Too Little, Too Late

Across the country, children are removed from their homes because of neglect, physical abuse, sexual abuse, and/or the parent's substance abuse, mental illness or mental retardation. In many cases children would be better served by remaining with their families, but the parent support necessary to prevent removal from home is not available. In many cases there are insufficient services to remediate parental inadequacies and reunification cannot occur successfully. In many cases children do not receive proper care and are unable to recover from maltreatment, which also jeopardizes reunification or the success of other permanent placements. 

The federal requirement of reasonable efforts to prevent removal and to reunify families is achievable. At its worst, reasonable efforts has become a meaningless checklist permitting federal funding without compliance. At its best at this point, reasonable efforts is an incomplete patchwork of programs. The purpose of this article is to clarify the broader dimensions of reasonable efforts in attending to the strengths and needs of the child, the family, and the foster family within a system of integrated, flexible, needs-based services. 

Little has been written about reasonable efforts for the audience of child welfare workers and attorneys who carry the daily responsibility of implementing the federal law. Child development, mental health, and educational terminology has made crucial information inaccessible to practitioners. This article attempts to develop a common language based on practice standards which child welfare workers and attorneys can apply to their cases. In the first section the article addresses the definition of reasonable efforts. The second section focuses on five groups of children who are in danger of being defined out of reasonable efforts. The third section describes a system of care which could meet the reasonable efforts requirement. 
 

In 1980, Congress enacted the Adoption Assistance and Child Welfare Act, Public Law 96-272, to reform child welfare. To receive federal funds, state child welfare agencies were required to make "reasonable efforts" to maintain children with their families or, if removal from home was necessary, to return the child to the family [42 U.S.C. §§ 671 (a)(15) and 672 (a)(2)]. * Ten years after P.L. 96-272 was passed by Congress, its reasonable efforts requirement has not been achieved. ** 

Neither the statute nor accompanying regulations specifically defined reasonable efforts.*** California, Minnesota, Missouri and Ohio have enacted reasonable efforts statutes. Caselaw in various jurisdictions has clarified reasonable efforts, including Martin A. v. Gross in which the New York Supreme Court held that New York city's child welfare agency "had a mandatory duty to conduct thorough evaluations, develop meaningful service plans and identify the services to be provided." The nationally-accepted definition for reasonable efforts, published by the National Council of Juvenile and Family Court Judges, Child Welfare League of America, Youth Law Center, and National Center for Youth Law, describes services which must be provided to prevent removal and, when a child has been removed, to reunify the family. * Other publications have clarified for judges how to make reasonable efforts findings and in many states practice guidelines including reasonable efforts have been developed for attorneys.** 

Making reasonable efforts has three essential components:

• The child's and family's needs must be carefully assessed
• Needs-based services must be provided
• The services must be regularly monitored and adjusted, based on their effectiveness in meeting the child's and family's needs.
   

In addition, the concept of reasonable involves defining with a child and family the quantity and timeframe of services to be provided. *** 



What do the child and family want?



Figuring out what the child and family want is not done best by mental health evaluations, although increasing reliance on psychological and psychiatric assessments appears to be a trend. Instead, each of the child's and family's wants must be itemized, based on interviews, school and family observations, and assessments. Although needs assessment is a fundamental aspect of good casework, children's and family's case files seldom contain a list of their strengths and what each wants. Typically interventions are developed from a problem statement and are conceptualized in terms of the services that are available. Services will not be effective if they are not designed to ameliorate a specific need and to build on a specific strength. 



For example, case plans will often contain a statement such as "Mother must attend parenting skills class." This is not an assessment of what she wants. We cannot conclude what service is required until we determine the need the service must meet. Instead, the record should state, "A strength of this mother is that she shows affection to her children. But when she has had to cope with their many demands by herself for long periods, she feels depleted, gets angry and sometimes loses control of her anger. She needs regular breaks from their demands to help her not get depleted." This particular need, once it is specified, would best be matched with a respite care service (not parenting skills class). 



Unfortunately, one essential aspect of needs assessment that is frequently overlooked is evaluating the attachment of the child to each of the important adults in his/her life. Family preservation may be the stated goal of services, but typically the importance of family members to the child is never identified. Children need to have an enduring, positive relationship with both parents (and other significant caretakers), but family problems often obscure this need, and it is not seriously considered in designing services for the child.* The child's point of view would dictate providing intensive, flexible services at home and school rather than removal in most cases. From the child’s point of view, the enduring harm caused by separation from family members to whom they are attached may be a greater risk than of maltreatment. Preventing maltreatment by intensive services is a remedy about which a great deal is known, in comparison to little documentation of positive treatment outcomes in addressing the attachment problems, anger, school adjustment difficulties, and identity struggles of children deprived of their families. 



Many practitioners are unaware of their anti-family bias--they do not think about what the family wants. Believing in family preservation as an ideal goal, in most individual cases, judges, lawyers, case workers, mental health professionals and school staff often think the child would be better off without the parents. In most cases the parent wants the child and wants to be a better parent. In most cases, the child wants to live with the parent. Family preservation means designing services around these wants to help families achieve their own goals. Doing so is seldom considered because practitioners view abusive and chronically neglecting families as hopeless. Instead of thinking the child would be better off without the parents, practitioners must look at what the child and family want and ask, "What would it take to protect the child from the loss of his/her family?” 



Family assessments should answer at least the following: 



1. What are the family's strengths?

2. How responsive are family members to the child's needs, how strong is the child's attachment to various family members, and what relationship does the child have to parent(s) absent from the home?

3. What are the family's rules and how does the family respond to the child’s disobedience and aggression?

4. How needy is the child, how needy are the child's primary caregivers, and how does the family handle conflict between these two sets of needs?

5. What is the impact of the family's culture on childrearing?

6. What are the environmental, employment, economic, substance abuse, health and other stressors on the family?

7. What is the family’s perception of help-seeking and intervention?

8. What specific needs does the family have?

9.  What specific services should be matched to each of the family's needs? 



Itemizing needs is skipped in many cases because of the lack of appropriate, accessible services. It seems impossible to get the parent what they want. In the example above, perhaps there is no regular respite care but there is a parenting skills class offered at a local mental health center. As the child's behavior deteriorates and the family's limited coping skills are stretched, the only available choice is placement. Caseworkers often ask, "Why bother doing careful needs assessment if the child's emotional needs cannot be met by existing outpatient services and his/her educational needs cannot be met by the local school?" 



Regardless of the services that are available, it is essential to itemize specifically in writing the child's educational, emotional, vocational and other needs and the family's needs.* Even talented case workers who have been practicing in systems where assessments are limited by services will have developed a narrow view of what the child and family want and require training in itemizing the strengths and needs of children and families and linking these to services. 



Matching services to what the child and family want 



Once each child's educational/vocational, emotional/behavioral, and other needs and his/her family's needs are thoroughly assessed and itemized, a service plan matching services to each need must be developed in collaboration with the parent. As described below, this is a step-by-step process of tailoring each services to meet each need. The caseworker, clinicians, educators, the child, the parent and anyone else actively involved in the child's life should meet for service planning. This process will be much more effective if the parent and child are asked, "How can we help you get what you want?" 



After services have been matched with each need, the case worker (or team), collaborating with the parent, must unify those services (often from several different providers) in a family-centered approach.** Sometimes a particular needed service has not been provided before and must be created, either by a public agency or contractor.*** In the example above, an arrangement is needed for a babysitter to go into the home, perhaps daily, to give the mother a regular break so she can make use of her strengths as a parent and not get so depleted that she loses control of her anger. In many cases, the package of services will necessitate caregivers going to the home to provide parenting skills instruction, chemical dependency treatment, and other services. The maximum number of home-based care hours should be attempted before utilizing out-of-home services. For chronically neglecting families, a variety of services may be required for years to help the family achieve its goals. Access to services is a required element of reasonable efforts: services must be within reach, affordable, acceptable to the client, and compatible with the family's ethnic and sociocultural background.* 



In chronically neglecting families, caseworker notes document incident after incident demonstrating the parents' inadequacies over the years. But typically the family's needs have not been carefully matched with services and sufficient services have not been provided in a way acceptable to the family in order to make an impact: 



"Arthur" is a 12-year old, the sixth of nine retarded children.** The agency became involved with his family when he was an infant because his father was disabled with kidney problems and his mother had been released from a psychiatric hospital. "Mental health counseling services were offered, but...since no services were requested, the case was closed." A year later the agency investigated because the mother had deserted the family and the 12-year old was staying home to care for younger children so the father could receive daily dialysis. A year later the children were reportedly truant and poorly dressed for school. Two years later several of the children went to school with burns, which were found to be the result of parental neglect. The father had a kidney transplant and started drinking; the mother left home again. A year later, after the children's second removal, an agency report concluded, "Due to the continued pattern the parents have shown of inadequate housing, poor hygiene and housekeeping skills, lack of supervision of the children, failure to comply with compulsory school attendance laws, and failure to benefit from agency services, it is the recommendation of the Department that parental rights be terminated permanently." 



In cases like this, a needs-based service plan to prevent removal would have required intensive, long-term home-based services to instruct and support the parents. Services to match the needs would have included: 

 

In matching services to itemized needs, a single program will seldom offer all the needed services. Placement in a program may appear to offer more to the children than remaining at home, but employing a methodical matching of services to needs will often reveal that the placement cannot meet significant needs of the child. Clustering services from various providers around the child in the family is the best way to match each need with a service (sometimes called “wraparound services” or “comprehensive services”). 



It is essential to view the child's needs in a family context. If the child must be removed to meet his/her needs, placement stability must be insured and efforts must be taken to reduce injury to the child from separation from the family.* 



Adjusting the services 



Once a needs-based service package has been implemented, it is essential to assess its effectiveness in meeting the child's and family's needs. The service package may require adjustment, by adding unanticipated services and/or providing services in different ways. The quantity of services and how long they are provided will depend on how effectively they respond to needs. In the example above, three services were matched with the need for regular school attendance. In-home support for school attendance might have been required for months or longer. If all but one of the children was attending school regularly, that service might be reduced for the other children but a new service was needed by the child who was truant (such as a change in school placement or a assistance in developing a an area of competence). The service plan will also require changes as the child makes transitions from one level of care to another. 



"Thomas" is a 13-year old who was physically abused by his father; his mother has divorced and remarried several times. His mother and stepfather could not manage his aggression and stealing. A progress report from the group home where he was placed indicated that Thomas had regressed to previous behavior problems, as had happened before when discharge was discussed. He was not in special education. He was not receiving individual therapy where he could be helped to understand the connection between his early abuse and his aggression. Family counseling was not being provided; steps were not being taken to improve his parents' ability to manage his behavior, although he was expected to return home soon. 



