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date: 31 March 2023

# Family Services

• Katharine Briar-LawsonKatharine Briar-LawsonUniversity at Albany, State University of New York
•  and Toni NaccaratoToni NaccaratoCalifornia State University, East Bay

### Summary

This overview of family services addresses some of the demographic trends and diversity in U.S. families. Inclusionary and exclusionary dynamics are cited, including the ways that income and race may insidiously determine discriminatory practices and differential outcomes. An array of family services are presented. They build on the evidence-based reviews related to the Family First Prevention Services Act. Key programs cited are Functional Family Therapy, Multisystemic Therapy, Brief Strategic Family Therapy, Motivational Interviewing, Nurse–Family Partnership, Healthy Families America, Parent–Child Interaction Therapy, Parents as Teachers, and Homebuilders and Kinship care. Questions are raised about the need for a family support agenda in the United States that addresses diverse intergenerational families, ensuring their capacity to deliver core services to their members and provide equitable and basic guarantees.

### Subjects

• Couples and Families
• Populations and Practice Settings
• Social Justice and Human Rights
• Social Work Profession

### Updated in this version

Content and references updated to reflect the latest developments.

Over the decades, family services have been one of the overarching features of social work practice, education, and research. As capacity builders, social workers recognize that families, however defined, provide intergenerational services to their members. These include counseling, education, child and elder care, healthcare, and norm enforcement, as well as economic and related supports (Briar-Lawson et al., 2001). In fact, families represent the only “cradle to grave” system of care for their members in society. Nonetheless, they often lack needed resources and effective supports to carry out these core functions and services.

Social work focuses on serving individuals in the contexts of their families to address intergenerational and diverse family systems. Individuals served and treated without their family context addressed may be insufficiently assessed and aided. The growing diversity in families compels more cross-cultural competence, and inclusive and responsive policies and services, along with evidence-based practices. Family service practitioners must increasingly address the social exclusion of many families while integrating support for economic, employment, and financial capability with counseling, skill training, and other interventions.

Historically, social work has been at the forefront in developing services for families. Early social workers such as Mary Richmond (1917) built a case for social work serving families in her landmark book, Social Diagnosis. Despite her role in demarcating services to families as a core domain for social workers, individualistic, psychopathological approaches dominated practice for the next three decades. As a countervailing force, family therapy emerged in the mid-1950s. Social work leaders such as Satir (1964) helped foster the family therapy movement, while Hartman and Laird (1983) focused attention on public sector families, and Reid (1985) led the movement for evidence-based and task-centered family services.

Knowledge development regarding family services has been building over the years with evolving practice models (Reid, 2002). Examples include family preservation (Fraser et al., 1991;Maluccio et al., 2002; Whittaker et al., 1990), family group conferencing and restorative justice (Burford & Hudson, 2000; Marsh & Crow, 1998; Van Wormer, 2003), family support and family resource centers (Weissbourd & Kagan, 1989), and family-centered interprofessional practices (Briar-Lawson et al., 2001; Corrigan & Bishop, 1997). The need to determine the efficacy and effects of interventions increasingly challenges researchers, policymakers, and practitioners. Evaluation rigor, unbiased systematic reviews, and construct validity are major concerns (Gambrill, 2006, 2019; Littell, 2005). Moreover, services may not be responsive to diverse families (Sue et al., 2019). Racial equity is a major concern affecting many services for families and involving their disparate if not impeded access to key programs, supports, and resources, contributing to disparities in outcome effectiveness. Disproportionalities based on race compel systematic interventions, programs, and policies to ensure that race does not dictate social or economic outcomes. Critical knowledge has also been developing since the late 1990s with the discovery of the prevalence of adverse childhood experiences (ACES) and trauma sequelae across several generations. Epigenetic and brain science implications have underscored the centrality of trauma concerns in family services (Anda et al., 2006; NASEM, 2019a). Additional research highlights the importance of structural contributors to trauma and toxic stress including adverse community environments (Ellis & Dietz, 2017; NASEM, 2019a). These additional adversities may include poverty, lack of opportunity, poor housing, violence, and racial discrimination (Ellis & Dietz, 2017; NASEM, 2019b). According to Child Trends (2021), life experiences for 1 in 10 children create harms to their health and development. Three or more adverse experiences may impact Black children and also poor children (Child Trends, 2021). These childhood adversities may track into adult health challenges and early death (Anda et al., 2006).

