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Healing the hole in the heart.

The happy news: More children than ever before are being adopted from foster care. The reality: They and their new families need special services, such as counseling, respite care and peer support.

When Rebecca Cole adopted Jack at age 8, he had little concept of home or family. Subjected to neglect and domestic violence, he was permanently removed from home at age 4 by county child welfare authorities. Between 2 and 7, Jack was moved 17 times among various foster homes, psychiatric hospitals and extended family members.

When Rebecca became Jack's court-appointed special advocate, he had already been diagnosed with severe depression, post-traumatic stress disorder, attention deficit disorder and severe reactive attachment disorder.

Knowing the risks, Rebecca and her husband decided to adopt the troubled youngster in 1995. Unfortunately, family life was punctuated by Jack's violent rages, when he trashed the house and often threatened to kill his parents. Conventional counseling didn't help, and residential treatment was unaffordable.

Ultimately, Rebecca and her husband had to relinquish custody of Jack to the county in order to have him placed in a treatment center. Now 14, he has been in seven different residential placements since his adoption. Living in a highly structured environment, however, has helped stabilize his emotions, and his behavior is improving during regular stays at home.

Looking back, Rebecca remembers a conversation she had with Jack when he first came to live with them. "He asked me if there would be room for two more people. I asked him if he wanted his birth parents to live with us. He said yes and started to cry. I said that his heart must be hurting, and he said he had a huge hole in his heart. He then corrected himself and said that the hole was so big that he didn't have a heart."

Although Jack may never be able to live at home full-time, the boy knows that his adoptive parents care about him and have committed to support him throughout his long and difficult journey. "I guess that more than anything," says Rebecca, "my husband and I are hoping that through consistency and love, we are able to help him heal his heart and feel whole again."

Fifteen years ago, Jack probably would have been declared unadoptable by the child welfare system. Without a permanent family, chances are he would have "graduated" from foster care to the juvenile justice system and, ultimately, the adult correctional system. With two loving and committed parents, however, he now has a shot at avoiding that fate.


Children are being adopted from foster care at unprecedented rates nationwide. The number of public agency adoptions increased from 25,644 in 1995 to 51,000 in 2000. Although the majority of children in foster care leave the system in less than two years, adoption is permanent. Analysts therefore project that within the next few years the cumulative number under 18 who have been adopted from out-of-home placement will exceed the number of children in foster care. A growing number of states, including Illinois, Michigan and Oregon, already have more children on adoption assistance than in foster care.

Although states have focused on changing law, policy, practice and agency culture to increase the number of adoptions, there has been less emphasis on what happens to families after they adopt. The social and emotional wounds caused by abuse, neglect and frequent moves among foster homes are not healed by the issuance of an adoption decree.

"Adoption is not the cure for every problem a child has experienced," says Richard Anderson, head of Utah's Division of Child and Family Services. "But we've acted like it is for a long time."

Because child welfare agencies have traditionally viewed adoption as the end of their responsibility, many families report feeling abandoned once their adoption is finalized. Most foster children are adopted by their foster parents, who often see a substantial reduction in the array of services and supports available to them.

Advocates, adoptive families, child welfare administrators and many policymakers argue that the availability of post-adoption services encourages people to adopt children from foster care, keeps adoptive families together and prevents children from re-entering foster care.

"As we increase national awareness about ensuring permanent homes for children in foster care," says Rita Soronen, executive director of the Dave Thomas Foundation for Adoption, "it is essential that we make parallel efforts to ensure that appropriate resources are available to every family adopting these very special children."

Kathy Ledesma, Oregon's adoption manager, argues that post-adoption services are cost-effective. "If we don't invest in supportive services, many of these children will pop up in the juvenile justice system, become street kids or end up in the adult correctional system."

Oregon Representative Jeff Kruse, chair of the House Health and Human Services Committee, agrees. He sponsored legislation in 1997 that established a task force to examine ways to expedite the adoption process and increase the number of children adopted from foster care. "Providing services to adoptive families is a net gain for both the state and the kids. The state saves money by keeping the kids out of foster care, and the kids get a permanent family."

Although there is limited research to support claims that post-adoption services keep families intact and save states money, it is clear that families who have adopted children with special needs face considerable challenges.

