Bows and ribbons,tape and twine: Wrapping the wraparound process for children with multi-system needs

The wraparound process for children with multi-system needs is one of the most innovative and popular reform efforts in children's services. Nonetheless, the articles in this special issue are indicative of a service reform process that is still maturing and evolving. In this commentary, three key questions regarding the wraparound process are posed: (a) What is wraparound? (b) What is the current state of research regarding wraparound services? and (c) What are the implications for the future? It is argued that the future of wraparound depends at least in part on: (a) carefully defining the wraparound process, including how to best integrate the process with reforms based on the principles of a comprehensive system of care; and (b) making a strong commitment at all levels to the process of cumulative knowledge, of building and creating innovative research and program efforts over time, one upon the other. It is concluded that a failure to invest in careful definition, refinement, implementation, and research on the wraparound process consitutes a failure to invest in children and families with multi-system needs.     

An Investigation of Treatment Integrity and Outcomes in Wraparound Services

Research on wraparound services has been generally positive, but has failed to include data regarding treatment integrity. Without such data, conclusions drawn from such studies are weakened. This study followed 28 children and adolescents receiving wraparound services in rural central Pennsylvania. Treatment integrity was defined as the percentage of service hours prescribed vs. received, and behavioral outcomes were defined as Total Problem Behavior T Scores on the Child Behavior Checklist. Preliminary analyses failed to reveal significant differences in sample means between included subjects and those excluded due to missing data. Outcome behavior ratings were significantly improved over baseline ratings. Regression analyses, however, failed to find a significant effect for treatment integrity when used in an outcome prediction equation for Therapeutic Support Staff, Mobile Therapy services, or Behavioral Specialist wraparound services. These results suggest that adherence to prescribed treatment hours may not be related to behavioral outcomes in a wraparound service setting.     

Developing comprehensive,individualized community-based services for children and youth with emotional and behavior disorders: Direct service providers' perspectives

Increased attention to the plight of children and youth with emotional or behavioral disorders (EBD) and their families has led to innovations in the manner in which these individuals are served. Two such innovations have been the development of public systems of comprehensive, community-based care and individualized wraparound services. This study was part of one community's attempt to merge these two innovations and provide individualized wraparound services to children and youth with EBD through the auspices of public agencies. Direct service providers were surveyed to gather their input into how such services could best be developed and implemented. The survey focused on existing barriers to providing services and specific service priorities for system development. Methods and results are presented. Implications for the local system and future research needs are discussed.     

Lorenz Curves: A New Model for the Distribution of Psychiatric Services

The growth of child and adolescent psychiatric services based on the wraparound philosophy raises new questions for medical directors, investigators, and clinicians interested in improving quality of care and outcomes. Typically, quality improvement studies have focused on standardizing care and decreasing variation while community based services following a wraparound model are by definition individualized. To date, little information on how to evaluate such services in a managed care environment has been available. We present one option for evaluating the distribution of medical services and the extent to which providers individualize services for children with severe emotional disorders. Specifically, we (a) review the philosophy and goals of wraparound services, (b) introduce the Lorenz curve as a tool for determining the degree of inequality in service distribution at a given institution, and (c) present a case study on the use of Lorenz curves by a Medicaid Behavioral Health Organization in profiling behavioral providers.     

Understanding Respite Care Use by Families of Children Receiving Short-Term, In-Home Psychiatric Emergency Services

Respite care is widely believed to be an important support service for families raising a child with a disability. We report the findings of a respite care utilization study conducted within the context of a larger research and demonstration project examining three models of intensive, in-home services for children experiencing psychiatric crises. Respite care, both in-home and out-of-home, was a support service available to families in two of the three study conditions. Overall, 34% of 146 eligible families used in-home and or out-of-home respite care. Utilization was lower than the estimates developed prior to implementation, prompting an inquiry at the end of the first project year designed to maximize use and to gather more information on caregiver and service provider attitudes toward respite care. The inquiry included caregiver and provider focus groups, surveys, and enhanced data collection and analysis. Caregiver interviews indicated that many families did not fully understand what it meant to receive respite care or even that it was available to them. A comparative analysis of respite care users and non-users revealed that respite care users were more likely to have younger children, children who had a greater number of assessed functional impairments, and fewer social supports. Respite care users also reported greater difficulty managing their children's difficult behaviors.     

Use of Out-of-Home Care Among a Statewide Population of Children and Youth Enrolled in Medicaid

System-wide research on the use of out-of-home care among children and youth is needed to inform the development of policies and services. We used Medicaid claims from North Carolina to examine patterns of out-of-home care, identify demographic and diagnostic differences between those who received care in residential treatment, psychiatric hospitals, or general hospitals, and determine whether demographic or diagnostic characteristics were associated with having more than one out-of-home stay during the year. Among those who received out-of-home care during a 1 year period, 36% received care in residential treatment only, 32.4% in general hospitals only, and 17.6% in psychiatric hospitals only, while 14.0% used more than one sector of out-of-home care. Boys, teenagers, and youth in foster care or diagnosed with emotional disturbance or hyperkinetic syndrome had higher odds of receiving care in residential treatment only whereas girls, youth age 19–21, and those with depressive and stress and adjustment disorders had higher odds of receiving care from hospitals only. Teenagers and youth in foster care had higher odds of having more than one stay. Among those with more than one stay, there were 300 patterns of care and nearly half received care from more than one service sector. The implications for services and policy are discussed. Further research is needed to understand patterns of out-of-home care and the factors that influence placement decisions.     