### Addressing Family Diversity, Social Inclusion, and Exclusion

Families, of origin or choice, are more diverse than ever before. The need to address differences in family structure, race and ethnicity, sexuality, gender fluidity or variant orientations, and socioeconomic status compels an array of responsive, equitable family services (NASEM, 2019b).

Definitions of families vary and remain contested. The National Association of Social Workers (NASW, 2007) defines a family as two or more persons “who assume obligations and responsibilities generally conducive to family life.” This broad definition encompasses the diversity of families, including single parents, kinship caregivers, divorced (stepparent), adoptive, chosen, and resource families, and gay, lesbian, bisexual, transgender, queer, or questioning (LGBTQ) individuals and their families. Dramatic structural changes in families have emerged since the 1960s. These are attributed to the rise in divorces (Jewell et al., 2017), cohabitation rather than marriage, and non-marital childbearing (Vanoram & Scommegna, 2018).

According to the Centers for Disease Control (CDC) 2020 Vital Statistics Report, nearly 40% of children were born to unmarried women that year (Martin et al., 2018). Single-parent families are more likely to be poor as there is only one wage earner, who often faces child support and childcare challenges (Child Trends, 2019;Yuan-Chiao et al., 2020). In 2017, the proportion of children in poverty by race/ethnicity was highest among Black and Hispanic children (29% and 25%, respectively, compared with 11%among white children) (Child Trends, 2019).

Same-sex married couples with children are also on the rise, especially made possible by the legalization of same-sex marriages in 2015. Two years after that date, 10% of LGBTQ Americans are married to their same partner (Jones, 2017). Few services or policies have addressed the implications of LGBTQ households and their family support needs (NASEM, 2020). Moreover, major challenges remain in the use of more inclusive language and research relating to LGBTQ families (Trans Students Educational Resources, 2019).

Fluidity in families represents some of the emergent aspects of diversity which affect family services. For example, increasingly some children, youth, and adults may prefer nonbinary gender identity. Fluidity is also seen in family structures. More than half of children today are living in blended families with remarried or cohabitating parents, or with a single parent (Pew Research Center, 2015). As cohabitating structural relationships become more prominent, single-parent women and their supports may need to be modified (Pew Research Center, 2019).

Ethnic and racial diversity has also increased, and projections are that by 2060 the white, non-Hispanic population will become a minority group in the United States (Colby & Ortman, 2015). By 2060, the Hispanic population in the United States is projected to be 111.2 million (28%) (Colby & Ortman, 2015). The pluralistic society of the United States also will see an increase in individuals representing two or more races. Such cross-cultural enrichments and the benefits of such diversity have major implications for the social work profession and family services. Inclusivity, a social work hallmark, is especially critical in these times given some attitudes of disdain among small segments of the population toward diversity seen in national immigration debates. Antiracism movements to counter white supremacy views are one of the many byproducts of bias, racism, and the lack of inclusionary and equitable practices in the United States. Rising numbers of immigrants add to the growth in minority families. However, for many ethnic and racial minority groups, economic disparities may be pronounced (Logan, 2014). Moreover, falling birth rates create problematic implications for the future workforce of the nation and for caregiving across the generations (Hamilton et al., 2019). By 2030, 20% of the population will be over 65 (Colby & Ortman, 2015).

Fertility problems alone may compel more governmental investments in successful life chances for diverse children and their families. Risk factors and adverse outcomes may increase in problematic births to low-income, single-parent mothers. This includes low-birth-weight babies and infant mortality (CDC, 2020). For example, a child’s life chances begin at birth if not before. Low birth weight is seen as a risk factor for death and related developmental problems. Moreover, infant mortality reveals racial disparities that have endured for a century (MacDorman & Mathews, 2011). Black babies have a death rate of twice that of their white counterparts at 14%. Approximately 7.9% of infants are low-birth-weight babies among American Indian and Alaska Native populations, as well as Asian Pacific Islander populations (Eli & Driscoll, 2020; Taylor et al., 2019).

Rising inequality between the top 1% of families compared to the bottom 99% has created unprecedented economic gaps in the United States. Instead of creating a more equitable income pie, economic conditions have become more disparate (Chetty et al., 2020). Social mobility should be a prominent public policy goal and one linked to social work services for families. In the early 21st century, social mobility rates among U.S. family members are far less than those in Canada or in European countries like Denmark (Isaacs, 2016). Thus, expectations that one’s mobility will be impeded may add to school dropouts, financial stress, joblessness, and lives of underutilized talents. Absent systematic ladders out of poverty, with economic, employment, and occupational support, mobility barriers may persist, especially for families of color.

