Passed by Congress in early 2018, the Family First Prevention Services Act (Family First) 1 is a major step forward in federal child welfare reform and has the potential to transform the way states provide services to children who are abused or neglected. This installment of Law and the Public’s Health offers an overview of the major provisions of Family First. As states and counties respond to the new incentives and restrictions imposed by the statute, collaboration among researchers, advocates, and policy makers will be needed to ensure that the promise of these reforms translates into meaningful change for children and families. Quality evaluations of new preventive services and changes to institutional care will be important, particularly in the early years of these reforms.
Family First combines 2 policy goals long championed by child welfare stakeholders and advocates: (1) reforming child welfare financing to allow federal dollars to be used for prevention services and (2) limiting federal financial support for placement of children and adolescents in group care. 2 , 3 With the need for child welfare reform becoming even more urgent amid the growing opioid epidemic, there was a strong push to pass the statute in 2016, but it ultimately failed. 4 Then, in early 2018, the bill was added to the Bipartisan Budget Act of 2018—the emergency spending agreement needed to keep the government open amid a budget impasse—and it was signed into law by President Trump on February 9, 2018. 1
Under Family First, federal entitlement funding can—for the first time—be used for services to prevent a child’s entry into the child welfare system. Previously, federal entitlement funding for child welfare services could be used only to fund costs incurred after placement. Family First also imposes substantial limits on federal funding for group care, reflecting the growing consensus among child welfare advocates, researchers, and policy makers that family-based placements provide better support for children and adolescents than group care (eg, group homes, child-serving institutions, and residential treatment facilities). 5 - 8 The statute includes many other provisions designed to support families and improve family-based placements, including development of model licensing standards, additional data collection requirements for children and adolescents placed in group care, and support for adolescents and young adults transitioning out of care. 9
Although some Family First provisions went into effect immediately, the funding for prevention services and the restrictions on group care went into effect on October 1, 2019, and states have the option to delay implementation for up to 2 years. 10 If states delay adoption of the group care restrictions, they must also delay receipt of the new funding for prevention services. States are currently deciding whether to be early adopters of the statute or to opt for additional time.
Family First implements its reforms largely by changing the ways states can use federal funds to finance their child welfare programs. Federal funds comprise fewer than half of the more than $29 billion spent annually on child welfare programs in the United States. 11 The biggest source of federal funds—comprising more than half of all federal child welfare expenditures—is Title IV-E of the Social Security Act, which was created in 1980 to separate federal foster care funding from funding for Aid to Families With Dependent Children (AFDC), the general federal welfare program at the time. 11 , 12 Title IV-E includes several child welfare programs, including the foster care program, adoption and guardianship assistance, and programs to support older adolescents and young adults. 13 The foster care program is the largest category of Title IV-E spending, and it entitles states to uncapped federal reimbursement for a set percentage of the costs expended for the care of “eligible children.” 14
To be considered eligible under the Title IV-E foster care program, children must be removed from their homes, come from families considered to be “needy” according to the 1997 public assistance guidelines, and be placed in an approved foster home or childcare institution, among other requirements. 14 Thus, before Family First, a state could not receive federal IV-E reimbursement if the child remained in the home, with the family receiving in-home preventive services. These services, as well as services for children who did not meet income requirements or who were placed in nonapproved settings, could be paid for only by using state or local dollars or capped federal dollars. A “needy” child placed in a group care or a foster home, on the other hand, could continue to generate federal reimbursement for the full duration of the placement. By opening federal funding for prevention services, while limiting funding for placement in group care, Family First alters this funding landscape, creating new incentives for states and counties.
Because of the numerous provisions in the statute, a full description of all Family First’s provisions is beyond the scope of this article. We focus on the 2 central provisions of the statute for public health: (1) new prevention services funding and (2) restrictions on group care. We also discuss the expansion of supports for adolescents and young adults transitioning out of care.
