Adoption Policy:The research-policy link and implications for

dissemination of programs into real-world settings

Richard P. Barth, Ph.D

Dean and Professor

School of Social Work

University of Maryland

rbarth@ssw.umaryland.edu

Presented at the Improving Outcomes for Adopted Children and Families Conference

Eugene Oregon

November 16, 2010

Structure of the Talk Who is being adopted from foster care after what length

of time? What are the adoptive family selection and preparation

processes like? What are the post-adoption services like now? What are the outcomes regarding the range of positive

and adverse outcomes by case characteristics? What else needs to be done to add effectiveness to:

1. adoptive family selection 2. adoptive family preparation 3. post-adoption support (at different levels of intensity)

What would the challenges be in implementing service changes? 2

Adoption from Foster Care

Who (by age) is being adopted from foster care after what length of time?

What happens to the children?

3

Who Gets Adopted by Whom? 20% of foster children who exit foster care

each year go to adoption (about 55,000/year)

About half (56%) of all children who are adopted are adopted by 5 years of age

66% of adoptive families have a 2 parent family

• 28% are single females

66% are non-relatives

Time to Adoption As many as 50% of all infants placed into

foster care may, ultimately, be adopted Adoptions take a long time—only 29% of

children who are adopted achieve that status within 2 years of entering foster care

Once children are legally free about half of them have a finalized adoption in the next year

4 years is a good estimate of the time from foster care placement to adoption for those who are adopted

5

Adoption Outcomesa. Continuing without clinical intervention (Only 9% of parents report no

MH use since adoption for children 8 or older, NSAP, unweighted)b. Continuing with use of (or need for) clinical intervention (91%)c. Disruption prior to finalization/legalization [never leaves foster care] About 11% over 3-5 yearsd. Dissolution/set aside after finalization/legalization [returns to CWA

custody] About 5% over 3-5 yearse. Displacement [moves to another setting but does not return to

custody of CWA] 15% of children 8 & older have lived away (2 wks) (NSAP, unweighted)f. Other adverse outcomes (run away, move to other kind of custody

[juvenile services or mental health] ????g. Disruption/Dissolution/Displacement/Other (c through f, called

“disruption” for short) About 20% over 10 years (my slightly educated guess)h. Adverse Adoption Outcomes (c through f, unduplicated) ????

6

Child and Family Risk Factors for Adoption Disruption

Older age at time of placement Partial disclosure of information regarding

child’s problems (strengths-based assessments are not enough)

Threatens people, trouble at school, and cruelty to others are indicators of concern

More educated and younger mothers may be more likely to experience disruptions• Rigid or very high expectations for academic

performance and family joining may increase risk7

Child and Family Protective Factors for Adoption Stability (Barth & Berry, 1988)

Younger children Placement of two siblings into home with

no biological children may cut risk Receiving subsidy may increase stability Children with physical handicaps have

reduced risk Sexual abuse, neglect, multiple foster

homes (Simmel, 2007) High Family Sense of Coherence

[Antonovsky] cuts risk (Ji, Brooks, Barth, Kim, 2010)

Expectations that are based on accurate information (Barth,

8

Service Characteristics Associated with Reduced Risk of Disruption

Comprehensive and realistic information about the child (and adoptive family)

Parents participate in group “home study” (peer-to-peer) process

Family receives educational support Family pursues timely adoption preservation

services that are flexible and long-lasting MAPP and PRIDE have shown no effect

• Yet the value of this approach has become canon

THERE HAVE GOT TO BE MORE!9

What Are Adoptive Family Selection And Preparation Processes?

10

Home Studies & Parent Preparation Purposes

• To educate and prepare foster and adoptive families for child placement

• To gather information about the family for purposes of matching parent capacities and interests to child

• To evaluate the fitness of the family (Children’s Bureau, 2004)

Process• Training (MAPP, PRIDE); individual and joint interviews;

home visits; health documentation; financial information; criminal background checks; references

No evidence of impact on outcomes

• Wide variability across agencies and jurisdictions• Little research over the last 30 years (Crea et al., 2007)

11

Adoptive Family Selection & Matching Adoptive parents are not rigorously screened

• No standardized home study• Many home studies fail to ask hard questions

about alcohol, violence, pornography, juvenile services history (not as rule outs but as conditions needing evidence of mitigation)

• There is no demonstration of parenting Matching of children’s needs with family

strengths and capacities is very informal and often based only on availability of parent and overt characteristics such as county they live in or parent and child race

12

Adoptive Family Preparation

MAPP and PRIDE adoptive and foster care preparation programs have vast reach but no evinced effectiveness• Mixed Goals

Recruit Screen Prepare

• Very Attachment Based• No application after child arrives in

home13

Increasing Effectiveness of “Intake” What needs to be done to add

effectiveness to:• Standardized home studies that actually

screen families while also looking to recruit them

• Routine post-adoption services planning based on information that is gathered during home study

• Need some kind of “Family Check-up” at outset of adoption

14

Post-Adoption Processes

Conventional procedure is to have 6-months of home visits from adoption agency (about 4 visits) after child is placed into the home that involve some observation and meetings with child(ren) and families

PAS is not well-funded or administered• There is some federal funding but it is not

designated for PAS• Almost no research exists on outcomes 15

Summary: Do Post-Adoption Services Reduce Disruption?

