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Family support programs and adolescent mental health: review of evidence

Authors Kuhn E, Laird R

Received 1 March 2014

Accepted for publication 6 May 2014

Published 10 July 2014 Volume 2014:5 Pages 127—142


Checked for plagiarism Yes

Review by Single-blind

Peer reviewer comments 2

Emily S Kuhn, Robert D Laird

Department of Psychology, University of New Orleans, New Orleans, LA, USA

Abstract: Family support programs aim to improve parent wellbeing and parenting as well as adolescent mental and behavioral health by addressing the needs of parents of adolescents experiencing or at risk for mental health problems. Family support programs can be part of the treatment for adolescents diagnosed with mental or behavioral health problems, or family support programs can be delivered as prevention programs designed to prevent the onset or escalation of mental or behavioral health problems. This review discusses the rationale for family support programs and describes the range of services provided by family support programs. The primary focus of the review is on evaluating the effectiveness of family support programs as treatments or prevention efforts delivered by clinicians or peers. Two main themes emerged from the review. First, family support programs that included more forms of support evidenced higher levels of effectiveness than family support programs that provided fewer forms of support. Discussion of this theme focuses on individual differences in client needs and program adaptions that may facilitate meeting diverse needs. Second, family support prevention programs appear to be most effective when serving individuals more in need of mental and behavioral health services. Discussion of this theme focuses on the intensity versus breadth of the services provided in prevention programs. More rigorous evaluations of family support programs are needed, especially for peer-delivered family support treatments.

Keywords: intervention, parent, mental and behavioral health


Many prevention and treatment approaches that have demonstrated effectiveness in promoting adolescent mental and behavioral health are family-centered.1 The effectiveness of family-centered programs suggests the importance of family factors in contributing to and protecting against adolescent behavioral and emotional problems. Family-centered inventions are often implemented as support programs, and family support programs will be the focus of this review. Family support programs aim to improve parent wellbeing, parenting, and adolescent mental and behavioral health by addressing the needs of parents of adolescents with mental health problems2 or at risk for mental health problems.

In this review, we first discuss the rationale for providing family support programs in adolescent mental health. Next, we provide an overview of the common components of family support programs in adolescent mental health and then discuss the modes through which family support programs are delivered. Evidence of the effectiveness of family support treatment and prevention programs is reviewed for several different typologies based on components and delivery method. This review aims to complement the more detailed descriptions and reviews of specific programs that are available elsewhere.2,3

Importance of and rationale for family support programs

Approximately 20% of adolescents aged 12–17 have mental health problems.4 Adolescents with mental health problems are more likely than other adolescents to engage in risky behaviors and to experience other negative consequences.5 Adolescent mental health problems also negatively affect adolescents’ families.4,69

According to ecological theories,10 individual development occurs within the context of multiple progressively larger socialization spheres. The central sphere of influence is the everyday environment the person encounters – particularly the family. Broader systems of social institutions – which can include health services and family support programs – can affect the development and mental and behavioral health of the individual and the family. Family support programs can provide parents with the resources and support to effectively interact with their adolescents and perform their parenting responsibilities.10

Although poor family function is not required for adolescents to experience mental health problems, and adolescent mental health problems do not inevitably lead to family dysfunction, poor family functioning is robustly linked to poor adolescent mental health. Adolescents’ mental health problems place a burden on families and can be a source of family distress.4,69 Higher levels of parental psychopathology, higher levels of parental stress, poor parenting practices, higher levels of parent–adolescent conflict, and lower levels of perceived family support are linked with higher levels of adolescent emotional, social, and behavioral problems.7,8,1115The link between family functioning and adolescent mental health is likely bidirectional and transactional. In any given family, poor family functioning may initially be a contributor to or consequence of poor adolescent mental health. However, over time, the two are likely to become linked through numerous transactions such that worsening mental health problems undermine family functioning and worsening family functioning exacerbates adolescent mental health problems. Regardless of whether family distress is a contributor to or consequence of adolescent mental health problems, family support programs have the potential to improve adolescent mental health by reducing family distress.

In line with ecological theories, family support programs acknowledge the impact of the family on the development of adolescents with mental and behavioral health problems and recognize that families need support. The goals of family support programs are to reduce both the adolescents’ mental health problems and the adverse consequences of adolescents’ mental health problems experienced by families. As such, impacts on parents and adolescents both provide evidence of the effectiveness of family support programs.