Foster care statistics from the US Children’s Bureau show that the number of children in foster care has been increasing since 2012, and the provisions in Family First on prevention services are a federal effort to combat this trend. 15 As of October 1, 2019, states, territories, and tribes can access federal Title IV-E funding for eligible prevention services for eligible children, young adults, and families. 10 Notably, these federal contributions are not linked to the AFDC income eligibility requirements, although placement services remain linked to the income eligibility restrictions.
Eligible services and programs include (1) mental health and substance abuse prevention and treatment services by qualified clinicians and (2) in-home parent skill-based programs, including parenting skills training, parent education, and individual and family counseling. Services and programs must be trauma informed and evidence based. 9
The evidence-based criteria for services and programs are modeled after the criteria used in the California Evidence-Based Clearinghouse for Child Welfare (www.cebc4cw.org), but they differ in several ways. For example, the requirement that a program be evaluated using a control requires only the use of a control group rather than a randomized controlled trial. 9 The statute defines 3 categories of evidence-based programs—“promising,” “supported,” and “well-supported” practices—and at least 50% of expenditures must be for prevention services and programs that meet the requirements for “well-supported” practices. Under the statute, to meet any of these categories of evidence-based practices, all of the following must be true:
There is documentation on what the practice consists of and how it is administered.There is no empirical basis or case data suggesting or showing risk of greater harm than benefit to those served.
The overall weight of evidence supports the benefits of the practice. Outcome measures are reliable, valid, and consistently administered. 16The program or service must also have been “found superior to an appropriate comparison practice in achieving improvements on important child and parent outcomes (eg, child safety and well-being, mental health).” 16 On November 30, 2018, the US Department of Health and Human Services released its first guidance on prevention services that meet the evidence-based standards. That guidance reinforced the statute’s requirement that prevention services be provided “in accordance with recognized principles of a trauma-informed approach” but did not further define that term. 17
Eligible recipients for these prevention services include (1) children who are candidates for foster care and/or their parents or kin caregivers and (2) adolescents and young adults in care who are pregnant or parenting. 9 These provisions have the potential to provide enhanced support services to parents in foster care, who often face multiple challenges accessing resources.
States must define for themselves who is a candidate for foster care, and the federal government provides limited guidance on how that term should be interpreted, clarifying only that a child cannot simultaneously be in a foster care placement and be considered a candidate for foster care. 17 Under the language of the statute, a candidate for foster care must be at imminent risk of entering care but, if provided services that prevent entry into foster care, may safely remain at home or with family. 9 A child who is reunified, adopted, or placed with a legal guardian or relative may be considered a candidate if the services or supports provided can be considered efforts to prevent the child’s removal from the home and reentry into foster care.
For each candidate child, the state must document the services or assistance needed, the permanency goal for the child, and how the services being provided are tied to the child’s placement and permanency goal and are trauma informed. Although no maximum is prescribed for the length of time a child may be considered a candidate, a state must document its reason for keeping a child in candidate status for longer than 6 months. Services may be provided for up to 12 months, per candidate episode. These services have no lifetime limit, so children and families are able to access these services more than once. 9
For many years, researchers, child advocates, and an increasing number of state and local policy makers have focused on reducing the number of children in group care and expanding access to family-based placements. 5 - 8 Family First is the first major contribution to this effort at the federal level, restricting federal funding to most group care settings and imposing robust requirements on the group care settings that can continue to receive federal dollars.
Both before and after passage of Family First, Title IV-E funds can be used to fund placements in a “family foster home,” defined as a home with 24-hour care for ≤6 children (with some exceptions) or a “child care institution,” defined as an institution for up to 25 children that is not a detention center. 18 Facilities that house more than 25 children are not eligible for federal Title IV-E reimbursement. Under Family First, a child’s Title IV-E eligibility ends after 2 weeks of placement in a childcare institution. 9 Thus, placements in settings with more than 6 children lasting longer than 2 weeks generally will be ineligible for federal funding once these provisions go into effect.
