Physical and Emotional Well-Being: Court Performance Measures for Children and Youth in Foster Care

Authors


Correspondence: nsydow@ncsc.org

Abstract

Given that courts have the responsibility to ensure the state is providing proper care to children in its custody, courts need to consider whether those children over whom they have jurisdiction are receiving a quality education and are physically and emotionally healthy. Court well-being measures were not developed when the safety, permanency, timeliness, and due process measures were established. However, there have been recent efforts to address this void. This article describes the newly developed set of well-being measures for courts to track success in improving well-being outcomes in the areas of physical health, mental health, maintaining permanent relationships, transition to adulthood, and enhanced family capacity to provide for their children's needs.

I. Introduction

Along with safety and permanency, well-being is one of the three major goals named in the Adoption and Safe Families Act of 1997, which is designed to improve outcomes for children. Consequently, well-being measures have been an integral part of the performance measures that child welfare agencies use to measure their own performance, and the standard that the federal government uses to assess state performance during the Child and Family Services Review (CFSR) process. Until now, there have been no equivalent well-being outcome measures directed at courts for ensuring well-being of children. Because courts have the responsibility to assure that the state is providing proper care to children in its custody, courts need to inquire whether those children are receiving a quality education and are physically and emotionally healthy.

Courts are responsible for making and approving decisions affecting children in foster care. To do so effectively, judges and court managers need information about individual children as well as information about how the court is functioning as a whole with regard to the overall outcomes. For child abuse and neglect cases, it is important to measure and evaluate the timeliness of case processing and the quality of court processes, but it is even more important to determine how these process measures result in improved outcomes for children and families. Court performance data can also help judges and court staff make process improvements and decide upon the best allocation of resources. Additionally, performance measurement permits courts to establish a baseline against which to measure the success of their improvement efforts and resulting progress in achieving better outcomes for children and families.

Given the need to measure joint progress toward achieving the ASFA goals, a collaborative effort between the American Bar Association (ABA), the National Center for State Courts (NCSC), and the National Council of Juvenile and Family Court Judges (NCJFCJ), with support from the David and Lucile Packard Foundation, initially proposed a set of court performance measures in the 2004 publication, Building a Better Court: Measuring and Improving Court Performance and Judicial Workload in Child Abuse and Neglect Cases. 1 That publication focused on the direct areas of interest that courts and child welfare agencies share—safety and permanency—as well as the importance of measuring the court-specific performance domains of due process and timeliness of court proceedings. The measures were field tested and revised and published as the Toolkit. 2 All 30 Toolkit court performance measures are listed in Appendix A. The Toolkit measures have been well disseminated, and technical assistance has been made available to states.

Work on well-being measures was postponed until the primary domains of safety and permanency were addressed because there was uncertainty as to how outcome measures in general would be received by courts. The court's role in well-being was seen as less direct, and the decision was made to focus first on safety and permanency—areas in which the courts were perceived to have more direct responsibility. Moreover, the reception given to well-being measures in the child welfare area was tentative in the sense that some child welfare professionals believed that determining child well-being would require them in effect to perform medical or mental health diagnoses, which they did not feel qualified to do. The same belief may have permeated the court community, where judges have typically exercised a more limited role in inquiring about the health and well-being of children.

Another reason for the hesitation in creating well-being performance measures was the increased collaboration that would be involved, which would have the practical consequence of expanding the data-sharing network. The Toolkit measures typically require an exchange of data between the courts and child welfare agencies. While the process of exchanging data with child welfare agencies has been a significant barrier in the past, advances in technology and the development of protocols for exchange, such as the National Information Exchange Model, 3 have made progress possible. Even so, adding well-being outcome measures means that the number of collaborative partners must be expanded from bilateral exchanges between child welfare agencies and courts to multilateral exchanges involving courts, child welfare agencies, and such entities as hospitals, medical professionals, and schools. Technological issues increase even if all parties are not part of a single exchange, for example if the child welfare agency exchanges information with medical professionals and then shares that information with courts rather than having all three institutions participate in one exchange. Moreover, adding collaborative partners dramatically increases concerns over privacy and confidentiality, even though recent developments in both policy and technology have ameliorated some of these concerns. 4

In a survey of Court Improvement Program directors in 2010, the National Resource Center on Legal and Judicial Issues found that the nine key Toolkit measures were being used statewide in Connecticut, New York, and Pennsylvania. Idaho, Kentucky, New Jersey, South Carolina, Utah, and West Virginia are using eight of the nine measures statewide, and many other states are using the measures in selected jurisdictions. Many respondents indicated the desire for assistance in the development of well-being measures. 5 Now that these Toolkit measures are in the process of being implemented, the time was right to complete the process by developing a set of well-being outcome measures for courts.

II. Well-Being: Completing the Set of Court Outcome Measures

Under ASFA, children's well-being refers to factors, other than safety and permanency, that relate to a child's current and future welfare—most notably, the child's physical and mental health as well as educational achievement. CFSR well-being outcome goals are that:

  1. Families have enhanced capacity to provide for their children's needs;
  2. Children receive appropriate services to meet their educational needs; and
  3. Children receive adequate services to meet their physical and mental health needs.

In discussing the development of well-being indicators in child welfare, Child Trends listed several “take home” messages, one being that well-being indicators can “change the discussion surrounding child abuse and neglect, and can help emphasize normal development and desired outcomes.” 6 Given that courts have the responsibility to ensure that the state is providing proper care to children in its custody, courts need to consider whether these children are receiving a quality education and are physically and emotionally healthy.

Because of the heightened interest in educational well-being outcomes for children in foster care, including its inclusion into the Fostering Connections to Success and Increasing Adoptions Act of 2008 (Fostering Connections Act), and because of the vagaries of project funding, the NCSC began work on educational well-being outcome measures first. 7 Indeed, the successful work on the measures of educational well-being provided the encouragement to tackle the measures of physical and emotional well-being.