Richard Barth, a leading adoption researcher at the University of North Carolina, has identified several risk factors for adoption failure. The leading factor is the child's age. Older children adopted from foster care may have been exposed to more abuse than younger children, have stronger ties to their birth parents, and have more ingrained learning and behavioral problems, making it more difficult for them to adjust to their new family. Adoptive families of children with serious behavioral and educational problems are also at increased risk for dissolution, especially when the children's progress does not meet the parents' hopes and expectations.


There have been numerous surveys of adoptive families that have identified a wide variety of needs. States may not be able to satisfy all of these desires, but a few services are essential to any post-adoption program.

Mental Health Services: Many adoption experts say that mental health services by providers who understand adoption is the most significant service gap. Although adoptive families have access to traditional mental health services, they often complain that therapists don't understand what they consider to be the unique, but predictable, problems that arise in adoption, including those related to grief and loss. Accordingly, some states have invested in training mental health providers in adoption dynamics.

Adoption experts also argue that short-term residential treatment should be more widely available to families who have adopted children with serious behavioral and emotional problems. Residential treatment represents "a big chunk of money, but a tiny percentage of kids," says Susan Klickman, manager of post-adoption services in Texas.

In some states, families must relinquish custody of their children to the child welfare agency in order to become eligible for residential treatment. Other states have eliminated this requirement.

Respite Care: In addition to mental health services, respite care is often cited as a critical unmet need. Respite provides adoptive parents and their child with time away from each other and a break from the difficult work of forming a family. "Sometimes older adopted children have a hard time tolerating the intimacy of family life," says Utah's Vicky Steffey, who is in charge of post-adoption services in the Salt Lake region.

In Texas, respite care has been "tremendously beneficial," says Klickman. The state provides a number of respite options, including summer camp. States also are tapping existing resources, such as after-school programs and subsidized child care.

Peer Support: Adoptive parents say that support groups and networks, both for parents and for the children, are extremely helpful. Many adoptive parents say that other adoptive parents are their most important resource.

Information and Referral: Finally, information and referral are critical post-adoption services. In many states, telephone "warm lines," Web sites, lending libraries, newsletters and workshops provide adoptive families with a wide range of information about the legal and psychological aspects of adoption, available community-based services and links to other adoptive families. "The availability of information that helps families understand what adoption often involves is crucial," says Barth. "Families that do not expect the problems that they encounter with their child and that do not observe the improvements that they hoped for are at greater risk for disruption."


In an era of budget shortfalls, states are finding it hard to meet the increasing demand for services caused by the surge in adoptions. "Funding for services has not kept pace with the increase in adoptions," says Klickman. "Families are now having to compete for services."

Although there is limited funding for post-adoption services under the federal Promoting Safe and Stable Families program, Ledesma says, "The federal funding streams do not address the increase in adoptions. The feds have heavily funded foster care, but we now have more adopted kids than foster kids."

States are coping with the resource issue in a number of ways. Crystal Ward Allen, director of the Public Children Services Association of Ohio, says the state has stretched its $3.7 million Post-Adoption Special Services Subsidy to cover more families. The state now requires counties to obtain more stringent medical documentation, eliminated educational services such as tutoring and lowered the maximum yearly subsidy amount from $20,000 to $15,000. In Texas, Klickman expects funding to remain flat in light of a projected $5 billion budget shortfall. In Massachusetts, the legislature eliminated the requirement that the state spend $1.25 million of its appropriation on post-adoption services.

A funding crisis in Utah led to major reforms in the way post-adoption assistance is financed and delivered. Like many other states, Utah was a victim of its own success in increasing adoptions from foster care. A state-funded supplemental subsidy covers extraordinary expenses that are not paid from other sources. In 2000, most payments covered specialized therapies and residential treatment not covered under the state's Medicaid managed care plan. The state Division of Child and Family Services (DCFS) was forced in the spring of 2000 to cut payments in response to a $1.4 million budget overrun.

The subsidy cuts generated an uproar among adoptive parents, who demonstrated at the State Capitol and threatened to sue the state. Governor Mike Leavitt vowed to restore the supplemental subsidies through the end of the 2001 legislative session. After that, he said, "It's up to the families to make their case to the Legislature." The families made their case in hearings before the Legislature's Child Welfare Oversight Committee.

