Family-based Services Research Articles

Implementing family-based interventions in opioid treatment programs: Preferences for method of delivery.

Interventions for substance use disorders (SUDs) are typically delivered face-to-face or remotely via telehealth. In recent years, there has been a rapid rise in the number of SUD services delivered using telehealth. However, the literature on which mode of service delivery SUD patients and providers prefer is still emerging, particularly with respect to family-based interventions in Opioid Treatment Programs (OTPs). This study sought to identify/explain preferences for delivering family-based programs among OTP patients and providers. Data collection from a total of 40 participants (20 patients and 20 providers) was conducted from August 2022 to October 2022 at two OTPs in Florida. An online survey was used to collect demographic data, while individual qualitative interviews were conducted to explore preferences for delivering family-based programs. Audiotapes of interviews were transcribed, coded, and thematically analyzed. Analyses revealed that patients and providers had similar preferences, with the most salient being (a) concerns about keeping children engaged during telehealth sessions, (b) concerns about communication barriers when using telehealth, (c) preference for telehealth using live video (as opposed to prerecorded content), and (d) preference for telehealth over face-to-face due to greater convenience for patients. These findings show that preferences for delivering family-based services are varied and may differ somewhat from preferences for delivering traditional individual therapy services. The data presented here can be used to develop and further refine protocols for adapting and delivering family-based interventions in OTP settings, and are especially timely as legislative discussions are currently occurring about expanding telehealth services in these facilities. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

A Novel Approach to Geographically Mapping Effective Family-Based Services: Feasibility and Quality Comparison with 2-1-1.

Community social services are often fragmented and difficult to navigate. This presents a barrier to programs, such as health navigation, that focus on connecting individuals to available services. Existing service mapping efforts, such as those generated by 2-1-1, are helpful but limited in the specificity they provide, particularly with regard to whether services are based on evidence-informed principles. This may lead to a distrust of service quality or poor referral match. We developed a novel service mapping protocol to identify local, evidence-informed, family-based services, and compared results to 2-1-1's resource list. Our mapping protocol identified more evidence-informed services than 2-1-1 and collected greater detail related to accessibility. Recommendations for integrating this approach into routine community mapping efforts (e.g., 2-1-1) or as a stand-alone approach are discussed.

Pediatric Antiretroviral Therapy Coverage and AIDS Deaths in the "Treat All" Era.

In 2015, CD4-based clinical staging criteria for antiretroviral therapy (ART) initiation were removed, expanding ART eligibility ("Treat All") for children, who shoulder an outsized burden of HIV-related deaths. To quantify the impact of "Treat All" on pediatric HIV outcomes, we examined shifts in pediatric ART coverage and AIDS mortality before and after "Treat All" implementation. We abstracted country-level ART coverage (proportion of children <15 years on ART) and AIDS mortality (deaths per 100 000 population) estimates over 11 years. For 91 countries, we also abstracted the year "Treat All" was incorporated into national guidelines. We used multivariable 2-way fixed effects negative binomial regression to estimate changes in pediatric ART coverage and AIDS mortality potentially attributable to "Treat All" expansion, reported as adjusted incidence rate ratios (adj.IRR) with 95% confidence intervals (95% CI). From 2010 to 2020, pediatric ART coverage tripled (16% to 54%), and AIDS-related deaths were halved (240 000 to 99 000). Compared with the pre-implementation period, observed ART coverage continued increasing after "Treat All" adoption, but this rate of increase declined by 6% (adj.IRR = 0.94, 95% CI: 0.91-0.98). AIDS mortality continued declining after "Treat All" adoption, but this rate of decline decreased by 8% (adj.IRR = 1.08, 95% CI: 1.05-1.11) in the post-implementation period. Although "Treat All" called for increased HIV treatment equity, ART coverage continues lagging in children and comprehensive approaches that address structural issues, including family-based services and intensified case-finding, are needed to close pediatric HIV treatment gaps.