Thomas had a goal of returning home, but the services being provided did not match his or his family's needs. For reunification to occur, instruction and support for the parent in managing the child's behavior are typically needed, beginning while the child is in placement and continuing as the child makes the transition home. Services often need to be intensified as reunification occurs. When he went home, in addition to continuing family support, Thomas would have needed at least an appropriate school placement and individual therapy and his parents might have needed respite care. Had Thomas subsequently resumed visits with his father, the service package would have required adjustment to provide special supports for them. 



If the family is labelled "unmotivated," it is a sure sign that the services must be adjusted. "Resistance" is an anti-family term, blaming the parents or the child for the service system's failures. If a family is not involved in the services, the child and/or parents must not believe the service will help them achieve their goals. Parents' legitimate reasons for not seeking services (such as lack of transportation or child care) and parents' need for home-based services (because they feel uncomfortable in agencies) are obscured by labeling the family "resistant." If the family does not become involved in services, it is essential to ask the child and family again, "What services will help you get what you want?" 



In conclusion, making reasonable efforts to prevent placement and to reunify families can be achieved through accepted practice standards: (1) the child's and family's needs must be carefully assessed; (2) needs-based services must be orchestrated in relation to strengths; and (3) the services must be regularly monitored and adjusted, based on their effectiveness in meeting the child's and family's needs. 

 

Needs-based services are required in every case. Many communities have not developed adequate services to meet the needs of children and families, even in the most common types of abuse and neglect cases. There is a danger that, because of their special needs, five groups of children who have consistently been overlooked will be left out of reasonable efforts: (1) sexually abused, (2) developmentally delayed, (3) behavior disordered, and (4) educationally handicapped children and (5) those with mentally ill parents. 



A. SEXUALLY ABUSED CHILDREN 



In many cases of sexual abuse, the primary intervention has been removal. Children who have been sexually abused must receive treatment for the sexual abuse at the time it occurs or when it becomes known. Children who have been sexually abused are typically fearful, angry, and depressed. They feel betrayed, worthless, ashamed, and powerless. Through individual and group therapy sexually abused children can recover from what has happened to them. If they are not given proper care, sexually abused children often become self-destructive, have continuing difficulty in trusting others, and show a vulnerability toward revictimization.* Children who have been sexually abused typically need continuing treatment of their anger, fear, and depression. 



"Rhonda" is a 14-year old placed at age 8 after being sexually abused by her mother's boyfriend (four of the five children had gonorrhea). She had 14 placements in six years, in part due to sexual behaviors unacceptable to the foster parents. She was placed in a special education classroom in second grade for behaviors typical of a sexually abused child: she was immature, had disturbed peer relations, and was rebellious. She continued to be an angry child who stole, acted out in school and was sexually active. The children were returned to their mother, with no services specified in the plan, either mental health or education services for Rhonda or support services for her mother. 



Rhonda needed treatment specifically designed to address the anger and inappropriate behavior resulting from sexual abuse. She needed counseling and special support in school and her foster parents needed special training, support and respite. If her behavior problems and low self-esteem did not improve, different and/or more intensive services should have been provided. As Rhonda returned to her mother, special services were needed to prevent behavior management problems and anger about the sexual abuse from jeopardizing reunification. 



The most effective treatment for sexually abused children has been group and individual counseling for children in conjunction with group counseling for non-offending parents. Treatment of children who have been sexually abused must help them recognize that what happened was not their fault; they must come to terms with their feeling of abandonment by the perpetrator and the non-offending parent.** Sexually abused children are at high risk to experience serious emotional difficulties in adolescence and adulthood. They need consistent treatment by mental health professionals experienced in working with sexually abused children. It is also essential that sexually abused children who are not at home have stable placements. 



Anti-family bias is widespread in the handling of incest cases. Practitioners' reaction of disgust to incestuous families results in inadequate assessment of the needs of the children in the context of their families. It is essential to insure that the victimization does not occur again, recognizing the denial of the perpetrator and often the complicity of the non-offending parent. Nevertheless, the child in an incestuous family has the same need as other children: to continue to have a relationship with both parents. Because of the anti-family bias of the service system, the non-offending parent's desire to be a good parent, the child's desire to be with the non-offending parent, and sometimes the child's continuing affection for the perpetrator are ignored. Incestuous behavior is the outcome of a complex interaction between the family's internal dynamics and individual pathology. Incestuous families need treatment to help the parents understand the needs of the children and develop non-victimizing ways of coping with stress; identifying and helping non-offending adults who can support the child at home is also an important element of treatment of incestuous families.* The automatic removal of children from incestuous families contributes to their lifelong feeling of being "damaged goods" and is an example of the system doing more harm than good while intending to protect the child. 



Making reasonable efforts for sexually abused children, to prevent removal or promote reunification, requires providing treatment for the sexual abuse at the time that it occurs or when it becomes known. Children who have been sexually abused are likely to exhibit anger and difficulty trusting others, and reasonable efforts also include helping parents and foster parents respond appropriately to this behavior. In addition, reasonable efforts include providing effective treatment of incestuous families while the child is at home or in placement and after the child returns home. 



B. DEVELOPMENTALLY DELAYED CHILDREN 



Many children (particularly those with low birth weights and those who were prenatally alcohol- or drug-exposed) show a variety of delays in cognitive, language, perceptual-motor and social skill development, including short attention span, delayed speech, perceptual deficits, and physical coordination difficulties. There is abundant evidence that low birthweight infants have enduring cognitive, language and perceptual-motor deficits, which are evident when they enroll in school.* 



Despite the high incidence of these delays, few agencies offer comprehensive developmental evaluation for cognitive, language, perceptual-motor and social deficits in preschool children. Stimulation, speech and language therapy, and physical/occupational therapy have demonstrable success in treating cognitive, language and perceptual-motor deficits. 



"Sandra" is an 8-year old who has been in one foster home since age 3 after being removed from her substance-abusing mother. Her foster mother asked that she be evaluated because at age 4 she did not know colors or how to count. She was seen by a pediatrician who noted that she was slow and clumsy; he wrote "I will just have to watch and see how she does." A year later because she was "extremely active" and did not sleep well at night the pediatrician prescribed Ritalin, with the dosage doubled a year later; he also prescribed Tofranil. Sandra was referred by her first grade teacher for evaluation for special education placement because even on medication she had a short attention span. A year later she had temper tantrums at home and received frequent paddlings at school; she was given Cylert by the pediatrician who noted, "I am not optimistic that we are ever going to be able to control Sandra with medication. I think a lot of it is going to have to come from Sandra as a lot of her problem is genetic since her sister has exactly the same behavior problems." 



Sandra never had a psychological evaluation or any specialized psychomotor, neurological, or speech evaluations. Proper treatment of developmental delay was not provided by this pediatrician. At age 3 her cognitive, language, and perceptual-motor deficits should have been diagnosed and aggressively treated with speech therapy and occupational therapy. Sandra's caretaker (her foster mother in this case, but parents or grandparents in other cases) should have been instructed in techniques for remediating speech and motor delay. 



Making reasonable efforts for delayed children, to prevent removal or promote reunification, requires thorough assessment and providing treatment for cognitive, speech and motor delay. Delayed children require stimulation and may be difficult to handle, and reasonable efforts also include helping parents and foster parents respond appropriately. 



C. CHILDREN WITH SEVERE BEHAVIOR PROBLEMS 



Medication has been the primary intervention for children with unmanageable behavior. More attention must be paid to evaluation for neurological deficits in children with behavior problems. Treating children and instructing caretakers in the connection between early childhood abuse and subsequent aggression is also essential.* 



"Christopher" is a 10-year old whose family was first investigated when he was seven months old and in a coma for several weeks. When Christopher was 7, he and his two siblings were removed due to his parents' alcoholism. In his third foster home he was repeatedly paddled in school. He was extremely aggressive and showed inappropriate sexual behaviors; he was medicated for hyperactivity. He had poor relationships with other children and needed one-on-one supervision. A hospital evaluation reported that he had an Attention Deficit with Hyperactivity Disorder, was self-abusive and had a seizure disorder. He had to be removed from a foster home after being whipped: "It became apparent that Christopher was uncontrollable in a foster home setting unless one resorted to harsh physical punishment." Twelve foster homes in 14 months found Christopher difficult to manage. After six months at a group home, they reported: "Christopher is a child who must be watched every second of the day and night. He is usually in trouble for something, often for refusing to follow directions, constant name calling, or provoking other children...temper tantrums...bizarre behavior...exposing himself to get attention." 



No child should be out of control for years like Christopher. His needs were never thoroughly assessed and were not matched with services. He showed no improvement for long periods, but the services were not modified. He needed careful neurological assessment and treatment. He should have been placed much sooner in a therapeutic foster home, with intensive day treatment. His foster parents needed to understand how his aggression was related to his early abuse and what techniques could help Christopher reduce his acting out. * Reasonable efforts for Chrisopher would have begun with a thorough itemizing of his strengths and needs, followed by orchestrating services in relation to those strengths and needs. Treatment of his seizure disorder, individualized instruction for him in managing his behavior, and considerable one-to-one care were evidently the kinds of services Christopher needed. 



Making reasonable efforts for children with severe behavior problems, to prevent removal or promote reunification, requires providing thorough assessment and proper neurological, emotional, and educational treatment. There is evidence that helping the behavior disordered child improve his/her self-regulation is essential to reduce significant interpersonal problems.** Reasonable efforts also include teaching parents and foster parents to manage behavior problems effectively. In addition, reasonable efforts mean providing instruction in behavior management and appropriate punishment techniques and support to families while the child is at home or in placement (and after the child returns home). 



D. EDUCATIONALLY HANDICAPPED CHILDREN 



It is essential for children to feel successful in school. Services to support parents and foster parents in helping all children experience school competence are among the most significant gap in the system of care. Every child’s caseplan should incorporate educational needs and the services to meet those needs. 



The services designed to promote school competence among handicapped children have often not met the needs of children in care. Most children with behavioral and emotional disorders do not function at grade level.* For emotionally disturbed, retarded and learning disabled children in the child welfare system, caseworkers must become involved in insuring that when school placements do not meet the needs of the child, educational services are modified. Public school practices of excluding children with behavior problems from the classroom must be stopped by active caseworkers, foster parents and supported parents.** Some children need educational evaluations while others need tutoring and/or advocacy for special placements. Caseworkers should attend IEP meetings to insure that handicapped children have proper school programs.*** Educational plans must be integrated into behavior management strategies used by parents, foster parents and other caretakers. 



