Reexamining risk factors in foster care

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Reexamining Risk Factors in Foster Care Evelyn F. Slaght George Mason University

After a decade of declining foster cam caseloads, the number of children in placement is again on the rise. Substance abuse seems to be the reason for the increase; however, there is limited documentation of the relationship of substance abuse to placement outcome. In an attempt to reexamine risk factors in foster care placement, a study was undertaken in Baltimore, Maryland, using a sample of 129 foster care cases, which were tracked over a two year period. It was hypothesized that cases where parental substance abuse was the primary reason for placement, a child would remain in care longer and recidivate with greater frequency. No significant differences were found in the outcomes of cases where substance abuse was the primary reason for entry as compared to those where mental health was the primary risk factor. This finding, along with the absence of adequate information in the case records to substantiate other risk factors (e.g., inadequate income) raises questions about whether identified risk factors are driving the decision-making tbat impacts on a child’s foster care experience and the services they receive.

Since the passage of the Adoption Assistance and Child Welfare Act of 1980 (P.L. 96272), most states have been successful in reducing the number of children in foster care and reducing the length of stay (Rosen, Fanshel & Lutz, 1987). Within the past several years, however, the trend has begun to shift and the number of children in placement is again on the rise. Data reported by Besharov (1990) places the increase in the number in care between Fiscal Year (FY) ‘88 and FY ‘89 at 28.6%. Efforts to reunite foster children with their own families has not always proven successful. Even with support services, about 30% of those who return home reenter care (Seltzer & Bloksberg, 1987), and there is little or no data to indicate whether children who return home are indeed safe (Jellinek, Murphy & Bishop, 1990). According to Bresharov (1990), a major reason for the increase in the number of children in foster care is the substance abuse of the caretaker. “The communities hardest hit by crack addiction have experienced startling increases” (p. 23). Reprintsmay be obtainedfromEvelyn F. Slaght, Social Work Program, George Mason University, 4400 University Drive, Fairfax, Virginia 22030, USA.

143

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Family preservation and prevention of out-of-home care remain the mission of child welfare agencies, in spite of questions regarding its success. In some cases, the policy is being implemented out of necessity rather than conviction. Most states are facing a crisis in the number of foster, shelter and adoptive homes available for children, especially minority children. Return home or placement with relatives is the only realistic choice in many cases. Yet premature reunification may increase the risk of family dissolution. Where drugs are involved, pressure to reunify may result in return home before the addict or alcoholic has recovered sufficiently. Children of addicts sometimes experience a number of foster care episodes in a relatively short period of time as they vacillate between the dysfunctional family and the foster home. This instability may result in emotional, behavioral and educational problems, and the ultimate outcome may be an older child coming into care because of his or her special needs or behavioral problems. In the majority of foster care cases, the reasons given for placement (abuse, neglect and/or abandonment) mask the contributing factors of a more causal nature. Most agencies are not systematically maintaining data on the primary risk factors that contribute to the placement outcome, but concentrate instead on documenting the abuse and/or neglect in order to justify to the courts the child’s removal. A more systematic tracking of risks associated with reabuse and neglect is needed, including the development of a finite list of the most common risk factors against which agencies can monitor case progress. According to Wald and Woolverton (1990), there is no basis in research for assessing what constitutes high or low risk, and therefore, no reliable base to risk assessment tools. This is not likely to change until there is systematic recording of the circumstances surrounding the incidents leading to removal and more research of the relationship of risk factors to case outcome. Review of the Literature

The National Black Child Development Institute (NBCDI) (1989), has identified a number of factors that are associated with foster care entry. Many placements, they point out, are attributable to “environmental stresses caused by chronic poverty” (p.37). Inadequate housing/homelessness, mental illness, and substance abuse are named as significant barriers to reunification among the black families they surveyed. They found drug abuse to be a factor contributing to placement in 36% of the cases. However, Besharov’s study (1989) suggests that substance abuse may be present in as many as 90% of the abuse and neglect reports in cities like

