Improving Child Welfare Outcomes

Balancing Investments in Prevention and Treatment

by Jeanne S. Ringel, Dana Schultz, Joshua Mendelsohn, Stephanie Brooks Holliday, Katharine Sieck, Ifeanyi Edochie, Lauren Davis

This Article

RAND Health Quarterly, 2018; 7(4):4

Abstract

To provide objective analyses about the effects of prevention and treatment programs on child welfare outcomes, RAND researchers built a quantitative model that simulated how children enter and flow through the nation's child welfare system. They then used the model to project how different policy options (preventive services, family preservation treatment efforts, kinship care treatment efforts, and a policy package that combined preventive services and kinship care) would affect a child's pathway through the system, costs, and outcomes in early adulthood. This study is the first attempt to integrate maltreatment risk, detection, pathways through the system, and consequences in a comprehensive quantitative model that can be used to simulate the impact of policy changes. This research suggests that expanding both prevention and treatment is needed to achieve the desired policy objectives: Combining options that intervene at different points in the system and increasing both prevention and treatment generates stronger effects than would any single option. The simulation model identifies ways to increase both targeted prevention and treatment while achieving multiple objectives: reducing maltreatment and the number of children entering the system, improving a child's experience moving through the system, and improving outcomes in young adulthood. These objectives can all be met while also reducing total child welfare system costs. A policy package combining expanded prevention and kinship supports pays for itself: There is a net cost reduction in the range of 3 to 7 percent of total spending (or approximately $5.2 billion to $10.5 billion saved against the current baseline of $155.9 billion) for a cohort of children born over a five-year period.

For more information, see RAND RR-1775-1-APFF at https://www.rand.org/pubs/research_reports/RR1775-1.html

Full Text

Every year, nearly 3 million children in the United States are maltreated (Sedlak et al., 2010). The child welfare system is intended to help them and their families by providing services to achieve safety, stability, and permanency for the child. But contact with the system itself can have negative consequences, disrupting families. The effects of maltreatment combined with experiences in the system can persist into young adulthood, manifested in numerous ways, including homelessness, underemployment, criminal conviction, and substance abuse. Overall societal costs associated with child maltreatment may total $80 billion annually (Gelles and Perlman, 2012).

There is broad consensus that the child welfare system and outcomes for the children it serves can be improved. It is also generally acknowledged that success will require action on multiple fronts, including both treatment and prevention.

The child welfare system is a complex network of organizations at the federal, state, and community levels. In 2014, the system spent more than $29 billion on child maltreatment prevention and child welfare services nationwide (Rosinsky and Connelly, 2016). Nearly half of the funds came from federal sources, primarily through Titles IV-B and IV-E of the Social Security Act; the remainder comes from a mix of state and local funding. This total likely does not include funding for all child maltreatment preventive services.

Under current policy, federal funds are primarily available after maltreatment is substantiated (meaning that the investigation concluded that the reported maltreatment did occur) to support such treatment services as foster care, adoption assistance, and kinship support. There has long been concern among state officials and child welfare advocates that this policy favors treatment over prevention. To address this issue, some states have obtained waivers to use some portion of federal funds for preventive services. The federal government has also dedicated resources to child maltreatment prevention and its evaluation through the Maternal, Infant, and Early Childhood Home Visiting state formula grant program. But the effects of increasing only prevention, only treatment, or both prevention and treatment are not well understood.

Our study results suggest that expanding both prevention and treatment is needed to achieve the desired policy objectives. In the simulation model we developed, when increases to targeted preventive and kinship care treatment services are pursued together, all of the policy objectives are met: Maltreatment and the number of children entering the system are reduced, children's experiences moving through the system are improved, outcomes in young adulthood are improved, and total lifetime expenditures on preventive and child welfare system services are reduced.

Specifically, we found that combining expanded prevention and treatment in the form of support for kinship care leads to a net cost reduction in the range of 3 to 7 percent of total spending (or approximately $5.2 billion to $10.5 billion saved against the current baseline of $155.9 billion) for a cohort of children born over a five-year period.

