe New York State Office of Alcoholism and Substance AbuseServices. See New York State Office of Children and Family Ser-vices. (2000). Prevention programs request for proposals. (On file atthe Permanent Judicial Commission on Justice for Children). TheRFP awarded $33 million in grants in 2001. A substantial grantwas awarded to the New York State CASA Association to fundthe CASA Statewide Safe Family Expansion (SSaFE) initia-tive (see <http://www.casanys.org/0102TANF.htm>). This ini-tiative will serve 350 children in 22 New York State countiesmeeting TANF eligibility requirements who are at-risk of beingplaced in foster care or who are currently in foster care with thegoal of returning home. The TANF funding will enable the ex-pansion of local CASA programs throughout New York Stateand supports recruiting, training, and supervising additional vol-unteers necessary to serve these children as well as enhancetheir training and technical and training.

An example of a local TANF initiative can be found in El PasoCounty, Colorado. Through the TANF program, the El PasoDepartment of Human Services provides kinship services to grand-parents raising their grandchildren, including preventative finan-cial assistance and support services aimed at keeping the extendedkinship family intact. Child welfare staff were transferred to theTANF program and matched with TANF technicians to create aunit specifically designed to serve grandparents and other rela-tive caretakers. Using TANF funds, the county has implementeda Child Care Coordination program that includes the develop-ment of a child care resource and referral database available to allrelevant families, including families receiving child welfare ser-vices. The Teen TANF program offers pregnant and parentingteens on TANF case management services, assessment, home vis-its, nurse visitation, continuing education, job training, andparenting instruction. This program is staffed in part by formerchild welfare workers who are now housed and funded with TANFmonies. The agency also is combining family preservation andfoster care placement prevention services with preventive TANFservices to create a service continuum that bridges the fundingand service philosophy gaps between child welfare and welfare.

39. Standardized forms that provide consent to release health-related information and court orders can facilitate sharing ofinformation among attorneys, caseworkers, health care provid-ers, and other professionals working with children in foster careand their families. (Sample court orders on file at New YorkState’s Permanent Judicial Commission on Justice for Children.)

40. A recent report documented that one-third to one-half ofchildren in foster care were not enrolled in Medicaid in themonth after their foster care eligibility ceased. See Rosenbach,Lewis, & Quinn in endnote 20.

41. Public Law. 105-89, 111 Statute 2115–2135 (1997) (codi-fied as amended in scattered sections of 42 U.S.C.)

42. 42 U.S.C. § 1396 (a) (10) & (43) (2000); 42 U.S.C. §1396d (a) (4) (B) (2000) & 1396d (r). See also 42 C.F.R. §441.50–441.62 (2000).

43. 20 U.S.C. § 1431 (2000); 34 C.F.R. Part 303 (2000).

44. 20 U.S.C. §1419(a) (2000); 34 C.F.R. Part 301 (2000).

45. Public Law No. 104-193, 110 Statute 2105. Assistance ismade through the TANF block grant. 42 U.S.C. § 607(a).

46. 42 U.S.C. § 603, 609. The basic federal awards, plus thestate required maintenance of effort funds, mean there is ap-proximately $27 billion per year available to serve these fami-lies. See Lazere, E. (2000). Unspent TANF funds in the middle offederal fiscal year 2000. Washington, DC: Center on Budget andPolicy Priorities <http://www.cbpp.org> for a breakdown of thevarious federal and state funding streams that contribute to thetotal figure.

47. States have broad discretion to define “needy” and can de-fine the term differently for different services and supports. 64Fed. Reg. 17825

48. 45 C.F.R. § 260.31. For a discussion of the significance ofthe assistance/nonassistance distinction in designing state poli-cies and programs, see Greenberg, M. & Savner, S. (1999).The final TANF regulations: A preliminary analysis. Washing-ton, DC: Center for Law and Social Policy <http://www.clasp.org/pubs/TANF/finalregs.PDF> and Greenberg, M..(1999). Beyond welfare: New opportunities to use TANF to helplow income working families. Washington, DC: Center for Lawand Social Policy <http://www.clasp.org/pubs/TANF/markKELLOGG.htm>.

49. For a fuller description of these appropriation principles andthe rules surrounding the use of TANF and Maintenance ofEffort (MOE) funds for child welfare services, see Hutson, R.Q. (Forthcoming ). Tapping TANF for child welfare: A guide toexpanding services and to filling gaps in the child welfare system.Washington DC: Center for Law and Social Policy <http://www.clasp.org>.

50. For an overview of allowable spending under TANF, seeU.S. Department of Health and Human Services. (1999). Help-ing families achieve self-sufficiency: A guide to funding services forchildren and families through the TANF Program. Washington,DC: U.S. Department of Health and Human Services <http://www.acf.dhhs.gov/programs/ofa/funds2.htm>.

51. While a total of 30 percent can be transferred, no morethan 10 percent can be transferred to Title XX, and Title XXtransfers must be for services to children and their families be-low 200 percent of poverty. Beginning in FY 2002, no morethan 4.25 percent of TANF funds may be transferred to TitleXX. Funds transferred to another block grant become subject tothe rules of that other block grant rather than to TANF rules.See 42 U.S.C. § 604. The 4.25 percent limit on the amounttransferred to Title XX was supposed to begin in FY 2001, but aspart of the final appropriations package adopted by the 106thCongress on December 15, 2000 (H.R. 4577), the 10 percentlimit on transfer to Title XX was maintained for FY 2001.