Theory and Research: Chapter 3.1 How, and Why, Does ...

This document was peer reviewed through the NWI.

How, and Why, Does Wraparound Work: A Theory of Change

Wraparound has always had implicit associations with various psychosocial theories (Burchard, Bruns, & Bur-

chard, 2002; Burns, Schoenwald, Burchard, Faw, & San-tos, 2000); however, until recently only preliminary efforts had been undertaken to explain in a thorough manner why the wraparound process should produce desired outcomes (Walker & Schutte, 2004). Using the foundation supplied by the specification of the principles (Bruns et al., 2004) and practice model (Walker et al., 2004) of wraparound, the National Wraparound Initiative (NWI) has proposed a more detailed theory of change to describe how and why wrap-around works.

Figure 1 (see following page) provides an overview of this theory. Beginning at the left, the figure illustrates how, when wraparound is “true” to the principles and practice described by the NWI, the result is a wraparound process with certain characteristics. Moving across the figure to the right, the various boxes summarize the short-, intermedi-ate- and long-term outcomes that are expected to occur. The figure illustrates with arrows several “routes” by which the wraparound process leads to desired outcomes.

It is important to remember, however, that this figure is a highly simplified representation of an extremely complex process. The various routes to change described here are not independent. They interact with and reinforce one an-other. Furthermore, the changes that emerge as a result of wraparound do not come about in a linear fashion, but rath-er through loops and iterations over time. Thus, an inter-mediate outcome that apparently emerges from one of the various “routes” may stimulate or reinforce a short-term

Janet Walker, Co-Director, National Wraparound Initiative, and Research Associate Professor, Portland State University School of Social Work

Theory and Research: Chapter 3.1

The Resource Guide to Wraparound

2

Section 3: Theory and Research

A wraparound process

characterized by:

High-quality planning

and problem solving

Respect for values, culture, expertise

Blending perspec-tives/ Collaboration

Family-driven, youth

guided goal structure and decisions

Opportunities for

choice

Individualization

Evaluation of strategies

Recognition/ Cel-ebration of success

••••••••

Short-term

outcomes:

Follow-through

on team

decisions

Service/support strategies that “fit”

Service/ support strate-gies based on strengths

Improved

service coordination

High satisfac-

tion with/

engagement in

wraparound

Experiences of efficacy and success

••••••

Intermediate

outcomes:

Increased resources and capacity for coping, planning, and problem

solving

Self-efficacy, em

powerm

ent, optim

ism, self-

esteem

Social support and com

munity

integration

Achievement of

team goals

•••• Intermediate

outcomes:

Enhanced effectiveness of services and supports, individually and as a “package”

•Long-term

outcom

es:

Stable, hom

e-like placem

ents

Improved m

en-tal health out-com

es (youth and caregiver)

Improved

functioning in school/ vocation and com

munity

Program-

specific outcom

es

Achievement

of team

mission

Increased assets

Improved

resilience and quality of life

•••••••

Phases and A

ctivities of the W

raparound Process

Ten principles of the W

raparound Process

Figure 1. A Theory of Change for Wraparound: Overview

3

Chapter 3.1: Walker

outcome that promotes changes through a differ-ent route. Finally, because wraparound is a highly individualized process, the various “routes” to change outlined here will operate to a different extent with different families and youth. After discussing the characteristics of the wraparound process and the main theoretical routes or mech-anisms of change, we will offer some specific ex-amples of this complexity.

Process: Effective, Value-Driven Teamwork

The theory assumes that, when wraparound is undertaken in accordance with the principles and the practice model specified by the NWI, the result is an effective team process that capital-izes on the expertise and commitment of all team members while also prioritizing the perspectives of the youth and family. Various strands of re-search provide a rationale for why this should be the case.

Research on teamwork across many different types of contexts provides strong evidence about what makes teams likely to be effective in reach-ing the goals they set for themselves. Specifically, a team is more likely to be successful when team members have decided on an overall, long-term goal or mission for the team (Cohen, Mohrman, & Mohrman, 1999; West, Borrill, & Unsworth, 1998), and when team members have clearly defined a set of intermediate goals specifying the major strands of activity that need to be undertaken to reach the long term goal (Latham & Seijts, 1999; Weldon & Yun, 2000). With this goal structure in place, effective teams work carefully to choose strategies for reaching the intermediate goals.

It is crucial that teams structure strategy se-lection deliberately, and that team members con-sider several different strategies before choosing one (Hirokawa, 1990; West, Borrill, & Unsworth, 1998). Research on collaborative problem solv-ing clearly shows that groups and teams have a propensity to jump to strategies and solutions too quickly, without considering a range of options. Generating several options before choosing one is important for at least two reasons. First, op-tions that are generated first tend not to be of as high quality as those generated subsequently; and second, the process of generating options helps

team members gain a clearer understanding of the “problem” to be solved. Working through op-tions in this manner enables groups and teams to be more creative and competent than individuals working separately at solving complex problems (Hirokawa, 1990; O’Connor, 1998; West, Borrill, & Unsworth, 1998).

Once strategies have been selected, effective teams set and use clear, objective criteria for judging whether or not the strategies are helping the team reach its goals (Cohen & Bailey, 1997; DeNisi & Kluger, 2000). Using these criteria, the team can then monitor whether or not a strategy is working, and can replace unsuccessful strate-gies with different ones. Finally, team effective-ness is also enhanced when teams acknowledge and celebrate success (Latham & Seijts, 1999).

The NWI’s practice model for wraparound (Walker et al., 2004) prescribes activities con-sistent with the elements of effective teamwork described above. Teams must develop a team mis-sion or family vision for the future (long-term goal) and prioritize a small number of needs or goals (intermediate goals) to work on. They generate options and select strategies, which they monitor regularly using indicators of success. When strat-egies are not working, teams are to select and then monitor different strategies. The principles of wraparound (Bruns et al., 2004) add further ex-pectations to the process of developing goals and strategies. For example, the principles specify teams should focus on developing community- and strengths-based strategies for the plan. These cri-teria are specific to wraparound (as compared to teams generally), but are easily accommodated within a framework of practices associated with effective teamwork.

Not surprisingly, there is more to team suc-cess than simply having these elements of ef-fective planning in place. Other research points for the need for teams to be collaborative—for team members to share the same goals and to feel that their perspectives have an impact in the decision-making process. Collaborativeness is enhanced when teams have clear expectations for how members should interact (Cohen, 1994; Cohen & Bailey, 1997), and when decision mak-ing is equitable (Beugre & Baron, 2001; Cohen & Bailey, 1997; Korsgaard, Schweiger, & Sapienza, 1995). Collaborative teams are more effective

4


than teams whose members do not feel invested in the team goals (Beugre & Baron, 2001; Cohen & Bailey, 1997; Korsgaard, Schweiger, & Sapienza, 1995; Tjosvold & Tjosvold, 1994). Team members who feel that their perspectives are not respect-ed during the decision-making process tend not to follow through on tasks that the team asks of them, thus making the team as a whole less ef-fective (Cropanzano & Schminke, 2001; Kim & Mauborgne, 1993).

Within wraparound, the principles call for a special sort of collaboration. The principle on col-laboration emphasizes the general idea that the wraparound process should be characterized by a

sharing and blending of perspectives such that all team mem-bers feel that their ideas and expertise are respected. Ad-ditionally, however, the principles fur-ther specify that the wraparound process is driven by family and youth “voice and choice.” Essentially, this means that the perspectives of the youth and family are to have a greater impact on the wrap-around process than other perspectives, and the youth and family must have the opportunity to make choices about the goals and strategies included on the plan.

The principles also specify that the wraparound team should learn about the values, culture, and strengths of the youth and family and incorporate these into the goals and strategies for the plan. Various activities in the wraparound practice model are intended to reinforce this special form

of collaboration; however, skilled facilitation, in-cluding a knowledge of group processes and par-ticipatory decision making, is essential to make this family- and youth-driven form of collabora-tion come to pass (Walker & Shutte, 2004).

In sum, when the wraparound process is car-ried out with fidelity to the principles and the practice model, it is an engagement and plan-ning process that promotes a blending of perspec-tives and high-quality problem solving, and is thus consistent with empirically supported best prac-tices for effective teamwork. Additionally, the wraparound process is driven by the perspectives of the youth and family. The team learns about youth and family values, strengths, and culture and actively uses this information in the planning process. Youth and family members also have the opportunity to make choices about the goals and strategies for the plan. These essential character-istics of such a wraparound process are summa-rized in the larger box at the left of Figure 1.

Routes to OutcomesHigh-quality wraparound teamwork is charac-

terized by collaboration and blending of perspec-tives, creative problem solving, and respect for each team member’s expertise and background. As noted above, teams that adhere to best practices tend to come up with good solutions to problems, and team members are likely to follow through on decisions that the team makes. Adherence to these best practices thus is expected to directly promote “achievement of team goals” (shown as an intermediate outcome in Figure 1) and, ulti-mately, “achievement of team mission” (shown as a long-term outcome).

Because the mission and goals1 in wraparound are selected by youth and family, it is assumed that achieving these goals will contribute to improved family quality of life, as well as other long term outcomes. Wraparound’s underlying philosophy also makes it likely that certain particular types of goals will be included in the plan, and that out-comes reflecting these goals will be part of the plan. For example, the wraparound principle of

The wraparound team should

learn about the values, culture, and strengths

of the youth and family and

incorporate these into the goals and

strategies for the plan.

1. There are variations in terminology for certain elements of wraparound plans. Some wraparound trainers and programs emphasize a “family long-term vision” (rather than a team mission) as the central long-term outcome for the wraparound process. Similarly, identify-ing and prioritizing needs (rather than goals) sometimes represents the intermediate steps on which a team focuses its efforts.

5

Chapter 3.1: Walker

“community based” stresses the importance of promoting family and youth/child integration into home and community life. This principle (which usually reflects family and youth priorities any-way) means that wraparound plans are often fo-cused on increasing stability in relationships and living situation, and helping the youth and fami-lies live and thrive—just like their more typical counterparts—in their homes, communities, and other “natural” settings. Similarly, the principle of “strengths based” encourages teams to create goals or missions that reflect building family and youth/child assets, capacities, and resilience. Thus the wraparound team effort will generally include, if not prioritize, these general areas, and related outcomes will be realized through the var-ious routes to change described below.

Additionally, team goals and mission are like-ly to be significantly influenced by the expecta-tions for the specific wraparound program. This is because wraparound programs or initiatives are typically designed to meet particular needs of their target populations and since agency repre-sentatives will bring into the wraparound process perspectives that reflect the goals of the agen-cies and organizations that sponsor the program. Thus, for example, wraparound teams that are sponsored through a child welfare agency almost always include a focus on child safety, and wrap-around that is implemented with youth with co-occurring disorders will likely include a focus on treatment for substance use.

Beyond this general result of achieving team goals, a faithfully implemented wraparound pro-cess can be expected to lead to desired outcomes through two main routes (illustrated by the two separate boxes labeled “intermediate outcomes” in Figure 1). In one of these routes, key features of wraparound process contribute to enhancing the effectiveness of the services and supports included in the plan, thus promoting desired out-comes. The second route highlights how increasing family and youth/child empowerment, optimism, and efficacy leads directly to positive outcomes (i.e., independently of therapeutic services/sup-ports provided in the plan) by developing ca-pacity and resources for coping, planning and problem-solving. As noted above, these routes are not independent from one another, and out-comes of different types may have impact on oth-

er outcomes and through several routes. After we describe the main routes, we will provide some examples to illustrate these interactions and it-erations.