National Trends in Implementing Wraparound: Results of the State Wraparound Survey, 2013

The wraparound process aims to provide an effective practice-level approach to coordinating care for youths with complex behavioral health needs, and reformed system structures to support such integration of care. The current study provides an update to two prior surveys of state children’s mental health directors, completed in 1998 and 2007, on the extent of wraparound implementation in the United States and implementation supports that have been employed. Results from 2013 found that 100 % of states reported having some type of wraparound program that conformed to the definition and yielded an estimate of 75,000 children and families served via wraparound in that year. States reported a continued increase in use of wraparound standards; however, fewer states reported collection of fidelity data, and availability of internal resources for training and coaching. Over three-quarters of states reported availability of parent to parent peer support, and 46 % of states are supporting wraparound implementation by blending or braiding funding across child-serving systems. Results also revealed that 61 % of states had a centralized oversight entity for wraparound, an important finding given that such “statewideness” was also associated with more youth served, greater accountability, use of standards, and other implementation supports.     

Factors Predicting Attrition Within a Community Initiated System of Care

We designed this study to elucidate child, family, and service level characteristics that may influence attrition from a continuum of care developed and maintained by a community initiated collaboration of local clinics and agencies. Subjects included 117 children and adolescents referred to the Middlesex County system of care from 1992–1999. Data were collected through a retrospective case review. The strongest predictors of attrition from the system of care both before and after the establishment of an individualized service plan included depressed/isolated symptoms, substance abuse, general risk for psychiatric problems, number of referral reasons and urgency status at program intake. Among youth exiting residential placement, those completing recommended services were more likely to be returned home earlier or within the expected time frame than were dropouts. Our study presents important preliminary findings regarding characteristics related to treatment adherence within a community initiated systems of care.     

Termination of Mental Health Services for Children

In this paper, we examine the termination of children's mental health services. Analyses were based on the 901 families in the Fort Bragg Evaluation Project who participated at Wave 1 and Wave 2 six months later. The project compared a full continuum of care provided at a demonstration site with traditional care at two comparison sites. The results showed that in most cases families and providers were partners in decisions to terminate treatment. About half of the clients self-terminated or were terminated solely at the discretion of the provider. Providers tended to play a more dominant role in terminating restrictive services; families played a more central role in terminating outpatient care. Regardless of initial psychopathology, children in single-headed households, whose parents were dissatisfied with services, did not expect their child to cooperate with treatment and did not expect treatment to help their child, were more likely to terminate care than others. While the Demonstration site had significantly fewer terminations, the sites did not differ with regard to the reasons for termination, who participated in termination decisions, or the factors that affected the likelihood to terminate care. Of most interest, mental health outcomes among children who had terminated all care did not vary by reasons for termination or by who participated in the termination decision.     

Access to Child and Adolescent Mental Health Services

Adequate access to child and adolescent mental health services for young people in high need populations is an important concern of service systems researchers and program evaluators. We present results of a statewide study of access to community mental health services for eight populations of special concern. The analysis relied exclusively on existing databases in conjunction with innovative statistical techniques to provide comprehensive measures of access to care. Our findings indicate that access to care varied substantially across special populations, although children and adolescents in each of our eight “special populations” had greater access to public mental health services than members of the general population of the state. The interpretation of the findings and directions for future research are discussed.     

Reliability of the Wraparound Observation Form: An Instrument to Measure the Wraparound Process

Within the past decade, the wraparound approach has gained significant popularity in providing services to children with challenging social and family needs. While a plethora of wraparound programs have been developed and studies have been conducted to assess their effectiveness, the need to develop instruments that measure the implementation of wraparound services is clear. The purpose of the present study was to evaluate the reliability of a scale that measures wraparound services. In this study, the Wraparound Observation Form (WOF), was developed to evaluate the implementation of the wraparound process in treatment planning meetings. The WOF includes 34 closed-ended items that requires the respondent to note the occurrence or non-occurrence of specific events or behaviors at treatment planning meetings. In the present study, two data collectors attended planning meetings and independently completed the WOF. The inter-rater reliability was 95%. The WOF appears to be a reliable instrument and be appropriate in evaluating wraparound services.     