Poverty remains a corrosive and critical social determinant of adversity in families. Nearly one in five children lived in poverty in 2017 (Annie Casey Foundation, 2020; Child Trends, 2019), and over 2.5 million experienced homelessness (Bassuk et al., 2014). Among seniors, the poverty rate has increased from 16.0% in 2015 to 18.1% in 2016 (Edwards et al., 2017). By race, in 2018, the poorest group comprised Native Americans at 25.4%, followed by Blacks at 20.8% and Hispanics at 17.6%. This is compared to the 10.1% rate among white as well as Asian populations (Poverty Facts, 2019).

In many cases, parents work full time and are still poor. Economic status early in life has a profound effect on future well-being. Poverty is a major risk factor for child abuse and neglect, delinquency, future health, and school problems (Child Trends, 2019; NASEM, 2019b), as well as adult imprisonment (National Research Council, 2014). Child poverty is estimated to cost the United States$800 billion to$1.1 trillion a year (NASEM, 2019b).

Cross-generational diversity also has ramifications for family-related policy and practice (Kahanana et al., 1994). Ten percent of grandparents and 10% of children reside together (Ellis & Simmons, 2014). Given the longevity of older adults, caregiving demands may span four to five generations, falling disproportionately on women. Nationally, approximately 3 million grandparents have responsibility for their grandchildren, increasing from 3.6% in 2000 to 3.8% in 2014 (Bureau of the Census, 2016a; Pew Research Center, 2013). Some of the increase in grandparents raising their grandchildren is due to the opiate epidemic (Anderson, 2019). Over 20% of these kinship care families are below the poverty line. Multigenerational households with two or more adult generations in the same home are also on the rise, representing 20% of all households (Cohn & Passel, 2018). Some of these multigenerational households may reflect great vulnerabilities and are overlooked in public policy income protections and social supports (Baker et al., 2010). The Covid pandemic has further exposed the caregiving challenges in the nation as women have been the primary caregivers for their children and others across the generations (Ciciolla & Luthar, 2019).

### Theoretical Foundations

Many theories inform practice with families. Learning theory fostering behavioral and cognitive behavioral approaches addresses family needs for more concrete skill acquisition. Other dominant theoretical perspectives include: ecological, empowerment, systems and family systems, stress and coping, resiliency, feminist, multicultural, crisis, communications, intersectionality, developmental social control, social learning, trauma informed, psychoeducational family counseling, structural family therapy, solution-focused therapy, and narrative family therapy. In some cases, practice with families, as well as research, is atheoretical and the link between theory and practice may be hard to discern (Corcoran, 2000, 2003; Van Hook, 2019).

#### Approaches

Approaches to family services vary. Dominant methodologies embrace risk and protective factors, strengths, or systems as the basis for assessment and intervention. Trauma-informed therapies are also on the rise. Research has focused on trauma-informed care with children, youth, and families in healthcare services (Stenman et al., 2019), social services (Barnett et al., 2018; Fraser et al., 2014), juvenile justice (Ford & Blaustein, 2013), education (Brunzell et al., 2019; Chafouleas et al., 2016; McIntyre et al., 2019), implications for organizational changes (Kirst et al., 2017; Sundborg, 2019), substance abuse (Kirst et al., 2017), and mental health services (Chung et al., 2009; Kirst et al., 2017). There is a growing demand for trauma-informed services because of new awareness of the prevalence of traumatic events involving children and their varied ramifications (Cutuli et al., 2019). According to Marsac et al. (2016), many definitions of trauma-informed services exist, but at the basic level these approaches offer an appreciation that children and families may have experienced ongoing or past traumatic events or that current care may be perceived as traumatic. There also is an understanding that the processes of negative and positive adaptation following these experiences may impact the way a family or child reacts and functions in relation to new challenges and situations (Cutuli et al., 2019).

