Policy and Practice Issues for Adoption and Foster Care of HIV-Infected Children
The National Adoption Information Clearinghouse (NAIC) published the factsheet "Adoption and Foster Care of Children with AIDS: An Analysis of State Policies" in 1989. Because of the rapidly expanding knowledge base in this area of child welfare practice during the last few years, NAIC undertook a second policy collection in 1991. In this factsheet, we present a summary of the original study as well as recommendations for practices, resources, and reference materials.
In the mid-1980's, a shift took place in the populations most often affected by HIV-related disease. The number of AIDS diagnoses in the homosexual community was decreasing, and new infections were most often appearing in heterosexual men, women, and children. As of June 1991, women accounted for 10 percent of all AIDS cases, and the incidence of AIDS in young people had doubled since 1989.
Many women do not realize they are infected with HIV until they give birth to a child who tests HIV+. Most often, they contracted the virus from their husbands or long-term partners. Chemical dependence, unemployment, isolation, and poverty
often compound the challenges of HIV-related disease for these families. Persons of color are disproportionately represented in the numbers of AIDS cases, particularly among women and children.
The implications for child welfare practice are enormous. Many children who are diagnosed with AIDS will also have parents who are sick or dying. Because of the stigma associated with AIDS, not all of these parents will be able to discuss permanency plans for their children with extended family members in an open manner. Workers may find themselves needing to place an HIV+ child in a foster or adoptive home with no official guidance regarding who is allowed to be told confidential health information. Existing agency policy may need to be modified to accommodate new situations that arise as more HIV+ children are identified in the child welfare system.
Many States have already developed specific policies to address the unique circumstances of HIV+ children in the public sector. This factsheet will discuss both the content of these policies and their implications for practice. What We Know About HIV
In order to truly appreciate the complexity of issues that HIV+ children bring into the child welfare system, it is important to understand the virus and its effects. First and foremost, HIV is a difficult virus to transmit. It is described as a fragile virus and is easily destroyed by household bleach. Direct contact with blood, semen, vaginal secretions, and/or breast milk is the only way the virus can be passed. There is no proven risk of transmission from saliva, tears, urine, fecal matter, vomit, nasal secretions, or casual contact with persons with AIDS.
Being HIV+ is different from having AIDS. Being positive simply means that an individual has the virus in his or her system. It does not mean that person is sick. Infected individuals can, however, transmit the virus to others by engaging in high-risk behaviors such as unprotected sex, sharing of needles, or breast feeding a child. A diagnosis of full-blown AIDS, acquired immune deficiency syndrome, is only given when a constellation of symptoms are present that fit the criteria developed by the Centers for Disease Control. These include the presence of opportunistic infections, such as pneumocystis carinii pneumonia (PCP) and Kaposi's sarcoma (KS). ■HIV-related disease■ is a term used to describe symptoms that occur as a result of the presence of HIV, up to and including full- blown AIDS.
HIV has a particular affinity for CD4 cells, the part of our immune system that protects us from infection. A reduction in the number of these cells per cubic millimeter of blood can be the first indication of serious complications resulting from HIV infection. Measuring the number of CD4 cells has also proven helpful in more accurately diagnosing children because it provides an accurate assessment of the child's immune system, not simply a reflection of the mother's health status. It can be used as a ■marker■ in children as young as 3 months of age to determine when to begin treatment with drugs such as AZT.
Two-thirds of the children who test HIV+ at birth with conventional testing methods (ELISA and Western blot) will seroconvert (test HIV-) before they are 2 years old. A child's immune system is not fully developed during these years, and conventional tests will not provide reliable information about the child's health. Many medical centers are now using CD4 levels in addition to HIV tests to obtain more accurate information about the HIV status of infants.
Medical intervention for AIDS is now available to pregnant women, infants, and young children through licensed drugs such as AZT and DDI and through clinical trials, which test newly developed treatments on human beings. Early intervention has improved the quality of life for many children and also increased their life expectancies. This phenomenon has caused many to recommend HIV testing in all cases where infection is suspected.Implications for Child Welfare
Because of the known routes of transmission of HIV, foster and adoptive parents of an HIV+ child who is part of the child welfare system can feel secure that the child poses no risk to them if they practice ■universal precautions■ when dealing with blood and other bodily fluids. These measures, which include wearing latex gloves, provide barrier protection against viral transmission and should be used with all children whose HIV status is not known, in the particular circumstances described. This is important information to communicate and reinforce throughout the foster and adoptive parent
recruitment and training process.