Characteristics of family support programs

Family support programs differ in program delivery method, in whether the program seeks to function as a prevention or treatment program, and in program characteristics. Family support programs may be delivered by either professionals, parent peers, or by a professional/peer team.2 Clinician-led models are typically delivered by master’s or doctoral-level clinicians and psychologists,2 but they may also be delivered by school personnel such as teachers.3 Peer-led programs are provided by parents or veteran parents to parents or caregivers.2 Team-led models include a parent peer and a professional/clinician.

Prevention programs aim to reduce the likelihood of new cases of a disorder by altering underlying mechanisms implicated in the development and maintenance of the disorder. Prevention is distinct from – but complementary to – treatment in their common goal of reducing the burden of mental and behavioral health problems.16 Treatment occurs when an individual who suffers from a disorder receives services in order to experience relief from the disorder.16 Prevention services are offered to individuals who do not meet criteria for a disorder, but the goal is to reduce the likelihood of developing a disorder in the future. Given that treatment and prevention programs may differ in the populations they serve and in specific program goals and methods, evidence of the effectiveness of treatment and prevention programs will be reviewed separately.

Many family support programs share common components, which have been aggregated and organized into five major categories: instructional, informational, advocacy, emotional, and instrumental supports.2 These components distinguish family support programs from other family-centered services.17 Instructional support includes teaching parents skills to effectively manage their adolescent’s behavior, engage in self-care practices including effective coping strategies, and effectively communicate with their family.2 Instructional support is designed to develop parents’ skills for effective family management and for attending to personal wellbeing. Informational support includes the provision of information about mental health problems, intervention options, and adolescent development.2 The goal of informational support is to increase understanding of mental health problems to set the stage for treatment and better management of behavioral and mental health problems. Advocacy supportive services typically aim to empower parents by providing information about parental rights and resources and training parents in areas such as assertiveness, communication, goal setting, and record keeping, which can help parents advocate for their adolescent’s services.2 Emotional support typically is provided via the opportunity to discuss issues, share experiences and insight in a group format. Some clinician-led family support programs provide the opportunity to discuss issues one-on-one with a clinician.18 Regardless of delivery format, the goal of emotional support is to enhance social connection and support, and to decrease feelings of isolation and helplessness. Instrumental support services incorporate broader supportive networks by linking families to concrete community-based resources such as childcare services, transportation services, and social services agencies.2 Encouraging families to utilize the natural resources of their communities is beneficial for maintenance of positive gains made while receiving family support services.

Review criteria

This review updates and synthesizes prior reviews,2,3 but concentrates on family support prevention and intervention programs delivered or evaluated with a focus on adolescence. Family support program evaluations with published outcome data relevant to mental and behavioral health and functioning were identified from previous reviews and by a literature search of studies published from 2009 to 2014 that cited previous reviews. We identified one new family support intervention19 and updated the findings for several programs with studies published since the earlier reviews.2023

Effectiveness of family support treatment programs

Many family support programs combine one or more of the five components, but the particular combination of components varies as a function of how the support program is delivered. Most family support treatment programs are clinician-led. For this review, clinician-led programs were divided into three groups that differ in program components. Among clinician-led programs, the combination of instructional and informational support is most common with a second group of programs adding advocacy to instructional and informational support. The final group of clinician-led programs combines emotional support with either instructional or informational support. Clinician-led interventions that did not include one of the most commonly identified groupings of program components (eg, clinician-led programs with only one form of support, or with all forms of support) were excluded from this review. There were too few peer-led or team-led programs to further divide those delivery categories based on components. The sections that follow summarize the evidence of effectiveness of family support treatments for clinician-led, peer-led, and team-led delivery methods.

Clinician-led with combined instructional and informational support

The clinician-led family support programs included in this review are described in Table 1. The majority of clinician-led programs combined instructional and informational support. Caregiver outcomes included improvements in24,25 as well as null26 and non-superior effects on25 mental health and stress. Beneficial findings included improved parental self-esteem, more positive cognitions regarding the child,24 and increased participation in27 and satisfaction with the treatments.24,28

Table 1 Clinician-led interventions
Abbreviations: CBFT, cognitive behavioral family therapy; FCBT, family cognitive behavioral therapy; RCT, randomized controlled trial; CBT, cognitive behavioral therapy.