Enhancing the Effectiveness of Services and Supports

One of the main routes to outcomes proposed in this theory is that using the wraparound pro-

cess to select and organize services and supports actually enhances the effectiveness of the chosen service/support strategies. For several reasons, the wraparound process is expected to lead to relatively high levels of youth and family moti-vation to fully engage in, and continue with, the services and supports that are included in the wraparound plan. Engagement and retention are perennial challenges in the delivery of children’s mental healthcare, and this is particularly true for children with the most severe problems (Kazdin, 1996). No-show rates to first appointments range from 15-35%, and families who initiate treatment have been shown to drop out prematurely at rates as high as 60% (Morrissey-Kane & Prinz, 1999). Not surprisingly, outcomes for children’s mental healthcare tend to be better when families are engaged and retained in services (Huey, Henggel-er, Brondino, & Pickrel, 2000; Tolan, McKay, Han-ish, & Dickey, 2002).

Choice and motivation. Within wraparound, decisions about what services and supports to ac-cess are made on the basis of family and youth

voice and choice. There is a wealth of research that compares the experiences of people who feel they are acting by their own choice and those who feel that they are externally controlled. People who feel they have chosen an activity or option tend to have more committed to the course of action and to have more success. (See the review in Ryan and Deci, 2000.) This result has also been found for people who are part of groups or teams.

People who feel included as part of a decision making process are more likely to follow through on their roles in the team plan (Maddux, 2002). Thus the collaborative, family-driven process of determining needs and selecting and monitoring strategies can be expected to lead to relatively high levels of youth and family commitment to the services and supports that are selected for the plan.

Relevance and feasibility. Additionally, the wraparound process works carefully to match ser-vices and supports with needs (as defined by the youth and family). This increases the likelihood that families and youth will find the individual ser-vices and supports, as well as the total “package” of services and supports in the plan, relevant and feasible. Parent perceptions of the relevance and feasibility of treatment has been linked in several studies to better outcomes from treatments (Ka-zdin, Holland, & Crowley, 1997; Morrissey-Kane & Prinz, 1999). Perceptions of service relevance and feasibility may be particularly important for families from minority populations, and thus par-ticipation in wraparound, with its careful atten-tion to community-based and family-driven care and overall cultural competence, may be particu-

larly valuable for them (Morrissey-Kane & Prinz, 1999). Finally, since the entire wraparound plan emerges in a structured way from youth and fam-ily perspectives, the wraparound process should result in family and youth perceptions of service coordination. Perceptions of greater coordination of services and supports have been linked to im-proved retention in services and enhanced out-comes (Bickman, Lambert, Andrade, & Penaloza, 2000; Glisson, 1994; Koren et al., 1997).

Shared expectations. Wraparound teams se-lect service and support strategies to meet spe-cific needs, and the success of a strategy is deter-mined by how it impacts objective indicators of success that the team has chosen. Thus the team establishes clear, shared expectations for treat-ment—what it’s for, what outcomes are antici-pated—that can be shared with service providers. Often, providers become members of the wrap-around team, and are thus part of the collabora-tive effort to define the purpose of service/sup-port strategies. Even when providers do not join the core team, the team often facilitates com-munication with providers, aimed at clarifying the purpose of services and the criteria by which the success of the service/support is judged. There is evidence supporting the proposition that hav-ing shared parent-provider expectations for treat-ment increases the likelihood that parents will be engaged in/continue with treatment for their children (Morrissey-Kane & Prinz, 1999; Spoth & Redmond, 2000).

Similarly, there is clear evidence that shared client-provider expectations about treatment (as should be the case when children and youth are involved in making decisions for their wraparound plans) also contributes to treatment effectiveness (Dew & Bickman, 2005). Taking this line of reason-ing one step further, there is also reason to expect that wraparound will enhance treatment effec-tiveness when, as often happens in wraparound, the team works with providers to tailor the servic-es and supports to better fit child/youth and fam-ily needs. There is evidence that retention in and outcomes from mental health treatment interven-tions are enhanced when treatment is modified to reflect family concerns and needs (Morrissey-Kane & Prinz, 1999; Prinz & Miller, 1994).

Strengths-based understanding of behavior.

6


The wraparound process models and communi-cates a strengths-based understanding of difficult or troubling behavior to team members, includ-ing youth and families. This helps youth and fami-lies to see that behavior is malleable, rather than dispositional, which in turn increases motivation to engage in therapeutic interventions and con-tributes to improved outcomes from intervention (Morrissey-Kane & Prinz,1999).

Whole-family focus. Wraparound may also im-pact service/support engagement, retention, and outcomes by virtue of its focus on the needs of the family as a whole. Providing support to whole family, particularly mothers, appears to improve treatment initiation/retention and outcomes (Morrissey-Kane & Prinz, 1999).

Capacity and Resources for Coping and Planning

This route to change highlights wraparound’s potential to increase family and youth resources and capacities related to planning, coping, and problem-solving. These resources and capacities are seen as contributing directly to positive long-term outcomes. In other words, these outcomes may arise directly from participation in wrap-around, and do not result only from participa-tion in services and supports (though services and supports may also contribute to these outcomes). These long-term outcomes include increased re-silience and developmental assets, higher quality of life, improved mental health, and increased ability to initiate and maintain heath-promoting behavior change.

Self-efficacy, empowerment, and self-deter-mination. The experiences of making choices and of setting and reaching goals contribute to the de-velopment of key human capacities of self-effica-cy, empowerment, and self-determination. In fact these three constructs are interrelated, and have at their core the sense of confidence that people have about their ability to overcome obstacles in their lives and to reach goals they set for them-selves (Snyder, Rand, & Sigmon, 2002). People develop these capacities in large part because of having successful experiences of achieving person-ally meaningful goals. Increases in self-efficacy, empowerment, and/or self-determination arise from several types of situations that are central

parts of the wraparound process: participating actively in planning, directing services and sup-ports, making choices, and experiencing success in reaching personally meaningful goals (Byalin, 1990; Curtis & Singh, 1996; Foster, Brown, Phil-lips, Schore, & Carlson, 2003; Maddux, 2002; Na-tional Council on Disability, 2004; O’Brien, Ford, & Malloy, 2005; Worthington, Hernandez, Fried-man, & Uzzell, 2001). While much of this research focused on adults, similar findings have emerged from the smaller body of research with children and adolescents (Peterson & Steen, 2002), includ-ing specifically those with emotional, be-havioral, cognitive, learning, and other disabilities (Cham-bers et al., 2007; Wehmeyer & Palmer, 2003; Wehmeyer & Schwartz, 1997).

There is robust re-search showing that people who believe that they can achieve the goals they set for themselves ex-perience a variety of positive outcomes, including a variety of outcomes related to mental health and well-being. People with higher self-effi-cacy tend to be more optimistic and hope-ful, and they per-sist and try harder in the face of obstacles (Maddux, 2002; Ridg-way, 2004; Snyder, Rand, & Sigmon, 2002). In turn, people who are more optimistic experience a variety of positive mental health outcomes, and hope is strongly linked to successful psychiatric recovery among adults with serious mental illness (Ridgway, 2004; Russinova, 1999; Snyder, Rand, & Sigmon, 2002). More generally, people who be-lieve they can solve problems in their lives have better general mental health and well-being, and they are more likely to avoid depression (Heppner

People who are more optimistic

experience a variety of positive

mental health outcomes, and

hope is strongly linked to successful

psychiatric recovery among

adults with serious mental illness.

7

Chapter 3.1: Walker

& Lee, 2002; Maddux, 2002, Russinnova, 1999, Snyder, Rand, & Sigmon, 2002; Thompson, 2002).

In general, people with higher self-efficacy cope better with stressful life circumstances. They are also more likely to take action to protect their health, to adopt new, healthy habits, and to main-tain behavior change (Maddux, 2002; Thompson, 2002). Children and adolescents who are trained in problem-solving have more optimism and avoid depression (Peterson & Steen, 2002). Adolescents who are optimistic tend to do better in school and college, abuse drugs less, are less angry, have better health and fewer social problems including fewer externalizing problems (Roberts, Brown, Johnson, & Reinke, 2002).

Social Support. Social support is seen as an im-portant resource that aids people’s efforts to deal with stress and adversity. There is a large body of research that demonstrates that people who are involved in supportive social relationships expe-rience benefits in terms of their morale, health, and coping (Cohen, Underwood, & Gottlieb, 2000; Cutrona & Cole, 2000; Walker, 2006). Conversely, low levels of social support have been repeat-edly linked to poor physical and mental health outcomes. A common element of models of com-munity-based mental healthcare—including wrap-around—is the emphasis on strengthening youth and family ties to supportive people within the family’s social environment (Cox, 2005). With-in wraparound, the inclusion of family friends, neighbors, and acquaintances on the wraparound team represents an important effort to create and strengthen social support.

This theory of change includes the hypothesis that increasing social support contributes to the positive outcomes mentioned above. Some stud-ies document the role of social support in recov-ery from psychiatric difficulties or general life troubles (Ridgway, 2004; Werner, 1993; Werner, 1995), and participants in wraparound anecdot-ally report that the social support offered through the team and its work is an important part of wraparound’s positive impact in their lives. How-ever, to date, there is a lack of definitive research showing that increasing social support for people who lack it actually leads to positive outcomes (Walker, 2006).

Conclusion: The “Positive Spiral” of the Wraparound Process

The dynamic complexity and the looping, it-erative nature of the wraparound process is most obvious in the planning process itself, with the child/youth and family, together with the rest of the team, participating in an iterative process of creating, implementing, evaluating, and adjust-ing successive versions of the wraparound plan. The looping nature of change—and interactions between the various “routes” to change—play out in other ways as well, for example, as im-proved coping and problem solving contribute to increased self-efficacy, which in turn leads to more opportunities to experience success within the wraparound process, which in turn reinforces self-efficacy.

In this way, wraparound produces a sort of “positive spiral.” Since people with higher self-ef-ficacy are better able adopt and maintain healthy behaviors and behavior change, and to apply what they have learned from treatment (Maddux, 2002), it can be expected that increases in self-efficacy enable families and youth to profit more from therapy and other services and supports. Conversely, people who experience less stress feel more self-efficacy, so people for whom ser-vices and supports are working could be expected to contribute more actively and confidently to the wraparound process in general. Parents who have more optimism are more likely to engage in services (Morrissey-Kane & Prinz, 1999); thus in-creasing self-efficacy and empowerment through the wraparound process represents another route to making services more effective.

Essentially, wraparound can be seen as a driv-er of a positive, change-promoting spiral that reinforces itself through multiple mechanisms or routes. This seemingly fortuitous confluence of positive impacts occurs not so much because discrete activities or elements of the wraparound philosophy just happen to reinforce one another, but because the whole “package” of wraparound springs from a single, coherent posture or mode of helping that is fundamentally respectful, optimis-tic, and empowering. The diagram and explana-tions presented here are thus simultaneously both too simple and too complicated to explain how and why wraparound can be expected to work.

8


9

Chapter 3.1: Walker

Nevertheless, this theory has clear implica-tions for practice, quality assurance, evaluation, and research. For practice, the theory highlights the importance of adherence to the principles and practice model, since outcomes are predi-cated on fidelity. For quality assurance, then, measurement of fidelity is essential. Addition-ally, programs would likely benefit from assess-ing other key indicators that gauge how well the various “routes” appear to be functioning. Thus, programs might want to consider monitoring plans or assessing team cooperativeness or cohesive-ness (for evidence of high quality teamwork and collaboration); assessing family and youth percep-tions of service relevance, helpfulness, or coor-dination (for evidence that the “enhancing the effectiveness of services” route is functioning); and measuring family and youth empowerment, self-efficacy, and/or optimism (for evidence that the “capacity and resources for coping” route is operating).

The most obvious implications of the theory for program evaluation have to do with relevant outcomes. To begin with, the theory places a high level of importance on outcomes that are not of-ten measured in human service contexts. These include the intermediate outcomes mentioned above, as well as long-term outcomes such as quality of life or assets. The theory suggests that evaluation that does not include these outcomes may well understate the effectiveness of wrap-around, since these outcomes reflect the poten-tially profound impacts that wraparound can have in the lives of children, youth, and families. Addi-tionally, the theory highlights the fact that wrap-around, because it is an individualized process, will not always be focused on achieving the same outcomes. Prioritized outcomes will vary not only from program to program, but within programs as well. Sometimes the outcomes that are the main focus of a team’s attention will be those that are commonly found on wraparound plans—stability of living situation, academic/vocational progress, etc.—but sometimes the most highly prioritized outcomes may be completely unique to a particu-lar child and family. Again, this points to the need for program evaluation strategies that can cap-ture the diversity of impacts that wraparound is anticipated to produce.

