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Orientation to Child and Family Team Practice

and the Pennsylvania Youth and Family

Institute

Jim Rast, Ph.D.John VanDenBerg, Ph.D.

December, 2007

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This Pennsylvania Effort… Pennsylvania has a long history of successful

collaboration and programs to support children and their families.

Through the PYFI, VVDB is committed to developing capacity to provide, coach and train sites with a commitment to implementing Child and Family Teams processes (high fidelity wraparound) in PA

VVDB is partnering with the PYFI, participating Counties, and State Level partners to help this transformation succeed

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Wraparound

Wraparound and wraparound are not the same thing.

PA uses the term wraparound differently than almost every other state.

Arizona had other uses for the term wraparound and chose to use the term “child and family teams” to describe the process of integration and individualization used at the practice level

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Development of WraparoundGrassroots Development General Principles Applied in many different ways Creativity and advances 200,000 children in 1999

Initial Results Life changing success stories Strong support Mixed evaluation results Research shows results match fidelity

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Defining Wraparound

Steps to Define Wraparound Duke meeting on principles National Wraparound Initiative

Who they are Process used Products produced

Wraparound Fidelity Assessment System

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Wraparound Process

Is a Process for Supporting Youth and Families that

Is defined by 10 principles of how the process is implemented;

Is done in four phases and related activities that describe what is to be done; and

Fits the four components of the theory of change that explains why it works.

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Principles for Wraparound

Family Voice and Choice

Team Based Natural Supports Collaboration (and

Integration) Community Based

Culturally Competent Individualized Strengths Based Persistence Outcome Based and

Cost Responsible

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Phases and Activities, and Skill Sets NWI phases and activities Vroon VanDenBerg specific skill sets for

wraparound facilitators, coaches and family support partners

VVDB performance based training and coaching products

Credentialing and Quality Improvement Used and been in over 35 sites across North

America. Sites using these products report greatly improved

outcomes and more satisfied families and staff.

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Impact on CAFAS Scores after 6 Months

-50

-40

-30

-20

-10

0

10

Trad MH Services High FidelityWraparound

Low Fidelity thenCoaching

Chn

age

In C

AFA

S S

core

s

6 months

10

2.0

2.2

2.4

2.6

2.8

3.0

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3.4

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3.8

4.0

Intake 6 Months 12 Months

Ave

rag

e F

RS

Sco

re

Overall

2.0

2.2

2.4

2.6

2.8

3.0

3.2

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3.6

3.8

4.0

Intake 6 Months 12 Months

Ave

rag

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RS

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Low Fidelity High Fidelity

Impact of Fidelity

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Breakdown of Fidelity Scores

00.10.20.30.40.50.60.70.80.9

1

Principle

Ave

rag

e F

idel

ity

Sco

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Low Fidelity High Fidelity

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Impact on CAFAS Scores after 18 Months

-70-60-50-40-30-20-10

010

Trad MH Services High FidelityWraparound

Low Fidelity thenCoaching

Chn

age

In C

AFA

S S

core

s

6 months 18 months

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The Theory of Change is

Is why we do wraparound Is what about wraparound that makes it

work Is what differentiates it from other service

coordination processes Defines expectations for what we hope to

accomplish through wraparound

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Efficacy

Theory of Change for WraparoundWhy Does Wraparound Work?

Integrated Plan

NaturalSupportSystem

Self

Efficacy

NEEDS

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Theory of Change for WraparoundWhy Does Wraparound Work?

Wraparound addresses the priority needs identified by

the youth and family

Efficacy

Integrated Plan

NaturalSupportSystem

Self

Efficacy

NEEDS

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Families are not Fully EngagedFamilies are not Fully Engaged

Research finds that Up to 60% of families drop out of services before

they are finished Children from vulnerable populations are less

likely to stay in treatment

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The Challenge of Full Family EngagementThe Challenge of Full Family Engagement

Why do families drop out?Treatment is stressfulTreatment seems irrelevantPoor relationship with therapistConcrete obstacles:

Time, transportation, child care, other priorities

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Wraparound Supports Engagement

Addresses family prioritized needs Plans for needed support Family-centered and youth guided Culturally competent Strengths- and community based Creative and Individualized

Teams brainstorm how to mobilize professional, natural, and community supports to meet unique needs

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Theory of Change for WraparoundWhy Does Wraparound Work?