Regarding child outcomes, family support programs that combined instructional and informational components yielded benefits such as reductions in various symptoms of anxiety disorders at post-treatment and follow-ups.26,28 Two studies showed non-superior (ie, equivalent) effects on behavioral problems relative to non-family support comparison29 and control25 conditions. One study found that family support alone is as effective as combined family support and medication and medication alone conditions for ameliorating child internalizing problems.30 Additionally, family support programs with instructional and informational components were associated with superior effects on reducing child anxiety disorder diagnoses among children of parents with anxiety disorders.29,31

In sum, clinician-led programs that combined instructional and informational support yielded mixed results. Outcomes included some benefits on caregiver mental health and child internalizing problems, as well as some null and non-superior effects relative to comparison and control conditions. Evidence suggested that children at higher risk for anxiety – due to having parents with anxiety disorders – may especially benefit from family support programs with instructional/informational components.29,31

Clinician-led with combined instructional, informational, and advocacy support

Clinician-led programs that combined instructional, informational, and advocacy support were the second most common type of clinician-led program. Among clinician-led programs that combined instructional, informational, and advocacy support, beneficial caregiver outcomes included reductions in distress,32,33 and aversive behavior34 as well as improvements in parenting skills,32,33,35 parenting confidence,35 and increased knowledge regarding the child’s disorder.34 Additionally, some studies reported high levels of caregiver satisfaction with the treatment.3436 Positive child outcomes included significant decreases in mental and behavioral health problems,32,33,35,36 reduced problematic cognitions,32,33 and increased parental social support.34 One study also reported high levels of child satisfaction with the treatment.34 Clinician-led programs that combined instructional, informational, and advocacy support yielded favorable results and were linked to improvements in caregiver’s mental health, parenting knowledge and skills, as well as benefits for children’s mental and behavioral health.

Clinician-led with a combination of either emotional and instructional or emotional and informational support

A minority of clinician-led programs included emotional support combined with either instructional or informational support. These programs were associated with null effects37 and initial improvements – that were not maintained at 3-month follow-up37 – on parental mental health. Although parents did not experience increased knowledge about the child’s disorder,39 they exhibited increased involvement in treatment.38 Child outcomes were also mixed and included initial but non-maintained improvements in behavioral problems,37 as well as reductions38 and null effects on mental health and social adjustment.38,40 Additionally, family support programs that combined emotional support with either informational or instructional support evidenced non-superior effects versus comparison non-family-support interventions in one study,40 and weaker effects than a family support intervention that combined informational and instructional support.29 Evidence for clinician-led programs that emphasized emotional support combined with either instructional or informational support is mixed, with positive and null effects, as well as equivalency but non-superiority or weaker effects relative to a comparison non-family support intervention and a family support intervention with different combinations of support components.


Peer-led programs were the second most common family support service delivery model after clinician-led programs.2 The peer-led family support programs included in this review are described in Table 2. Caregiver outcomes included improved mental health23 and increased self-care,22 but one study found no differences in parental strain.41 One study reported enhanced knowledge regarding mental health and treatment,23 but another study reported no effect of the program on knowledge of community resources or court knowledge.19 Two studies reported increased caregiver empowerment,22,42 and one study reported no differences in caregiver empowerment.41 One program was more effective among highly strained parents.20,21 Other caregiver outcomes included improvements in select aspects of communication22 and treatment satisfaction.19,23 Peer-led programs yielded little to no evidence of effectiveness for youth’s behavioral, emotional, and academic functioning.20,21,41,42 While veteran parents may serve as an important source of support for parents,2 there was inconsistent evidence of benefits from these programs for caregiver mental health and empowerment, and the effects on child functioning were largely null.

Table 2 Peer-led programs
Abbreviations: RCT, randomized controlled trial; EPSDT, Early and Periodic Screening, Diagnosis and Treatment Program; NAMI, National Alliance on Mental Illness.