And finally, the theory has research implica-

tions simply because it is a theory. The routes to wraparound’s effectiveness are at this point hy-potheses in need of testing. In order to support (or disconfirm) the hypotheses, research is needed to test each of the main assumptions that are part of the theory. To do this would require research that measures an appropriate spectrum of the intermediate and long-term outcomes, and that allows for testing assumptions about how these outcomes are interrelated. Knowing more about whether and how these various avenues to wrap-around “work” will in turn provide the foundation for future efforts to refine strategies for practice, quality assurance, and evaluation.

References

Beugre, C. D., & Baron, R. A. (2001). Perceptions of systemic justice: The effects of distributive, procedural, and interactional justice. Journal of Applied Social Psychology, 31, 324-339.

Bickman, L., Lambert, E. W., Andrade, A. R., & Penaloza, R. V. (2000). The Fort Bragg continu-um of care for children and adolescents: Men-tal health outcomes over 5 years. Journal of Consulting and Clinical Psychology, 68(4), 710-716.

Bruns, E. J., Walker, J. S., Adams, J., Miles, P., Osher, T. W., Rast, J., et al. (2004). Ten prin-ciples of the wraparound process. Portland, OR: National Wraparound Initiative, Research and Training Center on Family Support and Children’s Mental Health, Portland State Uni-versity.

Burchard, J. D., Bruns, E. J., & Burchard, S. N. (2002). The wraparound approach. In B. J. Burns & K. Hoagwood (Eds.), Community treat-ment for youth: Evidence-based interventions for severe emotional and behavioral disorders (pp. 69-90). New York: Oxford University Press.

Burns, B. J., Schoenwald, S. K., Burchard, J. D., Faw, L., & Santos, A. B. (2000). Comprehen-sive community-based interventions for youth with severe emotional disorders: Multisystemic therapy and the wraparound process. Journal of Child and Family Studies, 9, 283-314.

Byalin, K. (1990). Parent empowerment: A treat-ment strategy for hospitalized adolescents.

10


Hospital and Community Psychology, 41, 89-90.

Chambers, C. R., Wehmeyer, M. L., Saito, Y., Lida, K. M., Lee, Y., & Singh, V. (2007). Self-deter-mination: What do we know? Where do we go? Exceptionality, 15, 3-15.

Cohen, S., Underwood, L. G., & Gottlieb, B. H. (2000). Social relationships and health. In S. Co-hen, L. G. Underwood & B. H. Gottlieb (Eds.), Social support measurement and intervention: A guide for health and social scientists (pp. 3-25). New York: Oxford University Press.

Cohen, S. G. (1994). Designing effective self-man-aging work teams. In M. M. Beyerlein & D. A. Johnson (Eds.), Advances in interdisciplinary studies of work teams (Vol. 1, pp. 67-102). Greenwich, CT: JAI Press.

Cohen, S. G., & Bailey, D. E. (1997). What makes teams work: Group effectiveness research from the shop floor to the executive suite. Journal of Management, 23, 239-291.

Cohen, S. G., Mohrman, S. A., & Mohrman, A. M. J. (1999). We can’t get there unless we know where we are going: Direction setting for knowl-edge work teams. In R. Wageman (Ed.), Re-search on managing groups and teams: Groups in context (Vol. 2, pp. 1-31). Greenwich, CT: JAI Press.

Cox, K. F. (2005). Examining the role of social net-work intervention as an integral component of community-based, family-focused care. Jour-nal of Child and Family Studies, 14, 443-454.

Cropanzano, R., & Schminke, M. (2001). Using so-cial justice to build effective work groups. In M. E. Turner (Ed.), Groups at work: Theory and research (pp. 143-171). Mahwah, NJ: Lawrence Erlbaum Associates.

Curtis, W. J., & Singh, N. N. (1996). Family in-volvement and empowerment in mental health service provision for children with emotional and behavioral disorders. Journal of Child & Family Studies, 5, 503-517.

Cutrona, C. E., & Cole, V. (2000). Optimizing sup-port in the natural network. In S. Cohen, L. G. Underwood & B. H. Gottlieb (Eds.), Social sup-port measurement and intervention: A guide for health and social scientists (pp. 278-308).

New York: Oxford University Press.

DeNisi, A. S., & Kluger, A. N. (2000). Feedback effectiveness: Can 360 degree appraisals be improved? The Academy of Management Execu-tive, 14(1), 129-139.

Dew, S. E., & Bickman, L. (2005). Client expec-tancies about therapy. Mental Health Services Research, 7(1), 21-33.

Foster, L., Brown, R., Phillips, B., Schore, J., & Carlson, B. L. (2003). Improving the quality of Medicaid personal assistance through consum-er direction. Retrieved October 9, 2003, from http://www.healthaffairs.org/WebExclusives/Foster_Web_Excl_032603.htm

Glisson, C. (1994). The effect of services coordi-nation teams on outcomes for children in state custody. Administration in Social Work, 18(4), 1-23.

Heppner, P. P., & Lee, D. (2002). Problem-solving appraisal and psychological adjustment. In C. R. Snyder & S. J. Lopez (Eds.), Handbook of positive psychology (pp. 288-298). New York: Oxford University Press.

Hirokawa, R. Y. (1990). The role of communication in group decision-making efficacy: A task-con-tingency perspective. Small Group Research, 21, 190-204.

Huey, S. J., Henggeler, S. W., Brondino, M. J., & Pickrel, S. G. (2000). Mechanisms of change in Multisystemic Therapy: Reducing delinquent behavior through therapist adherence and im-proved family and peer functioning. Journal of Consulting & Clinical Psychology, 68, 451-467.

Kazdin, A. E. (1996). Dropping out of child psycho-therapy: Issues for research and implications for practice. Clinical Child Psychology and Psy-chiatry, 1(1), 133-156.

Kazdin, A. E., Holland, L., & Crowley, M. (1997). Family experience of barriers to treatment and premature termination from child therapy. Journal of Consulting and Clinical Psychology, 65, 453-463.

Kim, C. W., & Mauborgne, R. A. (1993). Procedural justice, attitudes, and subsidiary top manage-ment compliance with multinationals’ corpo-rate strategic decisions. Academy of Manage-

11

Chapter 3.1: Walker

ment Journal, 36, 502-526.

Koren, P. E., Paulson, R. I., Kinney, R. F., Yatch-menoff, D. K., Gordon, L. J., & DeChillo, N. (1997). Service coordination in children’s men-tal health: An empirical study from the care-giver’s perspective. Journal of Emotional and Behavioral Disorders, 5, 162-172.

Korsgaard, A. M., Schweiger, D. M., & Sapienza, H. J. (1995). Building commitment, attachment, and trust in strategic decision-making teams: The role of procedural justice. Academy of Management Journal, 38, 60-84.

Latham, G. P., & Seijts, G. H. (1999). The effects of proximal and distal goals on performance on a moderately complex task. Journal of Organi-zational Behavior, 20, 421-429.

Maddux, J. E. (2002). Self-efficacy. In C. R. Snyder & S. J. Lopez (Eds.), Handbook of positive psy-chology (pp. 277-287). New York: Oxford Uni-versity Press.

Morrissey-Kane, E., & Prinz, R. J. (1999). Engage-ment in child and adolescent treatment: The role of parental cognitions. Clinical Child and Family Review, 2, 183-198.

National Council on Disability. (2004). Consumer-directed health care: How well does it work? Washington, DC: National Council on Disability.

O’Brien, D., Ford, L., & Malloy, J. M. (2005). Person centered funding: Using vouchers and personal budgets to support recovery and employment for people with psychiatric disabilities. Journal of Vocational Rehabilitation, 23(2), 71-79.

O’Connor, K. M. (1998). Experiential diversity in groups: Conceptualizing and measuring varia-tion among teammates. In D. H. Gruenfeld (Ed.), Research on managing groups and teams (Vol. 1, pp. 167-182). Greenwich, CT: JAI Press.

Peterson, C., & Steen, T. A. (2002). Optimistic ex-planatory style. In C. R. Snyder & S. J. Lopez (Eds.), Handbook of positive psychology (pp. 244-256). New York: Oxford University Press.

Prinz, R. J., & Miller, G. E. (1994). Family-based treatment for childhood antisocial behavior: experimental influences on dropout and en-gagement. Journal of Consulting and Clinical Psychology, 62(3), 645-650.

Ridgway, P. (2004). Resilience and recovery from psychiatric disabilities: Links in concepts and research (Working paper). Lawrence, KS: Uni-versity of Kansas School of Social Welfare.

Roberts, M. C., Brown, K. J., Johnson, R. J., & Re-inke, J. (2002). Positive psychology for children. In C. R. Snyder & S. J. Lopez (Eds.), Handbook of positive psychology (pp. 663-675). New York: Oxford University Press.

Russinova, Z. (1999). Providers’ hope-inspir-ing competence as a factor optimizing psy-chiatric rehabilitation outcomes. Journal of Rehabilitation(October/November/Decem-ber), 50-57.

Ryan, R. M., & Deci, E. L. (2000). Self-determina-tion theory and the facilitation of intrinsic mo-tivation, social development, and well-being. American Psychologist, 55, 68-78.

Snyder, C. R., Rand, K. L., & Sigmon, D. R. (2002). Hope theory. In C. R. Snyder & S. J. Lopez (Eds.), Handbook of positive psychology (pp. 257-276). New York: Oxford University Press.

Spoth, R., & Redmond, C. (2000). Research on family engagement in preventive interventions: Toward improved use of scientific findings in primary prevention practice. The Journal of Primary Prevention, 21, 267-284.

Thompson, S. (2002). The role of personal control in adaptive functioning. In C. R. Snyder & S. J. Lopez (Eds.), Handbook of positive psychol-ogy (pp. 202-213). New York: Oxford University Press.

Tjosvold, D., & Tjosvold, M. T. (1994). Coopera-tion, competition, and constructive controver-sy: Knowledge to empower for self-managing work teams. In M. M. Beyerlein & D. A. Johnson (Eds.), Advances in interdisciplinary studies of work teams (Vol. 1, pp. 119-144). Greenwich, CT: JAI Press.

Tolan, P. H., McKay, M. M., Hanish, L. D., & Dickey, M. H. (2002). Evaluating process in child and family interventions: Aggression prevention as an example. Journal of Family Psychology, 16, 220-236.

Walker, J. S. (2006). Strengthening social sup-port: Research implications for interventions in children’s mental health. Focal Point: Re-

12


search, Policy, and Practice in Children’s Men-tal Health, 20(1), 3-9.

Walker, J. S., Bruns, E. J., Rast, J., VanDenBerg, J. D., Osher, T. W., Koroloff, N., et al. (2004). Phases and activities of the wraparound pro-cess. Portland, OR: National Wraparound Initia-tive, Research and Training Center on Family Support and Children’s Mental Health, Portland State University.

Walker, J. S., & Shutte, K. M. (2004). Practice and process in wraparound teamwork. Journal of Emotional and Behavioral Disorders, 12(3), 182-192.

Wehmeyer, M. L., & Palmer, S. B. (2003). Adult outcomes for students with cognitive disabili-ties three-years after high school: The impact of self-determination. Education and Training in Development Disabilities, 38(2), 131-144.

Wehmeyer, M. L., & Schwartz, M. (1997). Self-de-termination and positive adult outcomes: A fol-low-up study of youth with mental retardation or learning disabilities. Exceptional Children, 63(2), 245-255.

Weldon, E., & Yun, S. (2000). The effects of proximal and distal goals on goal level, strat-egy development, and group performance. The Journal of Applied Behavioral Science, 36, 336-344.