A qualitative study

A qualitative study

Mental Health Challenges, Parenting Stress, and Features of the Couple Relationship in Parents of Children With Fragile X Syndrome

BackgroundIndividuals with fragile X syndrome (FXS) have significant delays in cognition and language, as well as anxiety, symptoms of autism spectrum disorder, and challenging behaviors such as hyperactivity and aggression. Biological mothers of children with FXS, who are themselves FMR1 premutation or full mutation carriers, are at elevated risk for mental health challenges in addition to experiencing stress associated with parenting a child with significant disabilities. However, little is known about fathers in these families, including the ways in which parental well-being influences the mother-father relationship and the impact of child characteristics on paternal and couple functioning.MethodThe current study examined features of, and relationships between, parental well-being, couple well-being, and child functioning in 23 families of young boys with FXS. Mothers and fathers independently completed multiple questionnaires about their individual well-being, couple functioning, and child behavior. One parent per family also completed an interview about the child’s adaptive skills.ResultsResults suggest that both mothers and fathers in these families experience clinically significant levels of mental health challenges and elevated rates of parenting stress relative to the general population. Findings also indicate that the couples’ relationship may be a source of strength that potentially buffers against some of the daily stressors faced by these families. Additionally, parents who reported less parenting stress had higher couples satisfaction and dyadic coping. Finally, parents of children with less severe challenging behaviors exhibited fewer mental health challenges, less parenting stress, and higher levels of both couples satisfaction and dyadic coping. Parents of children with higher levels of adaptive behavior also reported less parenting stress and higher couples satisfaction.ConclusionOverall, this study provides evidence that families of children with FXS need access to services that not only target improvements in the child’s functioning, but also ameliorate parental stress. Family-based services that include both mothers and fathers would lead to better outcomes for all family members.

Exploring Clusters of Risk and Association With Child Maltreatment in North Carolina Counties.

Decision makers face challenges in estimating local risk for child maltreatment and how best to prioritize which factors to intervene upon. Using US Census and survey data for all US counties (N = 3141), we derived US county profiles characterized by the severity of child maltreatment risk factors observed at the county level, such as parental health, health care access, and economic distress. We estimated how five child maltreatment outcomes would vary across the profiles for North Carolina counties (n = 100): total maltreatment reports (including unsubstantiated and substantiated), substantiated neglect, substantiated abuse, whether services were received, and reported child's race/ethnicity. We derived three profiles of county-level child maltreatment risk: high, moderate, and low risk, denoting that predicted risk factors means within profiles were all high, moderate, or low levels compared to counties in other profiles. One risk factor did not follow this pattern: the drug overdose death rate. It was highest in the moderate-risk profile instead of the high-risk profile, as would have been consistent with other factor levels. Moderate-risk counties had the highest predicted rate of child maltreatment reports, with over 20 more reports per 10,000 residents compared to low-risk counties (95% CI, 1.38, 38.86). We included only factors for which aggregate, county-level estimates were available, thus limiting inclusion of all relevant factors. Results suggest the need for increased family-based services and interventions that reduce risk factors such as economic distress and drug overdose deaths. We discuss the implications for tailoring county efforts to prevent child maltreatment.

Implementation of Psychodynamic Multifamily Groups for Severe Mental Illness: A Recovery-Oriented Approach.

Background: Among Family-Based Services for the treatment of severe mental illnesses, multi-family models gained particular attention, given the potential usefulness of mutual feed-back, motivation and encouragement among families.Methods: The Psychodynamic Multi-Family Group Model has been proposed since 1997 in some Community Mental Health Services in Rome. Since 2011 multifamily groups are held weekly in all the six Districts of the Department of Mental Health that serves a population of more than one million people, and data have been collected since 2015 in three Districts. A total of 794 individuals attended the meetings in the period 2015–2019.Results: Eighty-six percent of those who started, attended more than one meeting. The mean of occurrences of participation among patients was 18.6, among mothers 25.6 and among fathers 21.6. The 794 participants belonged to 439 family units, among which 180 comprised only the patient, 76 only parent(s) or other close person(s), and 183 comprised parent(s) or close person(s) with the patient. Patients participating alone were older than those of families who participated as a whole. Families including the patient showed the longest duration of attendance and the highest prevalence of a diagnosis of schizophrenia in the index patient. Families who had been attending the multifamily groups since a long time maintained a high rate of attendance.Conclusions: Multifamily groups represent a setting where patients can meet with other people and professionals in a free still structured way, and with not strictly therapeutic objectives. The high number of patients who attended alone suggests that such participation corresponds to a self-perceived need of open and free setting facilitating sharing of problems and solutions. The good tenure of the interventions, the high participation, and the feasibility in the long-term suggest that multifamily groups can be implemented in the mental health services of a large city, are sustainable over many years, and can represent a valuable resource for many patients and families.