In October 2010, the NCSC, in partnership with Casey Family Programs, convened a Focus Group to develop dependency court performance measures specific to education as one of the components of well-being for children and youth. The Focus Group was comprised of distinguished representatives from child welfare agencies, educational and research institutions, the advocacy community, and the courts. 8 Its mission was threefold: to identify education performance measures; the data elements needed to produce the measures; and strategies to overcome obstacles to sharing data among courts, child welfare agencies, and education. The meeting produced a proposed set of key education performance measures designed to improve the educational outcomes for children involved in the foster care system. These measures have been released, and several states and local jurisdictions are in the process of field testing the measures. 9 As a result, this article will focus on the other measures of well-being in the areas of physical health, mental health, maintaining permanent relationships, transition to adulthood, and enhanced family capacity.

In June 2011, the National Resource Center on Legal and Judicial Issues convened a Well-Being Focus Group to identify outcome measures for the remaining well-being areas, including physical and emotional well-being. The focus group's members are all distinguished experts from child welfare agencies, the courts, and research institutions. 10 The group's purpose was to identify performance measures in the areas of physical and emotional well-being that would, combined with the recently developed education measures, complete the set of court-related well-being performance measures.

A. Physical Well-Being

1. The Issues

Some estimates say that approximately 80% of children in foster care have significant health care needs, including chronic health conditions and developmental concerns. 11 Many of these needs result from maltreatment and a history of inadequate health care. Once these children and youth enter the child welfare system, barriers exist in the coordination and provision of health care services. Courts are responsible for ensuring that children and youth under their jurisdiction receive health services necessary to secure their well-being, but judges often have difficulty making informed decisions regarding these children due to a lack of current and accurate health care information.

Another significant barrier includes problems with eligibility and access to health care coverage. All states have extended Medicaid coverage to children in foster care. However, policies exclude some children from coverage, including noncitizens, children with private health insurance, and children who leave foster care while on trial home visits. 12 Furthermore, youth who are also involved in the delinquency system are often excluded from federal financial participation through Medicaid while in detention. 13 Other barriers include inadequate funding for health care services, poor health care record keeping, and a lack of training for child welfare workers on the array of health care services needed by children in foster care. 14 The review of the 2001-2004 Child and Family Service Reviews by the Administration of Children and Families (ACF) also found that a common challenge 27 states faced with respect to meeting the physical health care needs of children in foster care was that “the number of physicians and dentists in the state willing to accept Medicaid is not sufficient to meet the need.” 15

Physical well-being court performance measures are designed to achieve the following outcomes:

  • Children and youth under court jurisdiction should immediately receive necessary physical and dental health care evaluations once under court jurisdiction.
  • Children and youth under court jurisdiction should receive all necessary physical and dental health care services, including preventative care and treatment.
  • Judicial decision makers, along with child welfare workers and health care providers, should have access to the child's complete health histories in order to make informed decisions.
  • Caregivers should understand all the health needs of the children in their care.

2. Proposed Measures of Physical Well-Being

  • 6A: Percentage of children and youth under court jurisdiction that received an initial health screening no later than 72 hours after the first hearing.16

What is the goal? Physical well-being

The American Academy of Pediatrics (AAP) recommends that all children in foster care receive an initial health screen within 72 hours of entering care. 17 According to a 2010 study by the Center for Health Care Strategies, 46 states require an initial physical health screening for children and youth removed from their home, and 11 of these states require the screening to occur within 72 hours. 18 To make this measure more relevant to courts, the Focus Group chose to change the point of measurement from placement to time of first hearing.

How is the measure calculated?

  • Identify all children who had an initial health screening.
  • Compute the number of hours between initial health screen and first hearing.
  • Calculate the percentage of children and youth who received initial health screen no later than 72 hours after the first hearing.

Implementation Notes

Courts will need to define what qualifies as an initial health screen. For example, would a child who received a comprehensive health assessment 48 hours before the first hearing require another one? 19 To calculate this measure precisely (to exactly 72 hours), courts would need to know the time and date of the initial health screen and the time and date of the first hearing.

Related Measures

Note that this measure applies only to cases where the child received an initial health screening. The court may also wish to consider a related measure that would show the percentage of children and youth under court jurisdiction who received an initial health screening.

  • 6B: Median number of days from first hearing to initial health screening.

What is the goal? Physical well-being

As noted in 6A above, the AAP recommends that all children in foster care receive an initial health screen within 72 hours of entering care. 20 According to a 2010 study by the Center for Health Care Strategies, 46 states require an initial physical health screening for children and youth removed from their home, and 11 of these states require the screening to occur within 72 hours. 21 To make this measure more relevant to courts, the Focus Group changed the point of measurement from placement to time of first hearing.

How is the measure calculated?

  • Identify all children and youth who had an initial health screening.
  • Compute the number of days between initial health screen and first hearing.
  • Calculate the number of days from initial health screen to first hearing.

Implementation Notes

Courts will need to define what qualifies as an initial health screen.

Related Measures

This measure applies only where the child received an initial health screening.

  • 6C: Percentage of children and youth under court jurisdiction who received a comprehensive health assessment within 30 days of first hearing.22

What is the goal? Physical well-being

Because children under court jurisdiction are at risk for medical, mental health, and developmental conditions, comprehensive health assessments can detect such conditions and inform about risks for ongoing health problems. 23 The AAP recommends that all children undergo a comprehensive health assessment within 30 days of placement in care. 24 According to a 2010 study by the Center for Health Care Strategies, 24 states require an in-depth health assessment for children removed from their home. Fifteen states require that the assessment be completed within 30 days of removal. To make this measure more relevant to courts, the Focus Group changed the point of measurement from placement to time of first hearing.

How is the measure calculated?

  • Identify all children and youth under court jurisdiction who had a comprehensive health assessment.
  • Compute the number of days between first hearing and comprehensive health assessment.
  • Calculate the percentage who received a comprehensive health assessment within 30 days of first hearing.

Implementation Notes

Note that courts will need to define what qualifies as a comprehensive health assessment.

Related Measures

Also note that this measure applies only where the child received a comprehensive health assessment. The court may also wish to consider a related measure that would show the percentage of children and youth under court jurisdiction who received a comprehensive health assessment.

  • 6D: The percentage of ASFA hearings where the child's preventative health care was addressed.

