Children belong in families, not facilities.¹

When compared to children placed in group and institutional settings, children in family-based settings have fewer placements, spend less time in out-of-home care, and are more likely to be placed with their siblings and near their community.² Community-based and-home-based services for youth at risk of entering residential treatment facilities also have been shown to result in better outcomes for youth, in addition to costing less.

In contrast, group and institutional placements³ generally produce poorer outcomes for youth than family-based settings — including higher rates of delinquency⁴ lower test scores,⁵ lower high school graduation rates,⁶ and delayed permanency. A breakthrough 2021 report that focused on young people’s direct experiences of group and institutional placement in foster care concluded that these settings often fail to offer consistent, caring relationships and actually prevented them from building the sort of relationships that are necessary for healing, returning to community, and successfully transitioning to adulthood. Young people frequently described group and institutional placements as punitive, prison-like, and traumatic. Unnecessary placement in group and institutional placements for children in foster care is harmful and more often impacts young people of color. Black and multiracial youth continue to be overrepresented in these settings. Therefore, ending the need for group placements is a key strategy for reducing disproportionate harm to young people of color in the child welfare system.

During the past 10 years in the U.S., both the number and percentage of youth in foster care living in group or institutional placements have decreased by about one-third.⁷ Yet in 2021, about 9% of young people in foster care (nearly 39,000 youth) were placed in a group home or an institution. The percentage is highest among older youth, with more than 30% of young people in foster care ages 13 to 18 living in facilities at any given time. An even higher percentage of older youth experience an institutional stay at some point during their time in foster care.⁸

This brief describes a set of key principles and values that child protection agencies and their partners should adopt to decrease the need for harmful group and institutional placements. The principles seek to operationalize what is known to work in child welfare, such as kinship care, child and family engagement, prevention supports for families, and cross-sector collaboration — all of which are designed to keep young people safe with their family or in family-like settings. The four key principles are: 

1. Children thrive with family.
2. Youth and family voice must be central to all decision-making.
3. Children and families need a culturally responsive, community-based continuum of both traditional and non-traditional support.
4. Systems must work together to support children and families.

The brief also offers questions for consideration to help child protection agencies further explore how they might apply these principles to improve the safety, permanency, and well-being of young people in their communities, while also acknowledging that ending the need for group placements is cross-systems work requiring commitment from multiple agencies. For additional information regarding the key levers and strategies to reduce group placements, please explore videos, discussion guides, and other resources at Ending the Need for Group Placements.

Background

Children and youth referred to out-of-home care should be placed in families. Placement in group settings for children and youth involved with child welfare is only appropriate on a time-limited basis and when clinically or medically necessary — with the assessment of necessity strictly defined, and the group care is limited to short-term, high-quality specialized treatment⁹ offered through Qualified Residential Treatment Programs (QRTPs) or the behavioral health system.¹⁰ Unfortunately, a 2015 U.S. Department of Health and Human Services report found that over 40% of children in institutions did not have a clinical reason to be in an acute-care setting. Many young people who have experienced group placement report that it was their first placement in foster care. Others have said that they ended up in institutional placements because caseworkers believed there were no other placement options for them, not because such placements would be best for them.¹¹

Young people can, and in most cases should, receive effective behavioral treatment in families and family-like settings through therapeutic foster care, wraparound services, and mobile response and stabilization services. Institutional group placements are a vastly inadequate substitute for life with a family. All young people need consistent, nurturing adults in their lives to form healthy attachments and develop positive social and emotional skills. Residential care facility staff and professionals rotating in shifts, even with the best of intentions, cannot provide that kind of consistency for youth. Unfortunately, many young people who have experienced group placements have reported uncaring relationships with staff, some of whom have been “unkind, cruel, untrustworthy, or indifferent.¹² Group and institutional placements also may curtail or prevent the development of supportive, sustained relationships with peers due to restrictions they place on age-appropriate activities and technology use.¹³

Principle 1: Children thrive with family

It is well established in scientific research that healthy brain development for young children requires consistent, supportive, and responsive relationships with at least one parent or caregiver. That need for family support doesn’t end at early childhood. All youth recovering from the effects of trauma and family separation, regardless of age, need the care and love of family and community. Therefore, every effort should be made to keep children safe with their families (including siblings) and, if extra support is needed, that support should be provided in the child’s own home and community.

