Board of Directors May 24, 2018

Christopher Taylor
President H.L. Whitman, Jr.
Sherea McKenzie Commissioner
V ice President Department of Family and Protective Services
Winell Herron P.O. Box 149030
Secretary Austin, Texas 78714-9030
Denise Rose
Treasurer Dear Commissioner Whitman,

Catherine Codispoti I’m writing to respond to your letter dated May 16, 2018, regarding our report on
Susan Hoff pregnant and parenting youth in foster care.
Ray Martinez
Roger Martinez We take your letter very seriously. We appreciate your leadership at DFPS and have
Doug McDurham
enjoyed a very collaborative partnership with DFPS leadership and staff since I joined
Delaine Mueller, MD
Texans Care for Children in 2015 and for decades prior to my tenure.
Kris Kaiser Olson
Amber Scanlan
Your letter and criticisms of our report were surprising given we made it a priority to
Natalie M. Smith
reach out to your senior staff multiple times throughout the production of this report,
Ashley Weaver
shared our data and draft findings, and sought your agency’s perspective in advance of
publication. To be precise, we shared drafts and analysis with your senior staff on
Founder February 22, March 22, April 3, and April 12. We incorporated the feedback they
Phil Strickland provided. However, the issues you raised in your letter were not shared with us when we
(1941-2006) sought your agency’s input on these occasions.

Founder’s Council Before I address a number of specific points in your letter, let me say respectfully and
Pat Ayres
unequivocally that we stand by our report. The goals of our report, as clearly outlined in
Bob Coleman
the document and in our press statements, were to explore the impact of teen pregnancy
Eleanor Butt Crook
on youth in foster care and their babies and highlight opportunities to improve
Marlin Johnston
pregnancy prevention among youth in foster care and enhance supports for teen parents
Clift Price, M.D.
in foster care. We supplemented our quantitative data analysis with interviews, focus
Caryl Sherman-Gonzalez
groups, and surveys of youth formerly in foster care, staff of Child Placing Agencies,
Carolyn Strickland
foster parents, and health professionals. We propose a set of logical, reasonable
Linda Gale White recommendations that build on current efforts. Not only did we conduct a multi-layered
internal review of our research methods and recommendations, but we also shared drafts
CEO
of our report with several health and child welfare stakeholders and with DFPS senior
staff, as noted above, for their review prior to publication.
Stephanie Rubin

I look forward to collaboratively working towards strengthening Texas’ efforts to

prevent pregnancy among youth in foster care, support parenting teens in foster care,
and take other steps to support our most vulnerable Texas children and families.
The role of state leaders

Your letter says, with respect to the high pregnancy rate in foster care, that our report “implies...that
DFPS and State Leadership is aware and ignores this circumstance.”

We do not question the character or goodwill of DFPS staff or state leaders. In fact, the introduction
to our report states that “Texas is not falling short because of indifference.” The introduction further
notes that among DFPS, state leadership, and child welfare stakeholders, a “growing number of
people recognize the importance of these issues.” That statement was intended to give credit to
DFPS, state leaders, and others for their growing recognition of the challenge.

Further, throughout the report we refer to the state’s ongoing efforts to improve services provided to
older youth or pregnant and parenting youth. For example, we recognize that the state has
developed minimum licensing standards related to this challenge (see page 12), included healthy
relationships and reproductive health in the the Preparation for Adult Living (PAL) curriculum (see
page 13), and established the Helping through Intervention and Prevention (HIP) program to
support pregnant and parenting youth. Regarding the HIP program, we discuss its successes and
advocate for continued investment on pages 24-26.

We regret if our words were misinterpreted to suggest that DFPS and state leaders willfully
“ignore” the subject. Rather, we acknowledged that the agency and state leaders have set up a
strong foundation upon which we can build.

Report’s impact on recruitment of foster parents

If I understand correctly, you believe that we were wrong to publicly draw attention to the high rate
of teen pregnancy in foster care. We respectfully disagree with that view.