What is the goal? Physical well-being

A child's preventative health care should be thoroughly addressed at every ASFA hearing 25 to ensure physical well-being for children and youth under court jurisdiction. According to the AAP, the purpose of preventative health care for children and youth in foster care includes:

  • To promote overall wellness by fostering healthy growth and development;
  • To identify significant medical, behavioral, emotional, developmental, and school problems through periodic history, physical examination, and screenings;
  • To regularly assess for success of foster care placement;
  • To regularly monitor for signs or symptoms of abuse or neglect; and
  • To provide age-appropriate anticipatory guidance on a regular basis to children and adolescents in foster care and to foster and birth parents. 26

Children and youth in foster care are eligible for Medicaid and states are required to offer periodic comprehensive health assessments and treatment services to children and youth up to age 21 who are enrolled in Medicaid. These Medicaid screenings, called Early and Periodic Screening, Diagnostic, and Treatment services (EPSDT), must include, at minimum:

  • Comprehensive health and developmental history;
  • Comprehensive unclothed physical examination;
  • Appropriate vision testing;
  • Appropriate hearing testing;
  • Appropriate laboratory tests; and
  • Dental screening services furnished by direct referral to a dentist for children beginning at 3 years of age. 27

State Medicaid agencies establish the standards for the timing and frequency of these services, but Federal regulations require that EPSDT services comply with reasonable standards of medical and dental practice determined by the state after consultation with recognized medical and dental organizations involved in child health care. 28

How is the measure calculated?

  • Determine the number of ASFA hearings completed.
  • Select and count the number of ASFA hearings in which the child's preventative health care was addressed.
  • Calculate the percentage.

Implementation Notes

To implement this measure, it will be necessary to determine what qualifies as a preventative health care question. This determination is critical for this measure to be valuable in measuring the court's performance in ensuring the physical well-being of children under its jurisdiction. For example, it is not sufficient to ask only, “Is the child healthy?”—more probing questions should be encouraged.

  • 6E: The percentage of children and youth under court jurisdiction who have current immunizations at exit.

What is the goal? Physical well-being

Courts are responsible for ensuring that children and youth under their jurisdiction receive necessary health services to ensure their well-being. Because immunizations protect against disease, courts should ensure that all children and youth under their jurisdiction have been properly immunized. 29

Besides the obvious health benefits, current vaccinations are important for school enrollment. Missing vaccinations can delay school enrollment and or jeopardize enrollment. Vaccination laws and school enrollment laws change, and it is critical for vaccinations to stay current.

How is the measure calculated?

  • Select and count all cases in which the child had current immunizations at exit.
  • Calculate the percentage.

Implementation Notes

Courts could consider as related measures the status of immunizations at entry into care and at intermediate points in care. The Focus Group explicitly chose to measure status of immunization at exit because it is outcome-oriented and best reflects the effectiveness of the court oversight role.

B. Emotional Well-Being

Emotional well-being includes issues of mental health surely, but as the Focus Group began to delve more deeply into the issues, it decided to separate emotional well-being into four categories reported here: mental health, maintaining permanent relationships, transition to adulthood, and enhanced family capacity.

1. Desired Outcomes

  1. Mental Health
    • Children and youth under court jurisdiction receive necessary mental health evaluations.
    • Children and youth under court jurisdiction receive the necessary mental health treatment services to include regular treatment progress reports.
    • Judicial decision makers, along with child welfare workers and mental health care providers, have access to the child's complete mental health histories in order to make informed decisions.
    • Caregivers understand all the mental health needs of the children in their care.
  2. Maintaining Permanent Relationships
    • Family relationships and connections for children and youth under court jurisdiction are preserved.
  3. Transition to Adulthood
    • Youth under court jurisdiction are well prepared for adulthood.
  4. Enhanced Family Capacity
    • Families have enhanced capacity to provide for their children's needs.

2. Emotional Well-Being Issues

  1. Mental Health

Children and youth in the child welfare system typically have significant mental health needs. They have experienced abuse and/or neglect and are often exposed to family violence, parental substance abuse and mental illness, homelessness, or chronic poverty. 30 If the mental health needs of these children and youth are inadequately met, the symptoms can persist into adulthood. Further, children with emotional and behavioral problems have a reduced likelihood of reunification or adoption. 31

The Northwest Foster Care Alumni Study reviewed the mental health diagnoses of foster care alumni and found the alumni were significantly more likely than the general population to experience mental illness (see Figure 1). The study also found that foster care alumni were six times more likely to suffer post-traumatic stress disorder, four times more likely to turn to substance abuse, twice as likely to experience depression, and more than two-and-a-half times more likely to be diagnosed with an anxiety disorder. 32

Figure 1.

The Proportion of Adult Alumni from Foster Care with Psychiatric Problems, Compared to Other Young Adults in the General Population33

Concerns exist regarding the identification of mental health problems for children and youth in foster care. A study of practices for mental health screening and assessment for children in foster care found that more than half of the child welfare agencies surveyed did not require systematic mental or developmental health evaluations for children entering foster care. 34 The review of the 2001-2004 Child and Family Service Reviews by ACF found no evidence of policies requiring an assessment of foster children's mental health in most states, and one state noted that children in care did not receive a mental health assessment unless problems were observed. 35

  • b. Maintaining Permanent Relationships

When children are removed from parents, siblings, and a familiar environment and placed with strangers in a new environment, this separation can create negative outcomes ranging from attachment disorders in young children, to significant acting-out behaviors, to clinical depression. Therefore, it is critically important to minimize familial separation whenever possible.