When a child cannot remain at home or with parents, kinship care — formal placement with relatives (by blood or marriage) or others who the child and family identify as “chosen family” — should always be explored as the first option for placement, before foster care with strangers and certainly before group placement. Numerous research studies have established the advantages of kinship care. Compared to non-relative care, kinship care yields greater placement stability, lower rates of re-abuse, better behavioral health, and a higher likelihood of permanency.¹⁴ Placement with kin (as defined by the child or family) can be an important element of treatment and recovery for children who have experienced family separation and other trauma, and keeps them connected to their community and their culture, which are critical protective factors.

An argument often is made that young people who require group placement have no family or nowhere else to go, but research has found that this often is a myth.¹⁵ Almost without exception, youth living in group placements have supportive people in their lives who could provide them a healing environment, but those people are either unaware of their placement or required to overcome unnecessary structural barriers to have the youth live with them. These barriers exist as a result of administrative or bureaucratic policy decisions or financial hurdles that with proper support could be overcome. Examples of unnecessarily exclusionary obstacles that can unduly get in the way of a kinship placement — and do not reflect the kin’s desire or ability to provide a child with a safe and loving home — include the caregiver’s living out of state, family status (such as existing family composition, work schedules, etc.), prior criminal record, housing status (including square footage requirements, room requirements, housing quality), or lack of adequate financial resources. Child protection agencies should do everything possible to eliminate such barriers to kinship placement by waiving non-safety-related licensing requirements, creating supports specifically for these purposes, and connecting families to all supports available (financial and/or therapeutic) to make the kinship placement safe and sustainable.

The Michigan Department of Health and Human Services, with support from the Harvard Kennedy School’s Government Performance Lab, created a set of administrative roadblocks and tools to change practice at the moment of referring a child to residential placement, which contributed to a sharp decline in referrals and entries to residential programs. Connecticut reduced its reliance on group and institutional placements for children under age 12 by nearly three-quarters between 2012 and 2020,¹⁶ in part by advancing a kin-first culture, implementing a child-by-child review process, and creating administrative barriers to placing children in residential settings. The state reinvested its $90 million per year savings in additional home- and community-based support services.

As institutional placements are utilized less and for shorter lengths of time, most agencies will need to identify, prepare, and support kin, as well as culturally appropriate resource family homes for young people who cannot be with their own families. Youth with more complex needs, including those stepping down from short-term QRTP stays, require kin and resource caregivers with additional training and support.¹⁷ Kin and other resource caregivers should be encouraged to work in partnership with the youth and the youth’s family, including providing coaching, advocacy, and even respite care after children return home.

Questions to consider:

• How is agency leadership promoting the idea with staff that kinship care is an effective alternative to group placement for youth recovering from family separation and other trauma?
• How does our agency acknowledge and operationalize the fact that, for some youth, staying or reuniting with family is an essential part of their well-being plan?
• How does our jurisdiction honor youth and families’ own definitions of kin?
• What policies and programs are in place within our agency to ensure children’s first and only placement is with kin?
• How could our jurisdiction reassess home study and licensing criteria to place more children safely with kin?
• How does our agency support kinship caregivers financially and therapeutically to ensure they can provide for the children in their care?
• How does our agency ensure that group placements are clinically and medically necessary, as well as time-limited, trauma-informed, judicially reviewed, and focused on engaging the youth’s family during and after treatment?
• How are our staff and foster parents trained to view problematic behaviors as a response to trauma?
• When needed, what therapeutic alternatives to group placements are available?
• How can our agency cultivate more options to group placement, including well-supported kinship care and therapeutic foster homes?

Principle 2: Youth and family voice must be central to all decision-making

One way to increase kin placements and therefore reduce the need for group or institutional placement is to ask youth where and with whom they want to live, and to do so regularly throughout their time in foster care — from outset to permanency. Youth often identify adults that caseworkers may not think of, or will identify placements that are more likely to be stable because they include what the youth needs. Engaging youth in permanency and case planning leads to more youth-centered practices that improve outcomes in many areas.¹⁸ For engagement to be meaningful, child welfare professionals must do more than just ask a single question. They must expand the dialogue to chosen kin and listen with an open mind to the youth’s response, all with a commitment to do everything possible to achieve the youth’s vision for their own living situation.

Family voice can help identify the most appropriate placement setting when a youth must enter foster care. Family team meetings are good opportunities to identify additional family members to support the young person, as well as inform relatives about the options they have to participate in the child’s care and placement, including how to become a foster parent. Family engagement in planning should continue throughout all key decision points. Kin who cannot provide a placement option still can offer children connection and a sense of belonging, and support them by supervising parenting time, providing childcare or respite care, serving as emergency contacts, acting as mentors, and transporting and/or accompanying them to appointments.