Foster Care Risk Factors

145

the District of Columbia. Jellinek et al. (1990) cite prevalence rates ranging between 33% and 80% (depending on the state) of Protective Service cases involving substance abuse; it is especially a factor, they point out, in cases of severe neglect. They found poverty to be a risk factor in two thirds of the abuse and neglect cases brought before the Boston Juvenile Court; “most are headed by a single mother and more than half included a parent with a serious psychiatric disorder” (p. 1629). Low income, single parenthood, and teen parenthood have been confirmed as risk factors contributing to child abuse and family violence (Gelles, 1989; Hulsey & White, 1989). Milner (1987) states that marital relationship, parent’s mental health, housing, financial stress and parentchild relationship are the most prominent social stressors associated with multi-problem families, like those seen in foster care. Kowal et al. (1989) identify financial problems, low self-esteem, single parenthood, lack of transportation, lack of child care, limited parenting skills, teen parenthood, history of or current use of alcohol or drugs, intergenerational abuse, and employment and housing difficulties, as primary problems that place families at risk of dissolution. Most of these factors, when identified and addressed by the worker, can be remediated, they found. The exception was substance abuse “where only 6.7% of the cases showed any improvement. [Substance abuse] is a long term problem and almost always requires specialized intervention”(p. 535). Cooper. Peterson and Meier (1987) agree that substance abuse is associated with high numbers of placements and lengthy stays in foster care, but also introduce age as an issue. Very young children are most at risk of more placements and longer care, they suggest, while older children are placed because of their own behavior rather than parental failings. Rzepnicki (1987) points to studies showing that children with behavior problems as reason for foster placement are older and more likely to be recidivists. These studies identify 10 risk factors, not all of which are supported by all nine researchers. These factors are consistently recognized as associated with child maltreatment, although they do not represent an exhaustive list. Nonetheless, for purposes of research, it was necessary to limit the study to those with the strongest empirical support and those most commonly recognized as risk factors (McDonald & Marks, 1991).

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Table 1 Studies of Risk Factors Associated with Placment of Abuse/Neglected Children in Foster Care

Environ- Single &Teen mental Referenced Studies ParenthoodNBCDI X Besharw X Jellinek, et al. X X Kowal, et al.hbpc X X Gelles X X Hulsey &White Milnea X Cooper et al. Rzepnicki X

Mental X X

Substance

Child Problems-

X X X X

Lack of supports &

X

X

X

X X

aAlso included poor interpersonal relationships/skills. bAlso included low self-esteem. cAlso included intergenerational abuse.

Five categories are most consistently regarded as strongly associated with foster care entry--environmental stress, single parenthood, teen parenthood, mental health, and substance abuse. Each effects the family differently and has varying degrees of impact on the ability of the family to function. When any two or more occur simultaneously, the impact may be multiplied. Yet there is little empirical research to document the degree of danger that confronts the child(ren) when these factors are present either singly or together. In lieu of documentation of the relative seriousness of these factors, agencies are left with no quantifiable means to prioritize cases for decision-making or intervention purposes. Our inability to predict foster care recidivism is particularly hazardous to reunification planning. If Rzepnicki (1987) is correct that, “Foster care recidivism is likely to increase unless services are specifically designed to address the population in care” (p. 66), then we need to understand more about reasons for placement in order to tailor our services more appropriately. Purpose of the Study In order to better understand the factors contributing to the replacement and length of stay of children in foster care and the relative importance of

147

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substance abuse as one of the risk factors, a two-year study was undertaken in Baltimore, Maryland, beginning in August, 1988. All of the children (129) who entered care in August, 1988, were included in the study. Case records were reviewed initially to identify reasons given for placement; they were reviewed again in August, 1990, to determine length of stay and which cases resulted in return to care. As of August, 1990, the average number of months in care for those who had returned home was two to six months, allowing at least 18 months from time of discharge to time of follow up. The time frame of 18 months is supported by the work of Block and Libowitz (1983). who found that 90.6% of the children who recidivate do so within 18 months of discharge.