Courts play a key role in ensuring maintenance of consistent contact with parents and siblings during out-of-home placement, unless visitation is not in the child's best interest. 36 The Fostering Connections Act encourages maintaining family connections. For example, the Fostering Connections Act requires states to make reasonable efforts to place siblings in the same foster, kinship, or adoption home, unless such a placement is contrary to the safety or well-being of the siblings. 37

  • c. Transition to Adulthood

Youth who age out of the child welfare system are often “woefully unprepared for independent adult life: only one-third have a driver's license, fewer than four in 10 have at least $250 in cash, and fewer than one-quarter have the basic tools to set up a household, let alone the skills to know what to do with those tools. With generally no more than a garbage bag of belongings, our foster youth commonly leave foster care with no significant connection to a responsible adult, no one to provide them with desperately needed guidance, and no place to turn when they falter.” 38

  • d. Enhanced Family Capacity

One of the three CFSR outcomes related to the ASFA well-being goal is that families have enhanced capacity to provide for their children's needs. Most of the well-being measures relate to children, but the Focus Group believes it is important to have some measures related to the well-being goal of enhanced family capacity.

3. Proposed Measures of Emotional Well-Being

  • 6F: Percentage of children and youth under court jurisdiction that received a mental health screening within 30 days of first hearing.

What is the goal? Mental health

The AAP recommends that children and youth in foster care should have a mental health evaluation within 30 days after entering care. This measure allows the court to see the percentage of cases that met this recommended benchmark.

How is the measure calculated?

  • Identify all children and youth under court jurisdiction who received a mental health screening.
  • Compute the number of days between first hearing and mental health screening.
  • Calculate the percentage who received a mental health screening within 30 days of first hearing.

Implementation Notes

While the AAP recommendation is tied to when children and youth enter care, the Focus Group decided that this measure should be applied to all children and youth under court jurisdiction, regardless of placement type. Therefore, the measure is tied to the date of the first hearing.

Related Measures

This measure applies only to cases in which the child received a mental health screening within 30 days of the first hearing. The court may also wish to consider a related measure that would show the percentage of children and youth under court jurisdiction who received a mental health screening.

  • 6G: Percentage of court-ordered child or youth mental health assessments that occur within 60 days of order.

What is the goal? Mental health

This measure will provide the court with a measure of the timeliness of mental health assessments.

How is the measure calculated?

  • Identify all children and youth under court jurisdiction who received a mental health assessment.
  • Compute the number of days between order and mental health assessment.
  • Calculate the percentage who received a mental health assessment within 60 days of order.

Implementation Notes

The AAP recommendation is tied to when children and youth enter care, but the Focus Group decided that this measure should be applied to all children and youth under court jurisdiction, regardless of placement type. Therefore, the measure is tied to the date of the order.

  • 6H: The percentage of ASFA hearings during which the child's mental health needs were addressed.

What is the goal? Mental health

A child's emotional and mental health should be addressed at every ASFA hearing to ensure emotional well-being for children and youth under court jurisdiction. Further, when the judge asks questions about the child's mental health from the bench, the judge sets expectations and standards for practice that will hopefully lead to a changed culture that includes a focus on the well-being of children and youth under court jurisdiction. This measure provides the court with an indicator of how often the child's mental health is addressed at ASFA hearings.

How is the measure calculated?

  • Determine the number of ASFA hearings completed.
  • Select and count the number of ASFA hearings in which the child's mental health needs were addressed.
  • Calculate the percentage.

Implementation Notes

It will be necessary to determine what qualifies as a mental health question. More importantly, it is not obvious or easy to identify who will record data on whether or not mental health questions were addressed and how that data will be put into court information systems. Courts that have clerks in the courtroom entering other key information may find it easier to include this data element as well.

  • 6I: When psychotropic medications are prescribed, the percentage of ASFA hearings during which the child's psychotropic prescriptions are reviewed.

What is the goal? Mental health

The prevalence of psychotropic medications among youth in foster care is estimated to be between 26% and 43%. The rate of psychotropic medication use among the general youth population is 4%. 39 National organizations such as the AAP, the American Academy of Child and Adolescent Psychiatry, and the Child Welfare League of America have called for experts to be involved in managing children's medications and asking states to implement oversight practices. Congress has passed legislation requiring states to explain to the federal government how they are monitoring prescription medications for youth in foster care. 40

The court plays a role in the oversight of this process, and in a few states, the court must actually consent to the psychotropic prescription for children and youth in foster care. In California, for example, consent rests entirely with the judge. The judge may delegate the authority to the parents when that decision will not pose a danger to the youth. When a California child in foster care is prescribed a psychotropic medication, the agency must request court authorization and within seven days of receiving the request, the court must approve or deny the request or set a hearing date. 41 This measure provides courts with an indicator of ASFA hearings where the child's psychotropic prescriptions are reviewed.

How is the measure calculated?

  • Identify all children and youth under court jurisdiction who were prescribed psychotropic medications.
  • Determine the number of ASFA hearings completed for the children and youth prescribed psychotropic medications.
  • Select and count the number of ASFA hearings during which the child's psychotropic medications are reviewed.

Implementation Notes

It is not obvious or easy to identify who will record data on whether mental health questions were addressed and how that data will be put into court information systems. Courts that have clerks in the courtroom entering other key information may find it easier to include this data element as well.

  • 6J: Percentage of children placed with all siblings who are also under court jurisdiction.

What is the goal? Maintaining permanent relationships

The Fostering Connections Act requires states to make reasonable efforts to place siblings in the same foster, kinship, or adoption home, unless such a placement is contrary to the safety or well-being of the siblings. This measure would provide the court with an indicator of how often all siblings are placed together.

How is the measure calculated?

  • Identify all siblings under court jurisdiction in out-of-home placement.
  • Select and count the cases where all siblings are placed together.
  • Calculate the percentage of children placed with all siblings who are also under court jurisdiction.

Implementation Notes

Courts may wish to analyze the instances in which siblings were not placed together. For example, was a reason documented why siblings were not placed together? Were reasonable efforts made to provide frequent visitation between siblings? Courts may also wish to consider applying this measure only to children who are removed at the same time. For example, the court may decide not to include in this measure older children placed many years earlier.

  • 6K: Percentage of children placed with at least one but not all siblings who are also under court jurisdiction.

What is the goal? Maintaining permanent relationships

As noted in 6J above, the Fostering Connections Act requires that states make reasonable efforts to place siblings in the same foster, kinship, or adoption home, unless such a placement is contrary to the safety or well-being of the siblings. This measure would provide the court with an indicator of how often siblings are placed together.