The ability to determine a child's true HIV status before the age of 24 months by measuring numbers of CD4 cells will also be helpful in expediting permanent placement. Potential foster and adoptive parents will have more accurate information about the child's health, and can make informed decisions regarding their commitment. Successful programs, such as the one at Leake and Watts in Yonkers, New York, which assigns both a social worker
and a nurse to each family caring for an HIV+ child, can provide models for other child welfare professionals to refer to when designing programs in their own service areas.
Permanency issues can be addressed with HIV+ children in the same ways as with other groups of children with special needs. Adequate supports need to be available to keep the child with the birth family whenever possible. In cases where the birth parents are unable to care for the child, adoptive placement with extended family is the next best option. When this is not possible, recruited adoption is a better plan than long-term foster care.
In determining the best placement for an HIV+ child, a number of practice issues take on special significance and must be revisited. The amount of openness between birth parents, adoptive parents, and adoptees; confidentiality/disclosure of health-related information; availability of community supports/resources; characteristics of successful adoptive/foster parents; and timeframes within which work must be completed are all made more complex by the overlay of HIV. Many States have addressed these concerns in their HIV-related policies. Massachusetts Adoption Resource Exchange (MARE) Policy Analysis--1989
Beginning in 1987, MARE conducted academic and library research as well as an informal survey of all 50 States regarding policy development for children with AIDS in need of out-of- home placement. MARE contacted each State to learn if policies on adoption and foster care of children with AIDS had been formulated, as well as to learn from State personnel which policy development issues were of primary concern to them. At that time, 17 States had policies, 18 were in the process of formulating them, and 15 had no policies and were not developing any.
MARE asked that States forward their policies for review and received 20 policies for analysis: 8 draft and 12 final versions. Sixteen were formulated by social service departments, one by a public health department, two by both public health and social service departments, and one by an interdisciplinary task force. Twelve of the twenty policies focused almost solely on foster care, eight focused on foster care and had varying degrees of information about adoption, and none focused solely on adoption.
MARE divided policies into three groups or levels. In general, LEVEL ONE policies needed significant additions (in MARE's view) in order to fully handle situations that could arise when a State agency must provide substitute care for HIV+ children. LEVEL TWO policies were considered adequate for the functioning of an agency, but would not necessarily cover all of the situations that could arise. LEVEL THREE policies covered almost every situation that could arise when placing HIV+ children in substitute care.
To be considered LEVEL TWO, a policy had to address these issues:
Education of employees and substitute care providers on all aspects of HIV-related disease, including infection control;
Testing guidelines, including who can write orders for testing, how it can be ordered, and who should be tested;
Confidentiality/disclosure guidelines regarding who needs to know an individual's HIV status, as well as legal issues of confidentiality; and
Discrimination protection for clients and employees based on HIV status and/or lifestyle choices.
In addition to the above, a LEVEL THREE policy must also serve as an educational tool that a social worker or supervisor could use as a guide to placing an HIV+ child in a foster or adoptive family. It had to discuss at least half of the following issues:
Characteristics of appropriate families;
Family recruitment guidelines;
Specific services for families providing substitute care for HIV+ children (including subsidy and intensive rates);
A community resource list; and
A bibliography for professionals.
MARE went on to discuss the 20 policies based on the 10 criteria specified above. What follows is a summary of their findings and the recommendations they made.Education
Of the 20 State policies received, 15 indicated a need to educate their social workers about AIDS, and 12 suggested training of foster and adoptive parents. West Virginia's policy provided a 12-page in depth outline for the training that was to be provided to staff members. This 4- to 6- hour training covered medical information, transmission, risk groups, definitions, testing, hygiene, ethical issues, patients' rights, personnel issues, legal issues, confidentiality, State policy, family dynamics, school attendance, and resources. A similar in depth outline was provided for training foster parents. Connecticut also provided a training outline for social workers, with clearly articulated training objectives.