"Alex" is a 14 year old who came into care in after he was physically abused by his mother. His father had been in prison for years; Alex had a poor relationship with his stepfather. He had a severe hearing loss since infancy, but was not evaluated until his placement at age 12. Alex's hearing loss may have been the primary cause of his disruptive behavior in school and inattentiveness to instructions and contributed to his mother's difficulty in managing him. The hearing problem should have been identified and treated when the agency was first involved with the family when he was 7. At age 12, he was in fifth grade, and neither his IEP nor his caseplan connected his educational service needs or his hearing problems with treatment of his emotional problems and return to his family. 



Alex is an educationally handicapped child who is not receiving proper educational services. His caseworker did not identify his educational needs. His caseworker and school staff did not see educational services in the context of other treatment goals for Alex. Unfortunately, the belief that Alex would always be disruptive in school obscured the recognition that it was essential to provide him with the services he needed to be successful in school. 



Making reasonable efforts for educationally handicapped children, to prevent removal or promote reunification, requires providing appropriate school programs and support services so the child can be successful in school. These services include special education classrooms, tutoring, counseling, in-school speech and occupational therapy, special schedules, special arrangements for individualized attention in art, music, and sports. Reasonable efforts also include involving parents and foster parents in decision-making regarding school placement and in behavior management techniques at home that are consistent with school practices. 



E. CHILDREN WITH MENTALLY ILL OR MENTALLY RETARDED PARENTS 



Often mental illness or mental retardation is cited as the cause of removal or the failure of reunification.* Neither mental illness nor mental retardation necessarily incapacitates parents. Special services must be provided to enable them to be minimally adequate parents. Community support services are increasingly available for mentally retarded and mentally ill adults, but these must now be expanded to include family preservation. 



Mentally Ill Parents



"Ms. Rice" is the mother of two children, ages 4 and 7, in foster care. She is 23 years old and was diagnosed schizophrenic five years ago; she has had several psychiatric hospitalizations. Her children first came into care when she was hospitalized three years ago. They returned home, but were placed in foster care when she was hospitalized again. Parental rights were terminated three years after the first removal because of the mother's diagnosis.



A number of studies have described the effectiveness of enhancing the skills of psychiatrically ill parents. Programs have been successful in preventing rehospitalization and avoiding the deleterious effects of the parent's mental illness on the child's development.* Unfortunately, services designed to enable mentally ill parents to care effectively for their children have not been widely incorporated into family preservation efforts. 



Ms. Rice had demonstrated that she was a loving mother whose parenting skills were diminished when she failed to take her prescribed medication. The research cited above indicates that with support services mentally ill mothers can parent their children adequately. These services must be designed specifically to enhance the capacity of mentally ill parents to (a) provide physical care and protection for their children; (b) maintain an ongoing emotional relationship with their children; and (c) have a differentiated awareness of signs of distress and pleasure in their children. Making reasonable efforts for children with mentally ill parents, to prevent removal or promote reunification, requires providing intensive support for adequate parenting including day treatment programs which mothers and children attend together, home visiting to ensure medication compliance and provide crisis intervention and parenting instruction, mothers' support groups, and therapeutic nursery. These services must be presented in ways acceptable to mentally ill parents who tend to think in concrete terms and to have difficulty in anticipating the future and conceptualizing the consequences of their actions. 



Mentally Retarded Parents 



There is evidence linking the cognitive and emotional deficits of mentally retarded parents with child maltreatment.* Unfortunately, the development of techniques for in-home instruction in parenting skills for retarded parents has lagged way behind the need.** 



The hospital emergency room asked for a Protective Services investigation after Ms. Thomas brought her 3-year old child in with his tenth ear infection. Ms. Thomas, who was retarded, was failing to administer antibiotics at the prescribed intervals, resulting in a chronic infection causing hearing loss. Although similar cases in the past had been handled by removal, the creative caseworker, finding that Ms. Thomas’ schedule was regulated by television, taught this retarded mother to give medication daily at the end of three shows she regularly watched. Using a similar technique, the caseworker taught Ms. Thomas to read picture books to her child. 



Several research efforts have demonstrated the effectiveness of teaching mentally retarded parents appropriate parenting responses for common problematic situations.*** 



Making reasonable efforts for children with mentally retarded parents requires providing parenting instruction specifically designed for individuals with low intelligence, as well as preschool enrollment to ensure that the children receive adequate cognitive stimulation. 

 

Children and families need a system of integrated, needs-based services. A great deal is known about child development, the parent-child relationship, and effective treatment of mental health, substance abuse, and educational problems, but there is a lag between knowledge and practice. There is a widespread, demoralizing fear among service providers that problems caused by early neglect and abuse cannot be remediated. Research about effective intervention must be the basis for efforts to keep children in their homes and services to them if they are removed. 



For many families services must be delivered in the home because parents are too overwhelmed or reluctant to seek services in agencies.* These services must be specifically designed to enhance parenting skills, reduce family stress and treat parental chemical dependency. For many families, home-based services must be long-term, providing continuing support for adequate parenting that extends beyond crisis intervention to prevent removal. Training must be provided to ensure that home-based services are culturally sensitive. 



When children cannot be served at home, strong support must be provided to foster parents. The system of care must insure that children do not experience multiple placements. Throughout the time a child is in placement, active steps must be taken to make reunification possible. 



A. HOME-BASED SERVICES FOR FAMILIES 



Many caretakers have pressing personal and economic problems, do not want to face their limitations, and do not seek services. Intervention to insure minimal adequate parenting and address children's cognitive, language, perceptual-motor and social problems must begin during infancy in the home. Chronically neglecting families must be the target of earlier, more intensive, long-term home-based care and specialized interventions, such as parent substance abuse treatment. 



Home-based care views the family as the client, emphasizing the interdependence of family members and their connection to their community. Home-based care includes: (a) parent counseling; (b) parent instruction in behavior management; (c) other support for improved nurturing and limit-setting by parents; (d) parent/child or family therapy; (e) counseling for the child; (f) school intervention, including arranging educational assessment, arranging proper school placement, assisting in behavior management in school, tutoring, and helping the parent supervise homework completion; (g) self-esteem building activities for the children, including sports, hobbies, group participation and outdoor activities; (h) in-home substance abuse services helping the parent recognize their chemical dependency and going with them to AA/NA meetings; (i) involving the parent and child in positive neighborhood activities including churches and other groups; and (j) crisis intervention as needed. 



This wide array of home-based services has several characteristics in common: 

• Commitment to serving children in their own homes. 

• Intensive services utilizing goal-oriented treatment plans family members themselves help create, designed to meet the needs of all family members, 24-hours a day, at a level of 5-10 hours/week lasting a month to a year or more, not just 30-90 day crisis services;* providers must develop culturally-sensitive techniques for serving "unmotivated" families who have been excluded from traditional services. 

• Linking family intervention and school services in order to teach parents how to encourage school competence and assisting school staff in being more welcoming to parents who they have previously viewed as not valuing education. 

• Guiding family members to become involved in rewarding community life and encouraging families to have more self-determination over their own lives.** 

• Immediate economic intervention (such as housing, food, transportation, clothes). 



Highly effective professional/paraprofessional team approaches to home-based services for emotionally disturbed children have been developed in many communities. Services are purchased individually to meet the needs of the child, with many children being served through day treatment while living in their own homes. Others are provided with services in therapeutic foster homes and then assisted in returning home or into independent living. These models can be adapted to rural areas, with individualized purchasing making it possible for counties with few cases to arrange local care.* 



Making reasonable efforts means insuring that the child has: 



• a responsive caretaker; 

• consistent, caring discipline; 

• a stimulating (but not overstimulating) environment; and 

• ensuring school competence. ** 



Achieving these aspects of minimally adequate parenting requires home-based services which target the following: (1) Enhancing parent responsiveness; (2) Teaching the parent stimulation techniques; (3) Teaching the parent disciplinary techniques; (4) Treating substance abusing parents; and (5) Appreciating family strengths. 



1. Parent Responsiveness 



Caretakers and infants engage in a complicated process of giving and responding to cues. The child's attachment depends upon the caretaker's responsiveness: sensitivity, cooperation and accessibility. Coordinated interaction with the infant appears to be a particularly important parental skill. Securely attached children are more competent with peers, self-confident, and flexible, and have lower rates of classroom behavior problems. The long-term effects of early parental responsive-ness on children's school performance have been documented in many studies.*** Maternal reciprocity in interacting with infants predicts children's performance on cognitive and language measures at six years of age. Children of psychologically unavailable mothers show disturbances of attachment as well as a variety of cognitive and social deficits. 



The success of improving parental responsiveness and enhancing subsequent child development has been documented. For example, an intervention of only 11 one-hour sessions which focused on improving the mother's ability to recognize and support her low birthweight infant's skills, establishing caretaking routines, and building reciprocity between parent and child had substantial long-term benefits. At six months the mothers felt more confident of parenting and perceived their children as being less difficult than the control group mothers. The children in the program had substantially higher scores on a measure of cognitive development at four years of age: the training and confidence developed in the program improved the parent-child relationship and was sustained over several years. * 



The research cited above has demonstrated that parents can be taught to be more responsive to their children, with long-term benefits for child development. Making reasonable efforts requires incorporating these techniques into home-based services for neglecting and abusive families.



2. Stimulation and Encouraging School Competence 



Stimulation of infants and toddlers is correlated with subsequent school achievement. A midrange of stimulation is best for child development: insufficient stimulation is related to reduced cognitive skills and excessive stimulation is related to overactivity. Caretakers who have knowledge about early childhood cognitive capacities stimulate their children's language skills. 



Some caretakers are too uninvolved with their children, ignoring cues from the infant. Other caretakers are overly directive of their infants, giving too many signals and not attending to the child's messages. Abusive mothers tend to be intrusive, overstimulating and unresponsive to feedback from the child. Neglectful mothers typically fail to stimulate their infants. 



Research has demonstrated that parents can be taught not to overstimulate or understimulate their children, with long-term benefits for child development.* As the children are enrolled in preschool and elementary school, parents need instruction in how to encourage their competence in school. Making reasonable efforts requires incorporating these techniques into home-based services for neglecting and abusive families.



3. Disciplinary Strategies 



Numerous studies of child rearing strategies have demonstrated that punitive discipline leads to uncooperative behavior in children. Highly controlling parental behavior is also associated with lower levels of cognitive competence. Abusive mothers tend to be punitive and highly controlling and unlikely to use explanatory techniques. Abusing parents perceive their children's neutral behavior as misbehavior and attribute misbehavior to characteristics of the child.** 



The use of explanation in discipline by parents has been found to enhance social and cognitive abilities in children. The research cited above has demonstrated that parents can be taught to establish consistent standards of behavior which they negotiate with and explain to their children, with long-term benefits for child development. Making reasonable efforts requires incorporating these techniques into home-based services for neglecting and abusive families.