Limited access to family-based addiction prevention services for socio-economically deprived families in Switzerland: a grounded theory study

BackgroundFamilies living in poor socio-economic circumstances, already confronted with social and health inequalities, are often not reached by family-based addiction prevention services. Besides quantitative models and health literacy approaches, qualitative research is lacking that could shed light on the exact circumstances and processes that lead to hindered addiction prevention service uptake by these families. Drawing on the concept of candidacy, we therefore reconstructed how socio-economically deprived parents and their (pre) adolescent children in the German-speaking part of Switzerland (non-)identified their candidacy for family-based addiction prevention services.MethodsFollowing grounded theory, we collected and analysed data in an iterative-cyclical manner using theoretical sampling and theoretical coding techniques. Sixteen families with children aged 10–14 years were interviewed in depth (parent/s and child separately). All but one family lived below the at-risk-of-poverty threshold.ResultsSocio-economically deprived families’ modes of recognizing and handling problems in everyday life were found to be core phenomena that structure the process towards (non) identification of candidacy for family-based addiction prevention services. Four modes anchored within socio-demographic resources were found: Families with mode A perceived their current life situation as existentially threatening and focused daily coping on the main pressing problem. Others (mode B) perceived prevalent multiple problems as normal (now); problems were normalized, often not recognized as such. In mode C families, problems were pragmatically recognized at a low threshold and pragmatically dealt with, mostly within the family. In mode D families, problems were constantly produced and dealt with early by the worried and anxious parents monitoring their child. From modes D to A, vulnerability increased concerning non-identification of candidacy for family-based addiction prevention services. Further, thematic relevance of addiction prevention, past experience with offers, integration in systems of assistance, strategies to protect the family, and families’ search for information influenced whether identification of candidacy took place.ConclusionsSocio-economically deprived families differ in modes of problem construction and handling in everyday life; this differently opens up or closes routes to family-based addiction prevention. Addiction prevention practice should build on a bundle of diverse strategies for outreach to these families, stressing especially interventions on the structural and environmental level.

Socio-economically deprived families’ routes to family-based addiction prevention services

Abstract Background Families living in poor socio-economic circumstances, already confronted with social and health inequalities, are often not reached by family-based addiction prevention programmes. Besides quantitative models and health literacy approaches, qualitative research is lacking that could shed light on the exact circumstances and processes that lead to hindered addiction prevention service uptake by these families. Drawing on the concept of 'candidacy', we aimed to reconstruct how socio-economically deprived parents and their (pre-)adolescent children in German-speaking Switzerland identify their candidacy for family-based addiction prevention services. Methods Following grounded theory, we collected and analysed data in an iterative-cyclical manner using theoretical sampling and theoretical coding techniques. Sixteen families with children aged 10-14 years were interviewed in depth (parent/s and one child separately). All but one family lived below the at-risk-of poverty threshold. Results Families' modes of recognising and handling problems in everyday life were found to be core phenomena that structure the process towards (non-)identification of candidacy for family-based addiction prevention services. Further, thematic relevance of addiction prevention, past experience with offers, integration in systems of assistance (social welfare, etc.), strategies to protect the family, and parents' search movements for support were important for families' identification of candidacy. Conclusions Socio-economically deprived families are not a homogeneous group. They differ in modes of problem construction and handling in everyday life; this differently opens up or closes routes to family-based addiction prevention services. Policy and practice should build on a bundle of diverse strategies for outreach to these vulnerable families. Key messages Our qualitative study adds scientific knowledge to a better understanding of socio-economically deprived families’ complex routes to family-based addiction prevention services. Results provide evidence that policy and practice should build on a bundle of diverse strategies to reach these vulnerable families. Equity in access to services can thus be improved.

Parent Management Training Oregon Model and Family-Based Services as Usual for Behavioral Problems in Youth: A National Randomized Controlled Trial in Denmark.

This randomized control trial used intent-to-treat analyses to compare parent management training-Oregon model (PMTO) (N = 64) to family-based services as usual (SAU) (N = 62) in 3.5-13-year-old children and their families in Denmark. Outcomes were parent report of child internalizing and externalizing problems, parenting efficacy, parenting stress, parent sense of coherence, parent-report of life satisfaction, and parental depressive symptoms. Outcomes were measured at pretreatment, post-treatment, and 18-20months post-treatment. Results demonstrated that both PMTO and family-based SAU resulted in significant improvements in child externalizing and internalizing problems, parenting efficacy, as well as parent-reported stress and depressive symptoms, life satisfaction, and aspects of sense of cohesion. Effect sizes at post-treatment and follow-up were in the small to moderate range, consistent with prior PMTO evaluations. However, there were no significant differences between PMTO and family-based SAU. Further research on the process and content of family-based SAU is needed to determine how this approach overlaps with and is distinct from PMTO.