With the applications of trauma-informed services, growing evidence shows service effectiveness, and there are new focuses on conceptual and theoretical issues (Cutuli et al., 2019; Lucio & Nelson, 2016; Marsac et al., 2016), as well as studies looking at the efficacy of specific psychosocial treatments following traumatic events (Dorsey et al., 2017). Risk reduction and resilience promotion through the enhancement of protective factors is drawn from public health and prevention science. Risk factors may include low parental income (Brooks-Gunn & Duncan, 1997), low parental supervision and involvement, abusive discipline (Lahey et al., 1995), parental depression, childhood abuse, and domestic violence (Fraser, 2004). Protective factors may include strong parental structuring of rules and norms, child supervision, and supports such as a nurturing extended family (Pecora, 2006). Families of color may also have additional protective factors such as spirituality, or church or religious affiliations, or attachments to ethnic communities (Hodges, 1993). Interventions often address multilevel risk and protective factors using an ecological perspective.

Complementing risk, protective and resiliency approaches are strength-based strategies and services which focus on assets, social capital development, and solution-focused practices (Pecora et al., 2019; Saleeby, 1992; Van Hook, 2019). Seen by some as preferable to the problem or deficit approach, the evidence base is still being developed. Practitioners seek to build capacity, enhance assets, build on strengths, and remain solution focused.

A systemic, social, relational, or family systems approach using a life cycle framework dominates much of the family therapy movement (Konrad, 2020). Family therapy draws on psychodynamic, structural, humanistic, strategic, and narrative models of practice (Congress & Gonzalez, 2005; Van Hook, 2019; Vosler, 1996). Family members are seen as interacting in an organized fashion for task accomplishment. A change in one individual is seen to affect others and the family as a whole. This systems approach reinforces an ecological perspective (Konrad, 2020; McCubbin & Patterson, 1983; Sue et al., 2019; Van Hook, 2019; Vosler, 1996), and is reflected across a variety of programs and services for families and their members.

Perspectives and practice models have emerged involving Black feminist practice and theory (Jones, 2020). Integrating resilience-building supports with a strengths-based and spirituality approach, alternative culturally relevant interventions are offered. These are contextualized against the backdrop of racial, gender, sexual, and political challenges faced by women of color, especially single Black mothers.

Other culturally relevant innovations have been emerging in tribal communities relating to family supports, best practices in placement prevention of children in out-of-home care, and in interprofessional practice and parent empowerment. While designed for tribal service delivery, these innovations include practices that treat child welfare and other families as “extended family members,” meeting their needs with concrete resources and not just psycho-educational interventions. As with Afrocentric and Black feminist practice, such tribal approaches have implications for family services across multiple systems and populations (Day et al., in press).

### Describing and Rating Family Services

The medley of services for children, youth, and families may be described across three tiers (McCroskey, 2004). This tier approach has been used in the past and included the following: tier I—prevention and early intervention for families facing minor challenges requiring family support and education; tier II—crisis services, involving counseling and mental health treatment; and tier III—those requiring state intervention (out-of-home placement or hospitalization) involving child protection or juvenile justice services (McCroskey, 2004). Many services addressing child abuse and neglect, juvenile delinquency, school problems, domestic violence, addictions, and health and mental health have been analyzed using the tier approach (Pecora et al., 2019). Some of these services have demonstrated efficacy (McCroskey, 2004; Pecora et al., 2019).

One strategy for rating family services and practices is the Title IV-E Prevention Services Clearinghouse (PSC). PSC was established by the Administration for Children and Families (ACF) within the U.S. Department of Health and Human Services (HHS) in 2018. The purpose of the PSC is to systematically review research on programs and services intended to provide enhanced support to children, youth, and families and prevent foster care and out-of-home placements. The PSC was developed in accordance with the Family First Prevention Services Act (FFPSA) of 2018, as codified in Title IV-E of the Social Security Act (Wilson et al., 2019). The PSC rates programs and services as “promising,” “supported,” and “well-supported practices.” These practices include substance abuse prevention and treatment services, mental health prevention and treatment services, and in-home parent skill-based programs, as well as kinship navigator programs. The PSC was developed to be a rigorous, objective, and transparent source of information on evidence-based programs and services that may be eligible for funding under Title IV-E of the Social Security Act as amended by the FFPSA.

