by Kirsta Grapentine and Beverly Belcher

With recent reports indicating that the HIV infection rate may be on the rise, it makes sense that this disturbing trend will eventually impact the child welfare system.

AIDS (Acquired Immune Deficiency Syndrome) is a disease caused by a virus known as the Human Immunodeficiency Virus (HIV). HIV works by attacking and killing CD4 (or "T") cells, a key component of the immune system. Once the CD4 count in the blood falls below a certain level, the body's ability to fight off disease is severely impaired. Infections and/or diseases that an otherwise healthy person would be able to fight can be extremely critical, even deadly, for a person infected with HIV. This condition is known as AIDS. Its onset is often marked by fatigue, diarrhea, night sweats, weight loss, skin rashes and swollen glands. Full-blown AIDS may include cancers, infections, and pulmonary difficulties.

HIV can be transmitted through blood, semen, vaginal fluids and breast milk. It is most often passed from one person to another through sexual intercourse, or sharing "dirty" needles with persons infected with the virus. It can also be transmitted from an infected mother to her unborn child during pregnancy, through child birth itself, or during breast feeding.

Outside the body, HIV is a relatively weak virus and dies quickly. It is therefore nearly impossible to pass it on through shaking hands, hugging, kissing, eating utensils, drinking fountains, toilet seats, swimming pools, or mosquito bites. In the United States, blood products are screened for HIV and tainted blood is destroyed, virtually eliminating the risk that HIV will be passed on through transfusions.

Testing for HIV is accurate and inexpensive, and can detect the virus within six months of exposure. An infant who tests positive at birth may eventually revert to a negative status as its own immune system matures. If this happens, it will normally occur by the time the child is 18 months of age.

The World Health Organization estimates that 22 million individuals throughout the world are infected with HIV. The United States accounts for 7% of those infected. In Michigan, there were 8,429 reported AIDS cases and an estimated 8,500-11,500 persons infected with HIV as of September 1997. Of the state's 83 counties, only 5 (rural) counties reported no cases of HIV infection. The Detroit area had the highest infection rate, with 3,929 reported cases of HIV infection.

Although AIDS was originally associated primarily with gay men and intravenous drug users, we now know that the disease can infect an individual regardless of race, sex, income, age, or sexual orientation. Currently in the United States, AIDS is increasing more rapidly among females than males. In fact, AIDS is the fourth leading cause of death among women ages 25-44. Not surprisingly, this shift in epidemiology has also impacted children. By the year 2000 it is estimated that there will be over 80,000 AIDS orphans in the U.S. On any given day there are an estimated 7,200 children in the U.S. under the age of 12 with AIDS and 10,000 who test positive for HIV. The number of children infected and affected by this disease continues to grow.

Knowing the facts about HIV and AIDS is important for workers and families in the child welfare system. Being informed and supportive about the condition is essential when working with families who are either infected or affected by HIV. Direct-service workers should keep in mind that in most cases, infected families have been shunned and avoided by extended family members who may not understand the disease. Children, especially, are looking for hugs and genuine affection, and can sense when someone is not comfortable with them. Workers need to build trust in order to help fortify these families. Take time to explain terms and concepts, and emphasize the importance of cleanliness, hygiene, and nutrition. Workers should re-schedule visits when sick so that family members with weakened immune systems are not needlessly exposed to germs. Making sure that families are connected with other support services is also essential when trying to keep families together. Children infected with HIV are eligible for SSI.

Planning for the future care of a child is essential in cases where one or both parents are infected with HIV. There are planning guides available for families, as well as various resource programs that can assist with this effort. Whether it be adoption or permanent guardianship, early planning is important since the physical and emotional factors associated with later stages of AIDS may make it more difficult for parents to plan at that time.

When an HIV infected child enters the child welfare system, it is imperative to place the child with a family who is trained to provide care for that child's special needs. In response to the rising HIV infection rate in the Detroit area, the Wayne County Family Independence Agency has developed a special unit specifically for these medically fragile children. The Medically Fragile Unit is designed to respond to the complex needs of children and families who are infected or affected by HIV. It also specifically recruits families who are willing to foster children who are HIV infected/affected, as well as children who require specialized medical attention.