4. Treating Substance-Abusing Parents 



Many children do not get their basic needs consistently met because of their parents' drug dependency. Often children who live with substance-abusing parents do not get identified as being at risk. Home-based services for substance-abusing families must have a two-pronged approach: identifying and supporting a caretaker who does not use drugs and providing chemical dependency services to the addicted parent. A number of programs have demonstrated that substance-abusing parents can be taught and supported to be minimally adequate.* 



Antifamily bias is apparent in the widespread indifference to the needs of substance-abusing parents. Practitioners are outraged that substance-abusing parents consistently put their own needs before those of the children. Requiring substance-abusing parents to seek services and abstain to prove their parenting capacity is a higher standard than used to judge middle- and upper-class families who have not come to the attention of the child welfare system. Moreover, this expectation denies that the substance abuse is the parent's method of coping with poverty, unemployment, and hopelessness. Making reasonable efforts requires incorporating treatment of substance-abusing parents into home-based services for neglecting and abusive families. 



5. Appreciating the family's strengths 



Intervening successfully requires respect for the family's strengths and the cultural diversity of parenting styles.** Although professionals are not effective when they impose middle-class values on families, little training has been available on how to put aside one's own values in order to appreciate the unique strengths of families of different cultures. The term "dysfunctional family" should be banned. It has no real meaning, except as a vague label that blames the family for the child's distress. It gets in the way of seeing any family strengths on which assistance could be based. All families have dysfunctional characteristics. The families of many abused/neglected children are surprisingly functional. Against all the odds of racism, poverty, lack of opportunity, and futurelessness they somehow survive. They offer love, deep family connections, spiritual values, and tradition. 



Furthermore, it is often difficult for service providers to incorporate into their work the recognition that the strengths of many families are compromised by the stress of poverty. * For families living with chronic levels of stress due to poverty, lack of education, unemployment or disabilities, each new demand increases their vulnerability. ** Neglecting families require services to meet a wide variety of needs including housing, income and daycare assistance as well as comprehensive in-home services, parenting skill development, and stress management instruction. Yet, often these "concrete" services are not be paid for by public and private agencies. For example, inadequate supervision of preschool-aged children is a common reason for referral for protective services, but few families receive daycare services (and most lack the funds to hire a babysitter), despite the availability of federal funds to support daycare which prevents removal of children from their homes. 



B. PROVIDING ADEQUATE SUPPORT FOR FOSTER PARENTS 



All children removed from homes have adjustment difficulties. They miss their families and are frightened in their new environment. If they have been sexually or physically abused, they are likely to be untrusting and angry. These adjustment difficulties may cause behavior which is difficult for foster parents to manage. It is essential to provide special supports to foster parents, including training, counseling on behavior management techniques, meetings between the school, therapist and foster parent, and respite care to enable them to handle behavior problems successfully. * 



"Tony" is a 7-year old who remained in his first foster home for two years. "The foster parents were extremely dedicated to Tony and worked diligently with him on his behavior problems. He received counseling and occupational therapy. After a baby was placed in the home for adoption he suddenly had to be removed because he threw a brick at a child in school." Tony deteriorated dramatically after being separated from these foster parents, showing aggression, temper tantrums, and cruelty to animals. He was hospitalized for severe depression. Tony's deterioration could have been prevented by an intensification of services to him and the foster parents when the baby was placed in the home. The foster parents needed instruction and family counseling and Tony needed one-to-one attention so he could stay in the home and weather the rejection of the adoption. 



Placement in a foster home was beneficial for Tony. But the foster parents were not given support to manage the behavior problems caused by his early neglect and abuse and, consequently, could not provide proper care. When foster parents do not receive support and respite care to enable them to handle behavior problems, the placement predictably breaks down, which is harmful for the children.* Flagrant sexual behavior in young victimized children can be particularly difficult for foster parents who must be trained specifically in how to respond to it.** 



Foster parents are often motivated by the belief that loving corrective parenting will compensate for the child's early lack of consistent nurturing. While foster parents have been successful "loving emotional damage away," it frequently backfires despite their good intentions. Unfortunately, what foster parents do so well is the source of the problem: providing a loving, traditional family competes with the child's birth parents unbearably. This unintentional competition is a major cause of foster home breakdown. Children do not want to see their families as bad. Disloyalty is a painful feeling for a child, particularly children who are protective of vulnerable parents. Many children come into their foster home defensive of their families, which sets them up to resist the nurturing of the foster parents. Children believe that if they love their foster parents, they will lose their biological parents. Many children worry about caring too much for their foster parents, for fear of losing them. Making reasonable efforts requires providing training to foster parents to reduce their competition with birth parents and to help children make peace with the past. 



C. PREVENTING MULTIPLE PLACEMENTS 



Many children in care experience a series of placements. It is not unusual for children to have six or more placements, including residential treatment centers and inpatient psychiatric hospitals. 



"Joshua" is a 17-year old who was first placed at age five, after his younger brothers had been adopted. In 12 years, Joshua had 14 placements, including three returns to his mother. Casenotes indicated that "Joshua and [his sister] have accepted their mother's limitations and continue to be fairly well-adjusted...Joshua [age 8]has asked to be adopted." A year later the report to court stated that "Joshua continues to express a desire for a home." A recent psychological evaluation found that Joshua saw himself as a failure with his peers, his family and at school and was pessimistic about his future. His stories were full of rejection, loneliness and suffering. His responses indicated that he had few warm relationships. He was severely depressed due to his mother's rejection and lack of a permanent home. Joshua should have been adopted when he requested it. When he was removed for the third time, he needed a therapeutic foster home placement and counseling to help him with the rejection he had experienced. 



Multiple placements were damaging for Joshua. His depression, withdrawal, pessimism, and lack of trust are the result of the rejection he experienced, not only from his family but from avoidable multiple placements. After each placement, children of all ages feel that they have failed and have been rejected. They are frightened by moving to an unknown placement and establishing new relationships. They are saddened by having only intermittent contact with family members. They have difficulty adjusting to new school placements. 



Joshua illustrates the complex causes of placement failure.* The early abuse and rejection experienced by Joshua and many other child cause severe behavior problems. Foster parents and program staff are not adequately trained to manage these behaviors. Frequently, children's special needs are not identified early enough, and comprehensive services to match their needs are not provided. At the point that the first foster home placement begins breaking down, special treatment needs should be identified and matched with effective services. Having been moved so many times, it is not surprising that children like Joshua have trouble forming trusting relationships, overcoming their anxiety about being rejected, and developing self-control and improved self-esteem. The behavior of children with multiple placements precipitates placement failure and changes in placement contribute to their deterioration. 



The lack of needed services is one of the major contributors to the child's misbehavior and consequent placement breakdown. Foster parents are not provided with respite; appropriate special education placements are not arranged; programs are too large to provide the individual attention needed by the child. When a placement has been effective, too often transitional services are not available, and the next placement breaks down. Continuity in therapy and school is difficult to maintain with multiple placements.* 



Making reasonable efforts requires preventing multiple placement. The child who experiences more than one placement will be less able to be reunified. At the time of the first placement special attention must be given to ensure that the child’s multiple needs are met, the foster parent is receiving adequate support, visitation is arranged, and immediate services are provided to begin reunification. The goal of each placement should be to provide all the services the child needs, at the intensity required, so the child can be successful. It is particularly important to insure that the child's first placement is designed to be successful because behavior and other problems predictability worsen with subsequent placements. In addition, emergency placements and intermediate placements should be avoided. Children should be moved directly into a resource matched to their needs as determined by assessments. Furthermore, there is a higher probability that the multiply placed child will end up in residential treatment or psychiatric hospital, which is not only costly but no more effective than therapeutic foster care and home-based care.** 



D. ENSURING REUNIFICATION 



Families need home-based services while their children are in placement and immediately after they return home.* What can be learned from recognizing that a third of children return to care after reunification is that intensive services are needed for children and their parents for a year or more after return home.** Reasonable efforts to ensure reunification also require special steps to make visitation successful. Foster parents need training to learn how to support reunification, particularly if the child acts out after visitation. 



Unfortunately, little attention is paid to reunification while children are in placement. It is essential that all the services the parent needed before the child was removed are provided while the child is out of the home. In addition, foster parents and other caregivers must be provided with training and support to encourage reunification. 



Visitation is a crucial element of reunification. Research has demonstrated unequivocally that there is a great decline in the probability of reunification after the first few weeks in placement. Making reasonable efforts requires arranging immediate and frequent visitation for children, particularly during the first three months after removal.*** 



Separation from families causes children to mourn. Foster parents, case workers and therapists helping the child with this mourning reduces the permanent damage caused by separation. Every effort must be made to enable the child to see his/her family soon after separation, even if the child is reluctant.* In the long run, harm is done by keeping children and their parents apart. Visitation with a frightened child requires supportive supervision and the child's therapist being committed to reunification and informed about the findings of research on visitation. 



The biological family is the child's lifeline. ** Although only intermittent contact between the parent and children in care may occur, biological parents continue to be significant in a child's development. The biological family is the source of identity for a child. What a child knows and imagines about the biological family helps to mold the child's self-perception. The continuing relationship between a child and biological parent cannot be denied. Neither adoption nor restricted visitation during foster care cuts the lifeline. Failing to come to terms with the lifeline to the biological family ultimately may cause foster care and adoption to break down. It is essential to the child's development to encourage a relationship with biological parents, regardless of whether the child will live with the parents. 



Foster parents are not trained to help with reunification, particularly the child's understanding their connection to their birth families. Although they could support reunification by helping biological parents improve their parenting skills, in fact the two families are usually kept away from teach other. Foster parents often develop hostility toward the birth parent, without being aware of it. The foster parent blames the birth parent for abusing and abandoning the child. The more the foster parent cares for the child, the angrier he/she is at the parent who has injured the child. 



Although judges, attorneys, case workers and mental health professionals are required to have a goal of reunification, their belief that the child is better off away from their birth families is sensed by the child whose frustration is acted out with foster families. The child may blame the foster parent for slow progress toward return home. The foster parent wants to encourage reunification but is upset by the parent's limitations. Visitation is the time when these feelings are strongest in the child and the foster parent: the child needs the most help with confusion about his/her family when the foster parent is least able to provide it. Not infrequently, deterioration in foster placements increases after each visit. 



The best way to help the child with reunification is to encourage the child to live happily in two different families. Enabling the child to see the strengths of both families, however, is a complicated process requiring active participation in reunification by foster parents who believe that the child's birth family can provide a minimally adequate home. 