Individually, none of the policies we considered achieves the full set of policy objectives. Increases in prevention lead to decreases in maltreatment and improvements in young adult outcomes but do not affect the experiences of children who enter the system and result in small additional costs. Increases in treatment lead to improvements in system experience and outcomes and reduce lifetime costs but do not reduce maltreatment. It is only when increases to prevention and treatment are implemented together that all of the policy objectives are achieved. It is not necessarily unexpected that this approach would generate reductions in maltreatment, improvements in system experience, and improvements in outcomes. What we learned from the simulation model was that this approach would result in a net cost savings. Our results suggest that these improvements can be achieved with lower lifetime costs for the cohort.

What We Did

We built a quantitative model that simulated how children enter and flow through the nation's child welfare system. We then used this initial model to project how national policies affect a child's pathway through the system, costs, and outcomes in early adulthood. There are many studies that address prevention, elements of the child welfare system, or subpopulations of children or families. However, ours is the first attempt to integrate maltreatment risk, detection, pathways through the system, and consequences in a comprehensive quantitative model that can be used to simulate the potential impact of policy changes.

The model provides a simplified representation of the child welfare system, which is extremely complicated. To do so requires many assumptions. In many cases, the literature and available data do not provide as much information as would be ideal, and there is certainly room for reasonable disagreement about the assumptions we have made. We have tried to mitigate this problem in two ways. First, we have tried to find the best available data and evidence on which to build the assumptions. Second, we have tried to be very transparent, describing our methods in detail in Appendix B (available on the project website at www.rand.org/child-welfare-model), so that readers can assess the assumptions themselves. The research team plans to continue refining and building on this initial model to explore additional questions and policy options and integrate new and emerging evidence into the assumptions.

Focus of the Model

The model we developed simulates maltreatment and its detection; describes the movement of children through the system; estimates the costs to federal, state, and local governments of providing child maltreatment preventive and child welfare services; and estimates how maltreatment and contact with the child welfare system affect outcomes in young adulthood. We calibrated the model to reflect the observed data on lifetime rates of experiencing the different events in the model (e.g., maltreatment, referral to the system, placement in foster home). The baseline model, therefore, is intended to represent the current situation. We then used the model to assess the average effects relative to baseline of implementing several different policy, program, or practice changes in jurisdictions across the nation.

Our model estimates lifetime maltreatment and/or involvement with the child welfare system from birth to age 18 of the cohort of children born between 2010 and 2015 (23,891,281 children). We pooled information from administrative data, survey data, agency reports, and research statistics to estimate the probabilities that children experience different events (for example, maltreatment, referral to the child welfare system, temporary foster care placement). We used these data to simulate the childhood experiences for the cohort through age 18 and for several outcomes in young adulthood (ages 23–25).

The model is built with national-level data, which offer an extensive breadth of information but also entail some limitations. In particular, national data aggregate across diverse states and suffer from state-to-state differences in data quality, completeness, and definitions of the underlying data sets (Green et al., 2015). Also, for some key life events, the national data are not longitudinal. The result is a model that estimates the average effect of implementing the policy in all jurisdictions across the country. To simulate the effect for a particular state or locale, the model assumptions and data would need to be changed to better reflect the population and system in the specific jurisdiction. Under some circumstances, such a model might produce results that are larger, smaller, or in a different direction than the results of the national model.

Where Should Efforts to Improve the System Focus?

To determine where policies might focus to achieve maximum effect in the system, we simulated the effect of increasing the quantity and quality of three policy options focused on different decision points in the model:

  • preventive services designed to prevent child maltreatment from occurring so that children do not enter the system
  • family preservation treatment efforts designed to provide services and supports (for example, substance abuse treatment for parents) so that children can remain with their parents
  • kinship care treatment efforts designed to increase temporary placement with kin and to support kin caregivers so that children find permanent placements with them.