Werner, E. E. (1993). Risk, resilience, and recov-ery: Perspectives from the Kauai longitudinal study. Development and Psychopathology, 5, 503-515.

Werner, E. E. (1995). Resilience in development. Current Directions in Psychological Science, 3, 81-84.

West, M. A., Borrill, C. S., & Unsworth, K. L. (1998). Team effectiveness in organizations. In C. L. Cooper & I. T. Robertson (Eds.), Interna-tional review of industrial and organizational psychology (Vol. 13, pp. 1-48). New York: John Wiley & Sons.

Worthington, J. E., Hernandez, M., Friedman, B., & Uzzell, D. (Eds.). (2001). Systems of care: Promising practices in children’s mental health, 2001 series: Volume II. Learning from families: Identifying service strategies for suc-cess. Washington, DC: Center for Effective Col-laboration and Practice, American Institutes for Research.

AuthorJanet Walker is Research Associate Professor in the School of Social Work at Portland State University and co-Director of the Research and Training Cen-ter on Pathways to Positive Futures. Her current research focuses on 1) exploring how individuals and organizations acquire capacity to implement and sustain high quality practice in human service settings, 2) describing key implementation factors that affect the ability of organizations and indi-viduals to provide high quality services and treat-ment, and 3) developing and evaluating interven-tions to increase the extent to which youth with emotional or mental health difficulties are mean-ingfully involved in care and treatment planning. Together with Dr. Eric Bruns, Dr. Walker co-directs the National Wraparound Initiative.

Suggested Citation:

Walker, J. S. (2008). How, and why, does wraparound work: A theory of change. In E. J. Bruns & J. S. Walker (Eds.), The resource guide to wraparound. Portland, OR: Nation-al Wraparound Initiative, Research and

Training Center for Family Support and Children’s Mental Health.


The Evidence Base and Wraparound

Over the past 20 years, the wraparound process has be-come a compelling and highly visible method for working

with youth and families with intensive needs. As described in the articles in this Resource Guide, wraparound provides a method through which teams come together to create and implement plans to meet needs, achieve outcomes, and im-prove lives. At the same time, wraparound provides an “on the ground” mechanism for ensuring that core system of care values will guide planning and produce individualized, family-driven and youth-guided support that is community based and culturally competent (Stroul & Friedman, 1996).

Wraparound’s alignment with system of care values and the aims of the family movement have made it extreme-ly popular with states and communities. A 2007 update to the 1998 State Wraparound Survey shows that 42 of 46 U.S. states (91%) that returned a survey have some type of wrap-around initiative in the state, with 62% implementing some type of statewide initiative. Over 100,000 youth nationally are estimated to be engaged in a well-defined wraparound process (Sather, Bruns, and Stambaugh, 2008). Compared to other prominent approaches to serving youth with serious and complex needs, wraparound is implemented through more programs and for more youth. Estimates show, for ex-ample, that Multisystemic Therapy (MST; Henggeler & Scho-enwald, 2002) is received by about 16,000 youths annually, and that Multidimensional Therapeutic Foster Care (MTFC; Chamberlain, 2002) is received by about 1,000 youths (Evi-dence-Based Associates, 2007).

That wraparound should be such a frequently deployed service delivery model is not surprising. There is broad con-

Eric Bruns, Co-Director, National Wraparound Initiative, and Associate Professor, University of Washington School of Medicine



2


sensus that the paradigm reflected in wraparound is an improvement over more traditional service delivery methods that are perceived as uncoordi-nated, inflexible, professional driven, and deficit based. In addition, the President’s New Freedom Commission Report on Mental Health (US DHHS, 2003) recently concluded that all families with a child experiencing serious emotional disturbance should have an individualized plan of care. This statement further reinforces the need for ap-proaches like wraparound.

In the current era of emphasizing “evidence-based practices,” however, all service delivery de-cisions are legitimately open to scrutiny, regard-less of how well they conform to current values of care. After all, there are many competing para-digms that could be used with youth and families who are experiencing intensive needs. These in-clude traditional case management, uncoordinat-ed “services as usual” (in which families negotiate services and supports themselves or with help of a more specialized provider such as a pediatrician or therapist), residential treatment, or inpatient hospitalization.

The picture is becoming increasingly compli-cated because wraparound is being used in more and more contexts and for more and more pur-poses. In juvenile justice, wraparound is being used as a means of diverting youth from detention and to help youth successfully transition to the community from secure placement. In child wel-fare, some state systems, such as Oklahoma, are experimenting with supporting child welfare care workers to use the wraparound model to achieve permanency, stability, and safety outcomes for children, youth and families (Rast & Vetter, 2007). States and localities are also deploying the wrap-around process to help adult prisoners re-enter society (see Chapter 1.4), to improve outcomes for high-risk pregnant women (Calleaux & Dechief, 2006), and to meet the needs of many other popu-lations. All these relatively new deployments of the basic wraparound model are alternatives to more traditional (or at least different) approach-es to supporting the target population. As such, each of these examples raises the question: Does wraparound work?

Fifteen to 20 years after “wraparound” be-came common parlance, this is still not a simple question, because wraparound is not a simple

phenomenon. The question is complex for several reasons. First, as noted above, wraparound has been deployed for many different populations. As such, the question “Does wraparound work?” needs to be answered for many different types of populations and proposed outcomes. This makes wraparound different from most treatments or interventions, which were designed to address a specific type of concern, such as, for example, ad-olescent depression, acting out by young children, or adult panic disorder. Thus, any synthesis of the wraparound evidence base has to ask both about the impact for specific populations as well as its impact overall, across these multiple purposes.

Second, wrap-around has been, and continues to be, an evolving phenome-non. Its development lies in “grassroots” movements to care for individuals in the context of their fami-lies and communities. No single developer owns wraparound, which means it typi-cally is implemented differently from one site to another. This makes it more dif-ficult to assess the evidence base, be-cause until recently there was little consensus on the specific activities that make up the wrap-around process. When a researcher finds no posi-tive impact of wraparound, we must ask “What kind of wraparound was implemented?” and “Was it implemented well?” In addition, since no one “owns” wraparound, the model does not have the same systematic development and testing history as other evidence-based practices, which are of-ten guided through developmental stages by re-searchers with a significant stake in finding the model to be effective. In contrast, wraparound has been created by family members and provid-

In juvenile justice, wraparound

is being used as a means of diverting youth from detention

and to help youth successfully

transition to the community from

secure placement.

3

Chapter 3.2: Bruns

ers whose first priority is not to oversee rigorous research projects but to do whatever it takes to help families in their community.

Third, wraparound is multi-faceted and indi-vidualized. It is typically deployed for families (or adults) with complex and multiple needs, whereas many programs have achieved “evidence-based” status by virtue of their focus on a single problem area or diagnostic category. Focusing on broad populations with complex and overlapping needs makes it harder to find positive impact for several reasons. First, the target population is challeng-ing and implementation is difficult. Second, wrap-around projects are often “system-level” initia-tives, required to enroll a wide range of children and families, as opposed to those with a specific complaint or concern. This means that target out-comes will be different for each participant, mak-ing it harder to find impact, especially when only one or two outcome measures are used (e.g., a standardized behavioral or functional scale).

Wraparound often is conceived as both an in-dividual-level intervention (a defined team-based planning process) and as a “system level” interven-tion (requiring communities to collectively over-see implementation, agencies to collaborate, the service array to be comprehensive, and so on). As such, it is generally difficult to assess what types of outcomes are appropriate and how to interpret findings. For example, in a very interesting paper, Stambaugh et al. (2007) assessed trajectories of behavioral and functional improvement for N=320 in a system of care for youth with serious emotion-al and behavioral concerns, the majority of which (n=213) received the wraparound process while a small subgroup (n=54) received multisystemic therapy (MST; Henggeler & Schoenwald, 2002), a specified evidence-based intervention for youths. The authors found similar improvements in func-tioning for the two groups but somewhat better improvement in behavior for the MST group and concluded that MST was overall more effective.

At the same time, the authors recognized that MST targets a specific population: older youth with antisocial and offending behaviors who are in families that are intact and fully engageable in the intervention. Thus the MST group likely met crite-ria specific to MST while wraparound was made broadly available youth of all ages with any type of emotional or behavioral disorder. Cast in this

light, the fact that youth in the wraparound group demonstrated quite impressive improvements (de-spite their heterogeneity and questions about the quality of specific services received) only slightly less positive than the MST group may be viewed as significant support for deploying wraparound as a method for addressing the needs of diverse youth in a large system of care. Regardless of one’s con-clusions, the study demonstrates the complexity of interpreting research on wraparound.

The Evidence Base and WraparoundIn sum, because there are so many variations

of “wraparound,” because it has been a grass-roots and evolving phenomenon, and because it is a complex approach that impacts systems as well as individuals, the question “Does wraparound work?” has been difficult to answer. Instead of considering the evidence base on wraparound, it may be more appropriate to frame the issue as the evidence base and wraparound. Other articles in this section of the Resource Guide are also geared toward this topic, including a review of the theory of change for wraparound (Chapter 3.1), a discus-sion of fidelity measurement (Chapter 5e.1), and a review of relevant current outcomes studies (Chapter 3.3). In the remainder of this article, we present some of the major themes from the story about the evidence base and wraparound.

1. Current thinking in children’s mental health emphasizes the importance of joining evidence-based practices to family-driven and individual-ized service processes like wraparound.

Like “wraparound,” the “science-to-service gap” in children’s mental health is a topic that is receiving increased attention among researchers and service providers. Research finds significant impact of treatments for children and youth under controlled conditions, such as laboratory studies where clinicians have low caseloads and intensive supervision and the children or youth have a sin-gle problem. But then, when these treatments are administered in actual community settings, they often don’t produce the same positive outcomes. Thus there is a “gap” between what can work un-der ideal conditions, and what does work in com-munity settings.

4


There have been many hypotheses about why this is so often the case. One prominent theory is that clinical services in “real world” communities are not delivered in a way that can achieve posi-tive clinical outcomes. Once transported to a real clinic in a real community, larger case loads, lack of training, limited availability and quality of su-pervision, staff turnover, and restricted resources all conspire against a treatment that has been found to work under more ideal conditions.

However, research also suggests other prob-lems. First, families tend not to be well engaged with their helping professionals. Second, care is often not well tailored to fit the full range of families’ complex real-world needs. Researchers point to such lack of full engagement, individu-alization, and comprehensiveness to explain why families often feel the care they receive is not relevant or helpful.

Our interpretation of this broad set of findings is that the science-to-service gap is at least part-ly due to systems failing to support full engage-ment of families in the treatments they receive. For families with intensive needs or children with serious emotional and behavioral problems, such full engagement will usually require the creation of highly individualized and creative plans of care that address all the major issues and stresses the family is dealing with. What’s more, such plans will need to respond meaningfully to the needs as expressed by the family. A well-implemented wraparound process provides for procedures to accomplish this for families with these most in-tensive needs. Thus, it is important that research on overcoming the science-to-service gap consid-ers the potential of the wraparound process to improve outcomes in real-world community set-tings.

At the same time, researchers, advocates, and practitioners must realize that families partici-pating in a wraparound process should also have available specific treatments (including evidence-based treatments) that might be part of their in-dividualized plan of care. The two are highly com-patible; after all, the intent of the wraparound process is to plan and implement the set of ser-vices and supports that is most likely to achieve positive outcomes for a family. At the individual youth and family level, this may include one or more empirically supported treatments.

At the organizational and system level, this means developing capacity to make available treatments that will be most beneficial to the tar-get population, and in some cases integrating evi-dence-based techniques into wraparound itself. For example, a wraparound project in King County, Washington, is training wraparound facilitators in Motivational Interviewing to help address youths’ substance abuse issues. In Maryland, a wraparound project for transition-age youth is making Sup-

ported Employment, an evidence-based practice, available as needed. And, as described by Lucille Eber in this Resource Guide (Chapter 5e.4), wrap-around as implemented in the context of school-wide Positive Behavior Supports often integrates efforts by clinicians to design effective behavior plans.