The PSC uses a systematic review process implemented by trained reviewers using consistent, clear, and transparent procedures and standards (Wilson et al., 2019). According to the Title IV-E PSC website (2019), the following nine programs as of 2021 have received a well-supported rating with three stars: Functional Family Therapy (FFT), Multisystemic Therapy (MST), Brief Strategic Family Therapy (BSFT), Motivational Interviewing (MI), Nurse–Family Partnership (NFP), Healthy Families America (HFA), Parent–Child Interaction Therapy (PCIT), Parents as Teachers (PAT), and Homebuilders. These nine programs are summarized briefly as follows. Also discussed is kinship care.

#### Family Treatment Services

FFT addresses youth who are exhibiting at-risk and antisocial behaviors and is recognized as one of the prominent evidence-based interventions that addresses the needs of delinquents and their families (Celinska et al., 2019; Lipsey et al., 2010). FFT’s behavioral interventions focus on maladaptive interaction sequences and parenting skill deficits using a structured method of educating families regarding living skills (Gordon et al., 1995; Hartnett et al., 2017; Limoncelli et al., 2019; Sexton & Alexander, 2000). As of 2021, FFT is recognized by various institutions as efficient and useful, including the Office of Juvenile Justice and Delinquency Prevention, the American Youth Policy Forum, the Centers for Disease Control and Prevention, the U.S. Departments of Justice, and the University of Colorado (Blueprints for Healthy Youth Development) (Celinska et al., 2019). FFT has been shown to be effective with low-income single parents of delinquents (Gordon et al., 1995), first-time offenders from middle-class families (Alexander & Parsons, 1982), and offenders released from state institutions (Gordon et al., 1995). Studies showed reductions in recidivism, maintained over periods from 6 months to 3 years (Celinska et al., 2019; Gordon et al., 1995; Sexton & Alexander, 2000; Waldron et al., 2001). Studies found slightly better outcomes in recidivism rates for females than males, but that recidivism rates for both genders are statistically effective overall (Baglivio et al., 2014). One review found that FFT met the criteria for being an effective program (Austin et al., 2005). Later studies are exploring the importance of family participation in FFT using qualitative and mixed methods research methodologies (Celinska, (2015); Limoncelli et al., 2019; McPherson et al., 2017).

MST is recognized as an important treatment within the multisystems approach with families (Konrad, 2020; Van Hook, 2019). Over 100 peer-reviewed studies have been completed on MST (Henggeler & Schaeffer, 2016; Pecora et al., 2019). According to Pecora et al. (2019, p. 375), “MST is built on the principle and scientific evidence that a seriously troubled child’s behavioral problems are multidimensional and must be confronted using multiple strategies.” MST showed cost-effective and positive results in long-term outcomes for youth and children exhibiting serious behavioral difficulties, as well as their families’ well-being (Henggeler, 1999; Henggeler & Schaeffer, 2016; Konrad, 2020).

MST interventions address individual youth and child functioning with family, peers, schools, and other systems (Henggeler, 1999; Henggeler & Schaeffer, 2016). MST characteristics include 24-hour intensive, time-limited, home- and family-based treatment for youth and children referred from the juvenile justice systems (Burns et al., 2000; Henggeler, 1999). MST has also been adapted to many different populations and is effective with children and youth exhibiting serious emotional disturbances (Burns et al., 2000), adolescent antisocial behavior (Schaeffer & Borduin, 2005; Tan & Fajardo, 2017), youth substance abuse (Henggeler et al., 2016, Tan & Fajardo, 2017), adolescents with poorly controlled type I diabetes (Ellis et al., 2007), those with co-occurring disorders, adolescents whose challenges stem from insufficient or neglectful parenting (Tan & Fajardo, 2017), those in mental health settings, and juvenile justice-involved youth and their families (Timmons-Mitchell et al., 2006). Although some of the research has shown positive effects, the magnitude, reliability, and replicability of these effects have been questioned (Henggeler, 1999; Littell, 2005; Timmons-Mitchell et al., 2006).

BSFT is grounded in structural and strategic models of family therapy (Santisteban et al., 2003). BSFT has demonstrated effectiveness in engaging families, youth, and children in treatment (Szapocznik & Hervis,2020). BSFT targets children and adolescents, especially Hispanic youth and families with behavior problems, including conduct, peer issues, early substance abuse, and problematic family relations (Robbins et al., 2002; Santisteban et al., 2003). BSFT has been used with youth and children between the ages of 6 and 17 and has been tailored to inner-city minority families (Robbins et al., 2002; Santisteban et al., 2003). BSFT’s strategies have been found to be superior to traditional approaches in engaging and retaining families (Santisteban et al., 2003; Szapocznik et al., 1989; Szapocznik & Hervis, 2020). BSFT with Hispanic youth has been found to demonstrate significantly greater improvement than a control group in parental reports of conduct problems, delinquency, youth drug use, and family functioning (Santisteban et al., 2003).