I understand your concern that awareness of the too-high rate of pregnancy among Texas foster
youth might affect recruitment of foster parents for teens, although we have not seen evidence to
that effect. Our report is certainly not the first public discussion about the challenges of youth in
foster care. Further, our report outlines suggestions for ways to recruit foster parents willing to
welcome older youth and pregnant or parenting youth into their homes. We recommend in our
report that Child Placing Agencies actively work to recruit or develop foster families that are
specifically interested in serving older youth and pregnant and parenting youth.

We believe that drawing attention to the numbers of Texas youth who become pregnant or a parent
while in foster care is an important step towards motivating stakeholders and policymakers to
commit to working harder to reduce the pregnancy rate and address the other challenges we
highlighted in our report.

Comparisons of the pregnancy rate in foster care

Your letter states that it is “misleading to compare youth in Texas foster care to youth in the general
population.” In fact, it is common in Texas and nationally to compare outcomes of disadvantaged
populations to those of the general population. We see it in other health, child welfare, and
education research studies and policy reports on a regular basis.

Of course, any comparison group that is not rigorously “matched” has its limitations, including a
comparison with youth enrolled in Medicaid, as your letter recommended. Not all children enrolled

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in Medicaid have the trauma histories of youth in foster care. For the children enrolled in Medicaid
due to low family income, their poverty alone is not an indicator of weak parental support, abuse, or
neglect. In fact, countless low-income children are raised in nurturing, resilient families. Moreover,
even if the pregnancy rates of youth in foster care and youth enrolled in Medicaid may be more
similar (evidence for which your letter does not provide), it certainly would not invalidate our
conclusion that the pregnancy rate of youth in Texas foster care is too high and requires further
attention.

Your letter further states that our report “misleads” because the overall teen pregnancy rate in Texas
is “likely underreported.” During the research and writing of this report we consulted with Texas
experts who focus on teen pregnancy, and none of those experts raised this issue. If your office has
data to support that claim, we would be happy to take a look at it.

The key point is that too many youth in foster care get pregnant when they are young and
insufficiently prepared, which impacts not only their trajectories in life but also the health and well-
being of their baby. In raw numbers, data from DFPS show there were 332 youth who were
pregnant in 2017 while in care and 218 youth in foster care were mothers or fathers. As the “parent”
to these vulnerable children, Texas is responsible for ensuring they have the knowledge and loving
support to develop healthy relationships, delay pregnancy, and thrive. We believe this is a challenge
worth addressing and we hope you agree.

Likelihood of pregnancy in foster care by age 20

Your letter states, “We are aware of no reliable data that indicates 50 percent of youth in Texas
foster care will “likely” be pregnant by age 19, as you claim.” The letter concludes that because the
agency is not aware of the data, our statement on the subject is not only “sensational” but
“deceptive.”

The exact statement in our published report is, “In fact, analysis of HHSC data indicates that more
than half of teen girls in DFPS conservatorship who age out of care or extend their time in care will
become pregnant before they turn 20.” Earlier drafts of the report expressed the point slightly
differently.

I am happy to share with you a detailed explanation of how we arrived at that conclusion working
in collaboration with outside experts on pregnancy data analysis. To estimate total prevalence of
adolescent pregnancy, we utilized data from HHSC to calculate a pregnancy rate by year for
adolescents aged 11-19. We subtracted out prior pregnancies in Medicaid and CHIP programs as
identified by HHSC (to take out any repeat pregnancies) and summed the annual risk. While not as
precise as individual-level longitudinal tracking, this method provides a reasonable estimation of
magnitude of risk exposure across years. Additionally, in an attempt to produce a more conservative
rate, we excluded 19-year-olds from the calculation, as pregnancy rates in that age group were
extremely high and it seemed plausible that pregnancy could make former foster youth more likely
to remain on the STAR Health plan. If 19-year-olds in STAR Health are included in the calculation,
it comes out to 73 percent.