We also assessed the effects of a policy package that combined increases in preventive services and kinship care.

These evidence-based options reflect two major debates in child welfare: (1) whether the focus should be on preventing maltreatment or responding once maltreatment occurs and (2) for families involved with the child welfare system, whether to emphasize in-home options or out-of-home placements.

What Effects Do Individual Policies Have?

To understand the effects of individual policies, we estimated how the quantity and quality of preventive services, family preservation efforts, and kinship care affect the number of children who are maltreated, their experience with the child welfare system, outcomes in young adulthood, and system costs. Increasing the quantity of services provided is relatively straightforward to implement with increased funding. Increasing the quality, however, may be more difficult, and the specific actions required may vary across jurisdictions. As such, the quality improvements may be viewed as more aspirational, providing a sense of what is possible if best practices were implemented across all jurisdictions. Consequently, below we summarize the results with a range for each policy option. The lower end of the range is the estimate of the effect of increasing the quantity of services, while the upper end of the range is the estimate of the effect if both quantity and quality are increased. The results we report are all in reference to the baseline—that is, the existing system.

Prevention

Model results illustrate the range of benefits associated with investing in preventive services. Prevention focuses on reaching children and their caregivers before they enter the system and preventing maltreatment from occurring. Consequently, of the options considered, prevention has the broadest systemwide impact: Across the range from only quantity to both quantity and quality, it reduces maltreatment episodes (−1.4 to −4.2 percent), the number of referrals to the child welfare system (−0.2 to −0.6 percent), and, ultimately, the number of substantiated cases being served by the child welfare system (−1.1 to −3.4 percent).

Moreover, reducing maltreatment and the resulting involvement with the child welfare system translates into improved outcomes in young adulthood for all four of the outcomes we considered:

  • substance abuse (−1.2 to −3.6 percent)
  • underemployment (−1.1 to −3.4 percent)
  • homelessness (−1.2 to −3.5 percent)
  • criminal conviction (−1.2 to −3.6 percent).

These outcomes, however, represent only a subset of those that prior research has indicated are related to maltreatment and child welfare system involvement (Avery and Freundlich, 2009). Reducing maltreatment might be expected to produce other benefits for children not captured here, such as improved mental and physical health outcomes (Ahrens, Garrison, and Courtney, 2014; Kessler et al., 2008; Pecora et al., 2009) and increased educational attainment (Mersky and Janczewski, 2013; Courtney et al., 2009).

Preventive services may have other short-term benefits that are not considered in the model. Programs that we use as the basis for the targeted preventive services in the model, such as the Nurse-Family Partnership, have been shown to have a number of positive benefits for children and families beyond reducing the likelihood of maltreatment (Olds, 2006). These benefits include improved infant and child health and development and maternal outcomes, such as fewer subsequent pregnancies, greater workforce participation, and less reliance on public assistance.

Increasing preventive services requires new expenditures to provide services to more children and families—a 45-percent increase for both the increased quantity scenario and the increased quantity and quality scenario. We assume that quality increases can be achieved by reallocating existing resources to implement best practices. The increase in spending for increased services is partially offset by reductions in spending on screenings, investigations, services, and temporary placements as fewer children flow through the system (−1 to −3 percent). The net increase is 1 to 3 percent of total spending in the status quo, depending on whether only quantity increased or both quantity and quality increased.

The cost estimates, however, only capture the direct costs of the child welfare system paid by the government and do not reflect any government cost savings that occur in related areas, such as the criminal justice system, physical and mental health care, social services, and education. Because we did not include potential cost savings in other related systems, the cost reductions estimated in the model are conservative and should be considered in combination with prior evidence on the indirect costs of child abuse and neglect (for example, Gelles and Perlman, 2012; The Perryman Group, 2014; Fang et al., 2012).