People with lived experience of the child welfare system are in the best position to propose solutions to the system’s most intractable problems, including its overreliance on group placement. Authentic engagement requires engaging youth and family members not just in their own placement decisions, but also in co-designing agency and systemwide policy and practice strategies to end the need for group placement in child welfare altogether. Youth and family members should be compensated appropriately for their time and expertise. Building trust is critical to youth and family engagement, especially among young people of color, who individually and as a group have experienced racist and inequitable child welfare policies and practices.

Questions to consider:

• What does our agency policy say about engaging youth and family members in decisions regarding the most appropriate placement setting for youth in foster care?
• How are family finding, family team meetings, and other strategies used to engage parents and relatives in placement decisions?
• How are families and youth with lived experience informing and influencing our policies and practices related to group placement?
• To what extent does agency policy require engaging youth and family members in non-placement decisions about the youth’s life and activities, treatment plan, etc.?
• How has our agency engaged with parents, even those whose rights have been terminated, as viable resources for supporting youth?

Principle 3: Children and families need a culturally responsive, community-based continuum of both traditional and non-traditional support

Supporting communities and families — not systems and facilities — to raise children is the most effective way to ensure safety, permanency, and well-being. Ending the harm caused by group placements is not about indiscriminately closing facilities or ending contracts with providers. Rather, it is about shifting where and how supports are provided to families so that children can remain safe at home and family separation is not needed. Sometimes, the best therapeutic intervention will involve keeping children with their parents, and then supporting those parents to care for them. This requires child protection agencies to reinvest their resources to advance system change — shift contracts and business models from supporting group facilities and toward the provision of prevention supports for children and families, including investment in trusted community organizations that families naturally turn to for support. These supports should be co-designed with people with lived expertise in child welfare and by the communities where they live. Both are best positioned to know what supports could have prevented a family’s involvement with the child welfare system in the first place. Consideration of both clinical and non-clinical mental health supports, as well as economic supports, is critical.

To be effective, services must be culturally appropriate. This means services that:

• Respond to each family’s unique and individual culture.
• Acknowledge and take action to address the harm caused by historical and continuing oppression and racism in the foster care and behavioral health systems.
• Create culturally specific and responsive spaces, including bringing in peer support for youth to connect with other peers close to their age who have had similar experiences. Medicaid reimburses for peer support in some states.
• Are delivered by a workforce that reflects the families it serves.
• Employ cultural brokers who provide training, coaching, and support to all team members to ensure services are culturally responsive and accountable to the community.
• Are designed by and for communities that have been disproportionately harmed by the child welfare system.

New Jersey has invested significantly in community-based services to prevent crises before they require child protection agency intervention, thereby reducing the need for group placement. The state’s behavioral health services are completely separate from the child protection division and are accessible to any family in the state. Mobile response units in all 21 counties respond within an hour to address crises at home or in schools. The state also dispatches mobile response when a child is first placed into foster care to help the family understand the child’s trauma history and make a proactive plan with the foster family to meet the child’s needs specific to the trauma. The treatment plan is developed together with the child and family and is strengths-based, child-centered, family-driven, community-based, trauma-sensitive, and culturally and linguistically mindful. A combination of clear policy and practice guidance, proactive training, and availability of mobile response has no doubt helped New Jersey reduce group and institutional placements by 76% between 2009 and 2020.¹⁹

Questions to consider:

• How can community-based crisis prevention services be expanded to reach more families before a safety issue is identified and placement is needed?
• What peer supports are available to youth in our community?
• How can our agency reduce barriers to peer support positions for applicants (for example, lowering or eliminating age and education requirements, providing paid training, rethinking criminal background checks, and offering a living wage)?
• How is our current service array addressing the unique needs of individual communities, and what communities are underserved by our current service array?
• How can our agency partner more closely with communities that have been disproportionality harmed by the child welfare system to co-design and support culturally responsive services and programs?
• Does our agency use strategies to encourage residential care providers to transform their business model away from group placement and toward prevention and community-based services for families, including financial support, changes in contracting, and other technical assistance?
• What efforts are being made to rebuild trust with Black and American Indian/Alaska Native families and other communities that have been disproportionately harmed by child welfare policies and practices?

Principle 4: Systems must work together to support children and families

Ending the need for group placement is a collective responsibility. Children and families often are the subjects of child protection hotline calls because they need support and services only after numerous other service systems have failed to meet their needs. The child protection agency’s ability to provide optimal support to children and families and avoid group placement also depends on other systems in myriad ways, including configuring the physical health care and behavioral health care systems to ensure availability of appropriate treatment options. A healing-centered, trauma-informed legal and judicial system that supports keeping families together whenever safely possible also is key, as is a provider network that reflects the community and provides the necessary resources. Policymakers also must be willing to create legal and fiscal policies to facilitate greater access to home-based services.