No affirmative clinical trials showing changes in interim benefits or disruption reduction

Yet, there is substantial need for PAS because of:• Behavior problems of adopted children • Inadequacies of Medicaid funded services• Dangerous and extreme methods in use

(e.g., holding therapy)

16

Research Regarding the Path to Adoption Disruption

The Path to Adoption Disruption Inadequate pre-adoption preparation Children fail to meet parent expectations

• Children’s behavior does not improve• Children do not act in ways that parents

view as showing closeness or appreciation

School related distress Injury or harm to birth children or parent Sometimes signaled by subsidy

adjustments in size or location of family• Rarely through abuse & neglect and removal

Pathways to Problems II Poor information prior to and during

adoption Family is unable to obtain needed

educational support Difficulty with child does not decrease with

time (staying the same is not good enough) Family pursues help that is too late or

focuses only on child treatment (rather than family and environmental qualities)

Perceived continued harm to biological children or parents if adoption continues

Length of Time until Dissolution (NC)

The number of days between the final adoption decree and subsequent dissolution

About 50% of these dissolutions occurs within 3 years of finalization of adoption

Post-Adoption Services & Support

CFS: Most Commonly Identified Family Needs

Relationship issues (47%)

Child – self-image (44%)

Birth family grief/loss (42%)

Child-peer/adult relationship (41%)

Child behavior at home (37%)

Prevention--education/info/support (35%)

School related (35%)

Post-Adoption Services & Supports: Types and Effectiveness

Self-help groups Warm-lines Increase subsidies to allow purchase

of services (e.g., residential care) Intensive Adoption Preservation

Services General Adoption Preservation

• Illinois Model• Maine GUIDES• Missouri• Oregon model???

23

Hard to Find Evidence of Impact of PASS

Homebuilders demo in 1980s failed (55% success rate)

Adoption preservation program in IL failed:• Restructured into longer program• Added educational advocate

Maine Adoption Guides failed• Program dominated by attachment

perspective as if adoption needs its own theory of family life 24

25

Missouri Did Better (Berry)

Slightly extended IFPS model (6 to 26 weeks; N=99)• Oldest child in the family at risk of

placement (mean age = 15.3 years)• Services began an average of two months

into the placement 9% disrupted before services began 83% of all the adoptive families were intact six

months later (8% disrupted after services)• Longer services were associated with

better outcomes at 1-year

Summary: Do Post-Adoption Services & Supports Reduce Disruption?

No affirmative clinical trials showing changes in interim benefits or disruption reduction• Disruption is not a well performing DV

Yet, there is substantial need for PASS• Behavior problems of adopted children • Inadequacies of Medicaid funded services• Dangerous and extreme methods in use

(e.g., holding therapy)• High rates of displacement

26

Building on Empirically Based Interventions

Develop empirically-based post-adoption services approaches based on other successful—or very promising--treatments for youth• PMT-O• Project KEEP• Abuse Focused-CBT• TF-CBT• Common Elements Approach of Weisz and

Chorpita

Add adoption sensitivity to improve the engagement of adoptive parents in EBPs: no need to create an entire set of interventions using attachment theory

27

Post-Adoption Competency Training

Examples of Clinical Adoption Competencies• Issues in the adoption triad• Legal issues in adoption• Differences between adoptive and not-

adoptive families• Loss, grief, separation, trauma,

attachment• Genetics, neuroscience, prenatal exposure

to stress and drugs• Openness in adoption• Advocacy 28

Challenges & Opportunities

What challenges (and opportunities) are there for implementing service changes?

29

Challenges & Opportunities The framework for adoption support is

limited• Just starting to do any “extra” licensing home

studies of foster parents (SAFE)• No history of parenting assessment• No history of post-placement Family Check up or

parenting services (beyond minimal checking prior to legalization)

• Adoption workers are not often clinically trained Home study workers are often contract workers

• Federal Safe and Stable Families funds are very limited and mostly used for recruitment 30

CHALLENGES: Post-Adoption Services Have Been Dominated by Attachment

Theories and Therapies Assumes that adopted children are more different

than the same as not-adopted children• Not-adopted children rarely, if ever, get

attachment focused treatments Assumes that the stress and disinhibitory responses

of adopted children are from attachment rather than other contributors (OSLC Investigators & Colleagues have shown otherwise)

Too often assumes that attachment is a practice theory that works across age groups and not a developmental theory for young children.