Because a child's HIV status is a highly sensitive issue, workers often struggle with the question of who specifically needs to know the child's HIV status when that child is placed in out-of-home care. One obvious party that must know the status of the child's health is the foster family. As temporary providers for the child, the foster family must be knowledgeable about the child's needs in order to provide proper care. Agency policies regarding confidentiality do permit the foster family to be informed of the child's HIV status. If the child subsequently becomes available for adoption and the foster family wishes to adopt, that family will already be aware of the child's special medical conditions.

MCI Superintendent Bill Johnson acknowledges that a child's HIV status needs to be held in strict confidence and should not be disclosed to individuals other than the family where the child is to be placed for care. He also recognizes that the child's HIV status may be shared between child care agencies in cases where a potential family has been identified from outside of the child's foster care agency. When an agency is recruiting families for an HIV positive child and another agency (or agencies) has a family who is interested in that child, the foster care agency may share the adoption evaluation and disclose the child's condition to the other agency. It is then up to the family's worker to determine if they feel the family can meet the child's medical needs. If the child's worker has more than one approved family to select from, that worker should make an initial assessment as to which family can best meet the needs of the waiting child. Once a family has been selected and the family determines they would like to proceed with adoption, disclosure of the child's HIV status can be shared at that time. If a family who has not yet been studied inquires about the child, no further information should be released until that family has been studied and assessed as to their ability to care for the child's special condition.

Balancing confidentiality and the need to identify an appropriate permanent family for HIV infected children can be challenging. By being knowledgeable about HIV/AIDS, confidentiality issues, and available resources to support families and children affected by the disease, we can do a better job of serving children and families.

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Child Protection Bills Signed into Law

reprinted from FIA Icon newsletter & Michigan Federation of Private Child & Family Agencies Law Changes Seminar Handbook

Parental rights will be terminated sooner in extreme abuse and neglect cases, and both courts and the Family Independence Agency will publish annual report cards evaluating their performance in foster care.

These are among the changes necessitated by a series of bills which passed the state Legislature late last year. The new laws provide greater protection for children and implement certain recommendations from the Binsfield children's commission report of 1996. Governor John Engler signed the bills December 29, 1997 at the St. Vincent Home for Children in Lansing.

"The work we are signing today will save lives," said Engler. "There's more to be done, but this package goes a very long way." Engler praised the work of Lt. Governor Connie Binsfield, who chaired the task force that developed the child protection proposals.

"I applaud Connie Binsfield's leadership and the legislature's action," said Engler. "Michigan has long been a leader in protecting children, and these changes will help assure we continue to lead."

The package is the first of a series of bills based on the recommendations of Ms. Binsfield's commission. Other legislation adding to the package is anticipated to be worked on in the next several months. Some of the bills the governor signed include:

• Public Act (P.A.) 163: Defines permanent foster family agreement; specifies certain time lines for court action; authorizes the court to order certain persons to leave the home of a child; requires FIA conduct a homestudy of a relative's home; requires release of certain information by a child placing agency to a foster parent upon written request; authorizes foster parents to object to a change in foster placement in certain circumstances; and restricts movement of a child from one foster home to another until review by a foster care review board and court in certain situations.
• Public Act (P.A.) 164: Requires substance abuse licensees to give waiting list priority to parent of a child who has been or is at risk of being removed from the home.
• Public Act (P.A.) 165: Allows Department of Consumer & Industry Services to grant a variance to licensing statute to allow siblings to remain or be placed together in foster home.
• Public Act (P.A.) 166: Requires a standard child abuse and neglect investigation and interview protocol in each county.
• Public Act (P.A.) 168: Mandates maintenance of a statewide, electronic central registry and specifies who has access to the records. Also sets out requirements for reviewing investigations of substantiated cases where harm came to the child, prohibits interviewing a child in the presence of suspected perpetrator, and requires FIA to file an abuse/neglect petition and request for immediate termination of parental rights in certain circumstances.
• Public Act (P.A.) 169: Stipulates limitations on court granting continuances or adjournments, discharging of attorney for good cause; requires timely issuance of opinion on petition for termination of parental rights, child's attorney must be present at all court proceedings, CSAO must publish an annual report evaluating the court's duty related to obtaining permanency for children.
• Public Act (P.A.) 171: Authorizes the superintendent of the Michigan's Children's Institute and attorneys representing a child to communicate regarding matters pertaining to commitment, placement and permanency planning, and directs the attorney to consult with the superintendent if said attorney has any objections or concerns regarding these issues.