MARE recommended that policy mandate AIDS education with a built-in method of accountability (Rhode Island policy was seen as a model for this), that training programs be outlined clearly, and that training include some live teaching, not simply distribution of written materials. MARE suggested that time should be allowed for questions and answers. MARE also recommended including content on infection control and universal precautions, community resources, and a reading list.Testing
Sixteen policies clearly defined groups of children who should be tested for HIV. Some States mentioned testing biological, adoptive, or foster parents, and their approaches on this issue varied widely. Kentucky and Wisconsin stated that HIV screening of foster and adoptive parents was not warranted, while Georgia, Idaho, and Ohio sanctioned testing of ■high-risk■ parents. Policies in New Jersey, California, Kentucky and Wisconsin took positions on the testing of biological parents but did not discuss testing foster or adoptive parents. No policies recommended blanket testing of either children or parents. Ohio policy was the only one to address testing of workers.
MARE recommended that every State policy explain step-by-step which workers can order testing, who they must consult in order to do so, whether or not they must obtain informed consent from the child, whether or not the child's biological parents need to give informed consent to administer a test, where the child can be taken, who needs to know that the test is being conducted, and who can be told about the test without breaking any laws regarding confidentiality.Confidentiality
All 20 policies mentioned that a child's privacy must be protected and that HIV status must be kept strictly confidential. Thirteen States described what is meant by a ■need to know■ basis for the sharing of confidential information. Some States also described procedures for determining who needs to know, including persons to involve in the decision making process. A few States deal specifically with protecting information contained in medical records.
MARE recommended that States delineate exactly who ■needs to know■ a child's HIV status and develop procedures to evaluate this issue on an ongoing basis.Discrimination
Ten of the twenty policies analyzed specifically mentioned the issue of discrimination. Six also mentioned the importance of adhering to antidiscrimination measures for employees who may be HIV+. Delaware policy was particularly clear in this area. Some States also discussed State laws that expressly forbid discrimination against persons with communicable diseases.
MARE recommended that States discuss discrimination clearly in their policies, citing any applicable legal statutes. It also recommended that States take a very firm stand against discrimination of those infected with AIDS or suspected of being HIV+.Liability
Only three policies addressed liability issues, and each did it differently. New Jersey and Rhode Island felt agencies should be held liable for knowingly withholding information about the health status of a child. Pennsylvania discussed the potential for legal action on behalf of noninfected children if transmission occurred by a child with AIDS in the same foster home or facility.
MARE recommended that liability issues be pursued with agency/facility legal counsel and that efforts be made to ensure that insurance carriers provide liability insurance to caretakers of persons with AIDS. Among the liability issues to be considered were viral transmission, placement of asymptomatic children who go on to develop AIDS, placement of HIV+ children who seroconvert at 24 months of age and have no medical problems, and disclosure of medical information.Appropriate Families
Only five State policies addressed the issue of placement criteria for foster and adoptive families of HIV+ children. Florida's draft policy clearly delineated the type of family that should be considered as foster parents for HIV+ children, addressing such issues as the ages of other children in the home, proximity to major medical centers, ability to deal with death and dying, and knowledge about AIDS. (Note: The Leake and Watts program in Yonkers, New York, has since identified several other important characteristics of appropriate families. See the resource section under ■model programs.)
MARE recommended that all State policies outline criteria for the preferred types of family placements for HIV+ children. These guidelines should be as straightforward as possible in order to aid social workers in their decision making. Family Recruitment
Only four State policies addressed the need for foster or adoptive family recruitment; only two laid out specific plans. Florida's draft policy mentioned a number of specific recruitment methods. West Virginia outlined a detailed pilot recruitment project to find and prepare families to care for children with AIDS. Provisions for placement, methods of payment, what to look for in the families, and how to go about placing a child in one of these families were also discussed.
MARE recommended that each State formulate a measurable recruitment plan to be included in the State policy, offering specific ideas for recruitment of foster and adoptive families for HIV+ children.Services for Families Providing Substitute Care
Five State policies discussed provision of a higher foster care payment rate to providers caring for HIV+ children. Three policies discussed the need for respite care, and three allowed counseling
and extra contact with social work staff. None mentioned advocacy or nursing services.