Community Coalition Kick-Off Events: Lessons Learned on the Launchpad

Research has found that collaboration is important for family service agencies, and community coalition building is a common form of collaboration. Guided by Community Coalition Action Theory, this article analyzes a community coalition convening around health and housing in a resource-challenged, large Midwestern metropolitan area. Implications for practice are discussed, describing initial lessons learned from the coalition kick-off event for community coalition convening. Using theory to anticipate coalition challenges and barriers, looking beyond simple meeting agenda objectives to identify specific coalition tactics, and asking hard questions about coalition capacity at kick-off are ways to strengthen health and housing interventions within family-based services.

Publicly Funded Home and Community-Based Care for Children With Medical Complexity: Protocol for the Analysis of Medicaid Waiver Applications.

BackgroundChildren with medical complexity are a group of children with multiple chronic conditions and functional limitations that represent the highest health care utilization and often require a substantial number of home and community-based services (HCBS). In many states, HCBS are offered to target populations through 1915(c) Medicaid waivers. To date, no standard methods or approaches have been established to evaluate or compare 1915(c) waivers across states in the United States for children.ObjectiveThe purpose of this analysis was to develop a systematic and reproducible approach to evaluate 1915(c) Medicaid waivers for overall coverage of children with medical complexity.MethodsData elements were extracted from Medicaid 1915(c) approved waiver applications for all included waivers targeting any pediatric age range through October 31, 2018. Normalization criteria were established, and an aggregate overall coverage score was calculated for each waiver.ResultsData extraction occurred in two phases: (1) waivers that were considered nonexpired through December 31, 2017, and (2) the final sample that included nonexpired waivers through October 31, 2018. A total of 142 waivers across 45 states in the United States were included in this analysis. We found that the existing adult HCBS taxonomy may not always be applicable for child and family-based service provision. Although there was uniformity in the Medicaid applications, there was high heterogeneity in how waiver eligibility, transition plans, and wait lists were defined. Study analysis was completed in January 2019, and after analyzing each individual waiver, results were aggregated at the level of the state and for each diagnostic subgroup. The published results are forthcoming.ConclusionsTo our knowledge, this is the first study to systematically evaluate 1915(c) Medicaid waivers targeting children with medical complexity that can be replicated without the threat of missing data.International Registered Report Identifier (IRRID)RR1-10.2196/13062

Measurement Training and Feedback System for Implementation of family-based services for adolescent substance use: protocol for a cluster randomized trial of two implementation strategies

BackgroundThis article describes a study protocol for testing the Measurement Training and Feedback System for Implementation (MTFS-I) and comparing two implementation strategies for MTFS-I delivery. MTFS-I is a web-based treatment quality improvement system designed to increase the delivery of evidence-based interventions for behavioral health problems in routine care settings. This version of MTFS-I focuses on family-based services (FBS) for adolescent substance use. FBS, comprising both family participation in treatment and family therapy technique use, have achieved the strongest evidence base for adolescent substance use and are a prime candidate for upgrading treatment quality in outpatient care. For FBS to fulfill their potential for widespread dissemination, FBS implementation must be bolstered by effective quality procedures that support sustainable delivery in usual care.Methods/designAdapted from measurement feedback systems for client outcomes, MTFS-I contains three synergistic components: (a) weekly reporter training modules to instruct therapists in reliable post-session self-reporting on FBS utilization; (b) weekly mock session videos of FBS interventions (5–8 min) for supportive training in, and practice coding of, high-quality FBS; and (c) monthly feedback reports to therapists and supervisors displaying aggregated data on therapist-reported FBS use. MTFS-I is hosted online and requires approximately 20 min per week to complete. The study will experimentally compare two well-established implementation strategies designed to foster ongoing MTFS-I usage: Core Training, consisting of two 3-h training sessions focused on FBS site mapping, selecting FBS improvement goals, and sustaining MTFS-I, followed by routine remote technical assistance; and Core + Facilitation, which boosts Core Training sessions with collaborative phone-based clinical consultation and on-site facilitation meetings for 1 year to promote FBS goal achievement. The study design is a cluster randomized trial testing Core Training versus Core + Facilitation in ten substance use treatment clinics. Study aims will compare conditions on MTFS-I uptake, FBS delivery (based on therapist-report and observational data), and 1-year client outcomes.DiscussionStudy contributions to implementation science and considerations of MTFS-I sustainability are discussed.Trial registrationClinicalTrials.govNCT03342872. Registered 10 November 2017

Family processes and duration of untreated psychosis among US Latinos.

