Using a Theory of Change to Drive Human Resource Development for Wraparound

Achieving coherence and integration across staff professional development activities is facilitated when training, coaching and staff evaluation are guided by a clearly articulated program theory or “theory of change” that describes how skillful practice promotes desired outcomes. We focus on a theory of change for wraparound, a widely implemented approach to providing community-based care for children with high levels of mental health and related needs. Training, coaching and staff evaluation efforts within wraparound programs have typically been linked only very loosely to theory. We argue that wraparound’s unique history allowed it to evolve with limited theoretical grounding, and we then describe a theory of change for wraparound, focusing on the major causal routes that are hypothesized to lead to outcomes. Finally, we provide an extended illustration of how the theory can provide the basis for a coherent and integrated approach to developing the skills and capacities of staff members playing key roles in wraparound implementation.     

Connecting the Dots: Stages of Implementation,Wraparound Fidelity and Youth Outcomes

Several necessary system and organizational support conditions for wraparound have been identified (Walker et al. 2003). Yet, the relationship between these necessary system level conditions and wraparound fidelity has only recently begun to be examined. Similarly, few studies have included a measure of wraparound fidelity when examining the relationship between wraparound implementation and youth outcomes. The statewide implementation of a wraparound demonstration grant offers the opportunity to explore these relationships and to identify factors that predict improvement in functioning for youth receiving wraparound. Findings suggest that significant relationships exist between (1) the stage of development of necessary support conditions for wraparound and wraparound fidelity and (2) wraparound fidelity and improvement in youth outcomes. Specific elements of wraparound (i.e., outcomes based and community based) and baseline needs and strengths (e.g., high levels of anxiety and conduct issues, poor functioning at home and in school, judgment, and risks) were found to predict a reduction in youth needs. Other unexpected relationships between youth outcomes and the cultural competence element of wraparound and being multi-racial were also discovered. These findings reinforce the importance of supporting high fidelity wraparound for youth and their families in a recovery focused behavioral health system.     

Effectiveness of the Wraparound Process for Children with Emotional and Behavioral Disorders: A Meta-Analysis

Wraparound is a team-based service planning and coordination process intended to improve outcomes for children and youth with serious emotional and behavioral disorders and support them in their homes, schools, and communities. Given the substantial resources devoted to implementing wraparound, a meta-analysis of outcome studies was conducted to better understand current empirical support for this process. A literature search identified seven studies between 1986 and 2008 that documented the effects of youth receiving wraparound compared to control groups. Mean treatment effects across outcome domains ranged from medium for youth living situation (0.44) to small for mental health outcomes (0.31), overall youth functioning (0.25), school functioning (0.27), and juvenile justice-related outcomes (0.21). The overall mean effect size across studies was 0.33. Interpretation of results was complicated by the lack of consistent documentation of implementation fidelity across studies and conditions, variations in target population and intended outcomes, and methodological concerns. The authors conclude that, though the published wraparound research base is expanding and findings are largely positive, it continues to be in a preliminary state of development. However, there are insufficient data to support calls for wraparound’s acceptance or dismissal based on the strength of existing studies.     

National Trends in Implementing Wraparound: Results from the State Wraparound Survey

The wraparound process has been promoted in the children’s services field as a mechanism to achieve collaborative service planning and delivery for families of young people with complex emotional and behavioral needs that span multiple agencies. We compared results of two surveys of state children’s mental health directors, completed in 1998 and 2008, to derive estimates of the extent of wraparound implementation in the United States and to better understand trends in how wraparound has been implemented and supported over time. Results from 2008 found that 88% of states reported having some type of wraparound program that conformed to the definition and provided an estimate of 100,000 children and families served via wraparound in that year. Between 1998 and 2008, states reported increased application of wraparound standards, a greater number of agencies involved in wraparound initiatives, and more formal evaluations of wraparound initiatives. Results provide substantiation of the widespread implementation of wraparound implementation in the United States, and evidence that the model is becoming more consistently supported by formal implementation structures over time.     

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.     