31

Opportunities Growing recognition of needs of

adoptive families expected from NSAP PP[ACA] may support more mental

health treatment for adoptive families As number of foster children drops the

resources from IVE may be freed to respond to “post-permanency” needs

Adoptive families are strong advocates International post-adoption problems

now getting recognition in State Dept.32

Take Home Points The US does more adoptions than all other

countries combined• More US children are in adoptive homes than in FC

We have a limited sense of the path to adverse adoption outcomes and need to know much more

Adoption interventions have been a disappointment

• Very little science has been applied Improvements in adoption outcomes are likely

to require pre-adoption advances as well as improved PASS

Improving adoption services offer the promise of teaching us about successful approaches to other difficult family problems

33

Partial References Annie E. Casey Foundation. (2003). Creative strategies for financing post-adoption

services. A White Paper. Baltimore, MD: Casey Family Services The Casey Center for Effective Child Welfare Practice.

Barth, R. P. (2002). Outcomes of adoption and what they tell us about designing adoption services. Adoption Quarterly, 6, 45-60.

Barth R. P., & Berry, M. (1988). Adoption and disruption: Rates, risks and resources. New York: Aldine.

Barth, R. P., & Brooks, D. (1997). A longitudinal study of family structure, family size, and adoption outcomes. Adoption Quarterly, 1, 29‑56.

Barth, R. P., & Miller, J. (2001). Building effective post-adoption services: What are the empirical foundations? Family Relations, 49, 447-455.

Barth, R.P., Wildfire, J., Lee, C.K., & Gibbs, D. (2003). Adoption subsidy dynamics. Adoption Quarterly, 7(2), 3-27.

Berry, M., Propp, J., & Martens, P. (2007). The use of intensive family preservation services with adoptive families. Child & Family Social Work, 12(1), 43-53.

Brooks, D. (2000). Outcomes of adoptions from the adoptee’s perspective. Unpublished doctoral dissertation available from the author at University of Southern California, School of Social Work.

Brooks, D. & Barth, R.P. (1999). Adjustment outcomes of adult transracial and inracial adoptees: Effects of race, gender, adoptive family structure, and placement history. American Journal of Orthopsychiatry, 69, 87-102.

Chorpita, B. F., Becker, K. D., & Daleiden, E. L. (2007). Understanding the common elements of evidence-based practice: Misconceptions and clinical examples. Journal of the American Academy of Child and Adolescent Psychiatry, 46(5), 647-652.

Partial References Coakley, J. F., & Berrick, J. D. (2008). Research Review: In a rush to permanency:

preventing adoption disruption. Child & Family Social Work, 13(1), 101-112.Cohen, J. A., Mannarino, A. P., Zhitova, A. C., & Capone, M. E. (2003). Treating child abuse-

related posttraumatic stress and comorbid substance abuse in adolescents. Child Abuse & Neglect, 27(12), 1345-1365.

Foulkes Coakley, J. (2005). Finalized adoption disruption: A family perspective. Unpublished manuscript, University of California at Berkeley.

Gibbs, D., Barth, R. P., & Houts, R. (2005). Family characteristics and dynamics among families receiving post-adoption services. Families in Society, 86, 520-532.

Goerge, R.M., Howard, E.C., Yu, D., Radmosky, S. (1995). Adoption, disruption, and displccement in the child welfare system (1976-1995). Chicago: Chapin Hall Center for Children at the University of Chicago.

Ji, J., Brooks, D., Barth, R. P., & Kim, H. (2010). Beyond preadoptive risk: The impact of adoptive family environment on adopted youth's psychosocial adjustment. American Journal of Orthopsychiatry, 80, 432-442.

Lahti, M., Detgen, A. (2005). Main Adoption Guides Project: Final Evaluation Report. University of Southern Maine.

Smith, S. L., Howard, J. A., Garnier, P. C., & Ryan, S. D. (2006). Where Are We Now?: A Post-ASFA Examination of Adoption Disruption. Adoption Quarterly, 9, 19-44.

Wind, L. H., Brooks, D., & Barth, R. P. (2007). Influences of Risk History and Adoption Preparation on Post-Adoption Services Use in U.S. Adoptions*doi:10.1111/j.1741-3729.2007.00467.x. Family Relations, 56(4), 378-389.