Treatment: Family Preservation

The option to increase family preservation services focuses on families already involved in the child welfare system. As a result, it does not have a significant impact on the rate of maltreatment or the number of children entering the child welfare system. Rather, it affects the paths that children take through the system, where they ultimately end up, and their likelihood of reentering the system. The family preservation option provides services and supports for families, increasing the likelihood that they are able to stay together and that the child will avoid subsequent maltreatment. Under this option, the changes to the pathways through the system take the form of increases in the likelihood of children remaining with their family and, when an out-of-home placement is needed, increases in the likelihood of reunification with family as a permanent outcome.

In most cases, these changes in system experience translate into better outcomes in young adulthood, due in part to such factors as the effects of the services provided and fewer disruptions associated with out-of-home placements. Specifically, family preservation efforts led to changes in the young adult outcomes, with the largest changes when both quantity and quality of the policy were increased. The effects ranged from 0.4 to −9.8 percent for substance abuse, from −3.6 to −11.2 percent for criminal conviction, from −2.0 to −8.6 percent for homelessness, and from 0.2 to −3.9 percent for underemployment, depending on the scenario.

Cost savings also accrue under the family preservation option. In-home care is less expensive per month than out-of-home placements, and the average duration in care for children who remain with or reunify with family is shorter than for children who have other permanency outcomes. Together, these factors more than offset the increased costs associated with providing family preservation services and lead to substantial cost savings (ranging between a 9- and a 13-percent decrease in total spending, depending on the scenario) for the family preservation option.

Treatment: Kinship Care

Support for kinship placements as a form of treatment within the child welfare system focuses on children and families when it has already been determined that an out-of-home placement is necessary. As a result, this option does not affect the number of children initially entering the system. Rather, for children who require a temporary out-of-home placement, the option seeks to increase the proportion placed with kin and provides services and supports to the kin caregivers. The ultimate goal is to decrease the amount of time a child spends in care and increase the child's chances of returning to the family. The increases in temporary kinship care and permanency outcomes with kin lead to small improvements in outcomes in young adulthood for substance abuse (−1.1 to −2 percent), criminal conviction (−2.1 to −2.9 percent), homelessness (−1.6 to −2.2 percent), and underemployment (−0.4 to −1.8 percent), depending on the scenario (quantity increased or both quantity and quality increased).

In addition, the kinship care option generates cost savings, largely because kinship care placements are less costly than other types of out-of-home placement. That cost savings is enough to offset the increased expenditures on services and supports to promote kinship care, leading to a decrease in total costs in the range of 6 to 7 percent, relative to the baseline.

The Effects of Combining Options

Improving the child welfare system has multiple objectives, and national-level policy proposals typically combine multiple options in one proposal as a way to satisfy multiple goals—for example, the number of children who are maltreated should be reduced; the children who are maltreated need to be identified and protected; and the effects of maltreatment on their well-being need to be mitigated in the short and long term—all while maintaining or reducing overall costs. None of the individual options that we considered achieves all these objectives.

We estimated the effect of a policy package that combined increases in preventive services and treatment in the form of support for kinship care. The results are summarized as a range for this combined policy option—from a lower end of the range when the quantity of services is increased for both preventive services and kinship care to the upper end of the range when both quantity and quality are increased. Under this option, we found that maltreatment episodes decrease by 1.5 to 4.1 percent. As a result, referrals to the child welfare system also decrease (−0.2 to −0.6 percent). There are fewer substantiated cases (−1.3 to −3.3 percent) and out-of-home placements (−8.3 to −11.2 percent).

The experience of children who do enter the system is improved because more children had temporary and permanent placements with kin. There is a reduction in the likelihood of negative long-term outcomes:

  • homelessness (−2.8 to −5.8 percent)
  • underemployment (−1.6 to −5.2 percent)
  • criminal conviction (−3.3 to −6.4 percent)
  • substance abuse (−2.3 to −5.6 percent).

The policy package combining increases to prevention and kinship care pays for itself; there is a net cost reduction of between 3 and 7 percent of total baseline spending, for a savings of approximately $5.2 billion to $10.5 billion, depending on whether only quantity is increased or both quantity and quality are increased. Underlying this net reduction, prevention spending increases by about 45 to 47 percent, but costs are offset by a reduction of 7 to 11 percent in system spending.