Wraparound strengthens youth and families

confidence that they can create positive change

in their lives

Efficacy

Integrated Plan

NaturalSupportSystem

Self

Efficacy

NEEDS

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Self-Efficacy is the belief in one’s capabilities to organize and execute

courses of action required to produce given attainments plays the central role in the cognitive regulation of

motivation

People with high self-efficacy are more likely to expend more effort, and persist longer

Low self-efficacy often results in poor task planning, as well as increased stress.

people with high self efficacy often take a wider picture of a task in order to take the best route of action

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Theory of Change for WraparoundWhy Does Wraparound Work?

Wraparound strengthens the social support system that

helps the youth and family succeed

Efficacy

Integrated Plan

NaturalSupportSystem

Self

Efficacy

NEEDS

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What or Who are Natural Supports

Natural supports are community resources available for use by youth and families within which are consistent with their cultural beliefs and practices.

Natural supports may involve individuals outside the immediate family and a variety of informal supports found in the neighborhood or larger community.

Natural resources are external to the child and family and, once accessed through active affiliation, become part of the child's and family's strengths.

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Research on Impact of Natural Supports

positively impact chronic disease related health behaviors

increase compliance to routine medical care improved health for older people with chronic

conditions decrease postnatal depression for new mothers decrease depression in older women positive natural supports decrease drug use positive natural supports decrease HIV risk behaviors decrease punitive punishment from parents increase coping, resilience and sustainability for

caregivers

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What Natural Supports Do for Caregivers

Natural Supports may support and influence improved and sustained care-giving by

Creating situations to observe and learn about effective parenting from people the family trusts

Providing a sense of attachment and someone to talk to during tough times

Someone to trust and provide respite from many types of demands of care giving

Providing access to resources and material goods

Providing coping resources

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Theory of Change for WraparoundWhy Does Wraparound Work?

Wraparound creates an

integrated and simplified plan for the whole

family

Efficacy

Integrated Plan

NaturalSupportSystem

Self

Efficacy

NEEDS

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Seriousness of the Problem

Prevalence of Serious Emotional Disturbance (SED)

Population Proportions (9 to 17 year-olds)

5-9% Youth with SED & extreme functional impairment

9-13% Youth with SED, with substantial functional impairment

20% Youth with any diagnosable disorder

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Children with Behavioral Health Disorders Across Systems

0%

20%

40%

60%

80%

100%

Child

Welf

are

Juve

nile

Justi

ce

TANF

Educa

tion

Pe

rce

nt o

f Ch

ildre

n

None

BH Dx

SED

0%10%20%30%40%50%60%70%80%90%

100%

None Child Welfare Juvenile Justice

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Fragmented System

Yet, for too many Americans with mental illnesses, the mental health services and supports they need remain fragmented, disconnected and often inadequate, frustrating the opportunity for recovery. Today’s mental health care system is a patchwork relic—the result of disjointed reforms and policies. Instead of ready access to quality care, the system presents barriers that all too often add to the burden of mental illnesses for individuals, their families, and our communities.

Michael F. Hogan, Ph.D. 2003 ChairmanPresident’s New Freedom Commission on Mental Health

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Tyler Family

Marge, 38 Evan, 39 Billy, 14 Sam, 12 Sally, 12

Major Strengths, Family Culture: Parents married 17 years Marge’s parents alive and in the area, care

about the family Marge has entrepreneur skills in area of home

cleaning business Family has history of surviving adversity using

their wits Evan has over a year of sobriety after a decade

of untreated alcoholism Children provide active support to each other Family culture prioritizes educational goals Billy knows what “cool” is

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Major Needs of Tyler Family

From the more detailed description of the Tyler family list concerns or risk factors

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Major Needs of the Tyler FamilyBilly: Serious Juvenile Justice involvement Breaking and entering, shoplifting,

thefts of all types Two years behind in school but lots of

potential

Twins (Sam and Sally): Bi-polar, extreme mood swings. In child welfare custody in a

specialized foster home School is having problems controlling

behaviors and engaging them in lessons

All school behavior plans have failed, and school is suggesting home bound instruction

Evan: Verbally and physically

abusive to children unemployed, unable to

hold job due to self described “Stubborn attitude about authority”

Recovering from severe alcoholism

Marge: Family history of major

depression (untreated); Suicidal ideation which is

likely to result in death.