 

The federal requirement of reasonable efforts to prevent removal and to reunify families is achievable. Reasonable efforts must be viewed in a much broader context than previously. Making reasonable efforts requires a system of integrated, needs-based services for children and families. These services should be informed by research. For many families services must be delivered in the home. Developing a comprehensive system of care for children and families should be guided by the following principles:*

• FAMILY-BASED 

• NEEDS-DRIVEN 

• ACCESSIBLE IN URBAN AND RURAL AREAS 

• FLEXIBLE and INDIVIDUALIZED 

• INTENSIVE 

• AVAILABLE WHEN NEEDED (including evenings and weekends and in crises) 



States must re-direct federal and state funding to the development of a quality system of care for children and families which emphasizes home-based services. Child welfare workers struggle to maintain children in their own homes and arrange services to meet their needs. But they have to rely on limited community mental health services, inadequate school programs, and insufficient chemical dependency and day treatment programs. 



Promoting adaptive functioning in children cuts across medicine, education, mental health and child welfare. Yet turf battles among these bureaucratic entities result in services being primarily single agency sponsored. Collaboration among social services, education, mental health, health, and substance abuse agencies is an essential aspect of reasonable efforts. * The capacity of the family to achieve its own goals is undercut by the fragmentation of service delivery systems: troubled families cannot be expected to negotiate their own services across agencies. Yet, most families do not receive interagency case management. Case workers need but seldom receive training in how to collaborate with staff of schools, mental health agencies, chemical dependency treatment programs, or housing authorities. Line staff have difficulty collaborating on cases when their agencies put up financial and confidentiality obstacles. Home-based service teams should be jointly funded and have shared intake, with school advocacy provided by education, mental health and substance abuse provided by the departments of health and mental health, protective services provided by child welfare, daycare provided by social services and private vendors providing other services through joint purchasing budgets. 



Citation: This article was originally written in 1991. A version of this article was published in 1996. Beyer, Marty (1996). "Too Little, Too Late: Designing Family Support to Succeed," Review of Law and Social Change, XXII, 2. 

APPENDIX 



1. Good Faith Efforts to Prevent Removal 



When a child comes to the attention of an agency as an abused or neglected child (ar a child at risk of abuse or neglect), and it appears to the agency that the child may have to be removed for his or her safety, the social work should, before removing the child, ask the question, "Is there any assistance, in the form of cash payments, services in lieu of cash, or social support services that would likely enable the child to remain safely at home?" 



If the answer to this question is "yes," the agency should either provide the assistance or meet a substantial burden of justifying the failure to provide the assistance. 



The steps required in determining whether to remove a child without providing prior services or to keep the child at home with services, and what services to provide, should include at the least the following: 



(a) A careful assessment of the family situation--including an identification of the specific problems, if any, placing the child at imminent risk of serious harm--to determine the likelihood of protecting the child effectively in the home. 



(b) Consideration of the family or child's specific problems to determine whether any of the services available within the agency or in the community might effectively address these problems. 



(c) Consideration of alternative ways of addressing the family's needs that would enable the child to be protected without removal when the services regularly provided by the agency appear unlikely to meet the family's needs or when waiting lists for these services are too long to prevent removal of the child. 



(d) Notice to the family concerning the services available within the agency and in the community that might address the family or child's problems. 



(e) An offer to the family to provide those services the agency considers most likely to address the problems identified as creating the risk of removal of the child. 



(f) An opportunity for the family to request other services not offered by the agency that the family believes might mitigate the risk of removal. 



(g) A mechanism for the child or family to seek a review of the agency's failure to provide the assistance or services the family believes would eliminate the need for removal of the child. 



2. Good Faith Efforts to Reunify the Family 



In making good faith efforts to reunify a family, the agency should adhere to the same principles set forth earlier with respect to good faith efforts to prevent removal. The agency's reunification efforts should include at least the following additional steps: 



(a) Development of an appropriate case plan 



(b) Establishment of an appropriate visitation schedule and other measures to ensure that visitation is facilitated and actually occurs. 



Making Reasonable Efforts: Steps for Keeping Families Together 



National Council of Juvenile and Family Court Judges 

Child Welfare League of America 

Youth Law Center 

National Center for Youth Law 

1985 



For many families services must be delivered in the home and should be available when needed and for as long as needed. Children who are particularly in need of special services include those who have been sexually abused, are develop-mentally delayed, have behavior problems, are educationally handicapped, and/or have substance-abusing and mentally ill parents. Making reasonable efforts for children with these special needs, to prevent removal or promote reunification, requires thorough assessment and services matched to their needs. Making reasonable efforts also requires helping parents and foster parents respond effectively to children's needs. Making reasonable efforts means insuring that the child has: (a)a responsive caretaker; (b) consistent, caring discipline; (c) a stimulating (but not overstimulating) environment; and (d) encouragement of learning. Achieving these aspects of minimally adequate parenting requires a system of care utilizing home-based services which enhance parent responsiveness, teach stimulation and disciplinary techiques, and treat substance abusing parents. Thorough needs assessment and long-term home-based services are known to be effective, but they have yet to be broadly applied with the families for whom the reasonable efforts requirement was conceived.







 * "To meet the requirement for reasonable efforts, a state must make available a full range of alternative services appropriate for different family situations. An individual child will be ineligible for IV-E reimbursement unless a comprehensive service program is in place and appropriate services are provided to the individual child."*  Allen, MaryLee, Carol Golubock, and Lynn Olson, "A Guide to the Adoption Assistance and Child Welfare Act of 1980,"in Hardin, M., ed., Foster Children in the Courts,Butterworth: Boston, 1983.  P.L. 96-272's legislative history shows that Congress included the reasonable efforts requirement because "such efforts were considered to be good social work practice and because of the importance of the constitutional right to family integrity."Shotton, Alice,"Making Reasonable Efforts in Child Abuse and Neglect Cases: Ten Years Later," California Western Law Review, 26, 1989-1990. 

** "Child welfare practice in the United States prior to the passage of P.L. 96-272 was largely based on a child rescue philosophy...to insure that no child was left in an unsafe situation. While well-intentioned, this philosophy often doomed children to years of drift in foster care...It also neglected or failed to recognize the harm that separation can cause to both children and their parents. P.L. 96-272, in contrast, is primarily based on a family preservation philosophy. This philosophy has as its starting point the belief that a child's biological family is the placement of first preference and that 'reasonable efforts' must be made to preserve this family as long as the child is safe. Where these efforts fail and the child must be removed, the family preservation philosophy holds that reasonable efforts must still be made to reunify the child with family...For many who have worked in the child welfare field prior to the passage of P.L. 96-272, switching to a radically different view of the value of working with the biological family has not been easy. For still others who generally believe in family preservation, implementing it in their day-to-day practice has been a challenge. The lack of adequate federal and state funding hinders implementation. Further, many times inflexible agency policies and funding streams help keep family preservation from becoming a reality in many jurisdictions."Shotton, Alice,"Making Reasonable Efforts in Child Abuse and Neglect Cases: Ten Years Later," California Western Law Review, 26, 1989-1990. 

*** HHS regulations listed preventive and reunification services: (1) 24-hour emergency caretakers and homemaker services; (2) day care; (3) crisis counseling; (4) individual and family counseling; (5) emergency shelters; (6) emergency financial assistance; (7) child care; (8) home-based family services; (9) self-help groups; (10) services to unmarried parents; (11) vocational, mental health, drug and alcohol abuse counseling; and (12) post adoption services (45 C.F.R. § 1357.15(e)(2)(1986). 

* National Council of Juvenile and Family Court Judges, Child Welfare League of America, Youth Law Center, and National Center for Youth Law. Making Reasonable Efforts: Steps for Keeping Families Together, 1985. 

** The Youth Law Center conducted a national survey of juvenile court judges who reported making negative reasonable efforts findings due to the lack of counseling or parenting classes, no case plan or failure to provide clear directions to parents in the case plan, failure to arrange visitation, and lacking mediation, in-home, medical, substance abuse and other services. See also:  Judicial Review of Children in Placement Deskbook, National Council of  Juvenile and Family Court Judges, Reno:1981. Ratterman, D., Dodson, G.D., and & Hardin, M. Reasonable Efforts to Prevent  Foster Placement: A Guide to Implementation, Washington: ABA, 1987.  Seaberg, J.R., "Reasonable Efforts: Toward Implementation in Permanency Planning," Child Welfare, 65, 1986.  Stein, Theodore, "An Overview of Services to Families and Children in Foster Care, in M. Hardin, ed., Foster Children in the Courts. Butterworth: Boston, 1983.  A three step process for making reasonable efforts determinations has been proposed: "(1) identifying the exact danger that puts the child at risk of placement and that justifies state intervention; (2) determining how the family problems are causing or contributing to this danger for the child; and (3) designing and providing services for the family that alleviate or diminish the danger to the child. If any one of these steps is missing, it is unlikely that the efforts made on behalf of the family will be reasonable." Shotton, Alice,"Making Reasonable Efforts in Child Abuse and Neglect Cases: Ten Years Later," California Western Law Review, 26, 1989-1990. 



*** For the concept of “How much is reasonable?” see The R.C. Case: Creating a New System of Care for Children, Mental Health Law Project, 1991.

* Everyone working in child welfare should be trained in assessing parenting capacity. "Should a child's developmental needs not be met within that child's natural family, a determined attempt should be made to assess the nature of the child's and family's problems and to help the family resolve them as much as possible..,A thorough assessment of child and family at an early stage may do much to clarify those factors in child and family contributing to the deterioration (underlining added)...Even should placement be necessary, an advance assessment and formulation will still prove invaluable in helping define a child's needs and areas of difficulty and in helping select a suitable alternative placement, thus minimizing the risk of unnecessary and damaging replacements."  Steinhauer, Paul, "Issues of Attachment and Separation: Foster Care and Adoption," in Steinhauer and Rae-Grant, Problems of the Child in the Family.  1983. See also Simmons, J.E. et. al., "Parent Treatability," Journal of the American Academy of Child Psychiatry, 20, 1981.  Standardized methods for family assessment have been developed, although they have questionable reliability and are based on treatment approaches that emphasize different dimensions of family functioning. Assessment tools have not been designed to help child welfare workers make decisions about services for the child and family.  It is important to have information about attachment, conflict, competition, family activities, organization, control, problem solving, parental responsiveness, and the child’s behavior problems to guide intervention.A family assessment should combine standardized measures and observation, with the information generated summarized so that services can improve the "fit" between the child's needs and the parent's responsiveness. Assessing the strengths of the extended family, family finances, parental substance abuse and its effect on the parent's capacity to meet the child's needs, and family needs for community support and services are also important elements of a family assessment.  [See Bryce and Lloyd, eds., Treating Families in the Home and Fisher, L., “Dimensions of Family Assessment: A Critical Review,” Journal of Marriage and Family Counseling, 2, 1976, 367-82.