Little is known about family processes and treatment seeking among Latinos with first-episode psychosis (FEP) living in the United States. This study examined family processes prior to treatment and their relation to duration of untreated psychosis (DUP) among Latinos with FEP and their family caregivers. Thirty-three Latinos with FEP and their low-acculturated family caregivers (n = 33) participated in qualitative semi-structured interviews focused on treatment-seeking experience and family relationships. Transcripts were analysed using thematic analysis and themes were grouped based on short (n = 18) or long (n = 15) DUP. Findings revealed differences based on DUP length. Patients with short DUP had stronger family relationships characterized by open communication and disclosure of symptoms that facilitated awareness and direct action by family caregivers. However, patients with long DUP had more troubled family relationships that often challenged early treatment seeking. Findings highlight the relevance of family context in the provision of early treatment for Latinos with FEP. Family-based services are needed that increase awareness of symptoms and provide families with support that can facilitate ongoing patient treatment during this critical period.

Perspectives on family caregiving of people aging with intellectual disability affected by dementia: Commentary from the International Summit on Intellectual Disability and Dementia

ABSTRACTThis article, an output of the 2016 International Summit on Intellectual Disability and Dementia, examines familial caregiving situations within the context of a support-staging model for adults with intellectual disability (ID) affected by dementia. Seven narratives offer context to this support-staging model to interpret situations experienced by caregivers. The multidimensional model has two fundamental aspects: identifying the role and nature of caregiving as either primary (direct) or secondary (supportive); and defining how caregiving is influenced by stage of dementia. We propose staging can affect caregiving via different expressions: (1) the “diagnostic phase,” (2) the “explorative phase,” (3) the “adaptive phase,” and (4) the “closure phase.” The international narratives illustrate direct and indirect caregiving with commonality being extent of caregiver involvement and attention to the needs of an adult with ID. We conclude that the model is the first to empirically formalize the variability of caregiving within families of people with ID that is distinct from other caregiving groups, and that many of these caregivers have idiosyncratic needs. A support-staging model that recognizes the changing roles and demands of carers of people with ID and dementia can be useful in constructing research, defining family-based support services, and setting public policy.

Concerns of Parents with or Raising Adolescent Children: a Qualitative Study of Iranian Families.

Introduction: Adolescence is a challenging period and cultural background plays an important role in families with adolescent. So exploring parents’ concerns in the specific context of Iran may improves nurses' family-based services and helps to reduce conflicts Iranian families with respect to adolescents. In this paper we explore perceptions of Iranian parents’ concerns in the family with raising adolescent children. Methods: Participants of this qualitative content analysis study were 23 parents with adolescents, who were recruited through purposive sampling. Data collection was done through semi structured in-depth interviews and analyzed based on Graneheim and Landman’s approach. Lincoln and Guba’s criteria were used to ensure the accuracy and strength of the study. Results: The theme "rebellion against parents’ authority" was supported by two categories: (1) parent-teenage conflict, and (2) difficulty in controlling. As the offspring enter adolescence, parents feel that their child is going to leave their domain. Conclusion: Findings from this study showed that the incongruity arises when traditional family norms fail to adapt to new patterns. Change of social and cultural norms in developing societies, has led to generational differences in families. This issue accompanied with adolescence, increases parents’ concern. So we recommend parental educational programs for learning effectively patterns for resisting internal challenges and communicate with adolescents.

One-year outcome and incidence of anorexia nervosa and restrictive eating disorders among adolescent girls treated as out-patients in a family-based setting

Aims To study the 1-year outcome and to analyse predictors of outcome of a cohort of adolescent girls with anorexia nervosa (AN) or restrictive eating disorders not otherwise specified (EDNOSr) treated as out-patients in a family-based programme at a specialized eating disorder service. To calculate the incidence of anorexia nervosa among treatment-seeking girls younger than 18 in Uppsala County from 2004 to 2006.Methods A total of 168 female patients were offered treatment, and 141 were followed-up 1 year after starting treatment, 29 with AN and 112 with EDNOSr.Results Of the 29 girls who initially had AN, 6 (20%) had a good outcome and were free of any form of eating disorder at follow-up; only 1 (3%) had AN. Of the patients with EDNOSr, 54 (48%) had a good outcome and were free of eating disorders. Three (3%) had a poor outcome and had developed AN. The incidence of AN was 18/100,000 person-years in girls younger than 12 and 63/100,000 in girls younger than 18.Conclusion Restrictive eating disorders, including AN, in children and adolescents can be successfully treated in a family-based specialized out-patient service without in-patient care.