Most bills become effective April, 1998.

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Overview of Adoption Subsidy

excerpted from the Michigan Adoption Subsidy Program Information Guide, State of Michigan Family Independence Agency

The purpose of support and medical subsidies is to remove financial barriers to the adoption of Michigan children with special needs. An adoptive child may be eligible to receive a support subsidy or a medical subsidy or both. The subsidies are intended to help with the costs of raising the child. They are not intended to cover every expense.

A support subsidy is a monthly payment to the parent or parents of an eligible adopted child. This payment provides assistance to support the adopted child and eligibility is determined before the petition for adoption is filed.

A medical subsidy pays for expenses that result from a physical, mental, or an emotional condition that existed, or the cause of which existed, before the adoption.

Adoption subsidies are administered by the Adoption Subsidy Program office which is located in the central office of the Family Independence Agency (FIA).

Questions concerning adoption subsidies should be directed to the local adoption worker prior to adoptive placement. After a subsidy case is opened, questions should be directed to an adoption subsidy specialist at the FIA in Lansing.

Adoption Support Subsidy Guidelines Definition

A support subsidy is a monthly payment to assist in the basic care of an eligible child who has been placed for adoption.

Eligibility

A child may be eligible for a support subsidy if all of the following are met:

1. The child has been in Michigan foster care for not less than four months before certification.
2. A reasonable effort has failed to locate a qualified family or person willing to adopt without a subsidy, or the placement is the only placement in the child's best interest, and the family is requesting a subsidy.
3. The child is certified eligible before the adoption petition is filed.
4. The adopting parent and the director of FIA sign a written assistance agreement indicating the amount of support subsidy payment before the probate court issues the final Order of Adoption.

Certification

The local adoption agency sends the information for certification to the FIA Adoption Subsidy Program office.

Support Payments

A support subsidy is based on the foster care rate paid for the child. The parents' income does not affect the amount of support subsidy. If the child has, or is eligible for, income from other sources (Social Security, Veteran's Benefits, etc.), the amount of support subsidy received may be affected.

Payment is effective the date the child is placed in adoption by order of the court if the parent(s) and the director of FIA have signed an assistance agreement before the date of the order. If the assistance agreement is signed after adoptive placement but before finalization, payment is effective the date the director signs the agreement.

The support subsidy payment is made to the adopting parent and normally arrives between the first and tenth to cover the month it is received. The first subsidy payment may be delayed for several weeks due to a transfer from the foster care payment system to the adoption subsidy payment system.

An adoption subsidy continues even if the adoptive family moves to another state or country.

Support Subsidy Case Closure

A support subsidy case is closed when one of the following occurs:

1. The family is no longer providing for the child's care.
2. The child turns 18 or is otherwise legally emancipated.
3. The child marries.
4. The child enters military service.
5. The child is placed outside the family home and the absence has lasted, or is expected to last, 30 days or more, and financial responsibility for the child is transferred from the family to another funding source ( public funding, including medical subsidy, private insurance, etc.).
6. The child dies.
7. The adoptive parent dies, unless a legal guardian is appointed by the court, and requests continuation of the support subsidy.
8. Government benefits paid to the family for the child, such as Social Security, Veteran's benefits, or Supplemental Security Income (SSI) exceed the amount of the support subsidy. When benefits are granted, but do not exceed the amount of support subsidy, subsidy shall not be terminated but shall be adjusted 50 that the total of benefits and subsidy equal, but do not exceed, the maximum support subsidy.

Medicaid

Medicaid is a government funded medical assistance program. Most, but not all, children who receive a support subsidy are eligible for Medicaid coverage.

Medicaid is different from medical subsidy. Medicaid eligibility does not affect eligibility for medical subsidy. Medicaid is automatically opened for eligible children. No application is necessary.

Adoption Medical Subsidy Guidelines

Definition

A medical subsidy provides payment for the treatment of physical, mental and emotional conditions that existed, or the cause of which existed, prior to the adoption of an eligible child.