Methodology

The case record review was expected to produce a finite list of risk factors, to which predictive values could be attached to allow workers to anticipate success or failure of reunification, and thereby plan intervention efforts. It was hypothesized that cases involving substance abuse would have the least favorable outcomes, when compared to cases where inadequate income or housing, teen or single parenthood, or physical or mental incapacitation were the primary family problems. Baltimore was an appropriate site for the study because Maryland was one of the first states to implement a reunification policy and systematically monitor length of time in care through a citizen review process. They were also progressive in computerizing foster care case information, so that data could be obtained on children in care with relative ease. Baltimore City, with a population of about 750,000, is a prototype of most medium-sized cities today. Like most other urban areas, minority populations are overrepresented in foster care caseloads, and adequate foster care homes are dramatically scarce and growing more so. Baltimore City had 1,104 children in foster placement in FY’88, which represents nearly half of the total number of children coming into care in that State. The sample represented 12.6% of the annual Baltimore City DSS foster care caseload. The schedule used to collect data from records required searching for the following risk factors: Teen parenthood Single parenthood Incarceration/institutionalizationof primarycaretaker Mental illness of caretaker Physical illness of caretaker

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Substance abuse of caretaker Inadequate income Inadequate housing Special needs of child History of domestic violence/abuse. Efforts were made to identify all risk factors as well as those considered the primary reason for removal and placement in care. Unfortunately case records were very sketchy, and crucial data regarding risk factors was absent from many of the records reviewed. For example, unless the family was on AFDC, information on amount and source of income was often missing. Information on teen parenthood (or mother’s age when her first child was born) could not be detected in cases where the older children were no longer in the home. As a result, teen parenthood and adequacy of income could not be analyzed because of missing data. Efforts were made to improve on the reliability of data by questioning workers about cases as the opportunity arose. (Unfortunately, it was not possible to do this in any systematic way). Most workers seemed to be more concerned with finding an alternative living arrangement for the child and getting him out of foster care than with documenting or investigating risk factors or remediating family problems. Therefore, this effort did little to improve the data. Inadequate case records are often problemmatic in obtaining data for research, but it was worse than usual here, a problem recognized by Kamerman and Kahn (1990) who acknowledge the impact that foster care reform and accountability pressures has placed on City Departments like this one. Additional cases were lost to the study because there were very few cases where reason for placement was identified as incarceration, physical illness, or inadequate housing. Consequently these could not be analyzed as discrete risk factors. Substance abuse and mental illness became the focus of analysis. This limited the final analysis to 107 cases. There were a number of cases where the child’s behavior precipitated the placement. These were age-related (i.e., more likely to involve adolescents); therefore, age was treated as a control factor and these cases were The survey schedule also asked for information analyzed separately. regarding service delivery, specifically efforts of the worker to secure outside resources, but very few records reflected any such effort. Because the study involved mostly nominal data, statistical analysis The relationship between was limited to Chi-square and correlations. substance abuse and mental illness (as primary risk factors), legal reason for placement (abuse or neglect), and status of caretakers (single head of household versus two parents) were examined in relation to the number of placement episodes and the number of months in care.

Fu&er

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Care Risk Factors Findings

Aside from abuse and neglect, the most commonly mentioned reasons for placement were mental illness of the primary caregiver and substance abuse. In 48 of the remaining 107 cases (37.2%), mental/emotional problems were identified as reason for placement, while in 59 cases (45.7%), drug abuse and/or alcoholism were the primary problems. Generally, these did not often overlap, and there were only 8 cases where the record indicated that both mental illness and substance abuse resulted in the decision to place. In 24% of the cases, the substance abused was alcohol, compared to 53% involving drugs; in 23% of the cases, both drugs and alcohol were named. In only 5 cases was physical illness or incapacitation the reason for placement and in 17 cases, the major reason was the child’s behavior. The only factors found to be significantly related were legal reason for placement and months in care. Children whose parents are neglectful tend to stay in care longer (over 18 months) as compared to children of abusive parents.

Comparisons

Table 2 of Risk Factors by Recidivism and Length of Time in Care

r of Episodes

Absence/presence of substance abuse Legal reason for placement (abuse/neglect) Number of caretakers (single vs 2 parents)

N

df

x2

104

1

2.029 .

107

1

2.502

104

1

.108

E;

Months in Care df

a+

1

1.51

.;2

.ll

2

7.982

.02

.74

2

2.219

.33

There is no statistically significant relationship between other risks (such as mental illness, substance abuse, or marital status) and either number of episodes or months in care. When age is controlled, there is a correlation between legal reason for placement (neglect, abuse) and substance abuse.