Evaluation of a Congressionally Mandated Wraparound Demonstration

In order to determine whether expenditures for mental health could be reduced and quality improved, Congress mandated that the Department of Defense conduct a demonstration project utilizing a wraparound mental health service system for child and adolescent military dependents. A longitudinal quasiexperimental design was used to evaluate the cost-effectiveness of the demonstration. The results showed that children in the Wraparound Group received more wraparound services than those in the treatment as usual (TAU) Comparison Group. These services included case management, in-home treatment, and other nontraditional services. The Demonstration also provided better continuity of care. Multiple methods were used to investigate the impact of wraparound. Both groups showed some improvement on some measures but there were no differences between the groups in functioning, symptoms, life satisfaction, positive functioning, or sentinel events. Regardless of which statistical model was used to estimate costs, the Demonstration was also more expensive. The higher level of expenditures for the Wraparound group was a result of some expensive traditional care and the addition of nontraditional services. Several possible explanations of these results are provided.     

How to Fix Peer Review: Separating Its Two Functions—Improving Manuscripts and Judging Their Scientific Merit—Would Help

Adequate access to child and adolescent mental health services for young people in high need populations is an important concern of service systems researchers and program evaluators. We present results of a statewide study of access to community mental health services for eight populations of special concern. The analysis relied exclusively on existing databases in conjunction with innovative statistical techniques to provide comprehensive measures of access to care. Our findings indicate that access to care varied substantially across special populations, although children and adolescents in each of our eight “special populations” had greater access to public mental health services than members of the general population of the state. The interpretation of the findings and directions for future research are discussed.Reprinted with permission from The Scientist. Originally published in the June 6, 2005 issue of The Scientist (www.the-scientist.com).     

School-based applications of the wraparound process: Early results on service provision and student outcomes

The application of a school-based wraparound approach presents different challenges, perspectives, and knowledge from those seen in mental health or child welfare settings. For the past three years, the La Grange Area Department of Special Education's Wraparound Project has been implementing a school-based individualized service network that is now being integrated into the larger local and state special education, mental health, and social service systems. We present school-based applications of wraparound for students with emotional and behavioral disabilities, including the community and system context, program application, evaluation process and preliminary results. Students who were identified through self-contained special education classrooms were compared to students who were identified from various other school and mental health settings. Students from the school-based program were less clinically involved than students identified from other settings. Service provision differed between program groups and by out-of-home experiences. Finally, the use of wraparound approaches across a variety of educational settings to prevent out-of-school and out-of-home care are discussed.     

After School Care for Children on the Autism Spectrum

Few programs exist for after school care designed to support children with Autism Spectrum Disorder (ASD). Not only do parents often depend on after school care, but also children with ASD are likely to benefit from opportunities to generalize skills in an authentic setting and interact with typically developing peers. This lack of support occurs at a time during which there is increasing research and community awareness regarding the need for high quality after school programs to support typically developing children. This study investigates reported experiences with and needs for after school care by parents of children with ASD. Survey results (N = 54) revealed that the majority of parents surveyed desired after school programs within their child’s school but are often denied access to such services or received low quality care for their child in after school programs. Recommendations are provided for future research and program development.     

Mental Health Problems of Children in Foster Care

We compared the rates of mental health problems in children in foster care across three counties in California. A total of 267 children, ages 0 to 17, were assessed two to four months after entry into foster care using a behavioral screening checklist, a measure of self-concept and, in one county, an adaptive behavior survey. Results confirmed previous research and indicated consistently high rates of mental health problems across the three counties. Behavior problems in the clinical or borderline range of the CBCL were observed at two and a half times the rate expected in a community population. Fewer children fell within the clinical range on the self-concept measure. No significant differences in rates between the three county foster care cohorts were observed, despite the different demographic characteristics of the counties. On the adaptive behavior scale, the mean scores for children in foster care were more than one standard deviation below the norm. Our findings suggest that the most important mental health screening issue with children in foster care is to identify what specific mental health problems need to be addressed so that the most effective treatment services can be provided.     

Child and Family Team Meeting Characteristics and Outcomes in a Statewide System of Care

Systems of care (SOC) have relied on the wraparound care process to individualize community‐based services for children and youth with serious emotional and behavioral difficulties. A core element of wraparound care is Child and Family Team meetings (CFTs), which are designed to give youth and families a leadership role in developing and guiding their plan of care. The National Wraparound Initiative (NWI) has identified Practice Standards regarding CFT implementation. This study examined CFT characteristics and the association between those characteristics and youth and family outcomes in a statewide SOC. Participants were 363 youth (M_age = 10.89, SD = 3.72) and their caregivers. Families completed measures of youth and caregiver functioning and symptoms at enrollment and 6‐month follow‐up. Care coordinators completed a survey assessing CFT implementation and characteristics following each meeting. Multiple regression analyses were used to examine the relationship between CFT characteristics and youth and caregiver outcomes. Results indicated that a higher number of CFTs was associated with poorer outcomes, while a higher percentage of natural supports at meetings was associated with better youth outcomes. Number of days to the first CFT was associated with greater caregiver strain. Implications for CFT implementation within wraparound are discussed.