How is the measure calculated?

  • Identify all siblings under court jurisdiction in out-of-home placement.
  • Select and count the cases where some but not all siblings are placed together.
  • Calculate the percentage of children placed with some but not all siblings who are also under court jurisdiction.

Implementation Notes

Courts may wish also to analyze the instances in which all siblings were not placed together. Was a reason documented why siblings were not placed together? Were reasonable efforts made to provide frequent visitation between siblings?

  • 6L: The percentage of ASFA hearings where sibling placement or visitation was addressed.

What is the goal? Maintaining permanent relationships

This measure would provide the court with an indicator of how often sibling placement and visitation are addressed at ASFA hearings. Visitation is particularly important where siblings are not placed together.

How is the measure calculated?

  • Identify all children and youth under court jurisdiction who have siblings also under court jurisdiction.
  • Determine the number of ASFA hearings completed for the children and youth with siblings under court jurisdiction.
  • Select and count the number of ASFA hearings where the sibling placement or visitation was addressed.

Implementation Notes

The court must define what constitutes a sibling placement or visitation question, and what constitutes a reasonable visitation schedule.

  • 6M: Percentage of youth parents placed with all their children.

What is the goal? Maintaining permanent relationships

Research suggests that female foster youth are at a high risk of becoming pregnant. 42 This distinct subgroup of the foster youth population, foster youth who are pregnant or parenting, requires special services and programs, including placement with their children. This measure provides the court an indicator of the percentage of youth parents who have custody of children that are placed together.

Federal regulations indicate that a child placed with a youth parent in the same home will receive a foster care maintenance payment sufficient to meet the child's needs without the state's taking custody of the child.43 Still, many appellate decisions, two class actions, and anecdotal accounts suggest that children are removed legally or physically from minor parents in care with less evidence of abuse or neglect than would otherwise be required.

How is the measure calculated?

  • Select all youth under court jurisdiction who have custody of their children.
  • Select and count youth who are placed with all their children.
  • Calculate the percentage of youth parents who are placed with all their children.
  • 6N: Percentage of children in out-of-home care placed in relative placement.

What is the goal? Maintaining permanent relationships

When a child is removed from home, every effort should be made to place the child in the least restrictive, most family-like setting, and efforts should be made to place the child in a relative or kinship placement. Relative placements tend to be less traumatic and disruptive for the child compared with other out-of-home placements. Relative placements also tend to be more stable placements than traditional foster care placements. The Fostering Connections Act requires state agencies to exercise due diligence to identify and provide notice to all grandparents and other adult relatives of a child (including any other adult relatives suggested by the parents) within 30 days after the child is removed from his or her parents' custody. This measure provides the court an indicator of how often children and youth under court jurisdiction, who are in out-of-home placement, are in a relative placement.

How is the measure calculated?

  • Select all youth under court jurisdiction who are in out-of-home placements.
  • Select and count youth who are in a relative placement.
  • Calculate the percentage who are in a relative placement.

Implementation Notes

Courts will need to define relative placement.

Related Measures

Courts might also wish to measure the percentage of children and youth under court jurisdiction in non-relative kinship placements.

  • 6O: Percentage of youth who have a court-approved transition plan within 90 days prior to aging out of care.

What is the goal? Transition to adulthood

The Fostering Connections Act requires that a personal transition plan for youth be in place within 90 days prior to their 18th birthday, or whatever later age the state may elect under section 201 of the Fostering Connections Act. This requirement does not replace the previously required independent living plan “for youth ages 16 and older” under ASFA at 42 U.S.C. § 675 (1)(D), or the case review documentation for youth age 16 and above of “the services needed to assist the child to make the transition from foster care to independent living” at 42 U.S.C. § 675(5). 44 This measure provides the court an indicator of the percentage of youth who have a court-approved transition plan within 90 days prior to aging out of care.

How is the measure calculated?

  • Select all youth under court jurisdiction who had a court-approved transition plan.
  • Select and count youth who had a court-approved transition plan in place within 90 days prior to their 18th birthday or later age established by state law.
  • Calculate the percentage of youth with a court-approved transition plan within 90 days prior to their 18th birthday or later age established by state law.
  • 6P: Median number of days from date of each parent's court-ordered mental health assessment to date of assessment completion

What is the goal? Enhanced family capacity

Families with parental mental illness face many barriers to reunification, including inadequate access to the proper mental health services. Further, a 2008 study of state statutes revealed that five states and the territory of Puerto Rico listed parental mental illness among possible “aggravated circumstances,” as potential grounds for not making reasonable efforts to reunify a family. 45 This measure would provide the court an indicator of the timeliness of court-ordered parent mental health assessments.

How is the measure calculated?

  • Identify all parents with a court-ordered mental health assessment.
  • Compute the number of days between order and mental health assessment.
  • Calculate the median number of days from date of each parent's court-ordered mental health assessment to date of assessment completion.
  • 6Q: Percentage of ASFA hearings during which parent visitation was addressed.

What is the goal? Enhanced family capacity

A large body of research suggests that children who have regular parental visitation “make better adjustments to care, are more likely to be reunified, and when reunification is not possible, are more likely to be adopted by their foster parents.” 46 Courts can establish visitation orders and are in the position to emphasize the importance of parental visitation and improve current practice. Because courts have the responsibility of determining whether the agency has provided reasonable efforts to parents who attempt to reunify with a child, courts arguably play a role in the oversight of parental visitation. 47 This measure provides the court with information on the percentage of ASFA hearings during which parental visitation was addressed.

How is the measure calculated?

  • Identify all children and youth under court jurisdiction in out-of-home placements.
  • Determine the number of ASFA hearings completed for the children and youth in out-of-home placements.
  • Select and count the number of ASFA hearings during which parental visitation was addressed.

Implementation Notes

Courts will need to define what qualifies as a parental visitation question. For example, it is not sufficient to ask only, “Have there been parental visits?” Instead, more probing questions should be encouraged, such as questions regarding the quality and quantity of the visits, reasons for failed scheduled visits, etc.

  • 6R: Median time from date of order for supervised visitation to date of first order for unsupervised visitation.