MARE recommended that each State assess its resources to determine what services (for example, counseling, increased subsidies, respite care, extensive education) it can provide for families adopting or fostering children who are HIV+. Available services should be outlined in each State's policy to aid social workers in obtaining the services for the children and families in their caseloads. State Policy 1991: General Issues
In revisiting State policy regarding out-of-home placement of HIV+ children, professionals in child welfare generally find that while many issues remain constant, some issues appear to be even more complex in 1991 than they were in 1989. It is now important to explore all levels and aspects of policy (Federal, State, local, agency, departmental, professional, etc.), as well as to understand the differences between guidelines, recommendations, policies, and laws. These differences must be illuminated in order for child welfare professionals serving HIV+ children to know how to perform their daily work. This issue came to light while developing criteria for evaluating State policies collected for this factsheet. Maine sent a legislative revision to its State Public Health Code that mandates coordination of services for HIV-affected families (but does not contain anything specific to child welfare), while Utah provided four pages from section III-K of its State Department of Family Services policy manual entitled ■Emergencies and Other Serious Situations.■ The question became how to compare and contrast these documents fairly. Conflicting policies in agencies or departments that collaborate may create barriers to permanency for children as workers struggle to interpret the parameters of their roles and responsibilities. It is important for child welfare agencies to consider whether their policies are compatible with their collaborators'. As would be expected, most policies reviewed in 1989 dealt strictly with departmental procedures and did not address the need to coordinate efforts and ensure compliance with Federal, State, and local regulations. Policies should also acknowledge both formal and informal mechanisms for prescribing practice in agencies. The subject of HIV will bring worker values to the surface that could influence the ways that policy is interpreted and followed. Ways to address this potential conflict should be discussed in policy documents or as a part of staff education and training. A proactive approach, not a reactive one, is recommended. Policies need to be updated and amended as new information is obtained about the HIV virus, medical interventions, and ways that other foster care and adoption programs are successfully meeting the needs of this population. The updating and amending process needs to be ongoing.State Policy 1991: Some Specifics
NAIC called upon MARE once again to collect data for this second factsheet on HIV+ children in the child welfare system, and the information obtained was forwarded for analysis to the Training and Leadership Division of Spaulding for Children, in Southfield, Michigan. Most of the policies sent for review were specific documents generated by the State departments or divisions responsible for child welfare. Not all States forwarded copies of their policy for review for this update, as was true in 1989.
In 1989, 35 States were involved in some stage of policy development relating to placement of HIV+ children. In 1991, this number increased to 37. The remaining 13 States had no child welfare policy regarding these issues at the time MARE contacted them. (Note: This could be the result of contacting the wrong person or department and is not a definitive measure of whether State policy does exist.)
The three levels MARE developed for analyzing policy relative to HIV+ children in 1989 are still appropriate for use in 1991, as are their recommendations for ideal policy cited in a previous section of this factsheet.
It is encouraging to observe that policies received for analysis in 1991 tend to be more comprehensive than those of 1989, and they address more specifics of child welfare practice. Of the 20 policies MARE analyzed in 1989, almost all were considered LEVEL ONE; only a few were LEVEL TWO or LEVEL THREE, and eight of those policies were still in the draft stage. In contrast, most policies received in 1991 are LEVEL TWO or LEVEL THREE, and most are in final form.
Even though most policies are now discussing all 10 criteria developed by MARE in 1989, they still may not adequately address all situations that can arise when placing HIV+ children in out-of-home care. This level of specificity seems to grow out of practical experience, as is evident in the policy developed by the States of New York and Maryland. (See resource section for the Maryland program contact, which is listed in addition to the New York program to which we already referred.)
New York policy addresses subsidy issues specific to HIV+ children. In addition to providing an exceptional (or intensive) rate, special provisions are made to continue subsidy to parents whose children are hospitalized for up to 60 days. Provisions are also made to continue this exceptional rate for 1 year from the date that a child seroconverts. Maryland policy says that the board rate for HIV+ children is the ■Intermediate Care Rate Type B,■ and that foster parents are also eligible for a ■difficulty of care stipend.■ Arizona also discusses subsidy in their policy, but not to the level of detail found in documents from New York and Maryland.
While some policies touch on the need for multidisciplinary teams and cross-system collaboration, only the Maine legislation provides procedures for how this should occur. No policies address the ways in which Federal Government recommendations from such groups as the Centers for Disease Control and the National Institutes of Health, or private sector groups such as the American Medical Association, can and should influence child welfare practice. Indiana
and Maryland make reference to the Federal Antidiscrimination Law in their policy. Maryland also specifically states that persons with AIDS are considered to be handicapped under Section 504 of the Rehabilitation Act of 1973 and therefore have the same rights as anyone else to employment, health care, welfare, and social services.