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Table 3 Legal Reason for Placement and Risk Factors

Legal Reason for Placement Risk Factors Mental/emotional problems

11 (61%)

13 (34.2%)

Substance Abuse

7 (39%)

25 (65.8%)

Cases where neglect and/or abandonment is the legal basis for removal are more likely to involve substance abusing parents than cases where removal is based on physical abuse. The following are some of the cases where this relationship is evident: a) single parent with history of leaving children unattended, she is a known drug abuser; b) mother jailed for prostitution, which was performed to obtain drugs; last child was born HIV positive; c) mother abandoned child in the hospital after the child’s birth; has history of drug abuse; d) mother placed voluntarily in order to go into a detoxification center. Although not statistically confirmed, case review would suggest that, in cases where drugs are present and the reason for placement is abuse, it is not uncommon for the abuser to be the mother’s common law husband or boyfriend who is also abusing drugs.

Implications

The fact that mental/emotional problems are a major reason for placement in the Baltimore study (37.9%) is consistent with previous studies. Sherman, Neuman and Shyne’s (1973) study found emotional problems to be the placement reason in 32% of the foster care cases. Substance abuse, however, has taken precedence over a variety of other reasons as the explanation for placement, which could account for the rising foster care caseloads.

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The study does not clarify to what extent environmental stressors (poverty, homelessness) directly contribute to foster care placement. One exception was a case in which discovery of lead paint poisoning resulted in homelessness and ultimately, placement, when the landlord was forced to evict in order to renovate. Frequently inadequate income or housing appears to be the byproduct of mental illness or drug abuse, although in other cases these factors appear to precede and contribute to drug abuse and/or mental illness. In a number of cases, drug abuse seems to have emanated from teen parenthood and the poverty and stresses associated with being a single unmarried mother. These multi-causal situations suggest greater risk for the children, but more data is needed to document their relative importance. The attention of the media on physical and sexual abuse of children has tended to give the public the impression that abuse cases are more serious than neglect. The association of neglect with substance abuse would suggest otherwise. That is, neglect may become a chronic condition for the child when the parent is unable to sustain abstinence. There is no obvious explanation for the finding of no significant relationship between substance abuse/mental illness and placement outcome. It does not appear to be based on the nature of the problem or the available resources to remediate the problem. The resources for treating the mentally ill are more established, but long term treatment is as much a problem as is extended treatment for substance abusers, where the resources for the urban poor are often limited to detoxification services lasting as few as three days. Both tend to be viewed as chronic problems for which there is no quick fix. If there are recognized differences as to successful intervention, they were not reflected in differentiated family treatment plans nor in actual outcomes in the cases studied. It may be that mental health problems get overlooked when drugs enter the picture; but in these cases, one would expect to find longer lengths of stay for drug-related cases, which is not consistent with these findings.

Limitations of the Study Studies that depend on case records with no independent external survey of outcomes have serious limitations since there is no way of knowing how safe children are when they return home. Even where there is followup through Protective Services or After Care services, the experience of having children removed may simply make the parent more aware of how to hide family problems from the agency. It may not be possible to assess with any certainty children’s safety and well being when they are returned home, (and therefore the degree of

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success of intervention relative to the family’s problem). But it is possible to improve the information that is available on the family, and to evaluate whether risk-specific intervention efforts effect recidivism and length of stay more than the current scattered approach. Inadequacies in case record keeping have been documented (National Black Child Development Institute, 1989; Pagelow, 1984), and it is clear that training is needed to teach workers how to obtain and record complete family histories when children enter care. Uniformity in data collection not only will allow services to be more targeted, but also promote intra and inter agency tracking of case outcomes relative to risk factors. The absence of data on environmental risk factors (poverty, inadequate housing) is a finding that requires some exploration. Perhaps workers feel compelled to focus on problems of greater complexity in order to justify why the child is in care. The central focus of the study was on the outcome for children once placed in foster care, and whether certain underlying problems contribute to length of stay and/or recidivism. It was not an attempt to investigate factors leading to a decision to remove a child from the home (as this would have required a sample of children with similar CPS contacts who were not removed). Nor was it an attempt to understand the rationale for return home, although studies are needed in both areas. It was an effort to recognize serious problems at time of placement and to examine whether the awareness of these problems makes any difference in case outcome. These issues need to be explicated from a prospective rather than retrospective approach, including worker interviews that could supplement case records in clarifying what is known or not known about the family and the rationale for decisions made. Reliance on records handicaps research, not only because of omissions in family information, but they tend not to contain complete information on the interventions that have been tried. We must not only be able to be assured that the worker has identified the underlying problems (beyond abuse and/or neglect) that are preventing family reunification, but whether agency efforts to intervene have made any differences. Are workers responding any differently when they know that substance abuse is a factor in the family dysfunction? Records would suggest that workers in this jurisdiction may be assuming a policeing role, focusing documentation on failures of families to alter their behavior (as justification for removal and continuance in care) rather than documenting changes in parents behavior along with their efforts to help. Conclusions While we have come a long way in individualizing case planning for children in foster care. we are still unable to assure that children who must