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Pairs Activity

After the concerns and risk factors for the Tyler family are discussed brainstorm typical services and plan(s) for them in your county. We are going for typical – what the average youth and family in their situation would get.

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Typical Plans for Tyler Family

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How complex is the Tyler Family?

Based on initial information, rate this family from one to ten, with one being least complex needs and ten being most complex needs….

What don’t you see that would make this family rate a higher number?

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26 Helpers and 12 Plans

School (5)Technical School (2)Child Welfare (1)Juvenile Justice (1)Children’s Mental Health (6)Adult Mental Health (3)Employment Services (2)AA (1)Housing Department (1)Bailey Center (2)Specialized Foster Care (2)

2 IEPs (Sally and Sam)Tech Center PlanPermanency PlanProbation Plan3 Children’s MH Tx Plans2 Adult MH Tx PlansBailey Center PlanEmployment Services

33 Treatment Goals or Objectives

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Collaborative Efforts in Tyler’s Town1. Local Judge is chairing a restorative justice effort to address

truancy and violence in schools. Juvenile Justice and law enforcement has major presence in local High Schools.

2. School Superintendent and United Way are leading an interagency effort for substance abuse prevention.

3. Local Health Department has a grant and steering committee to decrease teenage Pregnancy.

4. Child Welfare has a mandated interagency coalition that is planning for multi-agency involved children and youth.

5. Children’s Mental Health has co-located staff at child welfare supporting family preservation and family group decision making.

6. Adult Mental Health and Adult Addictions Services are in same agency.

7. There is a grassroots effort to develop more church involvement in supporting children and families.

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Your Collaboration

Is your communities more, the same, or less collaborative than the Tyler’s town?

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Current Services to Tyler Family School has IEP for each of the

twins and extensive behavior support and planning.

Billy is in a tech center but is rarely in school, school has offered many adaptive plans but none have worked.

Both schools call parents frequently.

Child welfare has substantiated Dad’s abuse of twins, has removed them from the home, created a strict reunification plan that includes family therapy and supervised visits

Twins are in specialized foster care with care and a therapist who supports the foster parents.

Twins are in therapy, two different therapists and a psychiatrist

TSS to help out with Billie

Juvenile Justice has just released Billy from detention over breaking and entering, Billy has new charges of theft,

Court ordered therapy Restitution supervised by local

youth services agency with a counselor and mentor

Housing is trying to find safer housing

Marge sees a psychologist occasionally in crisis times and has been referred to a psychiatrist, went once but does not want to go back.

Evan goes to four AA meetings a week and sees his sponsor twice a week, calls daily

Evan goes to court ordered anger management

Evan is working with Vocational Services on employment skills

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Monthly Appointments for the Tylers Child Welfare Worker 1Marge’s Psychologist 2Marge’s Psychiatrist ?Billy’s therapist 4Billy’s restitution services 4Appointments with Probation and School 2Family Based 4Therapeutic Support Staff 12Evan’s anger management 4Children’s Psychiatrist 1Other misc. meetings:, Housing, Medical 5AA Meetings 16

Also, consider daily schedule (School, tech center, and vocational training) and the dozen or more calls from the schools each month.

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Comments from the Files:

Parents don’t respond to school’s calls Family is dysfunctional Parents are resistant to treatment Home is chaotic Billy does not respect authority Twins are at risk due to parental attitude Mother is non-compliant with her psychiatrist, does not

take her meds Father is unemployable due to attitude Numerous missed therapy sessions Attendance at family therapy not consistent, recommend

group therapy for parents

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Mutual Perspective

How do the professionals involved with the Tyler family view this family, and their role in the family? Do they see their role as “Rescuer” “Stabilizer” “Enforcer” “Supervisor” “Teacher”?

How does the family view the professionals? Does the family feel that they are asking for help? Does the family want the same help as the help the professionals want to give?