I cite below four other resources with relevant findings. Please note that the STAR Health birth rate
is significantly lower than the pregnancy rate, and therefore the birth rates cited below are also
presumably lower than the pregnancy rate. We believe the reason the birth rate in foster care is
lower than the pregnancy rate in foster care is primarily attributable to the number of youth coming
in and out of care:

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 • Child Trends, the Annie E. Casey Foundation, and others regularly cite two studies that
surveyed youth formerly in foster care in the Northwest and Midwest US, which both found
that over 70 percent of youth who age out of care will become pregnant by age 21.
• In 2017, using data from the National Youth in Transition Database, Montclair State
University and William Patterson University released a study of early childbirth among
females transitioning out of foster care, which revealed that “over 40% of females had given
birth at least once by age 21, with a substantial increase in birth rates from adolescence to
early adulthood” [emphasis added]. This study also compares youth to the general
population.
• The 2012 Texas Foster Care Alumni Study Technical Report by Casey Family Programs of
young adults ages 23-24 previously in foster care revealed that “more than half [of former
youth surveyed age 23-24] (58.3%) had given birth to or fathered a child; 10.0% of all
alumni had done so before age 18” [emphasis added]. This study compares youth in foster
care to the general population.
• In the federal lawsuit against the state, testimony revealed that “49% of women who age out
of the foster care system are pregnant by age 19.” M.D. v. Abbott, No. 2:11-cv-00084, at 51
(S.D. Tex. Jan. 19, 2018).

Your letter notes the lack of a rigorous, longitudinal analysis following a cohort of children in
Texas foster care. We agree that such a study would be illuminating. As our report noted, better
data is needed to help understand how best to prevent pregnancy among youth in foster care and
effectively serve pregnant and parenting youth in foster care. If such a longitudinal analysis is of
strong interest to you, we would be happy to support your agency’s efforts to pursue funding for
this research from the Legislature, other government sources, or philanthropy.

Reasons for the high pregnancy rate in foster care

Contrary to the suggestion in your letter, our report neither states nor implies that Texas foster care
causes teen pregnancy. Our report section titled “Reasons for High Pregnancy Rate Among Youth
in Foster Care” explicitly lays out the factors we identified that may contribute to the too-high rate:
“youth in foster care often lack supportive and loving relationships” and the “effect of stressful and
traumatic events and the high number of placements and homes for some youth in foster care also
contribute to the high rates.”

Further, we articulated to DFPS senior staff verbatim that we do not believe foster care causes the
higher rate of pregnancy found in our report after one news story in particular took that slant (and
we complained to the producers about that story, which was subsequently pulled down).

We appreciate that improving placement stability and the availability of loving homes prepared to
support the needs of children in foster care are among your priorities and we hope your continued
attention to these challenges meets with success.

Low rate of early prenatal care

I am puzzled by your suggestion that our report implies pregnant teens in foster care are
“purposefully prevented” from receiving prenatal care. The report simply points out that the rate of
early prenatal care is low for pregnant teens in foster care in Texas. The report recommends that to
address the low rate, “Texas Should Use Best Practices, a Performance Improvement Project, and
Data to Improve Access to Care.”

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In fact, our report simply reiterates findings of the Institute for Child Health Policy at the University
of Florida, which Texas contracts with to perform external quality review of our state’s Medicaid
program. The Institute found that the prenatal and postpartum care rate “varies demonstrably”
between STAR and STAR Health and recommends higher-performing health plans share best
practices with lower-performing plans. Nothing in our report’s analysis or recommendations
suggests that that there is an intentional effort underway to prevent teens in foster care from
receiving prenatal care.

In closing, I appreciate this opportunity for a dialogue about our report and these important issues. I
am optimistic that the agency, as well as other state leaders and child welfare stakeholders, will note
several findings in the report that deserve strong support and action. If we can more effectively
reduce pregnancy among youth in Texas foster care, these vulnerable youth will have a better shot
at a successful future. For those youth in foster care who do become parents, ensuring they have the
tools and supports to raise healthy children is critical to reducing the cycle of CPS involvement.

We greatly appreciate the many bold actions you have taken as Commissioner to improve outcomes
for Texas children in foster care and look forward to working together with you and your staff
during the interim and the 86th legislative session. We want the best for Texas children and have no
doubt you also share that goal.

I would be happy to meet in person to discuss our report and other opportunities to improve the
lives of children in foster care and strengthen families.

Sincerely,

Stephanie Rubin, JD
CEO

cc: Governor Greg Abbott

Lieutenant Governor Dan Patrick
Speaker Joe Straus
Chairman Charles Schwertner
Chairman Richard Raymond
Executive Commissioner Charles Smith
Commissioner John Hellerstedt

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