* "It is important to set standards high enough so that families actually receive the services they need. Some states appear to shirk responsibility by defining reasonable efforts in terms of those services already available, however inadequate." Keeping Families Together: The Case for Family Preservation, Edna McConnell Clark Foundation, 1985. 

** "...professionals typically...limit themselves to consideration of what is 'practical' or 'reimbursable' rather than what is needed...The growth of individualized treatment approaches, made possible by the availability of flexible funds, has not only modified service systems but is prodding re-evaluation of basic concepts and approaches to assessment and treatment...It first of all calls for setting aside models that focus almost exclusively on deficits or problems and instead requires looking for strengths and interests of youngsters and other family members that can serve as a beginning point for developing an intervention. ..It calls for getting beyond viewing the family as the potential cause of the child's problem but rather looking at them as a partner and tremendous resource in the overall effort." Friedman, Robert. "Mental Health and Substance Abuse Services for Adolescents: Clinical and Service System Issues," 1990. 

*** "All too often, agencies develop 'boiler plate' case plans requiring every parent to attend a parenting class...a parent of a failure to thrive infant should have very focused parenting instruction that addresses the particular aspect of their parenting that has brought them into the system.  Likewise, parents who have physically abused their children with inappropriate discipline methods need special help in that area. To combine parents with such diverse needs in the same class may not be a 'reasonable effort.'" Model Questions for Defining Reasonable Efforts, Youth Law Center.



* Model Questions for Defining Reasonable Efforts, Youth Law Center, San Francisco. 

** Throughout this article, cases are real, but the names have been invented.

* "If the child's life or continued security and development remain at risk either because of the danger of imminent abuse or because of the family's inability to cooperate with or benefit from the best casework and other services available, the child may require removal from the natural family. The time to think of where a child will go after  being placed is before that child is removed (underlining added). In other words, children should only be removed from their families as part of an adequately formatted formulated plan of long-term management. Agencies that operate according to the philosophy, 'First we'll avoid abuse by taking the child into care; then we'll start to think about what to do next' are less likely to work intensively with the family in crisis at the point of family breakdown and are more likely to allow children to stagnate or drift into limbo....[Emergency placements] allow no time for adequate matching of child and resource, or for preparation of child and foster family for each other...Unless the risk of serious abuse is imminent, it is better for a child to remain in a known but inadequate situation a few days or weeks longer in order to allow for the development and initiation of a planned and adequately prepared alternative....Should a separation be unavoidable, the potential risk can be minimized by (a) insuring that the move is part of an overall plan of management rather than an isolated response whose long-term implications have not been adequately considered; (b) preparing the child adequately for separation and placement...(c) bearing in mind that parental figures to whom the child is attached will continue to have emotional meaning despite physical separation."  Steinhauer, Paul, "Issues of Attachment and Separation: Foster Care and Adoption," in Steinhauer and Rae-Grant, Problems of the Child in the Family.  1983.



* Browne, A. and D. Finkelhor,"Impact of child sexual abuse," Psychological Bulletin, 99, 1986. See also Conte and Schuerman.  Finkelhor.  Miller, Thomas and Lane Veltkamp, "Child Sexual Abuse: The Abusing Family in Rural America," International Journal of Family Psychiatry, 1988, 9:3.   Kolko, David, "Treatment of Child Sexual Abuse," Journal of Family Violence, 2, 1987.  Finkelhor, D. “Long Term Effects of Childhood Sexual Abuse,” Child Sexual Abuse, Free Press: New York, 1985. Finkelhor, D. Sexually Victimized Children. New York: Fre Press,1984. Conte, J.R. and L. Berliner, “The Impact of Sexual Abuse on Children,” Handbook on Sexual Abuse of Children, L. E. A. Walker, (Ed.), Springer, New York, 1987. 

**  "It is important to identify and treat these young children as early as possible, but they present special difficulties in treatment and prevention...it is essential for therapy to be structured and directive...anxiety-provoking issues will be avoided if not raised systematically by the therapist.  The therapist should be working toward 'cognitive restructuring,'trying to get these children to think differently about the events that have happened to them...Part of the trauma that must be addressed is the inducement or threat to the child to keep a terrible, burdensome secret...It is important for molested children to come to the conclusion that it is not their fault, it is the adult's fault, and that the adult should not have done this to them. Even if the children derived some pleasure or attention from the abuse and eventually sought it out, it was not their fault...Children's sense of shame and isolation is reduced if they are in group therapy and can hear that others have had some of the same experiences." Damon, L., J. Todd, and K. MacFarlane, "Treatment Issues with Sexually Abused Young Children, Child Welfare, LXVI:2, March-April, 1987.  See also Jones, David, "Individual Psychotherapy for the Sexually Abused Child," Child Abuse  & Neglect, 10, 1986. Schetky, Diane and Arthur Green, Child Sexual Abuse, New York: Brunel Mazel, 1988.  Jones, David, “Individual Psychotherapy for the Sexually Abused Child, Child Abuse and Neglect, 1986, 10, 377-85. James, B. and M. Nasjleti, Treating Sexually Abused Children and their Families, Consulting Psychologists Press, Palo Alto:1983. Giaretto, H. “A Comprehensive Child Abuse Sexual Treatment Program,” Child Abuse and Neglect, 1982, 6, 263-78.

* "There is no single cause of incestuous behavior...all families have a degree of vulnerability based on individual, family and environmental factors which may be expressed in some form of incest if (1) a precipitating situation exists and (2) the family's level of functioning and coping behaviors are insufficient...The most dysfunctional families tend to operate as isolated, closed systems, fearful and distrustful of the outside world, with little capacity to adapt to external demands or developmental transitions. Roles are blurred; children are pressed into meeting adults' needs...The abuse of power by adults is common in incest families...Members of such families cannot identify emotionally with the impact of their behavior on others...Incest families typically have difficulty controlling their impulses or setting limits on behavior. Behavioral guidelines tend to be either rigid or unadaptive to developmental issues or chaotic and contradictory... Incestuous families are highly vulnerable to recurrent incidents of incest even when the initiating offender is out of the picture. To prevent such recurrence, we must assess the ability of non-offending caretaker adults, like parents, grandparents, or adult siblings, to form a protective alliance with the victim." Sgroi, Suzanne, ed. Handbook of Clinical Intervention in Child Sexual Abuse. Lexington, Mass.: D.C. Heath, 1985.  See also Mrazek, P.B. and C.H. Kempe, Sexually Abused Children and their Families, New York: Pergamon Press, 1981. 



*Cohen, E.E. and L. Beckwith, “Preterm Infant Interactions with the Caregiver in the First Year of Life and Competence at Age Two,” Child Development, 50, 767-776, 1979. Jacob, S., H.E. Benedict, J. Roach and G.L. Blackledge, “Cognitive, Perceptual, and Personal-Social Development of Prematurely Born Preschoolers,” Perceptual and Motor Skills, 58, 551-562, 1984. Russell, Fay, Interdisciplinary Early Intervention for Developmentally Delayed Infants and Youth Children: A Family-Oriented Approach, University Center for Health Sciences, 1985.It is assumed, but not yet known, that drug exposed infants will show similar enduring delays. See Drug Exposed Infants, Government Accounting Office, June, 1990.  Also, Drug Exposed Infants.  Center for the Future of Children, Los Altos, California,1991





* In their study of schools' response to children with emotional and behavioral problems, Knitzer, et al found "The curriculum emphasis is often on behavioral management first, learning, if at all, second. Central to many of the classrooms that we visited was a great concern with behavioral point systems. Yet often, these seemed largely designed to help maintain silence in the classroom, not to teach children how better to manage their anger, sadness or impulses " (Knitzer, Jane, Zina Steinberg and Brahm Fleisch, At the Schoolhouse Door, Bank Street: New York, 1990). See also Cicchetti, Dante, Sheree Toth and Kevin Hennessy, "Research on the Consequences of Child Maltreatment and its Application to Educational Settings, Topics in Early Childhood Special Education, 9, 1989. 

* Lewis, Dorothy, Melvin Lewis, Lisa Unger, and Clifford Goldman, "Conduct Disorder and Its Symptoms: Diagnoses of Dubious Validity and Usefulness," American Journal of Psychiatry, 141, 1984."...violence, like fever, is a nonspecific symptom and may be present in varying degrees in a number of syndromes...by focusing...on manifest behavior, violence in particular, we obfuscate potentially treatable neuropsychiatric signs and symptoms. The types of disorders most frequently masked include psychosis, neurological impairment, learning disabilities, borderline retardation, and even manic states."

** Henker, Barbara and Carol Whalen, "Hyperactivity and Attention Deficits, American Psychologist, 44, 1989.  See also: Abikoff, H., An evaluation of cognitive behavior therapy for hyperactive children," in B.B. Lahey and A.E. Kazdin, eds., Advances in clinical child psychology, New York: Plenum, 1987.  Hinshaw, S.P., "On the distinction between attentional deficits/hyperactivity and conduct problems/aggression in child psychopathology, Psychological Bulletin, 101, 1987. Ross,D.M. and Ross, S.A., Hyperactivity: Current Issues, Research and Theory, New York: Wiley, 1982.

* Knitzer, et.al. 

** See Doe, in which the Supreme Court prohibited excluding children just because of their handicaps. 

*** PL 94-142 (passed in 1975) requires all states to provide a "free appropriate public education" to school-age children with handicaps. An IEP (individualized education program) must be developed annually which sets goals for the year, the services to be provided, and specifies how much the child will be mainstreamed in regular school programs.  PL 99-457 (passed in 1986) extends the rights given under PL 94-142 to all children ages 3 through 5 who have handicaps and helps states set up early intervention programs for children from birth through age 2 who need special services.  For infants and toddlers, an IFSP (individualized family service plan) must be developed identifying the child's needs, the family's strengths and needs, and services. A case manager is appointed to coordinate speech, hearing, and occupational therapies and other services. PL 99-457 gave states five years for implementation; it has not been fully implemented in any state and many states are far behind. See also Guidelines and Recommended Practices for the Individualized FamilyService Plan (Second Edition), National Early Childhood Technical Assistance System, 1991.



* In Interest of Devine, Appellate Court of Illinois, Fifth District, 1980.

   People in Interest of P.M., Supreme Court of South Dakota, 1980.

   People v. C.A.K., Colorado Court of Appeals, 1980.