The bottom line is that more and more chil-dren’s mental health researchers are recognizing the importance of joining evidence-based prac-tices to engagement and service coordination strategies such as wraparound (see, for example, Tolan & Dodge, 2005). The next wave of research on wraparound will likely feature studies of the impact of such innovations.

2. The principles of wraparound are supported by evidence from the research base as well as com-mon sense and social justice.

As described above, current thinking in chil-dren’s services supports the idea that the wrap-around process holds promise for overcoming

commonly-cited barriers to achieving outcomes for children and families. Additionally, there is research that supports the hypothesis that the wraparound process, when carried out in accor-dance with the principles, contributes to positive outcomes. This is presented in more detail in Ja-net Walker’s description of the theory of change for wraparound, found in this Resource Guide. A summary of support for several of the wraparound principles is described below.

Voice and choice. We have already described some of the reasons “voice and choice” may be critical to achieving outcomes. As discussed above, lack of full family engagement has been found to be a major impediment to treatment success. Research has shown that outcomes for children’s mental healthcare tend to be better when families are engaged and retained in ser-vices (Huey, Henggeler, Brondino, & Pickrel, 2000; Tolan, McKay, Hanish, & Dickey, 2002). In addi-tion, Heflinger et al. (1996) have created meth-ods for better engaging families, and studies ex-amining these approaches have found that family members’ overcoming of negative experiences of past treatments received is critical to achieving engagement, and possibly outcomes. And Spoth & Redmond (2000) have found that family members’ belief in the effectiveness of treatment influenc-es engagement and outcomes. These findings and others provide support for the principles of priori-tizing the family’s perceptions of what the family needs to function better.

Team-based, collaborative planning. Mean-while, the wraparound principles of “team-based” and “collaborative” have clear support from re-search across disciplines. Research on teamwork has shown greater success when teams set an overall, long-term goal or mission for the team (Cohen, Mohrman, & Mohrman, 1999; West, Bor-rill, & Unsworth, 1998), and when team mem-bers have clearly defined intermediate goals that help reach the long term goal (Latham & Seijts, 1999; Weldon & Yun, 2000). Effective teams also work carefully to choose strategies for reaching the intermediate goals, structure strategy selec-tion deliberately, and consider several different strategies before choosing one (Hirokawa, 1990; West, Borrill, & Unsworth, 1998). These are all features of a well-implemented wraparound team process.

In the child services research field, Stone and Stone (1983) found that positive child outcomes were more likely to result when foster parents viewed themselves as part of a team with a goal of positive outcomes. Meanwhile, evaluations such as that conducted by Burns & Santos (1995) have found that team-based care for adults with serious mental illness (SMI) was found to be su-perior to “brokered” case management models. Assertive Community Treatment (ACT; Bond et al., 2001), which uses a team-based approach to aid adults with SMI, has long been a standard for de-livering quality care to this population.

Community-based care. One of the signature principles of both wraparound and systems of care philosophy is that care is community based. Though honoring families’ desire to obtain support while keeping their children at home is a principle based in social justice and the family movement, delivering care in the natural environment in which a child and family functions is also grounded in theory and research. Bronfenbrenner’s (1979) and Bandura’s (1977) models stress that to be gener-alizable, behaviors must be taught in the environment in which they will be practiced. These models under-pin many evidence-based approaches to treatment (e.g., behavioral therapies and MST) that are in-tended to help youth and their families learn the skills they need to adapt more successfully to their everyday environ-ments.

The rationale for insisting on commu-nity-based treatment models wherever possible does not stop at theory. Many studies (e.g., Pfeiffer et al, 1990) have found that the best predictor of future out-of-home placements is whether out-of-home placement has been used in the past. Other studies show that both placement stability and youth perception of placement stability are significant predictors of

To be generalizable,

behaviors must be taught in the environment in

which they will be practiced.

5

Chapter 3.2: Bruns

future outcomes (Dubovitz et al., 1993; James et al., 2006). Thus, assuming that we hope to ensure that young people will eventually live effectively in their home communities, we must strive to pre-vent unnecessary out-of-home placements. This becomes especially important when we consider that, historically, we have spent a disproportion-ate amount of our child behavioral service dollars on residential and inpatient care, despite the fact that this treatment approach has the most poorly developed research base of all major child and adolescent treatment options (Burns, Hoagwood, & Maultsby, 1998).

Individualized care. Finally, theory and re-search both support the importance of individu-alized care for individuals with complex needs. This may explain why individualization is a corner-stone of the wraparound process and systems of care, and also why it is prominent among recom-mendations of the New Freedom report. Several influential psychosocial theories of child devel-opment, particularly social-ecological (Bronfen-brenner, 1979) and systems (Munger, 1998) theo-ries, stresses the importance of understanding the unique relationships between the child and vari-ous environmental systems (e.g., family, school, community). Effective intervention thus begins from an understanding of the child’s unique so-cial, cultural, and interpersonal systems environ-ment, and requires the tailoring of services and supports to this unique set of relationships. Mean-while, literature on case management for adults with serious mental illnesses has been consistent in its support of more intensive and early tailor-ing of community supports to client needs (e.g., Ryan, Sherman, & Bogart, 1997). Studies of case management have also found that a greater vari-ety of community-based supports leads to greater client satisfaction and retention in services (Burns et al, 1996).

3. Despite support for the wraparound philoso-phy, research also has demonstrated a “fidelity problem” in wraparound that is important to overcome.

As described above, both theory and research support the principles of the wraparound process and its potential for impact. In the classic frame-work for developing a treatment model, theory

and past research are prerequisites for moving forward with model development and tests of ef-fectiveness. However, in the case of wraparound, such empirical testing has been challenged by the very grassroots evolution and individualized nature that has made the model so compelling. Though wraparound is included as a “promising practice” in the Surgeon General’s Reports on Mental Health (USPHS, 1999) and Youth Violence (USPHS, 2001), its inclusion was based on its wide-spread use and testimonials about its importance within service systems. Typically, references to wraparound come with statements about its lack of specification and thin evidence for effective-ness. For example, in their review of treatments for youth with SED, Farmer, Dorsey, & Mustillo (2004) described the wraparound evidence base as being “on the weak side of positive.”

Perhaps even more problematic, wraparound’s history of being “value based” rather than explic-itly described (Malysiak, 1998) has caused a “fidel-ity problem” that results in confusion for provid-ers and families, and potentially poorer outcomes for children and youth. Even early on, there were warnings about defining the process and maintain-ing its integrity. As Clark & Clarke stated in 1996:

The push to rapidly implement wraparound approaches has resulted in a plethora of service models that vary widely in their implementation, processes, structures, and theories. While this push has been an important part of… the shift to less restric-tive, more integrated community-based service alternatives, it has also resulted in an unsystematic application of the wrap-around process (p.2).

Research eventually supported these early concerns. In observing over 70 wraparound meet-ings in 11 programs nationally, Walker and col-leagues (2003) found that less than one-third of teams maintained a plan with team goals. Only about 20% of teams considered more than one way to meet a family’s stated need. Only 12% of interventions reviewed were individualized or created just for that family. Finally, only about half the teams included a team member in the role of natural or peer support for the family (an-other 32% had only one such support). Meanwhile,

6


studies with our Wraparound Fidelity Index (WFI; Bruns et al, 2004) have found similar results about the “fidelity problem.”

The issue of defining, maintaining, and mea-suring fidelity in wraparound is discussed in anoth-er chapter of this Resource Guide (Chapter 5e.1). The point is that, despite the widespread promo-tion of wraparound principles such as being team based, individualized, outcome based, and relying on natural supports, our research suggests these principles are much more difficult to do in real-world practice than they are to embrace in princi-ple. Programs and communities need help to move

from values to high-quality practice if we are to overcome the fidelity problem in wraparound. The pathway to accomplishing this includes ensuring that the wraparound process being implemented is well understood by both core and partner agen-cy staff, and that adequate support is provided to families, teams, and providers to make sure that such a process can occur. The topic of how best to provide such support is also discussed later in this Resource Guide (Chapter 5a.1).

4. When high-fidelity wraparound is delivered, there is a greater potential for positive impact for families.

Research documenting the fidelity problem in wraparound begs the question: How important is it to achieve the wraparound principles when working with families? This question is only now being addressed, but results from some prelimi-nary studies suggest that it may be quite impor-

tant. Bruns et al. (2004) have found that families with higher WFI scores in the first six months of service achieved better outcomes in areas such as child behavior, residential restrictiveness, and parent satisfaction at both six months and down the line at 12 months after entry to service. Sim-ilar results were achieved in a study by Hagen, Noble, and Schick (2003), who studied the impact of different levels of wraparound fidelity on child negative and positive behaviors. Rast and Peter-son (2004; described in Bruns et al., 2006) found that facilitators who were more adherent to the wraparound model had youth and families who experienced better outcomes.

5. Achieving high-fidelity wraparound is a big chal-lenge, requiring significant effort and resources.

The findings reported in the previous section provide evidence that communities that wish to achieve positive outcomes for families via the wraparound process must fully support “high-fi-delity” wraparound. However, this is more eas-ily said than done. Once a model for wraparound is well understood, with policies and procedures incorporated that reflect it, families, teams, and providers must be well supported to imple-ment it. High quality training and staff support is necessary, as is the overall level of support to wraparound teams provided within the policy and funding context, often known as “the system.” This issue is discussed in a separate article in this Resource Guide, and in an influential monograph by Walker, Koroloff, & Schutte (2003; see Appen-dix 6f). In this monograph, the authors describe the major types of supports required by wrap-around teams, all of which need to be present in different ways at the team, organization, and sys-tem levels. After further research, these supports weresummarized in six major areas, including:

Community Partnership. Collective com-munity ownership of and responsibility for wraparound is built through collaborations among key stakeholder groups.

Collaborative Action. Stakeholders in-volved in the wraparound effort take con-crete steps to translate the wraparound philosophy into concrete policies, practic-es and achievements.

1.

2.

7

Chapter 3.2: Bruns

8


Fiscal Policies and Sustainabil-ity. The community has devel-oped fiscal strategies to meet the needs of children participat-ing in wraparound and methods to collect and use data on ex-penditures for wraparound-eli-gible children.

Access to Needed Supports & Services. The community has developed mechanisms for en-suring access to the wraparound process and the services and supports that wraparound teams need to fully implement their plans.

Human Resource Development & Support. The policy and fund-ing context supports wraparound staff and partner agency staff to work in a manner that allows full implementation of the wraparound model.

Accountability. The community has imple-mented mechanisms to monitor wraparound fidelity, service quality, and outcomes, and to assess the quality and development of the overall wraparound effort.

Research is beginning to show the importance of achieving these types of supports in communi-ties that wish to use the wraparound process. In one study, Bruns, Suter, Leverentz-Brady, & Bur-chard (2006) administered a survey to officials in ten communities that were implementing wrap-around programs. These communities were also using the WFI to monitor wraparound fidelity. Re-sults showed that higher wraparound fidelity was achieved in communities with more system and program supports.

6. What we have learned about wraparound so far is highly encouraging, and tells us we are on the right track.

We have learned much in recent years about wraparound from both experience and research. We have learned that administering individual-ized, team-based care planning and management to families with intensive needs is a high-prior-

3.

4.

5.

6.

ity activity being undertaken in hundreds of communities nation-ally (Sather, Bruns, & Stambaugh, 2008). In addition, providers and family members alike endorse the effectiveness of the wraparound process. One major survey of 615 providers working within the CMHS-funded systems of care com-munities demonstrated that 77% of all providers (18% of whom imple-mented wraparound personally) believed wraparound resulted in positive outcomes for youth and families. Interestingly, this per-centile was higher than for several prominent treatment types with evidence for effectiveness, includ-

ing MST (68%) Treatment Foster Care (67%) and Functional Family Therapy (49%) (Walrath, Shee-han, & Holden, 2004).