Team-led programs were a relatively rare model of service delivery. Team-led family support programs included in this review are described in Table 3. Beneficial caregiver outcomes included increases in caregiver knowledge about mental health services and increased self-efficacy regarding the ability to acquire mental health treatment for the child.43 However, several studies reported no effect or non-superior effects of the team-led family support treatments relative to comparison treatments for parental outcomes such as caregiver involvement in the child’s mental health services, parent problem-solving skills, coping skills, or perceived social support. In terms of child outcomes, one study showed reductions in child disruptive behavior, while another study showed non-superior effects of the team-led family support intervention relative to comparison treatment on child behavior. In sum, although team-led treatment studies showed some positive effects on caregiver outcomes, child outcomes were more mixed, and there was minimal evidence demonstrating the superiority of team-led family support programs over comparison treatments.

Table 3 Team-led programs
Abbreviation: RCT, randomized controlled trial.

Treatment effectiveness summary

Overall, treatment effectiveness varied by service delivery model. Clinician-led and team-led models often were evaluated using experimental designs and, most importantly, randomized controlled trials.2 In contrast, peer-led programs were less rigorously studied, and the research evidence regarding their effectiveness was weak. Clinician-led programs yielded positive benefits on caregiver mental health, parenting knowledge, and parenting strategies, as well as improvements in child mental and behavioral health. However, there were also some null effects and lack of evidence of superiority of clinician-led programs relative to comparison/control conditions. Team-led treatments were associated with some benefits including increased empowerment and reductions in child disruptive behavior, but as with clinician-led programs there was minimal evidence demonstrating enhanced outcomes of team-led family support programs compared with comparison/control conditions. Peer-led treatment outcomes were mixed regarding effects on caregiver empowerment, and there were largely no effects on child functioning.

Effectiveness of family support prevention programs

Methods of prevention can be classified along four levels – universal, selective, indicated, or multilevel.3 Universal prevention programs – sometimes referred to as primary preventions – aim to reduce the incidence of new cases of disorder by preventing the onset of disorder. Selective prevention programs – sometimes termed secondary preventions – attempt to reduce the prevalence of disorders via early identification and aggressive treatment of subclinical problems. Indicated preventions intervene with individuals displaying symptoms of, but not meeting full diagnostic criteria for, mental and behavioral health disorders, and these prevention programs focus on minimizing further negative consequences. Prevention programs containing more than one prevention level are classified as multilevel preventions.3 When multilevel preventions are employed, universal interventions may serve as a screening mechanism, and individuals may be identified for more intensive prevention based on increased risk. Program components were quite similar across preventions – with nearly all prevention programs including instructional and informational elements – therefore, prevention programs are organized by levels of prevention (universal, selective, indicated, or multilevel) rather than by program components.

Universal family support prevention programs

Universal prevention programs often attempt to promote mental and behavioral health through education. Universal preventions are the second most common type of family support prevention program.3 The universal family support prevention programs included in this review are described in Table 4. Positive child outcomes include decreases in withdrawal, hyperactivity, sexual behavior problems, and oppositional and delinquent behaviors4652 – however, there were some exceptions wherein programs did not have significant effects on problem behaviors.53,54 Youth in universal prevention programs experienced longer delays in the onset of involvement with antisocial peers, substance use, and arrests.51 While it is preferable to prevent rather than delay the incidence or onset, delaying onset is also important because it reduces the adverse impact of risky behaviors such as substance use by reducing the duration of them. Improvements in prosocial behavior such as increases in social competence were noted in some47,50 but not other55 studies. Reductions in mental health problems such as anxiety and depression were also experienced among youth who participated in universal preventions.26,5659

Table 4 Universal prevention programs
Abbreviation: RCT, randomized controlled trial.

Positive parent outcomes included reductions in poor parenting behaviors – such as parental rejection of the child, authoritarian parenting strategies, and physical punishment – as well as increased use of positive parent management strategies such as greater use of praise and effective discipline.46,47,4952,55 However, one study found no impact of the prevention program on parental monitoring or consistent discipline.49 Parent–child dyadic interactions became more positive in response to universal preventions, and these changes were maintained at follow-ups.47,48 Parents in universal preventions also experienced increased knowledge regarding parenting of children at specific developmental stages.48 Reductions in parental mental health problems – including depression and distress47,48 – and improvements in positive feelings – such as increased self-esteem and self-efficacy55 were also reported outcomes of universal programs – with some exceptions.54 Increased satisfaction with social support and parent satisfaction with the programs also were reported.47,48,55

Overall, evidence for the effectiveness of universal preventions is mixed – there were several positive findings, but also some null effects, as well as evidence that the universal prevention programs did not yield more beneficial effects compared with control conditions.53,54 Some evidence indicated that universal preventions may only be effective26,56 or may be especially effective50,51,58 for reducing mental and behavioral health problems among children displaying the highest levels of mental health issues. This interaction effect suggests that targeting interventions for youth who are at risk for mental and behavioral health problems may be a more efficient and productive strategy.60 More targeted preventative programs – selective preventions – will be reviewed next.