What is the goal? Enhanced family capacity

Because of the challenges that measuring improvement in the outcome of parents' enhanced capacity to provide for children's needs, this measure was proposed as a proxy. The rationale is that when visitation transitions from supervised to unsupervised, a parent's capacity to provide for the children's needs has improved. This measure would provide the court with an indication of the improvement in the parent's capacity to provide for their children's needs.

How is the measure calculated?

  • Identify all cases with supervised visitation orders.
  • Select and count the number of cases where supervised visitation transitioned to unsupervised visitation.
  • Count the number of days between order for supervised visitation and order for unsupervised visitation.
  • Calculate the median number of days.

Implementation Notes

Some thought may be given to cases that begin with unsupervised visitation.

III. Setting Priorities

The Focus Group recognized not only the importance of the measures listed above, but also many others. The Group consciously sought to find a balance between obtaining all of the measures that would be desirable to obtain a clear picture of the physical and mental health status of children in foster care and the cost in terms of personnel time and money required to collect all of the data that would assist decision making. Creating too many measures may discourage some courts and agencies from even attempting to obtain measures of well-being. With that in mind, the Focus Group was asked to select a smaller number of measures, akin to the nine key Toolkit performance measures chosen from the longer list of 30. Priority setting was done to preempt the argument that because some courts could not provide all of these measures, they would not do any. The Focus Group's response is that it is important to measure outcomes in all areas, but that the outcomes can be sequenced, and it is better to have some outcome measures to provide an indication of how successful we are in achieving goals than to have no indication at all. With that consideration in mind, the Focus Group was asked to select a small number of well-being measures that would provide courts with the most important outcome measures.

The five key priority performance measures selected by the Focus Group are:

  1. 6C: Percentage of children and youth under court jurisdiction who received a comprehensive health assessment within 30 days of first hearing.
  2. 6G: Percentage of court-ordered child or youth mental health assessments that occur within 60 days of order.
  3. 6J: Percentage of children placed with all siblings who are also under court jurisdiction.
  4. 6O: Percentage of youth who have a court-approved transition plan within 90 days of aging out of care.
  5. 6R: Median time from date of order for supervised visitation to date of first order for unsupervised visitation.

It may not be easy to produce these five priority measures of well-being, but the process should begin here. In addition to the data elements listed under each of the measures, this measurement scheme assumes that basic information about children in foster care is available. For example, a unique child identifier, as well as basic information about age, gender, and race of the children is assumed so that disparities in various performance domains can be calculated.

IV. Conclusion

The work of the Well-Being Focus Group has provided an excellent foundation for the mission of developing court-related well-being outcome measures for children in foster care. The next step in this project has been to vet these measures to a larger audience. 48 Other experts and stakeholders are reviewing and evaluating these measures for practicality and usefulness and to provide recommendations on how best to improve collaboration as well as how best to facilitate the exchange of data required to produce these measures. What data, for example, do courts require, and can they get that information from child welfare agencies? Does obtaining this information require an exchange of data between health care providers and child welfare agencies? Currently, the well-being measures are being pilot tested to determine how they work in practice and what obstacles arise when a way to measure well-being is instituted. Courts in some jurisdictions, such as Pennsylvania, are already able to produce data for some of these well-being measures.

The interest and positive feedback that this work on court-related well-being measures has received from the court community has been very encouraging. Focus on child well-being is not the exclusive responsibility of child welfare agencies—courts, schools, physicians, and mental health professionals also have an important role to play, and all are needed to improve the well-being of children in care.

Appendix: Appendix A

Toolkit for Court Performance Measures in Child Abuse and Neglect Cases 49

Safety Measures

Measure 1A: Child Safety While Under Court Jurisdiction

Measure 1B: Child Safety after Release From Court Jurisdiction

Permanency Measures

Measure 2A: Achievement of Child Permanency

Measure 2B: Children Not Reaching Permanency

Measure 2C: Children Moved While Under Court Jurisdiction

Measure 2D: Reentry into Foster Care after Return Home

Measure 2E: Reentry into Foster Care after Adoption or Guardianship

Due Process Measures

Measure 3A: Number of Judges Per Case

Measure 3B: Service of Process to Parties

Measure 3C: Early Appointment of Advocates for Children

Measure 3D: Early Appointment of Counsel for Parents

Measure 3E: Advance Notice of Hearings to Parties

Measure 3F: Advance Written Notice of Hearings to Foster Parents, Pre-adoptive Parents, and Relative Caregivers

Measure 3G: Presence of Advocates during Hearings

Measure 3H: Presence of Parties during Hearings

Measure 3I: Continuity of Advocates for Children

Measure 3J: Continuity of Counsel for Parents

Timeliness Measures

Measure 4A: Time to Permanent Placement

Measure 4B: Time to Adjudication

Measure 4C: Timeliness of Adjudication

Measure 4D: Time to Disposition Hearing

Measure 4E: Timeliness of Disposition Hearing

Measure 4F: Timeliness of Case Review Hearings

Measure 4G: Time to First Permanency Hearing

Measure 4H: Time to Termination of Parental Rights Petition

Measure 4I: Time to Termination of Parental Rights

Measure 4J: Timeliness of Termination of Parental Rights Proceedings

Measure 4K: Time from Disposition Hearing to Termination of Parental Rights Petition

Measure 4L: Timeliness of Adoption Petition

Measure 4M: Timeliness of Adoption Proceedings

  1. 1

    Building a Better Court: Measuring and Improving Court Performance and Judicial Workload in Child Abuse and Neglect Cases. (The American Bar Association, Center on Children and the Law, National Center for State Courts, and National Council of Juvenile and Family Court Judges, 2004), available at http://www.ncjfcj.org/sites/default/files/Building%20a%20Better%20Court.pdf.

  2. 2

    U.S. Department of Justice, Toolkit for Court Performance Measures in Child Abuse and Neglect Cases. (U.S. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention, 2008), available at http://www.ojjdp.gov/publications/courttoolkit.html.

  3. 3

    See www.niem.gov.

