- Katharine Briar-LawsonKatharine Briar-LawsonUniversity at Albany, State University of New York
- and Toni NaccaratoToni NaccaratoUniversity at Albany, State University of New York
Over the decades, family services have been one of the overarching features of social work practice, education, and research. Efficacy studies help to reinforce the focus on serving individuals in the contexts of their families and to address intergenerational family systems. Families provide the bulk of services to their members but require tailored resources, effective services, and supports. The growing diversity in families compels more cross-cultural competence, responsive policies, and evidence-based practices. Family service practitioners must increasingly address the social exclusion of many families while integrating economic and employment supports with counseling, skill training, and other interventions.
Social work has been at the forefront in developing services for families. Early social workers such as Mary Richmond built a case for social work serving families in her landmark book, Social Diagnosis (1917). 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 family services.
Knowledge development regarding family services has been building over the years from advancements of numerous movements and practice models (Reid, 2002). Examples include family preservation (Fraser, Pecora, & Haapala, 1991; Maluccio, Pine, & Tracy, 2002; Whittaker, Kinney, Tracy, & Booth, 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), family-centered interprofessional practice (Briar-Lawson, Lawson, Hennon, & Jones, 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; Littell, 2005). Moreover, services may not be responsive to diverse families (Sue & Sue, 1999).
Addressing Family Diversity and Social Exclusion
Families, of origin or choice, are more diverse than ever before. The need to address differences in family structure, race and ethnicity, sexual or gender variant orientation, and socioeconomic status adds to the complexity and array of family services.
Definitions of families vary and remain contested. 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, gay, lesbian, bisexual, and transgender (LGBT) families.
Dramatic structural changes in families are reflected by the fact that fewer than half of children in the United States currently live in a nuclear family (NASW, 2007). African American children are less likely than other children to be living with two married parents. In 2006, 35% of African American children were living with two parents, compared with 84% of Asian children, 76% of non-Hispanic white children, and 66% of Hispanic children. In 2006, 9% of all African American children did not live with either parent, compared with 5% of Hispanic children, 3% of non-Hispanic white children, and 3% of Asian children (Child Trends Data Bank, 2006). Births to single mothers rose from 5.3% in 1960 to 36.8% in 2005 (Carlson, McLanahan, England, & Devaney, 2005). Single-parent families are more likely to be poor as there is only one wage earner, who often faces child support and child care challenges (Holyfield, 2002).
Ethnic and racial diversity has increased, with 33% of the U.S. population constituting minorities (Population Reference Bureau, 2006). Minority populations proportionally will increase while their White counterparts will decrease. In fact the U.S Census Bureau projects that the minority populations will constitute ∼50% of the nation's population by 2050 (Day, 2007). Higher birth rates and rising numbers of immigrants add to the growth in minority families. This has implications for social workers as the families being served will have even more diverse needs based on language and culture (Fong, 2003).
Endemic inequalities are accentuated as ethnic and racial diversity grows. For example, the life expectancy of Black newborns is 5 years less than that of White counterparts (Child Trends Data Bank, 2006). Latinos lag more than other ethnic and racial groups in education, and school drop outs rates (Gutierrez, Yeakley, & Ortega, 2000). Approximately 7.9% of infants are low-birth-weight babies among American Indian and Alaska Native populations (National Center for Health Statistics, 2004).
Although underreported, gender variant diversity involving same-sex, unmarried, partner households has increased by 314% from 1990 to 2000 (Smith & Gates, 2001). Few services or policies have addressed the implications of LGBT households and their family support needs.
Increases in socioeconomic diversity have also been pronounced as widening economic inequality affects family functioning and life chances of members (Teachman, Tedrow, & Crowder, 2000). About 12% of the U.S. population is living in poverty, and 17% of children live with families struggling with poverty (Child Trends, 2007). Poverty is a major risk factor for child abuse and neglect, delinquency, and school problems (Child Trends Data Bank, 2006; Lindsay, 2003), as well as adult imprisonment (Children's Defense Fund, 2007). Child poverty is estimated to cost the U.S. $500 billion a year because of crime and imprisonment, unemployment, and poor health (Holzer, 2007).