Eligibility

A child may be eligible for a medical subsidy if all of the following conditions are met:

1. The child was in Michigan foster care at the time the petition for adoption was filed. (This is not a requirement for adoptions finalized in a Michigan court prior to June 28, 1992).
2. Certification of eligibility is requested before the child's eighteenth birthday.
3. The expenses to be covered by the medical subsidy are necessary because of a specified physical, mental or emotional condition which existed, or the cause of which existed, before the adoption petition was filed.

Certification

The application procedure to certify a child for a medical subsidy depends on whether the child's adoption is pending or the child is already placed in adoption. For a child whose adoption is pending, the local adoption worker requests certification. If a medical subsidy is requested after the adoptive placement, the adopting parents request certification by submitting Form 1341 A, "Request for Medical Subsidy for an Adopted Child", to the Adoption Subsidy Program.

Medical Subsidy Payments

After the adoptive child is certified eligible for a medical subsidy, the adopting parents sign an agreement that specifies the conditions covered and the date coverage begins.

Medical subsidy pays for treatment of conditions specified in the agreement. It does not pay for routine medical care. Medical bills are not processed until both the adoptive parents and the FIA director have signed the agreement. All other available coverage or resources (private health insurance, Medicaid, Children's Special Health Care Service, or any other public funds), must be applied before payment is made.

Medical subsidy payments are made for itemized bills submitted by the parent or service provider. Payment is made at the rate approved by the Agency. Payment can be made to the service provider, or the parent. Payment may be approved if all the following criteria are met:

1. The service is necessary to treat a certified condition.
2. The date of the service is on or after the effective date of the medical subsidy agreement
3. All other private or public payment resources have been exhausted.
4. When required, authorization is obtained prior to treatment.
5. The parent and service provider both acknowledge treatment was provided.

Whenever possible, the family is requested to have the service provider submit bills covered by a medical subsidy. These bills are to be sent to:

FIA Adoption Subsidy Program
Ste. 413
P.O. Box 30037
Lansing, MI 48909

Medical Subsidy Coverage

A medical subsidy provides payment for necessary treatment of covered conditions provided by a licensed and/or trained person or by a licensed facility. Parents are responsible for the selection of service providers.

Payment for treatment does not usually require prior authorization. However the following are not routinely covered by medical subsidy and must be authorized by the Adoption Subsidy Program prior to treatment:

1. Residential treatment or placement outside the family home including hospitalization.
2. Assisted care services.
3. Transportation.
4. Educational costs and services such as speech therapy, physical therapy, occupational therapy, tutoring, school equipment and supplies.
5. Durable medical equipment (wheelchairs, ramps, etc.).

Medical Subsidy Case Closure

A medical subsidy case is closed when one of the following occurs:

1. The family is no longer providing for the child's care.
2. The child is placed outside the family home and the family is no longer legally responsible for the child. (e.g. the child becomes a court ward, legal guardianship is transferred from the adoptive family, etc.)
3. The child turns 18 or is otherwise legally emancipated.
4. The child marries.
5. The child enters military service.
6. The child dies.
7. The child receives a family support subsidy from the Michigan Department of Community Health.

Adoptive Parent Responsibilities

The written agreement between the Agency and the parents identifies the rights and responsibilities of both parties. Parents responsibilities include but are not limited to the following:

1. To spend the adoption subsidy on behalf of, or to benefit, the child.
2. To file an annual report with the Adoption Subsidy Program
3. To notify the Adoption Subsidy Program in writing within two weeks of any changes which might affect subsidy eligibility (changes in address, child leaves the home, death of the child, marriage of the child, death of a parent, divorce/separation of parents, the child's receipt of other benefits, etc.).

Nonrecurring Adoption Cost Reimbursement

Families adopting some children with special needs are eligible for payment of "one-time-only" expenses related to adoption. Expenses such as legal fees, home study fees, medical and psychological evaluations, and transportation may be covered. Eligibility is closely linked to eligibility for a support subsidy. A separate agreement for nonrecurring adoption costs must be signed by the parent(s) and the Agency before finalization of the adoption. Your adoption worker can provide additional information and answer your questions regarding nonrecurring costs.