Improving Treatment for Drug-Exposed Infants
Treatment Improvement Protocol (TIP) Series 5

Assuring the Quality of Services For Infants in Foster Care

Quality assurance standards for child protective services, foster care agencies, and foster parents are important to ensure adequate and appropriate levels of care for drug-exposed infants in foster care. Standards of practice must be reviewed and updated on a regular basis.

Such quality assurance standards should include but not be limited to:

1. Caseload limits - In the current era of escalating social service needs and shrinking budgets, child welfare workers are often forced to handle ever increasing and complex caseloads, prohibiting the provision of effective child protective services. Administrators and service providers working with drug-exposed infants and their families should be familiar with public and private child welfare standards, which seek to address quality assurance issues such as caseload size. Both the private and public sectors are involved in the establishment of standards or goals for practice in the field of child welfare services. For example, the Child Welfare League of America (CWLA) develops and publishes child welfare standards to be used in planning, organizing, administering, and improving services; in establishing State and local licensing requirements; and in determining the requirements for accreditation. These standards include the development of recommended caseload and workload ratios for different types of services. (For example, in the area of child protective services needed for abused or neglected children and their families, CWLA standards describe the recommended number of active and new cases per month per social worker and the recommended ratio of supervisors per social worker.) Licensing provides basic protection for the well-being and protection of children. Through the licensing of child-placing agencies, residential group care facilities, foster family homes, and child day care facilities, States exercise their power to protect children.³
2. Number of infants or children per foster home - Child welfare agencies establish standards regarding the maximum number of high-risk infants to be placed in a foster home or residential facility. Drug-exposed infants in need of placement should be assessed to determine the intensity of services required to adequately care for the child. Due to inadequate staffing of child welfare agencies, established standards are not always followed and placement assessments are not always accurate. Programs serving drug-exposed infants should work closely with the child welfare agency to help guarantee that an appropriate foster care placement has been made.
3. Recruitment and training of foster parents - Agencies should be able to show evidence of ongoing recruitment of foster parents willing to accept drug-exposed infants. Prospective foster parents should receive special training concerning unique needs of drug-exposed infants. Training will also be needed regarding HIV infection and drug-exposed infants.⁴
4. Interagency agreements - Foster care agencies should develop memoranda of agreement with other service agencies to coordinate and avoid duplication of services to drug-exposed infants and children. These agencies should hold quarterly meetings to review existing standards, resolve problems, and recommend changes. Within the consortium of agencies, a single agency should be assigned responsibility for quality assurance compliance.
5. Foster parent review - The case plan of a drug-exposed infant placed in foster care should be reviewed every 6 months, with a mandatory home visit within the first month of foster care.
6. Cultural issues - Extensive efforts should be made to recruit foster parents from the same racial and cultural backgrounds as the infant. Effective efforts in this arena usually require extensive engagement with the community in the recruitment process. For example, ongoing or periodic foster home recruitment campaigns can be launched in coordination with local churches, sororities and fraternities, the media, civic organizations, and other grass-roots organizations familiar with the cultural nuances within the community. Many such organizations are eager to help recruit foster homes from the same racial or cultural background as the infant in need of placement. However, in addition to extensive community-based recruitment campaigns, consideration might be given to relaxing regulations that require placement of infants with parents from the same racial background. Such measures should be considered only when other efforts have failed to ensure the placement of drug-exposed infants in qualified foster homes. Such foster parents should receive initial and ongoing training around the need to understand and respect the racial and cultural background of the infant.
7. Followup surveys of client satisfaction - Followup surveys should be conducted with the biological parent(s), the foster parents, and the coordinating agencies to determine their satisfaction with the process and any recommendations for improvement.
8. EAPs for professional and volunteer workers - Employee assistance program components should be mandated and integrated into all agencies involved in child placement and foster care services. This will provide treatment and counseling services to caseworkers and other service providers who may themselves be substance users or abusers.
9. Professional attitudes and behavior - All professionals working with drug-exposed infants and their mothers and families should examine their own knowledge, attitudes, and behaviors regarding use of drugs, alcohol, and tobacco and should receive ongoing training on these subjects.
10. Stress management - Stress management training must be provided to workers involved in the care of drug-exposed infants and their families. Likewise, sensitivity training should be provided to caseworkers concerning their attitudes and behavior toward drug-using women so that a nonpunitive, supportive approach is maintained. Foster parents with drug-exposed infants also need stress management and sensitivity training. Whenever possible, such programs should be provided for these caretakers.