No policies address practice issues in the context of professional ethics, practice standards or local political climate. Community attitudes contribute significantly to the stigma and discrimination experienced by many HIV+ individuals and have a profound effect on recruitment efforts as well as the success of placements. These issues are sometimes addressed in the context of confidentiality but are never discussed in separate sections.
Arizona is the only State that has a built-in mechanism to update and review information every 6 months. Its policy also contains a specific section that lists all State statutes and rules that may be applicable to providing services to children who are HIV+.
Most policies developed after 1989 address adoption as a permanency option for HIV+ children. Long-term foster care is no longer the most appropriate plan. Arizona and Maryland have specific sections that discuss recruitment of families, evaluation of children, placement, supervision, and day care services. Maryland and New York policy go on to discuss enrollment of children who are temporary court wards in experimental medical treatment protocols.Implications for Practice
All HIV-related policy tends to fall along a continuum that stretches from inclusion to exclusion. In 1985, the Centers for Disease Control issued guidelines for foster care and education of HIV+ children, which recommended inclusion in all cases where there is no known risk of viral transmission. This philosophical stance remains at the core of almost all child welfare policy.
Nonrestrictive policy in its most simple form states that HIV+ children are to be treated the same as all other children in the system. Confidentiality and disclosure guidelines in most State child welfare policy, however, dictate that information about HIV+ children be handled in a different way than information about children with other medical conditions. This and other ethical dilemmas will be facing more child welfare professionals as more HIV+ children enter the system.
Risk management regarding HIV+ children and families is the main task of child welfare practice in the 1990's. Policy will continue to provide guidelines; however, there will always be room for interpretation. Two important strategies for sharing risk are ongoing training and team decision making. These forums can address ways to facilitate placement of HIV+ children and their siblings in culturally congruent homes. They can also create consistent ways of preparing foster and adoptive parents for the wide variety of outcomes their placement may hold and for the amount of openness with birth families that may be appropriate.
Risk management can also include modification of caseload size and job duties. HIV-affected families tend to have extremely complex and immediate needs, which include obtaining services from a number of different systems. Time and priority need to be given to developing relationships with these other systems, so that workers can provide comprehensive case management services. This cross-system collaboration can also facilitate resource sharing and be cost-effective.
Empowerment-based practice is critical to successful work with HIV-affected families. The greatest risks rest with the families, which obligates workers to include them in all decisions that will affect their lives. Postplacement services, including ongoing support, education, and counseling also need to be available.
As of 1991, child welfare agencies are making progress in the area of developing more complete policies for out-of-home placement of HIV+ children. The increasing complexity of issues, however, highlights the need to view policy development as an ongoing process. Continuing dialogue among all levels of the system will help ensure that worker values do not drive agency practice and that the best interest of the child is the focus of all efforts.
Written for the National Adoption Information Clearinghouse (NAIC) by Karal Wasserman, MSW, Trainer/Consultant, Training and Leadership Division of Spaulding for Children, Southfield, Michigan in 1992. Ms. Wasserman has been involved in AIDS-related efforts since the beginning of the epidemic. Prior to her position with Spaulding, she provided clinical services to individuals and their families at the Hemophilia Foundation of Michigan. Resource section updated by Debra G. Smith, Director NAIC, in 1996.Resources
Agencies Working with HIV-
Children's Aid Society
Family Pairs Program
3600 8th Ave. S, Ste. 300
Birmingham, AL 35222
Children with AIDS Project of
P.O. Box 83131
Phoenix, AZ 85071-3131
2146 W. Adams Blvd.
Los Angeles, CA 90018
Children's Home Society of
Central Administrative Office
P.O. Box 10097
Jacksonville, FL 32247-0097
Jewish Children's Bureau of
1 S. Franklin St.
Chicago, IL 60604
Lutheran Social Services
6525 W. North Ave., Ste. 212
Oak Park, IL 60302
Department of Social Services
HIV Parenting Partner Program
24 Farnsworth St.
Boston, MA 02210
Foundation for Children
1800 Columbus Ave.
Roxbury, MA 02119
Lutheran Social Services
594 Worcester Rd.
Natick, MA 01760
Maryland Department of Human
Social Services Administration
FaCT Model Project
311 W. Saratoga St.
Baltimore, MD 21201
Children's Hospital of New
Division of Youth and Family
50 E. State St., CN 717
Trenton, NJ 08625-0717
Brookwood Child Care
25 Washington St.
Brooklyn, NY 11201
Children Awaiting Parents, Inc.