MI is an evidence-based practice model that is considered robust and has extensive empirical support in engaging individuals. Miller and Rollnick (2013) developed MI in the 1980s. MI is accepted to be a model of collaborative conversation that enables users to resolve and identify ambivalence in changing behaviors. The empirical support has been found in the following health change behaviors: weight loss, sobriety, smoking cessation, lower HIV viral load, and improved diet, physical activity, and dental hygiene (Burke et al., 2003). Other research has found MI to be effective with disordered gambling (Yankovenko et al., 2015). Connors et al. (2001) stated that the “transtheoretical model of change, which informs MI, describes five stages that people move through in changing a given behavior” (p. 560). These five stages are: precontemplation, contemplation, preparation, action, and maintenance. Termination of the five-stage process has been suggested to occur when the individual is secure in her/his/their maintenance of change. The transtheoretical model of change has historically been applied to behavioral changes needed to improve health and well-being (Hoy et al., 2016).

#### Early Development and Parenting Home-Visiting Services

The conception of serving families in their residences began with the Friendly Home Visitors in America in the 1880s (Schweitzer et al., 2015). One strategy for serving families in their homes is an NFP. NFP nurses, sometimes referred to as home-visiting nurses, aim to improve outcomes related to child health and development, pregnancy, and parental life-course development. They do this by providing education, support, and care (Olds et al., 2015). NFPs have been found to be effective in promoting healthy adjustment to the parenting role and family functioning in the first years of a child’s life. This has been statistically associated with the prevention and early intervention of child maltreatment (Flemington & Fraser, 2016). Collaboration between child welfare agencies and NFPs varies by community; however, both professional disciplines practice risk assessment. Child welfare case managers and nurses struggle and face uncertainties and ambivalence during their assessment and decision-making processes (Williams et al., 2019). NFP has well-documented evidence dating back to the late 1970s, with randomized controlled studies showing consistent outcomes related to improved prenatal health, reduced child maltreatment, and a decrease in childhood injuries (Eckenrode et al., 2017).

Healthy Families America (HFA) is a home-visiting program for new and expecting families who are at-risk for ACES and/or maltreatment. HFA was developed by Prevent Child Abuse America and is a nationally accredited program (Cullen et al., 2010; Green et al., 2020; Title IV-E PSC, 2019). The goals of the program are to promote healthy childhood growth and development, strengthen nurturing parent–child relationships, and enhance family functioning by building protective factors and reducing risk behaviors. HFA includes assessments and screenings to identify families most vulnerable and needing services. This objective is accomplished by offering intensive, long-term, and culturally responsive services to parents, children, and youth, and connecting families to medical providers and other community services as needed (Title IV-E PSC, 2019).

HFA locations are able to determine which family and parent demographics they target based on community needs. Typically, families are offered services for a minimum of three years and receive weekly home visits at the start of the helping process (Cullen et al., 2010; Green et al., 2020; Title IV-E PSC, 2019). These visits are decreased depending on each family’s needs and progress after 6 months. All HFA home-visiting staff must have a minimum of a high school diploma or equivalent and are required to attend a four-day core training course and receive supplemental wraparound training. Supervisors and program managers must also complete additional trainings to supplement core trainings such as the Infant Mental Health Endorsement (Title IV-E PSC, 2019).

#### Parent and Child Interactions

PCIT is a family-centered intervention strategy for children between the ages of 3 and 7. PCIT provides caregivers with live and immediate behavior management coaching (Chakawa et al., 2020; Zisser & Eyberg, 2008). According to the Child Welfare Information Gateway (2013), PCIT is considered an empirically based therapy for at-risk children and youth and their caregivers that is designed for mental health professionals with a master’s degree or higher in psychology, social work, or a related field. The intervention is rooted in social learning theory, attachment theory, and operant conditioning (Zisser & Eyberg, 2008). There is limited research to date that has examined treatment options for adoptive foster parents struggling with managing and reducing difficult child behaviors (Chakawa et al., 2020).