Cross-generational diversity also has ramifications for family-related policy and practice (Kahanana, Beigel, & Wykle, 1994). Given the longevity of older adults, caregiving demands may span 4–5 generations, falling disproportionately on women. Currently, 22% of single women and 10% of single men over the age of 75 live with relatives (Jordan Institute for Families, 2004). Nationally, 2.4 million grandparents have responsibility for their grandchildren (Jordan Institute for Families, 2004).
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, developmental social control, social learning, and differential association. 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).
Approaches to family services vary. Dominant methodologies embrace risk and protective factors, strengths or systems as the basis for assessment and intervention.
Risk reduction and resilience promotion through the enhancement of protective factors are 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 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 (Saleeby, 1992). 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 or family systems approach using a life cycle framework dominates much of the family therapy movement. Family therapy draws on psychodynamic (insight oriented), structural (power and structural attributes of parents), humanistic, strategic, and narrative models of practice (Congress & Gonzalez, 2005; 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 (McCubbin & Patterson, 1983; Vosler, 1996) and is reflected across a variety of programs and services for families and their members.
Efficacy Studies and Model Services Across the Continuum
A patchwork of services for families may be found across a continuum or three tiers (McCroskey, 2004). Some of these services have demonstrated efficacy. These include 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, hospitalization, adult protection services) involving child protection or juvenile justice services (McCroskey, 2004). Many services addressing child abuse and neglect, juvenile delinquency, school problems, domestic violence, addictions, health and mental health can be located along such continua.
Illustrative of a tier I effective innovation is Families and School Together (FAST), a social-work-led community-based, collaborative, multifamily family-support program for elementary school children with behavioral difficulties (Fischer, 2003; McDonald, Billingham, Conrad, Morgan, & Payton, 1997; Substance Abuse and Mental Health Services Administration[SAMHSA], 2007). FAST integrates several research-based clinical approaches during 8-week multifamily sessions involving a series of interactive activities (McDonald et al., 1997). FAST is effective in increasing academic performance and reducing classroom behavioral difficulties with at-risk school-age children (Fischer, 2003; McDonald et al.). One randomized trial found positive effects for American Indian children in reducing at-risk behaviors and increasing academic competence (Kratochwill, McDonald, Levin, Bear-Tibbetts, & Demaray, 2004). FAST also improves bonding, and related social capital development (Terrion, 2006).
A tier II example of an effective service is Brief Strategic Family Therapy (BSFT), rooted in structural and strategic models of family therapy (Santisteban et al., 2003). This has demonstrated effectiveness in engaging families and youth in treatment. 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, Bachrach, & Szapocznik, 2002; Santisteban et al., 2003; SAMHSA, 2007). BSFT has been used with 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). Two randomized trials found that BSFT's strategies were superior to traditional engagement approaches in engaging and retaining families (Santisteban et al., 1996; Szapocznik et al., 1989). One randomized trial of BSFT efficacy with Hispanic youth demonstrated significantly greater improvement than the control group in parental reports of conduct problems, delinquency, youth drug use, and in family functioning (Santisteban et al., 2003).
Families who are facing more serious challenges (tier III) require more intrusive and intensive services, which may result in out-of-home placement of children and youth. The Oregon Multidimensional Treatment Foster Care (MTFC) Program, a community-based treatment program, is based on over 30 years of longitudinal research on the treatment of antisocial behavior. The MTFC works to create opportunities for youth to live successfully in their communities while providing them with intensive supervision, support and skills development. A series of studies have documented the effectiveness of MTFC with a range of children, adolescents, and their families (Chamberlain, 2003; Chamberlain, Leve, & DeGamo, 2007; Chamberlain & Reid, 1998; Eddy, Whaley, & Chamberlain, 2004; Leve, Chamberlain, & Reid, 2005).
Another tier III example of effectiveness is Functional Family Therapy (FFT) which addresses youth who are exhibiting antisocial behaviors. Behavioral interventions focus on maladaptive interaction sequences and parenting skill deficits using a structured method of teaching family living skills (Gordon, Graves, & Arbuthnot, 1995; Sexton & Alexander, 2000). 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 multiple offenders released from state institutions (Gordon & Arbuthnot, 1990). Studies show reductions in recidivism, maintained over periods from 6 months to 3 years (Gordon et al.; Sexton & Alexander, 2000; Waldron, Slesnick, Brody, Turner, & Peterson, 2001), and one review found that FFT met the criteria for being an effective program (Austin, Macgowan, & Wagner, 2005).