Family First has several exceptions to this funding restriction to meet the needs of adolescents, young adults, and young persons with special needs. First, Family First permits federal reimbursement for supervised independent living placements for young adults aged ≥18, allowing states that have extended their foster care programs to age 21 to continue to offer developmentally appropriate placements. Family First also exempts group care settings that provide “high-quality residential care and supportive services” to children, adolescents, and young adults who have been or are at risk of being victims of sex trafficking. Specialized settings for pregnant and parenting adolescents and young adults also retain Title IV-E eligibility after the 2-week cutoff. 9
Family First also creates a new placement type—the Qualified Residential Treatment Program (QRTP)—that is not subject to the 2-week cap. 9 QRTPs must be designed to accommodate children with serious emotional or behavioral disorders, use a trauma-informed treatment model, incorporate family members proactively, and provide discharge planning and aftercare, among other requirements. The statute also provides that, before placement in a QRTP, a child must receive an individualized assessment to identify the child’s strengths and needs and to determine whether placement is consistent with the child’s short- and long-term goals. The assessment process must include the child’s family and permanency team, and the placement decision is subject to court approval. In addition, Family First requires ongoing oversight of the child’s placement in a QRTP, with increasing levels of scrutiny the longer a QRTP placement continues. 9
In addition to the 2-year delay option, federal guidance allows states to continue to receive federal money for all children currently placed in eligible group care settings for the duration of that placement, potentially disincentivizing states from shifting children to family-based alternatives. 19 Some advocates who originally opposed the legislation are concerned that important settings in their state’s continuum of care may lose Title IV-E funding under the new restrictions. And unintended consequences, such as pushing more children into the juvenile justice system or encouraging overdiagnosis of behavioral health conditions, are possible. The statute attempts to avoid these potential pitfalls by requiring states to provide an “assurance of nonimpact on the juvenile justice system” and by imposing protocols to prevent inappropriate diagnosis. 9 But policy makers, researchers, and advocates must continue to work together as states implement the statute to ensure these provisions have their intended effect: expanding and strengthening the family-based placements available to children, adolescents, and young adults in foster care.
Family First also directly affects older adolescents and young adults, who are overrepresented in group care, by increasing the capacity of systems to support the successful transition to adulthood through modifications to the Chafee Foster Care Independence Program. Intended to assist young persons who are likely to age out of foster care, the Chafee Program allows states to apply for flexible funding grants to help these young persons with education, employment, financial management, housing, emotional support, and building connections to supportive adults. It also includes an Education and Training Vouchers Program to support the education needs of adolescents and young adults who are aging out of foster care.
Family First modifies these programs in several ways. First, the statute changes the program name to “Chafee Successful Transition to Adulthood,” in recognition that support should be provided to help adolescents transition to adulthood rather than overemphasizing “independence.” 9 Research on adolescent brain development shows that a major developmental window begins in adolescence and continues through young adulthood. 20 This period of growth provides one of the greatest opportunities for the brain to heal from past trauma. Gradual independence and increasing autonomy in a safe, nurturing environment are keys to success. Family First also provides states that have extended foster care programs with the option to extend Chafee supports and services to young adults until age 23 and extends eligibility for Education and Training Vouchers to young adults until age 26. 20 , 21 Recognizing the need for more research on transition outcomes, Family First requires improved data collection of the experiences and outcomes of adolescents and young adults in care. Finally, agencies must provide adolescents and young adults who have aged out of foster care with official documentation showing they were previously in care. 9 This documentation allows young adults to establish eligibility for special categories of benefits targeted at persons formerly in foster care, including Medicaid and financial aid for postsecondary education and training.
Family First mandates important new reforms to the child welfare system, and researchers whose work touches the young persons and families involved in that system should familiarize themselves with these changes. As implementation of the statute continues, child welfare service providers, health care professionals, policy makers, advocates, and other stakeholders must work together to address key issues, such as how to effectively scale up evidence-based practices, strategies for developing a true continuum of family-based alternatives to group care, and ways to avoid unintended consequences, such as expansion of the juvenile justice system. Research and program evaluation will be vital to understanding the success of the statute’s implementation and to ensuring that the promise of its reforms translates into meaningful improvements in the health and well-being of children and families.
The authors thank Jennifer Pokempner for her valuable feedback and contributions to this article.
Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
ORCID iD: Karen U. Lindell, JD https://orcid.org/0000-0002-8424-7689
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