Detailed results from our simulations of all three policies individually and for the policy package are available on the project website (www.rand.org/child-welfare-model).

Preventive services address root causes. Generally, options that address risk factors and root causes have the potential for the largest population-level impact and are the only ones that can affect the number of children who are maltreated. Among the policy options considered here, prevention is the only one in this category. Preventive services reduce the number of children who are maltreated, and that is the driving force in this option for improved outcomes in young adulthood. But prevention does not affect the experience of children in the system and also increases total expenditures on preventive and child welfare system services.

Treatments like family preservation and kinship care have positive effects. Efforts to help families stay together and encourage kinship care are very targeted, affecting only children who are involved in the child welfare system. As a result, their potential impact on outcomes is more limited because they potentially impact fewer children. Nonetheless, these options have important effects on the experience of those children who are in the system and their outcomes in young adulthood. Family preservation and kinship care efforts also lead to reductions in the overall cost of the system because they promote placements that are less costly than the other options (foster care or residential care). They have little effect, however, on the number of children who are maltreated.

Therefore, our results suggest that a combination of policies that incorporate additional preventive services and improvements in the experience of children in the system is needed to achieve all of the desired policy objectives. That is, combining increases in preventive services and treatment in the form of support for kinship care can reduce child maltreatment, improve a child's experience moving through the system, positively affect outcomes in young adulthood, and reduce total system costs.

Limitations

Our approach has several limitations. The model provides a simplified representation of the child welfare system, which is extremely complicated. To do so requires many assumptions. In many cases, the available data and literature do not provide as much information as would be ideal to inform those assumptions. For example, there is no one data source that tracks all children through the child welfare system over time. Rather, we have pieced together information from a wide range of sources that do not always perfectly align (e.g., different populations, different definitions). In other cases, we have made simplifying assumptions to make the model more tractable. For example, we did not consider interactions with other relevant systems, such as education, health care, or criminal justice.

More generally, the model is built at the national level, reflecting common elements of state systems that differ widely. As such, the results represent a macro-level simulation of how children enter and flow through the system and may not be replicable at the state and local levels without tailoring the model inputs to the specific context to determine the magnitude and direction of the effects. While building a national model was a reasonable starting point and provides information relevant to national policymakers, it does abstract from the important differences across states, such as how preventive services are provided, how the child welfare system is structured, and the characteristics of the population served. Decisions about specific policies to implement are made at the state and local levels, so a jurisdiction-specific model is likely more valuable for informing specific policy decisions. Adapting the model to specific jurisdictions would allow a number of important improvements, including more-specific information on pathways through the system; better data on children's experiences in the system; and information on how the child welfare system interacts with other related systems, such as education or criminal justice.

Conclusion

Despite the challenges and limitations, we believe that the simulation model and results will be useful to national policymakers interested in improving individual and child welfare system outcomes through changes in policy, practice, or programs. While there are many studies that address elements of the child welfare system or subpopulations of children or families, this is the first attempt to integrate maltreatment risk, detection, pathways through the system, and consequences in a comprehensive quantitative model that can be used to simulate the potential impact of policy changes. The estimates presented here provide policymakers with a sense of the relative costs and benefits of increasing different options individually or in combination that can inform the policy debate.

Given the number of assumptions and the limited evidence base on which to build, there is some uncertainty around the estimates presented here. We have done numerous sensitivity tests, and while the estimates of the effects of the policy options on the different elements of the pathway (e.g., maltreatment, referrals to the system, average number of out-of-home placements, young adult outcomes, costs) do vary, sometimes considerably, the overarching pattern of results and the basic story they tell is robust—a combination of increased prevention and treatment is needed to achieve all of the desired policy objectives: reducing maltreatment, improving children's experiences in the system, improving outcomes, and reducing expenditures.