Unfortunately, we have learned that it is much easier to embrace the wraparound principles in theory than to actually do them in practice. Nonetheless, when model-adherent wraparound is achieved, it may well pay off in the form of better outcomes for families. To achieve such high fidelity, we need to:

Have a good understanding of what faith-fully implemented wraparound is,

Provide adequate training and support to providers and partner agencies to do it, and

Work with our organizations and systems to support it by setting up a hospitable policy and funding context.

Though embracing and supporting the model is a challenge for many, the enthusiasm for wrap-around continues to be fueled by success stories from communities, evaluation studies, and indi-vidual families. The formal research base, de-scribed in detail in another article in this Resource Guide (Chapter 3.3), is small but growing. Such research findings are further supported by lessons that have been learned by local communities. In Milwaukee, for example, Wraparound Milwaukee has served over 700 youths via wraparound. As a result, the county’s expenditures for out-of-

•

•

•

9

Chapter 3.2: Bruns

home placements have been drastically reduced (Kamradt, 2001). Similar community-level results found in Ventura County (and later, 3 additional California counties) in the late 1980s and early 1990s (Rosenblatt & Attkison, 1992) were attribut-ed to the implementation of a systems of care ap-proach to integrating services, and a wraparound-style care management model. Other prominent examples abound, including the Dawn Project in Indianapolis. These evaluations have found that youth served by the wraparound program show better improvements in clinical functioning and less likelihood of re-entry to public systems such as juvenile court or probation, at lower overall expenditures, compared to youth served by tra-ditional means (Indiana Consortium for Mental Health Services Research, 2003).

Finally, success stories from families and providers alike abound. Some are captured in monographs (e.g., Burchard, Burchard, Sewell, & VanDenBerg, 1993; Burns & Goldman, 1999; Ken-dziora, Bruns, Osher, & Mejia, 2001), but many more are found in the stories told by family mem-bers and their advocates in communities across the country. Though research on the wraparound process has been challenging and slow to develop, there is a clear alignment between research and the evidence base. Though we will continue to re-fine the formal research base on wraparound, the enthusiasm for this important service approach, perhaps more than any other evidence, comes from these families’ stories.

References Angold, A., Messer, S.C., Stangl, D., Farmer,

E.M.Z., Costello, E.J., & Burns, B.J. (1998) Perceived parental burden and service use for child and adolescent psychiatric disorders. American Journal of Public Health, 88, 75-80.

Bandura, A. (1977). Social learning theory. En-glewood Cliffs, NJ: Prentice Hall.

Bickman, L., Lambert, E.W., Andrade, A. R., Pen-aloza, R. V. (2000). The Fort Bragg continuum of care for children and adolescents: Mental health outcomes over 5 years. Journal of Con-sulting & Clinical Psychology, 68, 710-716.

Bronfenbrenner, U. (1979). The ecology of human development. Cambridge, MA: Harvard Uni-

versity Press.

Bruns, E.J., Burchard, J.D., Suter, J.C., Force, M.D., & Leverentz-Brady, K. (2004). Assessing fidelity to a community-based treatment for youth: the Wraparound Fidelity Index. Journal of Emotional and Behavioral Disorders, 12, 69-79

Bruns, E.J., Suter, J.C., Burchard, J.D., Leverentz-Brady, K., & Force, M.D. (in press). Fidelity to the wraparound process and its association with child and family outcomes. Journal of Child and Family Studies.

Bruns, E.J. (2004). The importance of authentic wraparound to achieving outcomes for chil-dren and families. Keynote research address at the Circle Around Families Evaluation Con-ference, Merrillville, IN.

Bruns, E.J., Suter, J.D., Leverentz-Brady, K., & Burchard, J.D. (2004). A national portrait of wraparound implementation. In C. Newman, C. Liberton, K. Kutash, & R.M. Friedman (Eds.), The 16th Annual Research Conference Proceedings: A System of Care for Children’s Mental Health. Tampa: University of South Florida, Florida Mental Health Institute Re-search and training Center for Children’s Men-tal Health.

Burchard, J.D., Bruns, E. J., & Burchard, S.N. (2002). The wraparound process. In B. Burns, & K. Hoagwood, Community treatment for youth: Evidence-based treatment for severe emotional and behavioral disorders. New York: Oxford University Press.

Burchard, J.D., Burchard, S.N., Sewell, R., & Van-DenBerg, J. (1993). One kid at a time: Evalua-tive case studies and descriptions of the Alaska Youth Initiative Demonstration Project. Wash-ington, DC: SAMHSA Center for Mental Health Services.

Burns, B.J., & Goldman, S.K. (1999). Promising practices in wraparound for children with seri-ous emotional disturbance and their families. Systems of care: Systems of care: Promising practices in children’s mental health, 1998 series, Vol. IV: Promising practices in wrap-around for children with severe emotional disorders and their families. Washington D.C.:

10


Center for Effective Collaboration and Prac-tice, American Institutes for Research.

Burns, B.J., Hoagwood, K., & Maultsby, L. T. (1998). Improving outcomes for children and adolescents with serious emotional and behav-ioral disorders: Current and future directions. In M.H.Epstein, K. Kutash, & A. Duchnowski (Eds.), Outcomes for children and youth with behavioral and emotional disorders and their families. Austin, TX: Pro-Ed.

Burns, B.J. & Santos, A.B. (1995). Assertive Com-munity Treatment: An Update of Randomized Trials, Psychiatric Services, 46, 669-675.

Burns, B.J., Farmer, E.M.Z., Angold, A., Costel-lo, E.J., Behar, L. (1996). A randomized trial of case management for youths with serious emotional disturbance. Journal of Clinical Child Psychology, 25, 476-486.

Burns, B.J., Hoagwood, K., & Maultsby, L.T. (1998). Improving outcomes for cildren and adolescents with serious emotional and behav-ioral disorders: Current and future directions. In M.H.Epstein, K. Kutash, & A. Duchnowski (Eds.), Outcomes for children and youth with behavioral and emotional disorders and their families. Austin, TX: Pro-Ed.

Clarke, H.B., Prange, M., Lee, B., Stewart, E.S., McDonald, B.A., & Boyd, L.A. (1998). An in-dividualized wraparound process for children in foster care with emotional/behavioral dis-turbances: Follow-up findings and implica-tions from a controlled study. In M.Epstein, K. Kutash, & A. Duchnowski (Eds.), Outcomes for children and youth with emotional and be-havioral disorders and their families (pp. 513-542). Austin, TX: PRO-ED.

Evans, M.E., Armstrong, M.I., & Kupperinger, A.D. (1996). Family-centered intensive case man-agement: a step toward understanding indi-vidualized care. Journal of Child and Family Studies, 5, 55-65.

Faw, L. (1999). The state wraparound survey. In B.J. Burns & S.K. Goldman (Eds.), Systems of care: Promising practices in children’s mental health, 1998 series, Vol. IV: Promising prac-tices in wraparound for children with severe emotional disorders and their families (pp.

27-32). Washington DC: Center for Effective Collaboration and Practice, American Insti-tutes for Research.

Greenbaum, P.E., Dedrick, R.F., Friedman, R. M., Kutash, K., Brown, E.C., Lardieri, S. P., & Pugh, A. M. (1996). National Adolescent and Child Treatment Study (NACTS): Outcomes for children with serious emotional and behavioral disturbance. Journal of Emotional and Behav-ioral Disorders, 4, 130

Hagan, D., Noble, K.J., & Schick, C. (2003). An ex-amination of wraparound fidelity and impact on behavioral outcomes. In C. Newman, C. Li-berton, K. Kutash, & R.M. Friedman (Eds.), The 16th Annual Research Conference Proceed-ings: A System of Care for Children’s Mental Health. Tampa: University of South Florida, Florida Mental Health Institute Research and training Center for Children’s Mental Health.

Heflinger, C.A., Bickman, L., Northrup, D. & Son-nichsen, S. (1997). A theory-driven interven-tion and evaluation to explore family caregiv-er empowerment. Journal of Emotional and Behavioral Disorders, 5, 184-191.

Henggeler, S.W., Schoenwald, S.K., Borduin, C.M., Rowland, M.D., & Cunningham, P.B. (1998). Multisystemic treatment for antisocial behav-ior in children and adolescents. New York: Guilford Press.

Huey, S.J., Henggeler, S.W, Brondino, M.J & Pick-rel, S.G. (2000). Mechanisms of change in multisystemic therapy: Reducing delinquent behavior through therapist adherence and im-proved family and peer functioning. Journal of Consulting & Clinical Psychology, 68, 451-467.

Indiana Consortium for Mental Health Services Research. (2003). Fifth annual evaluation re-port. Downloaded September 2004 from www.kidwrap.org.

James, S, Leslie, LK, Hurlburt, MS, et al. (2006). Children in Out-of-Home Care: Entry Into In-tensive or Restrictive Mental Health and Resi-dential Care Placements. Journal of Emotional and Behavioral Disorders, 14, 196-208.

Jensen, P.S. (2004). Implications of the Multi-modal Treatment of ADHD Study. Colloquium

11

Chapter 3.2: Bruns

presented to the University of Maryland School of Medicine, Baltimore, MD.

Kamradt, B. (2001). Wraparound Milwaukee: Aid-ing youth with mental health needs. Juvenile Justice, 7, 14-23.

Kazdin, A. E. (2000). Psychotherapy for children and adolescents: Directions for research and practice. New York: Oxford University Press.

Kendziora, K., Bruns, E.J., Osher, D., Pacchiano, D., & Mejia, B. (2001). Wraparound: Stories from the field. Systems of care: Promising practices in children’s mental health, 2001 series, Vol. I. Washington, DC: Center for Ef-fective Collaboration and Practice, American Institutes for Research.

Malysiak, R (1998). Deciphering the Tower of Ba-bel: Examining the theory base for wraparound fidelity. Journal of Child and Family Studies, 7, 11-25

Mesch, J., Fahr, J.L., & Podsakoff, P. M. (!994). Effects of feedback sign on group goal setting, strategies, and performance. Group and Orga-nization Management, 19, 309-333.

Munger, R. L. (1998). The ecology of troubled chil-dren. Cambridge, MA: Brookline Books.

Owens, P.L., Hoagwood, K., Horwitz, S.M., Leaf, P.J., Poduska, J.M., Kellam, S.G.,& Ialongo, N.S. (2002). Barriers to children’s mental health services. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 731-8.

Pfeiffer S.I. & Strzelecki, S.C. (1990). Inpatient psychiatric treatment of children and adoles-cents: A review of outcome studies. Journal of the American Academy of Child and Adoles-cent Psychiatry, 6, 847-53.

Rast, J., Peterson, C., Earnest, L., & Mears, S. (2003). Treatment effectiveness: Compar-ing service process between wraparound and traditional mental health services. In C. New-man, C. Liberton, K. Kutash, & R.M. Friedman (Eds.), The 16th Annual Research Conference Proceedings: A System of Care for Children’s Mental Health. Tampa: University of South Florida, Florida Mental Health Institute Re-search and training Center for Children’s Men-tal Health.

Rosenblatt, A., Attkisson, C.C., & Fernandez, A. J. (1992). Integrating systems of care in Cali-fornia for youth with severe emotional distur-bance: II. Initial group home expenditure and utilization findings from the California AB377 Evaluation Project. Journal of Child and Fam-ily Studies, 1, 263-286.

Ryan, C.S., Sherman, P.S., & Bogart, L.M. (1997). Patterns of services and consumer outcome in an intensive case management program. Jour-nal of Consulting and Clinical Psychology, 65, 485-493.

Spoth, R., & Redmond, C. (2000). Research on family engagement in preventive interven-tions: Toward improved use of scientific find-ings in primary prevention practice. Journal of Primary Prevention, 21, 267-284.

Stone, N.M., & Stone, S. F. (1983). The predic-tion of successful foster placement. Journal of Contemporary Social Work, 1, 11-17.

Stroul, B. (2002). Issue Brief: Systems of Care – A Framework for System Reform in Children’s Mental Health. Washington, DC: National TA Center for Children’s Mental Health.