Foster

Care Risk Factors

153

be placed are returned home in a timely manner and that the home to which they return is more stable than when they were removed. Part of our failure is related to the absence of documentation of the underlying reasons for placement and our response to the families who experience these problems. Length of stay in care does not seem to relate to reason for entry, and research has not documented the factors that effect outcome. How can we tailor our intervention to the individual and family if we are not meting our approach to the most pressing problems? To define risk primarily in terms of the severity of the abuse and/or neglect rather than the primary precipitating factors that motivate the abuselneglect denies direction to the intervention. Is there really no difference for the child in the experience of living with a substance abusing parent as compared to a parent with psychiatric problems? Should we not anticipate some differences, and track these cases separately in our information systems? Likewise, if we are to design services to address the specific needs of children in foster care and their families, we need more research on the outcomes in these cases and what approaches tend to improve the family circums~es. This is particularly crucial because of the beginning trend towards increased caseloads, and the need to demonstrate that reunification can be an effective policy. Decisions regarding reunification must begin to be based on reasonable predictions about expected outcomes.

References

Besharov, D.3. (1989). The children of crack. PubZic Welfare, 47(4), 6-l 1. Besharov, D.J. (1990). Crack children in foster care. Children Today, 19, 21-26. Block, N.M., & Libowitz, A.S. (1983). Recidivism in foster cure. New York: Child Welfare League: Cooper, C.S., Peterson, N.L., & Meier, J.H. (1987). Variables associated with disrupted placement in a select sample of abused and neglected children. Child Abuse und Neglect, If, 75-86. Gelles, R.J. (1989). Child abuse and violence in angle-pint families. American Journal of ~~~p~c~~t~, 59.492-500. Hulsey, T.C., & White, R. (1989). Characteristics and behavior of foster children and non-foster childten. American Journal of Orthopsychiiatry, 59,502-509. Jellinek, MS., Murphy, J.M., & Bishop, S. (1990). Protecting severely abused and neglected children. New Englund Journal of Medicine, 323.628-630. Kamenmxn, S.J., & Kahn, M.J. (1991). Pattern of coping: The big cities. Children and Youth Services Review, 12,69-89.

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Kowal, L.W., Kottmeier, C.P., Ayoub, CC., Komives, J.A., Robinson, D.S., & Allen, J.P. (1989). Characteristics of families at risk of problems in parenting: Findings from a home-based secondary prevention program. Child Welfare, 68, 529-38. McDonald, T.M., & Marks, J. (1991). A review of risk factors assessed in child protective services. Social Service Review, 65, 112-3 1. Mimer, J.L. (1987). An ecological perspective on duration of foster care. Child Welfare, 66,113-123. National Black Child Development Institute. (1989). Who will care when parenrs can’t?: A study of black children in foster care. Washington, DC: Author. Pagelow, M. (1984). Family violence. New York: Praeger. Rosen, S.M., Fanshel, D., & Lutz, M.E. (Eds.). (1987). Face of the nation 1987. Silver Spring, MD: National Association of Social Workers. Rzepnicki, T.L. (1987). Recidivism of foster children returned to their own homes: A review and new directions for research. Social Service Review, 61, 56-70. Seltzer, M.M., & Bloksberg, L.M. (1987). Permanency planning and its effect on foster children: A review of the literature. Social Work, 46,65-68. Sherman, E.A., Neuman, R., & Shyne, A. (1973). Children ad@ in foster care: A study of altt!mative approaches. Washington, DC: Child Welfare League of America, Inc. Wald, M.S., & Woolverton, M. (1990). Risk assessment: The emperor’s new clothes? Child Welfare, 69,483-505.