   In the Matter of J.L.B., Supreme Court of Montana, 1979. 

* "While children of mentally ill mothers perform somewhat less adequately than children of well mothers on a variety of developmental measures...there appears to be a somewhat greater ability to 'catch-up' with development than had previously been anticipated." Cohler, B. and Musick, J. Psychopathology of Parenthood: Implications for Mental Health of Children, Human Sciences Press, 1983. Programs serving mothers who experienced psychiatric hospitalization have demonstrated improvements in "the mothers' adaptation to adult roles and their attitudes about mothering...while fundamental changes in personality were not effected by our programs, there were observable shifts in a mother's capacity to care for, nurture and relate to her child...Positive growth indexes such as these in a group of women having serious psychiatric disorder....point to the merit of providing crisis-oriented and supportive services for even severely troubled mothers. Second, at the beginning of the project almost all the children were, to some degree, delayed, deviant, or both in certain areas of child development...The provision of services which create a healthier social and caretaking environment for such children allows their natural resilience to assert itself."  Finally, the research indicates that the important aspect of the mother's disturbance for the child's development may be the separations and intense conflicts leading up to rehospitalization, rather than the disturbed interaction caused by the illness, and these can be reduced by specialized services.  Stott, Frances, et. al, "Intervention for the Severely Disturbed Mother," in Cohler and Musick, Eds Intervention with Psychiatrically Disabled Parents and their Young Children. 1984.  See also, Higgins, “Effects of Child Rearing by Schizophrenic Mothers, Journal of Psychiatric Research, 1976, 1, 7-8.  See also Roe v. Conn (417 F. Supp. 769, 776-7) in which an Alabama court found in 1976 that “[M]ost authorities agree that even psychotic or disturbed mothers can often do a good mothering job.” 

* Robinson, L.H., “Parental Attitudes of Retarded Young Mothers,” Child Psychiatry and Human Development, 1978, 8, 131-44. See also Schilling, R. F. and S.P. Shinke, “Maltreatment and Mental Retardation,” in J.M. Berg (Ed.), Perspective and Progress in Mental Retardation (Vol. 1), International Association for the Scientific Study of Mental Deficiencies, 1984. 

** Budd, K.S. and S. Greenspan, “Mentally Retarded Mothers” in E.A. Blechman (ed.), Behavior Modification with Women, Guilford: New York, 1984.



*** Fantuzzo, John, Laura Wray, Robert Hall, Cynthia Goins and Sandra Azar, “Parent and Social-Skills Training for Mentally Retarded Mothers Identified as Child Maltreaters, American Journal of Mental Deficiency, 1986, Vol, 91:2, 135-40.  Feldman, M.A., L. Case, F. Towns, and J. Betel, Parent Education Project 1: Development and Nurturance of Mental Retarded Parents,” American Journal of Mental Deficiency, 1985, Vol. 90:2, 253-8.Guidelines for Assessing Parenting Capabilities in Child Abuse and Neglect Cases with Special Reference to Infants of Mentally Ill and Impaired Parents, Michigan Association for Infant Mental Health, 1985. Crain, L.S. and G.K. Millor, “Forgotten Children: Maltreated Children of Mentally Retarded Parents, Pediatrics, 1978, 61(1), 130-2.

*  When families are able to benefit from services delivered outside the home, accessibility becomes an important aspect of reasonable efforts. See Model Questions for Defining Reasonable Efforts, Youth Law Center.

* "...the policy implications of findings that family maintenance and reunification too commonly risk children's well-being is to provide more intensive and lasting support to children in their own homes...Yet we ironically provide only a few months of services to families who have clearly shown long-term difficulties in meeting the challenges of parenting." The Adoption Assistance and Child Welfare Act of 1980: The First Ten Years, North American Council on Adoptable Children, 1990. See also Keeping Families Together, Edna McConnell Clark Foundation.  An Evaluation of the Effectiveness of Intensive Home-Based Services as an Alternative to Placement for Adolescents and their Families, Hubert H. Humphrey Institute for Public Affairs, University of Minnesota, 1986. 

** McKnight,  J., "Regenerating Community," Social Policy, 1987. See also Federation of Families for Children's Mental Health Philosophy Statement, 1990.



* This discussion was presented in depth in Comprehensive Services for Oklahoma's Delinquent, Deprived, INT and INS Children, Marty Beyer, Paul DeMuro and Ira Schwartz, 1990. See  also four publications from the National Resource Center on Family Based Services in Iowa: Placement Prevention and Family Reunification: A Handbook for the Family-Centered Service Practitioner (1985),Factors Contributing to Success and Failure in Family-Based Child Welfare Services (1988), Three Models of Family-Centered Placement Prevention Services  (1989),  and A Study of Chronically Neglecting Families in a Large Metropolitan County (1989). See also Family Centered Care for Children with Special Health Care Needs, Association for the Care of Children’s Health, 1989 and Building Family Strengths, Center for Family Strengths, University of Nebraska, 1986. 

** Silber, 1989. 

***  Beckwith, Leila, “Adaptive and Maladaptive Parenting--Implications for Intervention” in Handbook of Early Childhood Intervention, Meisels, Samuel and Jack Shonkoff (Eds.), New York: Cambridge University Press, 1990. See also: Egeland, Byron and L. Alan Stroufe, "Attachment and Early Maltreatment," Child Development, 1981.  Ainsworth, M., M. Blehar, E. Walters and S. Wall, Patterns of Attachment, Erlbaum: Hillsdale, N.J., 1987. Youngblade, Lise and Jay Belsky, "Child Maltreatment, Infant-Parent Attachment Security, and Dysfunctional Peer Relationships in Toddlerhood, Topics in Early Childhood Special Education, 9, 1989. Main, Mary and Ruth Goldwyn, "Predicting Rejection of her Infant from Mother's Representation of her own Experience," Child Abuse and Neglect, 8, 1984. Polansky, Norman, MaryAnn Chambers, Elizabth Buttenwieser, and David Williams, Damaged Parents, Chicago: University of Chicago Press, 1981 found that 41% of neglectful mothers had themselves been in foster care and  60% had been physically abused.  See also Barrera, Maria, Kathleen Kitching, C.C. Cunningham, D. Doucet, and P.L. Rosenbaum, “A Three Year Early Home Intervention Follow-up Study with Low Birthweight Infants and Their Parents,” Topics in Early Childhood Special Education, 10 (4), 14-28, 1990. Silber, Sharon, “Family Influences on Early Development,” Topics in Early Childhood Special Education, 8(4), 1-23, 1989. See also Fantuzzo, John, Laura DePaola, Leslie Lambert, Tamara Martino, Genevie Anderson, and Sara Sutton, “Effects of Interparental Violence on the Psychological Adjustment and Competencies of Young Children, Journal of Consulting and Clinical Psychology, 1991, 59:2, 258-65.

* When the infant is delayed, the caretaker tends to dominate the interaction and become controlling and overstimulating, leading the infant to become even less responsive. These problems worsen as the child gets older. One program decreased parental directiveness and control and increased their sensitivity and responsiveness to their delayed children by focusing on turntaking and helping parents match their behavior to the child's interests and developmental level.  "Mothers who abuse their children...interfere insensitively with their infants' goal-directed behavior more frequently, and display more instances of covert hostility...When adolescent mothers experienced both rejection during their own childhood and limited support from their partners after the birth of their babies, they were likely to show punitive parenting...and their children were more likely to be angry and non-compliant.  If, in addition, the children were irritable at three months, they were particularly vulnerable to adverse parenting and were more likely to be angry and noncompliant and to show less confidence than less irritable infants exposed to the same kind of parenting." Beckwith, 1990. 

* Bradley, R. and B. Caldwell, “The Relation of Infants’ Home Environment to Achievement Test Performance in First Grade: A Follow-upStudy,” Child Development, 55, 803-809, 1984. 



** "Mothers who abuse their children...interfere insensitively with their infants' goal-directed behavior more frequently, and display more instances of covert hostility...When adolescent mothers experienced both rejection during their own childhood and limited support from their partners after the birth of their babies, they were likely to show punitive parenting...and their children were more likely to be angry and non-compliant.  If, in addition, the children were irritable at three months, they were particularly vulnerable to adverse parenting and were more likely to be angry and noncompliant and to show less confidence than less irritable infants exposed to the same kind of parenting." Beckwith, 1990.  See also Minton, C., J. Kagan and J. Levine, “Maternal Control and Obedience in the Two-Year Old Child,” Child Development, 42, 1873-94, 1971.

* Jiordano described the effectiveness of intensive home-based services for crack-using parents, with interventions designed according to the frequency of substance abuse. She found that crack-using parents are not incapable of caring for their families and that risks to children's safety can be significantly reduced and care of children significantly improved by intensive (5-20 hours weekly) in-home family services: 75% of crack-using parents maintained sobriety for a 12-month period after family-based treatment.  Jiordano, Mary, "Intensive Family Preservation Services to Crack-Using Parents," Prevention Report, Spring, 1990. The Families First program in Detroit has also been successful in working with crack-using parents. Moore, B. In-Home Services for Crack Using Mothers in Detroit. Washington, D.C.: HHS, 1989. See also materials from the National Association for Perinatal Addiction Research and Education (NAPARE) in Chicago.



** "...families, like individuals, have their own characteristics that may or may not reflect what is considered to be typical for their culture. In many instances there is as much variability within cultures as between them, and variables such as socioeconomic status, educational level, length of residence in the United States and degree of cultural identification may be even more potent than culture itself. Therefore, culturally sensitive interventions can only occur when each family is viewed and treated as a unique unit that is influenced by its culture but not defined by it."  Guidelines for the Home Visitor were developed to assist in gaining an accurate, culturally sensitive picture of the family's structure and child-rearing practices, perceptions and attitudes, and language and communication skills. "The home visitor must cultivate rapport and trust with families who may view the world very differently. Successful relationships with families require a large degree of self-awareness on the part of the home visitor and an understanding that the values, beliefs and practices that are not shared with families are points of learning and not points of conflict." Wayman, et. al, 1991. See also  Keeping Families Together, Edna McConnell Clark Foundation, 1985. "In family-based work, trust and communication between families and staff are essential to success. One article from the field warns programs of 'issues such as intrusiveness, subtle coercion, or violations of a family's values' if workers are not sensitive to a family's cultural values. ..staff must understand parents and children in the context of their family, community, and culture..." See also Cross, T., Bazron, K. Dennis, and M. Isaacs, Towards a Culturally Competent System of Care, CASSP Technical Assistance Center, 1989.  Zane, N., S. Sue, F. Castro and W. George, "Service System Models for Ethnic Minorities," in Reaching the Underserved,  See also Wayman, Karen, Eleanor Lynch and Marci Hanson, “Home-Based Early Childhood Services: Cultural Sensitivity in a Family Systems Approach, Topics in Early Childhood Special Education, 10 (4), 56-75, 1990. 