U.S. Department of Health and Human Services (2003). New Freedom Initiative on Mental Health. Downloaded January 22, 2004 from www.mentalhealthcommission.gov/reports/FinalReport.

U.S. Public Health Service (1999). Mental health: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.

U.S. Public Health Service (2001). Youth violence: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.

Walker, J.S. & Bruns, E.J. (Eds.) (2003). Quality and fidelity in wraparound. Focal Point: A na-tional journal on family support and children’s mental health, 17.

Walker, J.W. & Schutte, K. (in press). Practice and process in wraparound teamwork. Journal of

Emotional and Behavioral Disorders.

Walker, J.S., Koroloff, N., & Schutte, K. (2003). Implementing high-quality collaborative indi-vidualized service/support planning: Neces-sary conditions. Portland, OR: Research and Training Center on Family Suppport and Chil-dren’s Mental Health.

Walrath, C.M., Sheehan, A., & Holden, E.W. (2004). Evidence-based practice: Provider knowledge, training, and practice. Atlanta: ORC Macro, Inc.

Walrath, C. (2001). Evaluation resources and needs assessment. Unpublished report to ORC Macro, Inc.

Author

Eric Bruns is a clinical psychologist and Associate Professor at the University of Washington School

of Medicine in Seattle. He spends much of his professional life conducting research on innova-tive community-based models for helping youth and families with complex needs, including fam-ily treatment drug courts, treatment foster care, parent support programs, and the wraparound process. He is a lead developer of the Wraparound Fidelity Assessment System and, with Janet Walk-er, co-directs the National Wraparound Initiative.

12


Suggested Citation:Bruns, E. (2008). The evidence base and wraparound. In E. J. Bruns & J. S. Walker (Eds.), The resource guide to wraparound. Portland, OR: National Wraparound Ini-tiative, Research and Training Center for

Family Support and Children’s Mental Health.

A Narrative Review of Wraparound Outcome Studies

The wraparound process has been described as having a promising body of evidence (Burns, Goldman, Faw, &

Burchard, 1999; National Advisory Mental Health Council, 2001; New Freedom Commission on Mental Health, 2003), to the point it has been included in two Surgeon General re-ports (U. S. Department of Health and Human Services, 1999, 2000), recommended for use in federal grant programs (U. S. Department of Health and Human Services, 2005), and presented as a mechanism for improving the delivery of evi-dence-based practices for children and adolescents with se-rious emotional and behavioral disorders ([SEBD] Friedman & Drews, 2005; Tolan & Dodge, 2005; Weisz, Sandler, Durlak, & Anton, 2006). Not everyone, however, is convinced. Bick-man and colleagues (Bickman, Smith, Lambert, & Andrade, 2003) have stated that “the existing literature does not pro-vide strong support for the effectiveness of wraparound” (p. 138). Farmer, Dorsey, and Mustillo (2004) recently char-acterized the wraparound evidence base as being “on the weak side of ‘promising’” (p. 869).

There are several significant concerns about the state of the wraparound evidence base. As presented in Figure 1, though the number of publications about wraparound has grown steadily over time, the number of outcome studies remains relatively small. Many outcome studies that have been published used less rigorous designs and included rel-atively small samples. Finally, the wraparound model has developed in a “grassroots” fashion and has been driven largely by local priorities. This means that there has his-

Jesse Suter, FacultyUniversity of Vermont





2


torically been a wide range of populations of chil-dren and families for which wraparound has been implemented and studied, as well as wide varia-tion in adherence to the core principles of wrap-around (Bruns et al., 2004). With many target populations, no real consensus on what exactly constitutes “wraparound,” and no single research group invested in documenting wraparound out-comes, the outcomes research base has been slow to emerge, and results are less consistent than for more strictly defined models. In addition, re-views of outcomes studies of children’s services have tended to mischaracterize some evaluation studies as pertaining to the wraparound process. For example, one widely cited review (Aos, Lieb, Mayfield, Miller, & Pennucci, 2004) cited evalua-tion studies of “systems of care” (e.g., Bickman, Sumerfeldt & Noser, 1997) as speaking to the evidence base on the wraparound process, even though the two models are quite distinct in prac-tice (Stroul, 2002).

Taken together, these concerns have made it difficult to draw clear conclusions about wrap-around’s evidence base. Therefore, it is important to take stock of the full range of existing outcome studies on wraparound. To date, three wraparound narrative reviews have been published (Burchard, Bruns, & Burchard, 2002; Burns et al., 1999; Farm-er et al., 2004). However, they did not capture all available outcome studies, and additional studies have been published since those reviews. Given that published research on wraparound seems to be growing at an increasing rate, it is important to conduct regular reviews of the literature to characterize the status of wraparound’s evidence base.

The primary goal of the present narrative re-view was to identify and summarize the full scope of wraparound outcome studies, to serve as a re-source for researchers and practitioners. While traditional reviews of outcome studies may use inclusion criteria to analyze only studies with the most rigorous designs, the current review was in-tended to be more inclusive of the full breadth of outcome studies on wraparound. Because much of the outcome literature on wraparound is com-posed of program evaluations, the studies are often not published in traditional outlets (e.g., peer-reviewed journals). Such studies are often referred to as “gray literature” (Petticrew & Rob-

erts, 2006, p.90). This does not make them less important for a review (Lipsey & Wilson, 2001), just more difficult to find. Therefore, the authors acknowledge that the present review may not capture all empirical studies on wraparound. With this recognition, this review is conceptualized as a resource as well as a working document that will most likely need to be revised and amended as more studies on wraparound are conducted and identified.

Method

Selection CriteriaStudies chosen for this review evaluated inter-

ventions following the wraparound process at the child and family level. Because the goal was to provide a comprehensive resource to the field, se-lection criteria were chosen that were much more inclusive than most reviews. More specifically, the following selection criteria were chosen.

Intervention. The team-based planning pro-cess used in the study must have been identified as wraparound or sufficiently described by the au-thors as sharing the primary components of wrap-around (see related descriptions elsewhere in this Resource Guide). Interventions that included community-based planning for children with emo-tional and behavioral disorders (e.g., case man-agement), but did not explicitly incorporate other wraparound principles were excluded. Similarly, systems of care evaluation studies that followed similar principles as wraparound but were evalu-ated primarily at the system rather than the indi-vidual family level were also excluded.

Participants. The target population of the study was children or adolescents (5 to 22 years) with SEBD and significant functional impairment. Evidence of significant functional impairment included those at-risk of (or returning from) an out-of-home placement (e.g., psychiatric hospi-tal, residential treatment center, juvenile justice facility, foster care), as this is a common target population for wraparound.

Design. Study design selection criteria were es-pecially liberal to allow a full breadth of outcome studies on wraparound. As such, experimental (e.g., randomized controlled trials), quasi-experi-mental (e.g., non-randomized group compari-

3

Chapter 3.3: Suter & Bruns

sons), and non-experimental designs (e.g., single group pretest-posttest) were permitted. Qualita-tive and quantitative single subject designs were also permitted.

Outcomes. Study outcomes must have includ-ed measures of child functioning in their homes, schools, or communities. This could include emo-tional or behavioral functioning, academic or job performance, violence or delinquency, changes in living situation, or substance use.

Timeframe and Language. The study must have been made available between January 1, 1986 and February 29, 2008. This timeframe was

chosen because the wraparound process, as it is currently conceptualized, was reported to have begun in 1986 (VanDenBerg, 1999). To be acces-sible to the researchers, the study had to be in English.

Literature SearchEligible studies for this review were identified

through electronic and manually based searches of the literature. First, 16 studies identified in previous reviews were included.1 Second, elec-tronic databases (Web of Science, PsycINFO and ERIC) were used to search for the keywords: wrap-around, wrap-around, individualized services, and individualized service plans. Third, a manual search was conducted of the Journal of Child and

Family Studies, Journal of Emotional and Behav-ioral Disorders, and the annual research confer-ence proceedings of A System of Care for Chil-dren’s Mental Health: Expanding the Research Base hosted by the University of South Florida, Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children’s Men-tal Health. These three sources were chosen for a manual search because traditionally they have been the primary outlets for research on wrap-around.

Findings

Study CharacteristicsThe literature search yielded 36 studies (20

more than the latest review, Farmer et al., 2004), presented in 56 separate reports. When multiple reports were available for the same study, all ci-tations were included in this review. Additional reports for the same studies seemed to reflect either updates (earlier reports represented pre-liminary findings; Vernberg, Jacobs, Nyre, Puddy, & Roberts, 2004; Vernberg et al., in press), moves from unpublished to published sources (e.g., con-ference proceedings to journal article; Anderson, Kooreman, Mohr, Wright, & Russell, 2002; Ander-son, Wright, Kooreman, Mohr, & Russell, 2003), or presentation of findings in evaluation reports and publications (Evans, Armstrong, Kuppinger, 1996; Evans, Armstrong, Kuppinger, Huz, & John-son, 1998). Of these 56 separate reports, the most common outlet (45%) were peer-reviewed journals (n = 25), followed by conference proceedings (n = 19), book chapters (n = 4), doctoral dissertations (n = 3), federal reports (n = 2), paper presenta-tions (n = 2), a manuscript submitted for publica-tion, and a published monograph.

Focusing on the 36 unique studies, over 60% (n = 22) resulted in at least one publication in a peer-reviewed journal. The remaining studies were presented in conference proceedings (n = 9) dissertations (n = 3), 1 published monograph, and 1 paper presentation. Research designs included: 23 pretest-posttest single group designs; 6 quasi-

1. Studies identified from previous reviews are noted in Tables 2 – 5.

experimental (non-equivalent comparison group designs); 4 randomized clinical trials; and 3 single case design studies (2 qualitative and 1 multiple-baseline). The lead agencies running the wrap-around initiatives across the 36 studies included mental health (n = 20), education (n = 6), child welfare (n = 4), juvenile justice (n = 4), and in-teragency initiatives (n = 2). Figure 1 presents a timeline of wraparound outcome publications (in-

cluding the 36 primary outcome studies and the 19 additional study reports). The most common publication year was 1996 (n = 9; the year the Journal of Child and Family Studies published a special issue on wraparound) followed by 2003 (n = 7) and 2006 (n = 7).

Participant CharacteristicsInitial sample sizes for the 36 studies ranged

4


Figure 1. Number of Wraparound Publications by Year Including All Publications with “Wraparound” in Title or Abstract

Outcome Studies

Publications with “Wraparound” in Title or Abstract

Num

ber

of P

ublic

atio

ns

0

10

20

30

40

50

90 -

93

94 -

96

97 -

99

00 -

02

03 -

05

06 -

08

Publication Year

n = 174) retrieved from PsycINFO (1/1986 through 2/2008) and primary outcome studies meeting criteria for inclusion in this review (n = 36).

from 6 to 1031 (M = 183.31, SD = 251.34). Howev-er the largest study (Kamradt, Gilbertson, & Lynn, 2005) was an extreme outlier, being a large-scale evaluation of a statewide program. Attrition rates also varied widely, ranging from a low of 0 to a high of 92%. The majority of participant attrition was due to incomplete data rather than partici-pants dropping out of treatment (though typically information on attrition was not reported). For ex-ample, one program stated that 324 participants received wraparound, yet data were available for only 27 (Robbins & Collins, 2003). As shown in Table 1, not all studies shared data on partici-pant demographics, and there was great variabil-ity among the data that was presented. Partici-pants received wraparound on average from 3 to 36 months. Mean participant ages ranged from 9 to 17 years. Approximately three-quarters of the studies presented information on participant gen-der (study samples ranged from 0 to 50% female), and less than two-thirds presented information on the race or ethnicity of participants (studies ranged from 0 to 73% participants identified as ra-cial or ethnic minorities).