  4. 4

    For example, a privacy policy development tool has been developed by the National Resource Center for Child Welfare Data and Technology. See Privacy Protection: A Technical Framework for Policy Enforcement (National Resource Center for Child Welfare Data and Technology, 2011) at http://www.nrccwdt.org/2011/12/privacy-protectio/. See also Diana Graski & Thomas Clarke, Automating the Enforcement of Privacy Policies, Future Trends in State Courts (National Center for State Courts, 2012), at http://www.ncsc.org/sitecore/content/microsites/future-trends-2012/home/Privacy-and-Technology/Enforcement-of-Privacy-Policies.aspx.

  5. 5

    The National Resource Center on Legal and Judicial Issues, Current Use of Dependency Court Performance Measures. Unpublished document (Sept. 2010).

  6. 6

    Rosemary Chalk, Kristin Anderson Moore, & Alison Gibbons, The Development and Use of Child Well-being Indicators in the Prevention of Child Abuse and Neglect, Final Report to the Doris Duke Charitable Foundation, Child Trends (December 2003), at 2 .

  7. 7

    Fostering Connections to Success and Increasing Adoptions Act of 2008, Pub. L. No. 110-351, 122 Stat. 3949 (2008).

  8. 8

    Focus Group members were Ms. Kate Burdick, Zubrow Fellow, Juvenile Law Center; Dr. Gretchen Cusick, Chapin Hall; Hon. Robert R. Hofmann, Associate Judge, Child Protection Court of the Hill Country, Mason County, Texas; Michelle L. Lustig, MSW, Ed.D., Coordinator, San Diego County Office of Education; Ms. Kathleen McNaught, Assistant Director, ABA Center on Children and the Law; Mr. Ronald M. Ozga, Governor's Office of Information Technology, Colorado Department of Human Services; Ms. Regina Schaefer, Director, Education Unit, New York City Children's Service. Their invaluable contribution to this effort is gratefully acknowledged.

  9. 9

    The education measures can be found in Nora E. Sydow & Victor E. Flango, Educational Well-Being: Court Outcome Measures for Children in Foster Care, 50 Family Court Review, 455-466 (2012). See also Victor E. Flango & Nora Sydow, Educational Well-Being: Court Outcome Measures for Children in Foster Care. Future Trends in State Courts. (National Center for State Courts, 2010), available at http://www.ncsc.org/sitecore/content/microsites/future-trends/home/Special-Programs/~/media/Microsites/Files/Future%20Trends/Author%20PDFs/Flango%20and%20Sydow.ashx.

  10. 10

    Focus Group members are Ms. Sarah Fox, CIP Training Specialist, New Hampshire Court Improvement Project; Ms. Sandi Metcalf, Director of Juvenile Services, 20th Judicial Circuit Court, Grand Haven, Michigan; Hon. Robert R. Hofmann, Associate Judge, Child Protection Court of the Hill Country, Mason County, Texas; Ms. Sandra Moore, Administrator, Office of Children and Families in the Court, Pennsylvania; Mr. Ronald M. Ozga, Governor's Office of Information Technology, Colorado Dept. of Human Services; Ms. Sonya Tafoya, Senior Research Analyst, AOC Center for Families, Children and the Courts, California. Staff representatives to the project include Dr. Victor Eugene Flango, National Center for State Courts; Ms. Lisa Portune, Consultant; Ms. Nora Sydow, National Center for State Courts; Ms. Deborah Saunders, National Center for State Courts; Mr. Scott Trowbridge, ABA Center on Children and the Law; and Dr. Alicia Summers, National Council of Juvenile and Family Court Judges. Their invaluable contribution to the project is gratefully acknowledged. The authors would also like to acknowledge the contribution of Ms. Eva Klain, ABA Center on Children and the Law, for her invaluable review of this manuscript.

  11. 11

    United States Government Accountability Office, Foster Care: State Practices for Assessing Health Needs, Facilitating Service Delivery, and Monitoring Children's Care (Feb. 2009).

  12. 12

    Rob Geen, Anna Sommers, & Mindy Cohen, Medicaid Spending on Foster Children (The Urban Institute, 2005), available at http://www.urban.org/publications/311221.html.

  13. 13

    42 U.S.C. § 1396d (a)(28)(A); 42 C.F.R. § 435.1009(a)(1). See also Youth Law Center, Medicaid for Youth Involved in the Juvenile Justice System (Feb. 2011), at http://www.ylc.org/pdfs/MedicaidforYouthintheJuvenileJusticeSystem2011.pdf.

  14. 14

    Christopher Hartney, Madeline Wordes, & Barry Krisberg, Health Care for Our Troubled Youth: Provision of Services in the Foster Care and Juvenile Justice Systems of California (National Council on Crime & Delinquency, March 15, 2002).

  15. 15

    Summary of the Results of the 2001-2004 Child and Family Service Reviews. Administration for Children and Families, accessed Nov. 21, 2011 at http://www.acf.hhs.gov/programs/cb/cwmonitoring/results/genfindings04/genfindings04.pdf.

  16. 16

    The measures proposed below are numbered sequentially following the pattern of the other court performance measures. Now that the Toolkit measures have been extended to cover well-being, it is clear that a better numbering scheme is needed. For this document, however, the format of the old measures will be used. After all the measures have been tested, adopted, and recommended, perhaps a new numbering sequence will be considered.

  17. 17

    AAP recommendations for components of initial and comprehensive health screenings can be found in Fostering Health: Health Care for Children and Adolescents in Foster Care, 2nd ed., American Academy of Pediatrics, Task Force on Health Care for Children in Foster Care (2005) at http://www.aap.org/fostercare/PDFs/FosteringHealth/FosteringHealthBook.pdf [hereafter Fostering Health].

  18. 18

    Kamala Allen, Health Screening and Assessment for Children and Youth Entering Foster Care: State Requirements and Opportunities. (Center for Health Care Strategies, Inc., Nov. 2010), available at http://www.chcs.org/usr_doc/CHCS_CW_Foster_Care_Screening_and_Assessment_Issue_Brief_111910.pdf.

  19. 19

    Supra note 17.