Learning’s from community and home-based newborn care experiences of India for strengthening Rajasthan’s Community Level Newborn interventions

Introduction: This study was conducted to understand the evidences generated on community and home-based interventions related to newborn health in India, a systematic review of studies on community and home based interventions from India for last decade 1999-2000 to 2010-2011 is presented. Methods: The data was reviewed from various online reports and publications available and the three main sources from where health services, and morbidity and mortality data are derived for the study include the NFHS, DLHS and the Report of RGI. Study data was summarized and analyzed using appropriate statistical tools. Results: An analysis of all community based interventions till 2010 demonstrate a reduction in NMR, early NMR, still births and perinatal mortality. It also showed an increase in referrals to health facility for pregnancy – related complications and improved rates of early breastfeeding. The results were significant when impact was estimated for early neonatal mortality. The results are more encouraging if the proven interventions are implemented effectively with high coverage and targeted at areas and population where they are needed the most. Conclusion: Community based interventions have to be supported by facility-based interventions. With phased planning, outreach and family-based services can be effective in ensuring access of the poor to basic services, while professional clinical care is being strengthened and made more equitable. Even with a relative weak health system, it is possible to achieve measurable reduction in mortality with adequate coverage of community-based services.

Changes in treatment engagement of youths and families with complex needs

This study examined changes in treatment engagement of 437 youths and their caregivers receiving mental health services in the United States. The youth sample had an average age of 12.03years (SD=2.98). Nearly two-thirds (64.1%) of the youth sample was male and approximately the same proportion was Caucasian. Youths were diagnosed primarily with externalizing (50.1%) and internalizing (46.0%) disorders. Most youths (86%) received services from intensive settings (i.e., behavioral health rehabilitation, treatment foster care, family-based services) that provide care beyond the scope of services provided to youths receiving services in traditional outpatient settings. Using KIDnet, an electronic outcomes management system, youths and their caregivers reported on three domains of treatment engagement: therapeutic alliance, satisfaction with services, and treatment participation at each 90-day reporting cycle until treatment termination. Youths and caregivers receiving services from high intensity treatment settings reported significantly lower initial engagement compared to youths and caregivers receiving less intensive outpatient services. Regardless of setting, treatment engagement reported by youths and caregivers increased over time. These promising findings suggest that families receiving intensive treatment develop connections to service providers and hold positive perceptions of services over time. These results provide the foundation for future research to examine the practices that are associated with changes in treatment engagement over time.

Child maltreatment in Japan

Summary Over the past 15 years, the number of child maltreatment incidents reported to Child Guidance Centers in Japan has increased more than three fold. Reviewing a wide range of policy white-papers and research reports in Japan, we discuss the prevalence of child maltreatment, its social construction over time, societal factors contributing to child maltreatment, and the development and design of the Japanese child welfare system. We conclude with a discussion of emerging issues and challenges. Findings A variety of risk factors exacerbate maltreatment in Japan. These include the decline of extended familial supports, low paternal involvement in childrearing, and demanding work routines for both men and women who seek professional careers. Throughout the paper, we discuss historically competing social constructions of the child, family, and work. In addition, we discuss the gendered roles of men and women in Japanese society. Japan's legacy of Shintoism and Confucianism, the institutionalization of patriarchy in the Tokugawa and Meiji Periods, and the modern constraints placed on families by Japanese corporations are explored as factors affecting child maltreatment and the services rendered by the child welfare system. Under the Child Welfare Act of 1948 and the Prevention of Child Abuse Act of 2000, approximately 90% of children in need, including maltreated children, receive care in large group home settings in Japan. Compared to other nations, Japan places great reliance on out-of-home care. Preventive systems to strengthen families and avert out of home placements have not be adequately developed. Applications Japanese scholars are re-examining the child welfare system in efforts to design family-based policies and services to both prevent maltreatment and provide alternatives to out-of-home care.