The Parents as Teachers (PAT) Home Visiting model provides services to families with children from prenatal through kindergarten and is used by PAT affiliates. It is a home-visiting program focusing on parent education using parent educators doing home visits (Neuhauser et al., 2018; Title IV-E PSC, 2019). PAT seeks to discern and prevent health issues, developmental delays, child abuse and neglect, and to increase school readiness and success for at-risk families. PAT promotes community resource networks, supportive group connection events, child health, and developmental screenings and assessments. Services are offered on a weekly or biweekly basis and are usually held for 60 minutes in the family’s residence as well as in family resource or childcare centers or schools.

#### Intensive Family Preservation Services

The Homebuilders model is constructed to provide intensive, in-home counseling, skill-building and support services for families that have children (0–18 years old) who are in placement and cannot be reunified without intensive in-home services or who are at imminent risk of out-of-home placement (Title IV-E PSC, 2019; Washington State Institute for Public Policy, 2006). The model is considered an intensive family preservation model. The Homebuilders model was initially funded by the Edna McConnell Clark Foundation in the 1980s (Schweitzer et al., 2015). The Homebuilders model takes advantage of challenges and crises in families and the focus of practice professionals such as social workers and clinicians on a family’s strengths, values, and barriers to achieving goals while also conducting ongoing, behaviorally specific, and holistic assessments (Schweitzer et al., 2015; Title IV-E PSC, 2019; Washington State University for Public Policy, 2006). Homebuilder’s practitioners collaborate with family members, representatives, and referents to deveintervention goals and corresponding service plans. These intervention goals and service/case plans focus on risk factors related to out-of-home placement or reunification. Throughout the intervention, the practitioner uses clinical strategies and develops safety plans designed to promote safety and child well-being. Practitioners have small caseloads of two to three families. The practitioners are available for consultation and intake 24 hours a day, seven days of week, for a four-to-six-week period (Washington State University for Public Policy, 2006). Treatment services primarily take place in the residence of the client. Practitioners are required to have a master’s degree in psychology, social work, counseling, or a closely related field, or a bachelor’s degree in social work, psychology, counseling, or a closely related field with at least two years of related experience (Title IV-E PSC, 2019).

#### Kinship Care

Kinship care is thought to be an important placement type when children are unable to reside with their parents due to child maltreatment. The Child Welfare League of America defined kinship care as the “full-time protecting and nurturing of children by grandparents, aunts, uncles, godparents, older siblings, non-related extended family members, and anyone to whom children and parents ascribe a family relationship) (Child Welfare League of America, 2021). More children today are being raised by their grandparents than at any other time in history in the United States (Duerr Berrick & Hernandez, 2016; Pecora et al., 2019). There are a disproportionate number of children of color residing in relative homes (Pecora et al., 2019). Historically, this can be traced to cultural responses to poverty, slavery, and incarceration of parents (Roberts, 2012). Kinship care has been associated with family displacement, substance abuse, incarceration, death of a parent, and hardships related to the health and/or mental health challenges of a child’s parent (Gleeson & Seryak, 2009). There are numerous types of kinship care arrangements, such as state-independent kinship care (e.g., informal kinship care), state-mediated care (e.g., kinship diversion, legal guardianship), and state-mandate care (e.g., kinship foster care, voluntary placement agreements, kinship guardianship, kinship adoption) (Duerr Berrick & Hernandez, 2016). However, there are limited data on children’s characteristics and their caregivers in these kinship arrangements (Duerr Berrick & Hernandez, 2016).

### Disparities: Focusing on Cultural Competence and Relevance

Cultural competence with diverse families requires effective interactions and skills at interpersonal, group, agency, and systems levels (Hyde, 2004; Lum, 2005; Min, 2005). Cultural competence and multimodal interventions may address some of the impediments to service and disparate outcomes faced by minority families and their members (Tomita, 2000). Programs such as family preservation services, questioned for their effectiveness because of flawed research designs, continue to show promise for families of color (Ayon & Lee, 2005). Moreover, family group conferences, developed by the Maori of New Zealand, have been adapted successfully to diverse families in child welfare and juvenile justice in the United States (Burford & Hudson, 2000; Marsh & Crow, 1998; Van Wormer, 2003).