Deciphering the Tower of Babel: Examining the Theory Base for Wraparound Fidelity

I present the results of a study that examined a theoretical and paradigmatic basis to better define fidelity in a wraparound approach to service delivery. I first examined the literature to clarify terms and to suggest a paradigmatic and theoretical base for the easily misinterpreted, value-laden philosophy of wraparound. Two deceptively simple constructs were identified and examined through a multi-case, multi-method design. Results suggested that wraparound is an emerging collaborative model based in critical and constructivist thought and in ecological systems theory. My study provides a preliminary but essential step in clarifying the process of implementation and evaluation of the wraparound approach.     

Integrating Wraparound into a Schoolwide System of Positive Behavior Supports

We describe the structure for implementation of the wraparound process within a multi-tiered system of school wide positive behavior support (SWPBS) to address the needs of the 1–5% of students with complex emotional/behavioral challenges. The installation of prerequisite system features that, based on a 3 year demonstration process, we consider critical to full operation of the Tier 3 wraparound intervention within a system of SWPBS is also described. We include examples of system implementation benchmarks that occur concurrently with student outcome data and are logically linked to full operation and sustainability of wraparound implementation. Challenges surrounding implementation and proposed advancements are also discussed.     

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.     

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.     

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.     

Evaluating the vermont system of care: Outcomes associated with community-based wraparound services

Evaluation of innovative community-based interventions is becoming a high priority for child and adolescent mental health service system research. The present study examined outcomes for a sample of Vermont children (N=27) experiencing emotional and behavioral problems and receiving individualized, wraparound services. One year after initiation of wraparound care, incidence of negative behaviors rated as placing a child at risk of removal from the community had decreased significantly, compliance behavior had increased, and a significant decline in Total Problem Behavior scores on the Child Behavior Checklist was observed. In addition, though 70% of the participants had previously required inpatient or residential treatment, 89% were maintained in the community after one year of services, and the total cost of services was less than that of out-of-state residential care. Although further comparative research is needed, this study suggests that for many of these children, wraparound services may be a more efficient intervention than long-term psychiatric hospitalization or residential treatment.     

Moving Forward with Systems of Care: Needs and New Directions

The articles in this Special Issue on system change within systems of care (SOCs) provide guidance regarding strategies for modifying SOCs to address the needs of different populations, and ways for changing systems to support more positive child and family outcomes. This paper frames central needs, unanswered questions, and issues that remain for those working to implement SOCs. Specific needs and new directions considered include: (1) rigorous implementation-focused research to identify the necessary and sufficient elements of SOCs and the primary practice approach currently used in SOCs, wraparound; (2) applied research to assess SOCs and document their effectiveness in non-standard or non-traditional settings (i.e., non-mental health settings, including child welfare, juvenile justice, local housing authorities); (3) controlled outcome studies for school-based wraparound initiatives; (4) research to document the effectiveness of the family support efforts that are part of most SOCs; and (5) attention to context, for families, service providers, and collaborative implementation efforts, by researchers and providers alike. Progress in these areas can inform well-targeted system change efforts in the context of SOCs, a critical need given changes in federal funding for these initiatives.     

The <Emphasis Type="Italic">Community Supports for Wraparound Inventory</Emphasis>: An Assessment of the Implementation Context for Wraparound

The wraparound process has emerged as perhaps the most frequently implemented comprehensive approach for planning and providing individualized, community-based care for children and adolescents with serious mental health conditions. Providing comprehensive care through the wraparound process necessarily requires a high level of collaboration across organization and agency boundaries. This need for significant inter-agency or “system-level” collaboration creates a complex implementation environment for wraparound. It is therefore not surprising that creating and sustaining a hospitable implementation environment has proven to be extremely challenging. For the people who are responsible for managing the inter-organizational collaboration, it is not easy to evaluate the adequacy of local system-level support for wraparound and to see exactly what kinds of supports are lacking or where system-development efforts should focus. Furthermore, as system-development strategies are put into practice, it can be difficult to assess whether or not meaningful progress is occurring. The Community Supports for Wraparound Inventory (CSWI) was developed to respond to the need for an assessment of the extent to which a community has developed system-level capacity to implement wraparound. This article reports on a study that evaluated the reliability and validity of the CSWI for use in communities implementing wraparound. Findings indicate that the CSWI shows promise as a reliable, valid and useful tool.     