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Help isn’t help unless it is asked for!*

Sometimes people need help even though they don’t ask for it. How can we engage them in a way that

helps them trust us when we see a need that they do not see? Will any plan work if the Tylers are not on

board or don’t see the plan is theirs?

*Quote from Help: The Original Human Dilemma (pub. By Harper, 2004), author is Garret Keizer

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Cost

Specialized Foster CarePsychiatristPsychologistTherapy (Individual and Family Based)Therapeutic SSTech CenterVocational TrainingSchoolRestitution

Per Month

Plus the cost of the salaries for the public staff and the time from AA. If there is a crisis, detention, or higher levels of care the cost goes up considerably

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Going From Collaboration to Integration is a Needed Shift

Collaboration: Agencies are familiar with each other’s missions and roles, key staff work with each other at the child/family level, but retain single system decision making power and planning.

Integration: Agencies are familiar with each other’s missions and roles, key staff work with each other at the child/family level, sharing decision making in a team format that includes the family, producing a single plan that meets all system mandates and that is owned by the entire team.

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Rate your town…

On collaboration, rate your town from one to ten, with ten being most collaborative?

On integration, rate your town from one to ten, with ten being most integrated?

If ratings were different, what are non-blaming or shaming reasons for the differential ratings? For example, staff may not be trained to integrate.

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First: Crisis Stabilization

Before team building, stabilize immediate crises with safety plan for Billy’s criminal behavior, Marge’s suicidal behavior and maintenance of Evan’s sobriety

Crisis planning involves prediction of worst case scenario, functional assessment to target plan on function of crisis behaviors, implement individualized, strengths-based, culturally competent prevention efforts, and plan for what to do if crisis occurs

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Initial Tyler Wraparound Team

All of the immediate family (5) Marge’s Parents (2) Twin’s behavioral staff from school Probation Officer Child Welfare Case Worker Marge’s business co-owner Evan’s AA Sponsor Care Coordinator Family Support Partner

14 total, team can change over time…

Later, teachers, therapists, vocational staff, others in consulting roles

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Next, Prioritize Needs and Plan Notice that needs are addressed in sequence with integrated

approach to selection of need priority, with family in controlof final decisions with court approval

1. Billy’s thefts – highly individualized plan using the “cool” grandfather to help stop criminal behavior, do individualized restitution to victims, and build on Billy’s strengths

2. Support of twins and highly individualized plan to gradually move toward reunification, done at approximately same time as #3 so that school, foster home, and home are consistent

3. Plan to stabilize twin’s school behavior using Marge, grandparents and others as volunteer aides, including accelerated plan to get Billy up to grade level using volunteer aides who are “cool”

4. Support Marge’s business efforts to keep income rolling in5. Continued Vocational Services for Evan, with team support of job

finding

And so on, over a year (predicted)

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Benefits of an Integrated Approach for the Tyler Family and the Town

Tyler family has real hope from their plan and process, have more energy each time a goal is met.

The professionals involved get to maximize the use of their own expertise. For example, which plan would you rather be the psychiatrist in? Or the teacher?

The professionals get to practice integration skills which will benefit 1000’s of other families, trading control and autonomy for outcomes at the family level, and more satisfying jobs. Also may decrease professional turnover.

Taxpayers get return for their investment Potential multi-generational positive effect Community building a family at a time.

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Cost

Not why we are here, but the real five year cost of Tylers was in excess of $250,000 – real money paid by real taxpayers

Is the “typical plan” a good deal for taxpayers?

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0%

10%

20%

30%

40%

50%

60%

70%

6 Month Intervals

Pe

rce

nt o

f Yo

uth

in P

erm

an

en

cy S

etti

ng

Comparison DHS Wrap

Comparison 23.5% 20.6% 14.7% 20.6% 26.1%

DHS Wrap 5.4% 13.5% 32.4% 43.2% 65.2%

B1 B2 1 2 3

Permanency

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THE Placement The most important part of finding the placement is really getting to

know the strengths, culture and needs of the youth. Talk to the youth at length and also talk to people who know the youth

(caregivers, former caregivers, teachers, etc) Strengths include people who might provide some level of support Needs focus on what it will take in an environment to be successful for

the youth and what the youth wants out of life Needs include the challenges that make the youth hard to place