Representative Trisha Beck, herself a parent of a child with special needs, remembers being "very impressed" with the stories of adoptive families. "When a family adopts a child with special needs, they have taken on not just the dynamics of having another child in the family, but also the challenges posed by the child's special needs. It is absolutely critical to support these families."

Ultimately, the state responded to the fiscal crisis with a series of reforms at the legislative, departmental and community levels. The Utah Legislature approved a supplemental appropriation to cover the short-fall and allowed adoptive parents to opt out of the Medicaid managed care plan.

The Medicaid "carve-out" was particularly important because foster parents, who were not required to enroll in the managed care plan, were required to do so if they adopted their foster child and wanted to maintain their child's Medicaid eligibility.

Senator Chris Buttars, director of the Utah Boys Ranch, says the carve-out has been a great improvement. "The state had been paying one organization that may not have been getting any referrals and that may not have been providing adequate services to families that were referred," he say. "These kids have heavy-duty problems, and families were very dissatisfied."

Perhaps the most important change, however, was that DCFS began reaching out to communities and enlisting existing service providers--including schools, child care resource and referral agencies, family support centers and mental health professionals--to help improve post-adoption services at the local level. DCFS and the state Adoption Exchange sponsored an adoption summit in April 2001, solicited input from hundreds of adoptive families and developed a three-year plan to create local support networks with no new state funding.

During the first year of the plan, DCFS designated staff in each region of the state to serve as post-adoption workers, conducted an assessment of local needs and resources, implemented the Medicaid carve-out, and developed an adoption-specific training curriculum for service providers currently working with adoptive families. The Adoption Exchange established a toll-free information line, created a post-adoption Web site, and published a resource guide for adoptive families.

As a result of these and related changes, Utah is poised to provide more and better post-adoption services with less state money. In FY 2002, the Medicaid carve-out, together with the use of federal funds under the Promoting Safe and Stable Families program, resulted in savings of $1.3 million in state-funded supplemental assistance compared to FY 2000.

Leroy Franke, the state's adoption specialist, says that families are no longer complaining about lack of support. "We've made a tremendous about-face" since the funding crisis in 2000. "We now know that state programs will never be enough to meet the needs of all adoptive families. But the resources are out there. Public-private partnerships are the key."


As in so many other areas of human services, the lesson that emerges from the experiences of families who adopt foster children is the importance of prevention and early intervention.

Experts say that adoptive families need ongoing support so that problems do not become crises. Children need stable, consistent care at an early age; multiple moves in foster care can be as devastating to a child as parental neglect.

Rebecca Cole knows about the value of early intervention. In 2000, she and her husband decided to adopt a 5-month old baby girl born to a mother addicted to methamphetamine. Unlike Jack, who spent years in foster care, Natalie came directly from the birth parent. Even as an infant, however, she exhibited troubling behaviors, such as biting and head-banging. "My husband and I and all of her workers were shocked at the level of damage to such a young child," says Rebecca. "It reinforced why our son is having such a difficult time overcoming the trauma in his past." With intensive occupational and play therapy, Natalie's behaviors have improved dramatically.

"Today, at age 3, she is doing really well. She takes swimming and tumbling classes and is in preschool two mornings a week. There is no doubt in my mind that without the early intervention, we would have a very different child on our hands."


Adoption literature is heavily influenced by attachment theory. Many psychologists and adoption experts believe that attachment issues, the inability to bond with adoptive parents, often underlie the behavioral problems of adopted children.

They disagree, however, about what constitutes effective treatment of attachment disorder, particularly in older children. Desperate parents sometimes resort to controversial therapies, such as "rebirthing" or "holding therapy." The death of 10-year old Candace Newmaker during a rebirthing session prompted Colorado to ban the practice in 2001.

Richard Barth thinks the emphasis on attachment is misplaced. "The adoption field's near obsession with attachment issues as the cause of difficulties in parenting is leading the field astray, in some cases with tragic results," he says. "There is no scientific basis that I am aware of that points to attachment problems as a primary cause of parent and child problems or suggests that any of the attachment-based therapies are effective in reducing these problems."

Barth says that other proven interventions, such as multisystemic family therapy and Assertive Community Treatment, could be adapted to meet the needs of adoptive families.

Steve Christian covers child welfare policy for NCSL.
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Title Annotation:foster care
Author:Christian, Steve
Publication:State Legislatures
Geographic Code:1USA
Date:Dec 1, 2002
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