The Impact of Child and Family Team Composition on Wraparound Fidelity: Examining Links Between Team Attendance Consistency and Functioning

Although a growing body of literature has examined wraparound implementation and fidelity, child and family team (CFT) members’ levels of participation and the consistency of their attendance have not been systematically examined. This study explored the relationship between CFT member attendance consistency and the fidelity of wraparound team level implementation processes in a System of Care (SOC). Specifically, utilizing Participant Rating Form (PRF) data collected from caregivers, facilitators, youth, supportive persons, and service providers, as well as meeting attendance records, the relationship between team attendance consistency and fidelity of wraparound implementation was explored. Records for 88 teams, with a total of 2,643 members’ ratings of CFT meetings between 2004 and 2009, were examined. Analyses indicate that the structural team factors of attendance consistency and mean team members present relate to CFT members’ ratings of team functioning and the degree to which meeting processes are consistent with the tenets of wraparound. Team attendance variables related to the views of meeting functioning by facilitators, service providers, and caregivers, the individuals most often responsible for implementation of the plan of care, but not ratings by youth or supportive persons. These findings have implications for policy and the successful implementation of wraparound, underscoring the relevance of attending to and tracking the composition of the CFT and more actively encouraging consistent meeting attendance. Results also highlight the need to measure structural variables that may have salience in fidelity and implementation assessments and, more globally, the effectiveness of SOCs.     

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.     

Individualized services and supports through the wraparound process: Philosophy and procedures

The wraparound process is emerging as an alternative to the traditional treatment planning processes inherent in categorical services for children and adolescents with emotional and behavioral disorders. We describe the current practices which have been developed in the field. Key elements of the value and philosophical base for the wraparound process are discussed. Proposed procedural steps are described to aid communities in the implementation of the wraparound process. Due to social and policy pressures, it is likely that wraparound process implementations will continue to develop.     

Perceptions of Family Environment and Wraparound Processes: Associations with Age and Implications for Serving Transitioning Youth in Systems of Care

Addressing the unique needs of youth transitioning to adulthood has long been viewed as a priority in implementation of systems of care (SOCs) and wraparound. Developmental research and "practice-based evidence" suggest that there are differences between transitioning youth and their younger peers in family environment and wraparound team processes. Although these differences are thought to have significant implications for wraparound practice, few studies have examined them empirically. The present research involves two studies examining differences across several age cohorts (i.e., 10–12, 13, 14, 15, 16–17 year-olds) ranging from early adolescent to transitioning youth in: (1) caregiver perceptions of role-related strain and family environment quality, and (2) facilitator, caregiver, and youth perceptions of wraparound processes. In Study #1, older age was associated with higher levels of caregiver strain. In Study #2, age was associated with differences between youth and other team members' perceptions of wraparound processes, such that older youth perceived teams as less cohesive than others on their teams. These findings suggest that transitioning youth and their families merit special consideration in wraparound implementation and underscore the importance of considering the perceptions of transitioning youth in system change and practice improvement efforts (192 words).     

Quality and Individualization in Wraparound Team Planning

In children’s mental health, collaborative, team-based individualized service planning is most commonly known as wraparound, and has become one of the primary strategies for improving services and outcomes for children with the highest levels of need. We report on analyses of data gathered at 72 wraparound team meetings from communities around the United States. We describe the composition of the teams and the quality of the planning process they engaged in, and explore the extent to which these factors were associated with team member satisfaction and the individualization of plans. Teams in our study were numerically dominated by professionals. Parents attended a large majority of meetings, participation by youth and family advocates was frequent, participation by other family members infrequent, and participation by other members of the family’s informal or natural support networks rare. Observed teams varied considerably in the quality of their planning process and the degree of individualization of plans. Higher-quality planning was significantly associated with increased individualization of plans and with team member satisfaction with meeting productivity.