A third example of an effective tier III program is Multisystemic Therapy (MST), which has shown positive results in long-term outcomes and cost benefits for youth exhibiting serious behavioral difficulties and their families (Henggeler, 1999). MST interventions address individual functioning with family, peers, schools, and other systems (Henggeler, 1999). MST characteristics include 24-hr intensive, time-limited, home- and family-based treatment for youth referred from the juvenile justice system (Burns, Schoenwald, Burchard, Faw, & Santos, 2000; Henggeler, 1999). MST has also been adapted to many different populations and is effective with children exhibiting serious emotional disturbance (Burns et al., 2000), adolescent antisocial behavior (Schaeffer & Borduin, 2005), youth substance abuse (Henggeler et al., 2006), adolescents with poorly controlled type I diabetes (Ellis, Templin, Cunningham, Podolski, & Cakan, 2007), and in a mental health setting with juvenile justice involved youth and their families (Timmons-Mitchell, Bender, & Mitchell, 2006). Although some of the research has shown positive effects, the magnitude and replicability of these effects have been questioned (Henggeler, 1999; Littell, 2005; Timmons-Mitchell et al., 2006). Littell's systematic review (2005) revealed methodological flaws in studies.
Disparities: Focusing on Cultural Competence
Cultural competence and multimodal interventions may address some of the impediments to service and differential 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). LGBT individuals share common experiences with other minority populations; however, important within group differences have service implications (Cochran, Peavy, & Robohm, 2007). Facing impediments to the legalization of same-sex relationships through civil unions and same-sex marriage, LGBT 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, and becoming homeless or infected with HIV (Nolan, 2006). Like ethnic and racial minorities, gay and lesbian individuals often face barriers when seeking care for either themselves or for their families. This includes psychotherapy/counseling, intimate partner violence, substance abuse treatment for gay and lesbian youth, and pediatric and gynecological care (Maccio & Doueck, 2002; Nolan, 2006; Simpson & Helfrich, 2005). Specialized services in foster care placements and transitional living programs serving LGBTQ youth have shown promise (Nolan, 2006). According to Elliot and Bonauto (2005), “In the interest of economy of language, the acronym ‘LGBT' for ‘lesbian, gay, bisexual, and transgendered' is used” (p. 92). The “Q” has been added as youth may also be questioning their sexual orientation (Woronoff & Estrada, 2006). However, “Q” can also refer to Queer (R. L. Miller, personal communication, November 14, 2007).
Most services to members are provided by families themselves. These include counseling, child and elder care, norm enforcement, economic and related supports to members (Briar-Lawson, Lawson, Hennon, & Jones, 2001). The United States does not have a family policy or a framework for investing in families and in helping them with their vital roles and responsibilities. Moreover, the United States, unlike Western European countries, does not provide demogrants and other entitlements to families.
Economic and employment supports need to be integral components of 21st century family services (Adams & Nelson, 1995; Sallee, Lawson, & Briar-Lawson, 2001). Services alone will not systematically lift families out of poverty (Schorr, 1997), nor will they address some of the pronounced disparities experienced by minorities (Hill, 2007). Such disparities require advocacy to address exclusionary dynamics (Kahn & Kamerman, 2002) and economic, employment, and income rights.
Other challenges that need to be addressed by practitioners, researchers, and policy makers include the following:
Increasing standardization in nomenclature and best practices involving family-centered, family-focused, family-guided, family support services
More research and practice exemplars addressing co-occurring conditions in families such as domestic violence, elder abuse, child abuse, trauma, mental health disorders, and addictions
Practice as well as research to better address adverse early childhood experiences and adult consequences, including the intergenerational transmission of risk factors
More efficacy studies to examine families and children rather than only child level outcomes
Developmental research agendas to advance service innovations and improvements, especially addressing service disparities
Efficacy studies and practices that encompass more culturally relevant and effective approaches to families, including those who are LGBT
Services, supports, resources, and rights that address economic, employment, and income support for families across the life span
Effective systems of care for families
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