* "In our work with the families of developmentally delayed infants and toddlers, we have come to the realization that unmet family needs in basic areas such as nutrition, shelter, safety, health care, child care, and so forth negatively affect parents' health and well-being, which, in turn, decreases the probability that parents will carry out professionally prescribed child-level interventions, because the parents do not identify child-related intervention needs as a high priority.  It is our hypothesis that when self-identified needs go unmet, this acts as a force that presses one to invest emotional and physical energy to meet these needs. This, in turn, takes its toll on personal well-being and health, and makes attention to professionally prescribed regimens a low priority, particularly when professional recommendations do not involve actions designed to meet self-identified needs.  Thus, a family's failure to adhere to a professionally prescribed regimen may not be because its members are resistant, uncooperative, or noncompliant, but because the family's circumstances steer behavior in other, more pressing, directions....if certain family needs are found to be unmet, efforts must be made to provide or mediate the types of support that insure that a family has adequate resources."  Dunst, et al., 1988. 

** A study on neglect found extreme poverty in most chronically neglecting families: "Chronically neglecting families were assessed at intake as having more problems including child hygiene and nutrition, money management, unemployment, mental retardation in children and adults, medical neglect, parent-child conflict, child mental illness, truancy and other school problems. "Landsman, Miriam, Kristine Nelson, Ed Saunders, and Margaret Tyler, "Chronic Neglect in Perspective," Prevention Report, Fall 1990.  Mowrer, Charles, "The Family Worker and the Incestuous Family," Prevention Report, Spring, 1987. Wieder, et. al. described a group of high risk parents as "multiply traumatized" because they had experienced nine major life misfortunes (in comparison to an average of fewer than one misfortune in the low risk group): 64% were from families characterized by recurring poverty and psychiatric illness, 64% reported disruptions in parental care prior to age 12, and more than two-thirds had been physically and/or sexually abused as children. Wieder, Serena, Michael Jasnow, Stanley Greenspan, and Milton Strauss, "Identifying the Multi-risk Family Prenatally," Infant Mental Health Journal, 4, 1983. Hartley recommended that home-based service support family members in improving such skills as making and carrying out rules, decisions, and schedules, insuring safety, managing money and interacting with the service system. Furthermore, based on findings that mothers living in poverty who did provide good care for their children felt emotionally supported and were not as isolated as neglecting mothers, Hartley recommended that in-home services engage parents in a positive neighborhood support system. Hartley, Roland, " A Program Blueprint for Neglectful Families," an unpublished paper from Oregon Children's Services Division, 1987. 

* The National Black Child Development Institute  found significant discrepancies between the needs of children entering foster care and the services provided to them (Who Will Care When Parents Can't, 1989). The North American Council on Adoptable Children called for screening, extensive training and support and decent wages for foster parents, citing the Living in Family Environments program in Detroit which recruits and trains families living on public assistance and pays them $22,000 per year plus respite to foster special needs children. The Adoption Assistance and Child Welfare Act of 1980: The First Ten Years, 1990. 

* "The worker must be aware of the child's prior disturbance and avoid blaming foster parents for their reactions to the child's preexisting pathology. Only if they are sure that the worker clearly sees (a) the degree of the child's disturbance and (b) the fact that it existed prior to placement with them will foster parents allow examination of their reactions to the child without extreme defensiveness. The primary role of the worker is to help child and family work out their relationship with each other by learning to deal, both individually and together, with the feelings--especially hostility, anxiety and rejection--they elicit in each other." Eastman, 1979

** "Therapists and parents must help abused children to learn what is appropriate to touch and what is not. The children need appropriate substitutes for sexualized behaviors, without incorporating a sense that their behaviors were 'bad.' For many such children, sexuality and nurturance are fused. They have to learn that their desire for nurturance is valid, but that they must find other ways to satisfy it. " Damon et al, p132-3.

* See Cautley and Aldridge (1973)

* Goerge emphasized the need to address the problem of multiple placements, with the possibility of never returning home: "One implication for the care of foster children that arises from the large proportion remaining in care and the low probability of reunification after a prolonged duration is that planned long-term care should be a permanency option of high priority in these cases. Cases that have the characteristics that result in a low probability of reunification should be reviewed and considered for this option. If planned long-term care becomes a more acceptable option for caseworkers, stability and continuity of care could be improved for children who now experience multiple replacements. Maintaining a stable, long-term placement requires additional planning and casework intervention because foster parents may require greater early support in such cases. It requires special skills of the foster parents that allow them to maintain a stable placement for the child" (pp. 452-3). Goerge, Robert, "The Reunification Process in Substitute Care," Social Service Review, 64, September, 1990.  See also: Taber, M.A. and K. Proch, "Placement Stability for Adolescents in Foster Care," Child Welfare, 66, 1987.  Rutter, Michael, "Parent-Child Separation: Psychological Effects on Children," Journal of Child Psychology and Psychiatry, 12, 1971.   Fine, Paul, "Clinical Aspects of Foster Care," in Foster Care: Current Issues, Policies and Practices, M.J. Cox and R.D. Cox, eds., Borwood, N.J.: Ablex, 1985. 

** "...not a single study has proven residential programs, including hospital treatment, superior to alternative treatments. On the other hand, iatrogenic effects [problems caused by the treatment itself], especially of large facilities, are well-documented...In view of the lack of demonstrated efficacy for residential treatment and the ethical and legal preference for treatments that are no more restrictive and intrusive than necessary, a clear corollary is a policy against further development of residential treatment programs."  Melton, G. Service Models in Child and Adolescent Mental Health: What Works for Whom?, 1987. See also Dalton,R., Muller, B. and M. Forman, "The Psychiatric Hospitalization of Children," Child Psychiatry and Human Development, 1989. Lewis, J., "Are Adolescents Being Hospitalized Unnecessarily?" Journal of Child and  Adolescent Psychiatric Mental Health Nursing, 1989. 

* Goerge summarized the reasons for reunification:  "First it is believed that, in most cases, the child's well-being is enhanced by a continuous caretaking relationship. The legal right of the biological parent to maintain custody of the child and the societal norm of the natural parents as the best place for the child to live favor reunification with the parents rather than adoption. Second, it is possible that a child will be psychologically harmed in foster care.  Even if the separation lasts no longer than a few days for infants or  a few months for older children, the relationship between parents and child may be irreparably damaged. Third, the state prefers reunification for administrative reasons because foster care is costly and adoptive families are difficult to find." He sensibly recommended a three month administrative review for children who are likely to be reunified: "Practically, since the probability of reunification from the first placement drops below 50 percent at about 10 weeks for the average child, 90 days after initial placement would be a more timely intervention into the substitute care career of the child. However, all the information that is required for a complete review, such as child and family assessments, may not be available before 90 days. Asking an already overburdened caseworker staff to gather information more quickly is, however, the price that needs to be paid in order to improve outcomes for foster children." 

** "Time limits developed for P.L. 96-272 to govern child welfare services were primarily established to resduce foster care drift by forcing child welfare agenciers to decide on a permanent placement in a timely way. Time limits were chosen with guidance from research showing a drop off in reunifications after 18 months. Use of such time limits for in-home supervision has no equivalent empirical basis...services to children who have been reunified are often inadequate and end prematurely ...reabuse is likely when parents receive fewer than six months of treatment...Data presented in this review argue for extended time limits for cases supervised in-home or that involve return of children from foster care."  The Adoption Assistance and Child Welfare Act of 1980: The First Ten Years, North American Council on Adoptable Children, 1990. See also: Ten Broeck, E.  and R.P. Barth, Lessons from Implementing a Pilot Permanency Planning Program, Child Welfare, 69, 1986.

Ferleger,N., D. Glenwick, R.R.W. Gaines and A.H. Green, "Identifying Correlates of Reabuse in Maltreating Parents," Child Abuse and Neglect, 12, 1988. 

*** Fahlberg, Vera. Attachment and Separation, Michigan Department of Social Services, 1979.

Fanshel, David and Eugene Shinn, Children in Foster Care: A Longitudinal Investigation. New York: Columbia University Press, 1976.  In re Kristina L, 520 A.2nd 574 (Rhode Island 1987). Littner, N. Some Traumatic Effects of Separation and Placement, Child Welfare League of America, 1976. Maluccio, Anthony and Edith Feing, "Growing Up in Foster Care," Children and  Youth Services Review, 7, 1985. Matter of Shiela G., 462 N. E. 2d 1139 (New York 1984).  Seltzer, Martha and Leonard Bloksberg, "Permenency Planning and its Effects on Foster Children: Review of the Literature, Social Work, 32, 1987.



* "To avoid [visitation]on the grounds that it will prove unpleasant or traumatic is to encourage the child to repress the experience....Generally speaking, those children who do best in long-term foster care are those who remain secure in their foster homes but have continuing access to natural parents to whom they remain attached but on whom they cannot depend for the caring, consistency and guidance they needs. Visits with the natural family should be used to make it possible for the child to maintain the continuity of important relationships; to remain in touch with--that is, to have stirred up, and therefore available to casework--the feelings and conflicts left unresolved since coming into care; to help the child see directly the reasons for coming into care. By stopping visits the relationship with the parents is not eliminated; this merely encourages the child to idealize and perpetuate in fantasy the absent parents rather than to seek solace in new relationships."  Steinhauer. 

** Beyer, Margaret and Wallace Mlyniec, "Lifelines to Biological Parents: Their Effect on Termination of Parental Rights and Permanance," Family Law Quarterly, 20, 1986.  Beyer, Margaret, Helping Children in Care Overcome Emotional Obstacles to Independence, American Foster Care Resources, 1986.



* Adapted from Stroul, B. and Friedman, R., A System of Care for Severely Emotionally Disturbed Children and Adolescents, CASSP, 1986.                        

* Golden, Olivia, "Collaboration as a Means, Not an End." Kennedy School of Government, 1990.  Gardner, Sid, "Failure by Fragmentation," 1989.  What it Takes: Structuring Interagency Partnerships to Connect Children and Families with Comprehensive Services, Education and Human Services Consortium, Istitute for Educational Leadership, 1991. Soler, Mark and Carole Shauffer, “Fight Fragmentation: Coordination of Services for Children and Families,” Nebraska Law Review, 1990, 69:2.  Kagan, Sharon, Ann Marie Rivera and Faith Parker, Collaboration in Action: Reshaping Services to Young Children and the Families, Yale University, 1991.