Once you know the youth use the information to match to THE placement Use the strengths to sell the youth to the placement Be very honest about the challenges and needs so placement knows

what to expect Plan with the youth and placement before the youth arrives so the initial

experience is better Frequent communication and support over time to youth and placement

once there In the meantime

Stall Use the same principles and keep working on the THE placement if a

temporary stop is required

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Youth Story - THE Placement

Youth was 16 and in lock down for shoplifting and AWOL from TFC. History of sexual abuse and had become sexually reactive. Multiple failed placements because of sexual and aggressive to other kids. No supports or visits for several years.

Strengths – good with adults, motivated to succeed Challenges – around younger kids or kids in home, learning

disability requires very structured situation and instructions THE placement – a mature couple with no other children in the

home The Results – found grandmother and brother who want to support

him but could not provide placement. Developed long range vision of work with need for supported living. Completed school and went to Job Corp. Will return to live with grandparents supported by brother until he is ready to go out on his own.

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Stability of School Placement

1

1.1

1.2

1.3

1.4

1.5

1.6

1.7

1.8

1.9

2

Control WrapAv

era

ge

Nu

mb

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of

Sc

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pe

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ix M

on

ths

Baseline 6 Months

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Summary of Results

Outcome (Data Source)Positive Direction

Comp DHS Wrap NC Wrap

Average Number of Days in Permanency Setting (KIDS) 7 92* 63*

Percent of Youth in Permanent Placement 12 to 18 months (KIDS) 4.1% 55.7%** 29.5%*

Change in Number of Residential Moves per Six Months (KIDS) + 0.7 - 0.6* 0

Number of Schools in Six Month Period (Caregiver Survey) 2.0 1.2* 1.4

Changes in Restrictiveness of Living Scale (KIDS) + 0.7 -1.26** -.32*

Change Level of Family and Caregiver Stress (Caregiver Survey) + 4.4 - 6.0** + 3.6

Change in Level of Youth Problems (Ohio Scales) + 1.3 - 5.8** +1.8

Change in Level of Youth Functioning (Ohio Scales) - 5.2 + 3.0** - 1.1

Change in Level of Impairment (CAFAS) - 11.4 - 25.0** -10.5

Reduction in Medicaid Spending (OHCA) $75,383 $400,906** $222,384*

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Impact on Medicaid Spending

-500,000

-400,000

-300,000

-200,000

-100,000

0

100,000M

ed

ica

id B

HS

Co

stC

ha

ng

e f

rom

Ba

selin

e P

er

Pe

rio

d

Control DHS Wrap

Control 56,837 -10,604 -121,616 -75,383

DHS Wrap 35,711 -97,580 -339,037 -400,906

1 2 3 Total

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Facilitator Credentialing using VVDB tools…

Novice -- has completed 24 hours of class room (or E-Learning) instruction, in-class behavioral rehearsals, pre and post tests, and 20 hours of shadowing

Practitioner -- has a professional development plan, is receiving appropriate supervision and coaching, and has demonstrated competency using VVDB documentation and observation review tools.

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VVDB Observation and Review Tools

Either the Supervisor/Coach or Coach actively reviews document products and observes key activities based on NWI Phases and Activities

Documentation Reviews: SNCD; Wrap Plan; Functional Assessment; Crisis Plan; Progress Notes; Transition Plan

Observation Reviews (live): Initial Engagement meeting; Initial Team Meeting; Follow-up Meeting

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Barriers to High Fidelity Wraparound in PA

1. In small groups, assign a recorder with good hand writing (the notes will be turned in)

2. Begin the discussion by introductions. Then, list out top barriers which may get in the way of implementing wraparound as defined by the National Wraparound Initiative (30 minutes)

3. Prioritize the list and choose the top barrier (5 minutes)

4. Then (most important) make a recommendation for removing the top barrier. (10 minutes)

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Remember one thing…

High Fidelity Wraparound is a process of integration for children and families with co-occurring disorders. It is specifically designed to lead to positive clinical outcomes and is based on a theory of change

In general, the field has greatly underestimated the complexity of doing a good job with wraparound at the supervisor and staff levels.