Cultural competence also applies to sexual minorities (Van Den Berg & Crisp, 2004). LGBTQ individuals may share common experiences with other minority populations; however, important within-group differences have service implications (Cochran et al., 2007). Facing impediments to high quality of treatment, despite the legalization of same-sex relationships through civil unions and same-sex marriage, LGBTQ families are often reluctant to disclose their status because of discrimination fears (Maccio & Doueck, 2002). Youth who reveal their sexual orientation are placed at higher risk of suicide attempts, substance abuse, human trafficking, and becoming homeless or infected with HIV (Eisenberg et al., 2017; Hall, 2018; Nolan, 2006). Like ethnic and racial minorities, LGBTQ individuals often face barriers when seeking care for either themselves or for their families. This includes psychotherapy/counseling, intimate partner violence, behavioral health treatment, and pediatric and gynecological care (Maccion & Doueck, 2002; NASEM, 2020; Nolan, 2006; Simpson & Helfrich, 2005). Specialized services in foster care placements and transitional living programs serving LGBTQ youth have shown promise (Nolan, 2006).

Until programs and services are developed in response to the needs of diverse families and communities effectiveness remains elusive because of the potential lack of applicability and inclusion. Services that are not relevant to some families may further disparities and inequitable outcomes.

### Moving to a Family Support Agenda

Legislation such as the Family First Prevention Services Act (FFPSA) offers aid for parents whose children run the risk of out-of-home placement. Moreover, new ways of imagining and evaluating family service programs are being discussed and debated. The introduction of Parent as Teachers (PAT) as led to further innovations in implementation and evaluation strategies. In the past, the California Clearinghouse, the Cochran and Campbell Collaboration, and McCroskey’s three-tier system have been the structure and frameworks for assessing and evaluating family service programs. However, what is sorely needed in addition to these frameworks is a family support agenda with a better understanding of the importance of theoretical approaches that are blended rather than single-issue interventions. For example, this includes integrated behavioral health interventions such as the Homebuilders model that uses MI in collaboration with family preservation principles, teaching new skills that facilitate behavior change. The family services discussed here have been shown to be effective and rated by PACT and the California Clearinghouse, as well as independent research studies. However, results and findings have been mixed and further criteria need to be developed to increase the empirical rigor to better understand program efficacy and impacts. Innovations transferred from other nations, including First Nations, are also warranted as a cross-national perspective on family services programs may open up new approaches, including those that arise in indigenous communities and that may serve diverse families. Many individuals and families face compounding harms of discrimination and preventable hardships as a consequence of the intersectionalities that include homophobia, sexism, racism, ableism, classism, and ageism.

### Future Trends

The United States does not have a family policy or a framework for investing in families and helping them with their vital roles and responsibilities. Moreover, the United States, unlike Western European countries and other social-democratic nations, does not provide demogrants such as family allowances and other income entitlements to families other than Temporary Aid to Needy Families (with strict eligibility requirements) (NASEM, 2019b).

Economic and employment supports need to be integral components of 21st-century family services (Adams & Nelson, 1995; Briar-Lawson et al., 2001; NASEM, 2019b). Services alone will not systematically lift families out of poverty (Schorr, 1997), nor will they address some of the pronounced disparities and disproportionalities experienced by minorities (Hill, 2007). Such disparities require advocacy to address exclusionary dynamics (Kahn & Kamerman, 2002), economic, employment, and income rights, and racial equity.

While families provide counseling, education, healthcare, caregiving, norm enforcement, and economic and related support for their members, many lack capacity building, income supports, and related social protection programs to aid them. Thus, 21st-century reforms need to respond to family needs at the outset before a preventable crisis occurs. In effect, family services should focus on ways to aid and support families. Family resource centers, Parents Anonymous, wrap around services, kinship care, and navigator programs are a few of the examples that emerge. They, like programs approved by the PAC, need to be subjected to rigorous evaluation and include diverse populations as collaborators, researchers, and service beneficiaries. In some cases it may be found that stand-alone services are insufficient to meet needs. In fact, income supports such as increases in Earned Income Tax Credits and related material services such as housing may optimize some of the therapeutic and psycho-educational services reviewed here.

As of the early 21st century, the bulk of “family services” in this nation and elsewhere are provided informally by family members for one another. Vulnerabilities and preventable problems can be addressed through more systematic attention and policy supports buttressing the multifaceted care role families’ play across the generations. Equitable and supportive family policy must also ensure that intersectionalities and discrimination are systematically addressed. The well-being of most individuals often depends on the families and family-like structures that support them, and on the family policies that invest in the resilience, durability, and capacity of their care systems.