References

Ahrens, K. R., M. M. Garrison, and M. E. Courtney, "Health Outcomes in Young Adults from Foster Care and Economically Diverse Backgrounds," Pediatrics, Vol. 134 (No. 6), 2014, pp. 1067–1074.

Avery, Rosemary J., and Madelyn Freundlich, "You’re All Grown Up Now: Termination of Foster Care Support at Age 18," Journal of Adolescence, Vol. 32 (No. 2), 2009, pp. 247–257.

Courtney, M., A. Dworsky, J. Lee, and M. Raap, "Midwest Evaluation of the Adult Functioning of Former Foster Youth: Outcomes at Age 23 and 24," Chicago, Ill.: Chapin Hall at the University of Chicago, 2009.

Fang, X., D. S. Brown, C. S. Florence, and J. A. Mercy, "The Economic Burden of Child Maltreatment in the United States and Implications for Prevention," Child Abuse and Neglect, Vol. 36 (No. 2), 2012, pp. 156–165.

Gelles, Richard J., and Staci Perlman, Estimated Annual Cost of Child Abuse and Neglect, Chicago, Ill.: Prevent Child Abuse America, 2012.

Green, B. L., C. Ayoub, J. D. Bartlett, C. Furrer, A. Von Ende, R. Chazan-Cohen, J. Klevens, and P. Nygren, "It’s Not as Simple as It Sounds: Problems and Solutions in Accessing and Using Administrative Child Welfare Data for Evaluating the Impact of Early Childhood Interventions," Children and Youth Services Review, Vol. 57, 2015, pp. 40–49.

Kessler, R. C., P. J. Pecora, J. Williams, E. Hiripi, K. O'Brien, D. English, J. White, R. Zerbe, A. C. Downs, R. Plotnick, I. Hwang, and N. A. Sampson, "Effects of Enhanced Foster Care on the Long-Term Physical and Mental Health of Foster Care Alumni," Archives of General Psychiatry, Vol. 65 (No. 6), 2008, pp. 625–633.

Mersky, J., and C. Janczewski, "Adult Well-Being of Foster Care Alumni: Comparisons to Other Child Welfare Recipients and a Non-Child Welfare Sample in a High-Risk, Urban Setting," Children and Youth Services Review, Vol. 35 (No. 3), 2013, pp. 367–376.

Olds, D. L., "The Nurse–Family Partnership: An Evidence-Based Preventive Intervention," Infant Mental Health Journal, Vol. 27 (No. 1), 2006, pp. 5–25.

Pecora, Peter J., Catherine Roller White, Lovie J. Jackson, and Tamera Wiggins, "Mental Health of Current and Former Recipients of Foster Care: A Review of Recent Studies in the USA," Child & Family Social Work, Vol. 14 (No. 2), 2009, pp. 132–146.

The Perryman Group, Suffer the Little Children: An Assessment of the Economic Cost of Child Maltreatment, Waco, TX, November 2014. As of April 14, 2017:
https://www.perrymangroup.com/wp-content/uploads/Perryman_Child_Maltreatment_Report.pdf

Rosinsky, K., and D. D. Connelly, Child Welfare Financing SFY 2014: A Survey of Federal, State, and Local Expenditures, Bethesda, Md.: Child Trends, 2016. As of November 6, 2017:
https://www.childtrends.org/publications/child-welfare-financing-sfy-2014-a-survey-of-federal-state-and-local-expenditures/

Sedlak, A. J., J. Mettenburg, M. Basena, I. Petta, K. McPherson, A. Greene, and S. Li, Fourth National Incidence Study of Child Abuse and Neglect (NIS–4): Report to Congress, Washington, D.C.: U.S. Department of Health and Human Services, Administration for Children and Families, 2010.

This research was funded by Pritzker Foster Care Initiative and conducted jointly under the auspices of four units at the RAND Corporation: Health; Labor and Population; Education; and Justice, Infrastructure, and Environment.

RAND Health Quarterly is produced by the RAND Corporation. ISSN 2162-8254.