  20. 20

    Id.

  21. 21

    Allen, supra 18.

  22. 22

    The AAP recommends that all children in foster care receive comprehensive health screen within 30 days of entering care. See Fostering Health, supra 17.

  23. 23

    Eva Klain et al., Healthy Beginnings, Healthy Futures: A Judge's Guide. (ABA Center on Children and the Law, National Council of Juvenile and Family Court Judges, & Zero to Three, 2009), 21 , available at http://www.americanbar.org/content/dam/aba/migrated/child/PublicDocuments/healthy_beginnings.authcheckdam.pdf.

  24. 24

    Fostering Health, supra 17.

  25. 25

    The Focus Group wanted to limit this measure to substantive hearings such as the protective custody, adjudication, disposition, six-month review, permanency, and TPR hearings. “ASFA hearings” is a term designed to refer to these hearings, but exclude hearings that are strictly periodic and administrative in nature.

  26. 26

    Supra 23.

  27. 27

    42 C.F.R. § 441.50 et seq.

  28. 28

    Id.

  29. 29

    For the most recent nationally recommended immunization guidelines published jointly by the Centers for Disease Control, the Advisory Committee on Immunization Practices (ACIP), and the AAP, visit http://www.cdc.gov/vaccines/.

  30. 30

    J.D. Osofsky et al., Questions Every Judge and Lawyer Should Ask About Infants and Toddlers in the Child Welfare System, Technical Assistance Brief. (National Council of Juvenile and Family Court Judges, 2002), 5 .

  31. 31

    Id.

  32. 32

    P.J. Pecora et al., Improving Family Foster Care: Findings from the Northwest Foster Care Alumni Study. (Casey Family Programs, 2005), available at http://www.casey.org/resources/publications/ImprovingFamilyFosterCare.htm.

  33. 33

    Id.

  34. 34

    Jessica M. Levitt, Identification of Mental Health Service Need among Youth in Child Welfare, 88 Child Welfare, No. 1 (2009), 32 , citing Leslie et al., Comprehensive Assessments for Children Entering Foster Care: A National Perspective, 112 Pediatrics (July 2003), 134-142 .

  35. 35

    United States Government Accountability Office, Foster Care: State Practices for Assessing Health Needs, Facilitating Service Delivery, and Monitoring Children's Care (United States Government Accountability Office Report to the Chairman, Subcommittee on Income Security and Family Support, Committee on Ways and Means, House of Representatives, Feb. 2009), available at http://www.gao.gov/new.items/d0926.pdf.

  36. 36

    This article uses the term “visitation” to refer to the time children spend with their parents, guardians, and/or siblings when they have been placed in out-of-home care. The term “visitation” is widely used, accepted in courts and in statutory language, as well as understood by the general public. There is a trend away from using the word “visitation” because it can be perceived to diminish the role of parents/guardians and inaccurately represent the purpose of the time spent together—which is to build stronger familial bonds through regular face-to-face interactions. Alternative phrases include “family time,” “family contact,” “family access,” and “parenting time.”

  37. 37

    ABA Center on Children and the Law, Judicial Guide to Implementing the Fostering Connections to Success and Increasing Adoptions Act of 2008 (PL 110-351). (Grandfamilies State Law and Policy Resource Center, 2011), available at http://www.grandfamilies.org/Portals/0/JudicialGuidetoFosteringConnections2011[1].pdf.

  38. 38

    American Bar Association Commission on Youth at Risk, Charting a Better Future for Transitioning Youth: Report from a National Summit on the Fostering Connections to Success Act (2010), available at http://www.americanbar.org/content/dam/aba/publications/center_on_children_and_the_law/youth_at_risk/transitioning_foster_youth_report.authcheckdam.pdf.

  39. 39

    Karen Worthington, Psychotropic Meds for Georgia Youth in Foster Care: Who Decides? (Georgia Supreme Court Committee on Justice for Children, Jan. 2011), 3 , available at http://w2.georgiacourts.org/cj4c/files/Psych_meds_paper%20(2).pdf.

  40. 40

    Fostering Connections to Success and Increasing Adoptions Act of 2008, supra note 7.

  41. 41

    Id. at 29.

  42. 42

    Amy Dworsky & Jan DeCoursey, Pregnant and Parenting Foster Youth: Their Needs, Their Experiences. (Chapin Hall, 2009), available at http://www.chapinhall.org/sites/default/files/Pregnant_Foster_Youth_final_081109.pdf.

  43. 43

    45 C.F.R 1356.21(j); based on 42 U.S.C.A. § 675(4)(B).

  44. 44

    Judicial Guide, supra 37.

  45. 45

    B.J. Friesen et al., Parents with a Mental Illness and Implementation of ASFA, in Intentions and Results: A Look Back at the Adoption and Safe Families Act. (Urban Institute, 2009), available at http://www.urban.org/uploadedpdf/1001351_safe_families_act.pdf, citing J. Scott, Reunification Statute Table (UPenn Collaborative on Community Integration, University of Pennsylvania, 2008).

  46. 46

    Leonard P. Edwards, Judicial Oversight of Parental Visitation in Family Reunification Cases, Juvenile and Family Court Journal (Summer 2003), 3 , available at http://www.f2f.ca.gov/res/pdf/LenEdwards.pdf.

  47. 47

    Id. at 10.

  48. 48

    The National Resource Center on Legal and Judicial Issues hosted a live video webcast on May 17, 2012 that included a panel of experts discussing these new measures. An archive of the webcast can be viewed at http://icmelearning.com/well-being-webcast/.

  49. 49

    Toolkit for Court Performance Measures in Child Abuse and Neglect Cases, supra 2, available at http://www.ojjdp.gov/publications/courttoolkit.html.

Biographies

  • Nora E. Sydow, J.D., is a Senior Analyst at the National Center for State Courts. She provides training and technical assistance to state courts across the country in a variety of court improvement areas, including family courts.

  • Victor Eugene Flango, Ph.D., is the Executive Director, Program Resource Development, at the National Center for State Courts. He is the author of more than 100 publications, monographs, and articles concerning child welfare issues.

Ancillary