Selective family support prevention programs

Selective preventions focus on early identification of individuals at high risk for developing a disorder due to experiencing environmental or psychosocial risk factors for the disorder. The majority of family support prevention programs are selective.3 The selective family support prevention programs included in this review are described in Table 5. Outcomes for divorcing parents included improved communication,61 reductions in conflict,62,63 and reductions in interjecting the child in the parent’s conflict,61 but also increases in64 and null effects on conflict.61 Additionally, female – but not male – ex-spouses perceived improved ability to effectively cooperate as co-parents.63 Other studies yielded improvements in parenting,65,66 improvements in mental health (although in one study, improved mental health was not maintained at follow-up),6568 prevention of mental health problems interfering with parenting,69 increased perceived familial support and closeness and better family functioning,67 with an exception.70 In one study, an interaction effect was found such that parental discipline improved for mothers who demonstrated more inconsistent (as opposed to less inconsistent, or more consistent) discipline at pre-treatment71 – adding to the accumulation of findings that program effects are stronger among high-risk participants. Another study reported improved parental behaviors with, and attitudes regarding children, and these gains increased with time since the intervention.70 Parent satisfaction with treatments was also reported.62,72

Table 5 Selective prevention programs
Abbreviation: RCT, randomized controlled trial.

Child outcomes were more mixed – including reductions in62,68,71 and no effects on64,71 child behavior problems, no effects on child internalizing problems,68,71 but improved child coping and mental and behavioral health and functioning.67,73,74 In several studies, reductions in internalizing and externalizing problems were only experienced among youth at higher risk for, or experiencing the greatest difficulties with, these problems pre-treatment.65,71,75

Similar to the evidence for universal preventions, the evidence for the effectiveness of selective preventions is also mixed. Selective preventions yielded more beneficial effects for parents than children, although effects on conflict between divorcing parents was mixed. For children, both improvements in and null effects on internalizing and externalizing problems were found. In keeping with the theme of findings from other programs in this review, selective prevention effects were sometimes only found among families with the worst pre-treatment level of functioning – again, suggesting the increased efficacy of interventions for individuals at highest risk.

Indicated family support prevention programs

Indicated preventions target youth displaying minimal but noticeable symptoms of mental or behavioral health disorders suggesting the possibility of developing a clinical disorder in the future, although diagnostic criteria is not met at the time prevention is enacted.16 The indicated family support prevention programs included in this review are described in Table 6. Child outcomes from the indicated preventions were generally positive, although outcomes from some programs were inconsistent. Beneficial child effects included significant improvements in youth mental and behavioral health and social functioning,7685 with some exceptions of no effects on mental health or behavioral or social functioning.76,78,86,87 Two studies noted greater benefits of the indicated preventions among youth at higher risk for, or experiencing more, mental health problems at pre-treatment78,81 – consistent with the pattern of findings suggesting that treatments targeting high-risk groups may be more efficient.

Table 6 Indicated preventions programs
Abbreviations: PTSD, posttraumatic stress disorder; RCT, randomized controlled trial.

Parent outcomes were less studied among indicated programs compared with universal and selective preventions.3 Among those indicated intervention studies that assessed parenting outcomes, results were positive – and suggested improvements in positive parenting and use of effective discipline strategies.82

The evidence for indicated family support preventions was generally favorable. Child outcomes included reductions in both internalizing and externalizing problems, as well as improvements in the cognitive mechanisms contributing to depression – in line with the principle of prevention to target factors implicated in the development and maintenance of disorders. Two of the three instructional-support-only indicated programs yielded inconsistent findings, while results of the third instructional-support-only indicated program were consistently positive. Given that the majority of instructional-support-only indicated programs produced inconsistent results relative to programs that combined multiple forms of support, it is possible that providing only one form of support – which may not be helpful to all clients – is not as effective as providing multiple forms of support that are more likely to impact many. Across all of the indicated programs, parent outcomes were not well studied, and the only parent outcomes studied were parenting strategies – parental wellbeing and mental health were not evaluated. Despite the lack of attention to parenting outcomes among indicated programs, parental outcomes that were addressed showed beneficial effects of the indicated programs.