700 Exchange St.
Rochester, NY 14608
Episcopal Social Services
18 W. 18th St.
New York, NY 10011
Leake and Watts
Children with AIDS Foster
487 S. Broadway, Ste. 201
Yonkers, NY 10705
Little Flower Children's Services
186 Remsen St.
Brooklyn, NY 11201
National Hemophilia Foundation
110 Greene St., Ste. 406
New York, NY 10012
New York Council on Adoptable
AIDS Orphan Program
666 Broadway, Ste. 820
New York, NY 10012
Society for Seamen's Children
25 Hyatt St.
Staten Island, NY 10301
The Children's Village
Dobbs Ferry, NY 10522
Lutheran Family Services of the
P.O. Box 12287
Raleigh, NC 27605
Pediatric HIV Permanency
Duke University Medical Center
Dept. of Pediatrics
Durham, NC 27710
My Sister's Children
United Methodist Family Services
715 Baker St., Ste. 201
Virginia Beach, VA 23462
(804) 490-9791Assistance for Parents Dying of
AIDS to Plan Their Children's
AIDS Orphan Adoption Project
National Council for Adoption
1930 17th St., N.W.
Washington, DC 20009
Because You Love Them, A Parent's
Child Welfare League of America
440 First St., N.W., Ste. 310
Washington, DC 20001
(202) 638-2952Training and Technical
American Red Cross
Contact local chapter
Association for the Care of
7910 Woodmont Ave., Ste. 300
Bethesda, MD 20814
Child Welfare Institute
Two Midtown Plaza
1349 Peachtree St., N.E., Ste. 900
Atlanta, GA 30309
National Adoption Information
5640 Nicholson Lane, Ste. 300
Rockville, MD 20852
National Association of Children
P.O. Box 15485
Durham, NC 27704
National Association of State
Boards of Education
1012 Cameron St.
Alexandria, VA 22314
National Pediatric HIV Resource
15 South 9th St.
Newark, NJ 07107
(201) 268-8251 or 1-(800) 362-0071
Training and Leadership Division
of Spaulding for Children
National Resource Center for
Special Needs Adoption
16250 Northland Dr., Ste. 120
Southfield, MI 48075
(810) 443-7080Written Materials--General
American Bar Association
AIDS Coordination Project
740 15th St., N.W., 9th Floor
Washington, DC 20005
Centers for Disease Control
1600 Clifton Rd.
Atlanta, GA 30333
Child Welfare League of America
440 First St., N.W., Ste. 310
Washington, DC 20001
Health Care Financing
Office of Research and
U.S. Government Printing Office
Washington, DC 20402
National Abandoned Infants
Assistance Resource Center
1950 Addison St., Ste. 104
Berkeley, CA 94704
National AIDS Information
P.O. Box 6003
Rockville, MD 20850
National Commission on AIDS
1730 K St. N.W., Ste. 815
Washington, DC 20006
The Orphan Project
121 Avenue of the Americas,
New York, NY 10013
U. S. Public Health Service
Office of Disease Prevention and
ODPHP National Health
P.O. Box 1133
Washington, DC 20013-1133Written Materials--Specific
Community Based Services for
Children with HIV Infection and
South Shore Mental Health
6 Fort St.
Quincy, MA 02169
HIV Infection and Developmental
Disabilities: A Resource for Service
Crocker, Allen C., Herbert J.
Cohen, and Theodore A. Kastner,
eds. Baltimore, MD: Paul H.
Brookes Publisher, 1992
Mortality and Morbidity Weekly
Available from the Centers for
Disease Control and Mass.
CSPO Box 1920
Waltham, MA 02254
Pediatric AIDS: The Challenge of
HIV Infection in Infants, Children
Pizzo, Philip A. and Catherine M.
Wilfert Baltimore: Williams and
Wilkins Publisher, 1991
Report of the Surgeon General's
Workshop on Children with HIV
Infection and their Families
U. S. Dept. of Health and Human
Services, Washington, DC,
Publication No. HRS-D-MC 87-1,
Credits: Child Welfare Information Gateway (http://www.childwelfare.gov)