In order to prevent group placements, child protection agencies must actively partner and collaborate with other public systems such as education, Medicaid, and behavioral health, as well as social service agencies that provide families economic supports. Working together, these systems and agencies can provide much-needed relief for families struggling to provide a safe environment to raise their children. Collaborating with law enforcement and juvenile justice also may be important given that some youth may be involved in both systems.

Questions to consider:

• How does our agency engage the judicial system, the state Medicaid agency, public health agencies, social service agencies, community-based providers, law enforcement, juvenile justice, and other partners in the effort to end the need for group placements?
• How does our agency help to inform policymakers about the harms to young people caused by group placement?
• How can our agency use funds, such as those provided through the Family First Prevention Services Act of 2018, to increase investment in community-based prevention services that help keep more young people with family or in family-like settings?

1 Content of this brief was informed through ongoing consultation with members of the Knowledge Management Lived Experience Advisory Team. This team includes youth, parents, kinship caregivers, and foster parents with lived experience of the child welfare system who serve as strategic partners with Family Voices United, a collaboration between FosterClub, Generations United, the Children’s Trust Fund Alliance, and Casey Family Programs. Members who contributed to this brief include Dee Bonnick, Alisa Thornton, and Robert Brown.
2 Barth, R. P. (2002). Institutions vs. foster homes: The empirical base for the second century of debate.
3 Consistent with federal definitions and guidance for the Adoption and Foster Care Analysis & Reporting System (AFCARS), the term “group and institutional placements” refers to non-family based placements that house young people in large, medium, or small congregate settings, including emergency shelters, group homes, institutions, and residential treatment facilities, centers, campuses, and cottages with 24-hour shift care or house parents. “Group homes” are defined as placement settings that house 12 or fewer youth, while an “institution” is defined as housing more than 12. For additional information, see: www.acf.hhs.gov/sites/default/files/documents/cb/afcars_elements_definitions.pdf and www.acf.hhs.gov/cwpm/public_html/programs/cb/laws_policies/laws/cwpm/policy_dsp.jsp?citID=150.
In this brief, “group and institutional placements” refer to those types of placements in out-of-home care in the child welfare/foster care context. There still is a need for a limited amount of short-term, clinically indicated, medically necessary treatment delivered in a high-quality group setting through the behavioral health system.
4 Ryan, J. P., Marshall, J. M., Herz, D., & Hernandez, P. M. (2008). Juvenile delinquency in child welfare: Investigating group home effects. Children and Youth Services Review, 30, 1088-1099.
5 Annie E. Casey Foundation. (2015). Every kid needs a family: Giving children in the child welfare system the best chance for success.
6 Ibid.
7 Children’s Bureau, U.S. Department of Health and Human Services. (2022). AFCARS Report #29
8 Adoption and Foster Care Analysis and Reporting System (AFCARS) data, made available by the National Data Archive on Child Abuse and Neglect Data (NDACAN) and analyzed by Casey Family Programs, September 2022.
9 Pecora, P. J., & English, D. J. (2016). Elements of effective practice for children and youth served by therapeutic residential care. p. 2.
10 Even when they may be clinically necessary, federal policy stipulates that those settings be time-limited, trauma-informed, judicially reviewed, and focused on engaging the young person’s family during and after treatment, with the goal being a swift return to family and community life. For more information, see: How are some child protection agencies attending to Qualified Residential Treatment Program requirements?
11 Think of Us. (2020). Away from Home: Youth Experiences of Institutional Placements in Foster Care.
12 Ibid
13 For more information on the importance of normalcy for youth in foster care and a selection of resources, see the Child Welfare Information Gateway’s Normalcy for Youth in Foster Care resource page.
14 Casey Family Programs. (2018). The Impact of Placement with Family on Safety, Permanency, and Well-Being.
15 Think of Us. (2020).
16 Adoption and Foster Care Analysis and Reporting System (AFCARS) data, made available by the National Data Archive on Child Abuse & Neglect Data (NDACAN), analyzed by Casey Family Programs on 10/24/2022.
17 As an example, see the kinship provider training from the Foster Family Treatment Association.
18 Capacity Building Center for Courts. (2017). Pathways to Permanency; Expanding on Another Planned Permanency Living Arrangement (APPLA) Provisions and Youth Engagement to Improve Permanency.
19 AFCARS data, made available by NDACAN, analyzed by Casey Family Programs on 10/24/2022.