Multilevel family support prevention programs

Multilevel family support prevention programs integrate assessment and prevention to maximize beneficial outcomes. With multilevel family support preventions, the intensity and nature of the prevention strategies provided may be adjusted depending on an individual’s responsiveness. Multilevel family support preventions are as common as indicated preventions and – like indicated preventions – were relatively rare compared with universal and selective programs.3 The multilevel family support prevention programs included in this review are described in Table 7. Beneficial child outcomes associated with multilevel family support preventions included reductions in externalizing behavior88,89 and internalizing problems,90 as well as improved prosocial behavior.88 Participation in more intensive prevention levels accounted for two programs’ beneficial effects,90,91 and one study reported an interaction effect wherein intervention participants at highest initial risk evidenced reductions in diagnoses and behavioral symptoms.92

Similar to indicated preventions, parent outcomes were not a primary focus of studies testing multilevel family support preventions. However, parenting outcomes reported were positive, and included improvements in mental health and parenting skills.88 Additionally, an interaction effect was found wherein parents in a more intensive prevention level experienced reductions in the use of over-reactive parenting strategies91 – again suggesting that greater intensity of intervention may be helpful.

Multilevel prevention programs appeared to be highly effective. Positive child outcomes primarily included reductions in externalizing behavior and involvement with antisocial peers. The reduction in involvement with antisocial peers is in line with the aim of prevention programs to alter causal mechanisms contributing to disorder. Although parent outcomes received less attention, positive caregiver outcomes included both mental health improvements as well as improvements in parenting behavior and skills.

Table 7 Multilevel preventions programs
Abbreviation:RCT, randomized controlled trial.

Prevention effectiveness summary

Overall, prevention programs appear to be effective – although effectiveness varies both across levels of prevention, and within levels across specific prevention programs. Multilevel programs and indicated preventions yielded more consistently positive results than the less intensive preventative interventions – selective and universal. Findings from studies that evaluated whether increased intensity of preventions improved outcomes are in line with a body of other evidence suggesting that increasingly intensive and comprehensive levels of prevention are more effective than less intense preventative measures. Another consistent finding across prevention levels was that individuals with elevated levels of mental and behavioral health problems experienced better outcomes compared with individuals less in need of the services. This suggests that it may be more efficient for prevention efforts to target individuals at high-risk for mental and behavioral health problems than to target the entire population – as in universal prevention strategies. It is possible that more consistently positive evidence was found among indicated and multilevel preventions simply because there were fewer of these programs than the universal and selective preventions. Overall – across all prevention levels – parent outcomes were less studied than child outcomes. Parent outcomes primarily included improvement in parenting strategies, but some studies also focused on parental mental health and wellbeing. In terms of child outcomes, reductions in externalizing behavior were most common, followed by improvements in mental health and internalizing problems such as anxiety and depression, and only a few studies noted improvements in prosocial behavior such as social competence.

Overall summary

Family support programs demonstrated some effectiveness in improving caregiver mental health and parenting strategies as well as enhancing child mental and behavioral health. Among treatment programs, clinician-led programs that provided a combination of instructional, informational, and advocacy support demonstrated the most effectiveness. Peer-led programs had the weakest research base and least effectiveness. More research is needed to investigate the efficacy of peer-led programs given that parents/veteran parents who typically lead peer-led programs can serve as important supports and mentors for parents enrolled in the family support programs.2 Among prevention programs, multilevel and indicated programs demonstrated greater levels of effectiveness compared with the lower-level – universal and selective – preventions. Across all programs reviewed, those that included the most diverse forms of support were the most effective. Combining different forms of support may be useful, because different clients may need different forms of support and approaches. The evidence reviewed here suggests that when family support programs are riveted to providing one form of support, their effectiveness is limited. In other words, being rigid in the provision of support can shut out potential solutions to meeting each family’s needs. For instance, multilevel prevention programs can improve the ability to select the best forms of support and tailor them for individual clients and presenting concerns. While all family support programs need not provide every form of support, it may be beneficial for family support programs to be open to using forms of support other than the primary form to enhance effectiveness and efficiency.


The authors report no conflicts of interest in this work.



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