Narrative ReviewThe outcome studies are summarized in Tables

2-5, which present, respectively, single case de-sign studies, pretest-posttest single group design

studies, quasi-experimental group comparison studies, and randomized clinical trials. Each table presents the following information: study citation and source (e.g., journal article, book chapter, etc.), a brief program description, characteris-tics of the participants, primary measures and study findings, and notable details of study analy-ses. Each row represents a unique study. In cases where multiple reports exist for the same study, they were included in the same row, and findings from the most complete set of outcomes were pre-sented (in a few cases this involved pooling infor-mation across multiple reports). For studies that compared wraparound to a comparison or control group, effect sizes were calculated whenever suf-ficient information was available (e.g., means, standard deviations). By Cohen’s convention (Co-hen, 1992), effect sizes have been classified as small (d = 0.20), medium (d = 0.50), and large (d = 0.80). Grouped by study design, the following sections briefly summarize the findings of these 36 empirical studies highlighting their strengths and limitations.

Single Case Design Studies Three single case design studies were identi-

fied. Two qualitative case studies described two of the earliest formal applications of the wrap-around process (Burchard, Burchard, Sewell, &

5


Demographic Variable n M SD Min Max

Sample size 36 183.31 251.34 6 1031

Mean number of months re-ceiving wraparound

32 13.61 6.61 3 36

Mean age 26 13.05 2.40 8.8 17.3

Percentage of study partici-pants identified as female

28 28.58 13.86 0 50

Percentage of study partici-pants identified as racial or ethnic minority

23 34.73 23.94 0 73

Table 1. Participant Demographics Reported by Wraparound Outcome Studies

Citation(s) / Source(s)

Program Description Participants Primary Measures /

Findings

Design & Analytic Details

(Burchard et al., 1993)*

Published monograph

Alaska Youth Initiative (AYI)

Lead Agency: Mental Health

Setting: urban & rural regions in Alaska

Duration: M ≈ 22 months (9-36)

N=10 SEBD youth with history of residential treatment

Age: 9-21, M=17.1

Sex: 50% female

Race/Ethnicity:60% Caucasian,30% Native Alaskan,10% Latino

Structured interviews and record reviews: 9 out of 10 youth stabilized in community settings; 5 no longer requiring services, 4 receiving less intensive services, and 1 not stabi-lized in community

Qualitative retro-spective analysis

Participants selected because rated “successful” and “instructive” cases by AYI staff from initial sample of 84

(Cumblad, 1996)*Cited in (Burchard et al., 2002)

Doctoral dissertation

Kaleidoscope Program

Lead Agency: Private child welfare agency

Setting: urban setting in Chicago, IL

Duration: M = 36 months

N=8 SEBD youth referred due to high-risk behaviors

Age: unknown

Sex: unknown

Race/Ethnicity: unknown

Interviews and record review: At assessment no youth were displaying problems behaviors that led to referral, no evi-dence of abuse/neglect, four youths reunited with families, two not reunited but ongoing contact (remaining two youths’ parents were deceased)

Qualitative retro-spective analysis

(Myaard et al., 2000)*

Journal article

(Myaard, 1998)

Conference proceedings

Wraparound Initiative

Lead Agency: Juvenile Justice

Setting: rural Michigan

Duration: M = 8.6 months (7-10)

N = 6 SEBD youth (with attrition: N = 4)

Age: 14-16, M = 14.7

Sex: 100% male

Race/Ethnicity:100% Caucasian

DAIC: was used to provide daily longitudinal ratings of compliance (improved), peer interactions (im-proved), physical aggres-sion (improved), alcohol/drug use (eliminated), and verbal abuse (improved)

CAFAS: substantial reduc-tions in CAFAS scores

Multiple baseline study

Parent provided daily rating of behaviors and was not blind to start of treatment

Table 2. Single Case Design Studies on the Wraparound Process

Note: SEBD = serious emotional and behavioral disorders; DAIC = Daily Adjustment Indicator Checklist; CAFAS = Child and Adolescent Functioning Scales

* Report included in a previous review

6


VanDenBerg, 1993; Cumblad, 1996). These two studies have frequently been cited in the liter-ature as providing compelling evidence for the positive changes wraparound can achieve for chil-dren with SEBD (Burns, 2002; Burns et al., 1999). The first study, conducted as a doctoral disserta-tion, provided a retrospective qualitative analysis of eight youth with SEBD receiving care through Chicago’s Kaleidoscope Program (Cumblad, 1996). This program targeted children in the child wel-fare system with histories of abuse and neglect. After receiving services through Kaleidoscope for an average of three years, there was no longer any evidence of maltreatment and none of the participants were removed from their families. Further, the participants no longer presented the behaviors that led to their initial referrals.

Burchard and his colleagues authored a thor-ough description and evaluation of the Alaska Youth Initiative ([AYI] Burchard et al., 1993). AYI was modeled after the Kaleidoscope Program, and the authors’ description of the model of care closely paralleled that program. This evaluation was also conducted retrospectively using qualita-tive data from interviews and record reviews of ten children with SEBD. Overall, nine of the youth were successfully maintained in community set-tings following the intervention (five no longer required services and four needed less intensive supports).

Myaard and his colleagues (Myaard, Craw-ford, Jackson, & Alessi, 2000) conducted a mul-tiple-baseline study of four adjudicated children participating in a wraparound program in rural Michigan. This design demonstrates the effect of an intervention by showing that outcome change occurs with (and only with) the introduction of wraparound at different points in time. The au-thors used the Daily Adjustment Indicator Check-list (Bruns, Woodworth, Froelich, & Burchard, 1994) to track five daily behavioral ratings (com-pliance, peer interactions, physical aggression, alcohol and drug use, and extreme verbal abuse) for each of the youth. Participants began receiv-ing wraparound after 12, 15, 19, and 22 weeks. For all four participants, on all five behaviors, dramatic improvements occurred immediately following the introduction of wraparound.

Bickman and his colleagues (2003) criticized this study on the grounds that it had a small sam-

ple size and lacked a control group. These con-cerns need to be addressed because they repre-sent a misunderstanding of the multiple-baseline approach. The purpose of the small sample size in the multiple-baseline approach is to collect a wealth of data before and after an intervention begins (in this case daily ratings for one year). If the pattern of data changes abruptly with the start of treatment, one can be much more confi-dent about making a causal inference than if only two data points (pretest and posttest) had been collected. While no specific rules exist regarding how many baselines a study should have, Kazdin has suggested “two baselines are a minimum, but another one or two can measurably strengthen the demonstration” (Kazdin, 2002, p. 219). Bickman and colleagues (2003) also implied that causal inferences could not be made because the study did not have a control group. On the contrary, the experimental nature of multiple-baseline designs makes them well suited for addressing threats to internal validity. A more inherent limitation of this design is with external validity (i.e., gener-alizability of findings); however, this problem per-vades many of the between-group designs in the literature as well (Kazdin, 2002).

These case studies provided a wealth of quali-tative information regarding both outcomes and implementations of wraparound. As descriptions of the Kaleidoscope Program and AYI, they have been used as rationale and as guides for creat-ing new wraparound interventions around the U.S. However, it is important to note that these case studies do not provide definitive evidence connecting wraparound and positive outcomes. No comparison groups were used, participants were not selected at random (in fact the partici-pants from AYI were selected because they were deemed successful cases), and findings were col-lected retrospectively. As such, selection bias is a strong threat to validity. Therefore, the studies should be interpreted as offering evidence for po-tential or best case outcomes.

Single Group Pretest-Posttest Studies The majority of the outcome studies reviewed

(n = 23) used a pretest-posttest, no control group design (Anderson et al., 2003; Bartley, 1999; Broth-ers, McLaughlin, & Daniel, 2006; Bruns, Burchard,

7


Citation(s) & Source(s)

Program Description Participants Primary Measures

/ Findings Analytic Details

(Anderson et al., 2003)

Journal article

(Anderson et al., 2002)*


Dawn Project System of Care


Setting: Marion County Indiana

Duration: 12 months

N = 384 SEBD youth (with attrition: N = 156)

Age: M = 13

Sex: 35% female

Race/Ethnicity:70% African American or biracial

CAFAS: significant im-provement in clinical functioning (to-tal scores)

Decrease in percentage of youth in restrictive living placements

Completing project was related to a significant drop in recidivism rates

(Bartley, 1999)

Doctoral dissertation

Children’s Health and Mental Health Preservation Services


Setting: Philipsburg, PA; supports in home & school

Duration: 16 months

N = 25 SEBD youth (5 prematurely discharged)No attrition

Age: 6-13, M = 9.8

Sex: 20% female

Race/Ethnicity: not reported

SCICA: 60% of partici-pants improved

CBCL: 59% of partici-pants improved

TRF: 40% of participants improved

No tests of statistical significance

(Brothers et al., 2006)


Project T.E.A.M. (Tools, Empower-ment, Advocacy, & Mastery)

Lead Agency: Juvenile Justice

Setting: Urban; King County, WA

Duration: 12 months

N = 99 SEBD youth involved with court system

Age: 7-17, M = 14.7

Sex: 37.4% female

Race/Ethnicity: 62.6% Caucasian,18.2% African Ameri-can, 11.1% Multi-racial, 10.1% American Indian, 2% Asian, 1% Hawaiian/ Pacific Islander, (6.1% Hispanic)

No significant changes were found for num-ber or type of parent reported community connections (i.e., rela-tionships).

CAFAS: Significant improvements in CAFAS total score from intake to 12 months

Purpose of study was to compare effects for Caucasian and minority youth.

8


Table 3. Single Group Pretest-Posttest Studies on Wraparound Process



FindingsAnalytic Details

(Bruns et al., 1995)*

Journal article

Vermont’s statewide wrap-around initiative


Setting: urban & rural areas

Duration: 12 months

N = 27 SEBD youth

Age: 8-18, M = 13.6

Sex: 30% female


CBCL: significant improvement on total, internalizing, and externalizing scales

DAIC: significant improvement on total nega-tive behaviors

ROLES: no significant change

Costs: no significant change

(Bruns et al., 2005)

Journal article

Nebraska Family Central System of Care


Setting: Rural

Duration: 6 months

N = 36 families with youth with SEBD

Sample was split into two overlapping groups to compare fidelity and outcome data. Only one group is included in present review (n = 32).

Age: 6-17, M = 12

Sex: 19% female

Race/Ethnicity: 100% Caucasian

Means and standard deviations reported in article showed outcomes moved in negative direction for:

-BERS Total Score

-ROLES

-FSQ Satisfaction with ser-vices

-FSQ Satisfaction with prog-ress

One small positive effect was found with CAFAS Total Score

Purpose of study was to examine relationship be-tween fidelity and outcomes, so no analyses were conducted on outcomes alone

(Clarke et al., 1992)*

Journal article

Project wraparound pro-viding individu-alized services to youth


Setting: rural New England; in home & school

Duration: 12-24 months

N = 28 SEBD youth receiving services in home and school [with attrition: school (n=12) home (n=19)]

Age: 5-18, M = 11

Sex: 100% male

Race/Ethnicity: 53% Native American47% Caucasian

CBCL (home): significant improvement on total, inter-nalizing, and externalizing scales

TRF (school): no significant improvement on total, internalizing, and externalizing

SCRS: significant improvement at home but not school

Connors Hyperkinesis Index: significant improve-ment at home but not school

Child Well-Being Scale: significant improvement

Outcomes ex-amined sepa-rately for home and school-based wrap-around groups

9


CONTINUED: Table 3. Single Group Pretest-Posttest Studies on Wraparound Process



Findings Analytic Details

(Copp et al., 2007)

Journal article

Georgia SAMHSA Site


Setting: Rural

Duration: not reported (data collected every 6 months)

N = 15 youth with SEBD with pretest-posttest data (out of a larger group of 45)

Age: 8-14, M = 10.5

Sex: 46.7% female

Race/Ethnicity: 53.3% Caucasian, 46.7% African American

CAFAS (total) and CBCL (total): No statistically sig-nificant improvements were found over 6 months

(Eber et al., 1996a)*

Journal article

Wraparound in Schools (WAIS) & wraparound Inter-agency Network (WIN)

Lead Agency: Education

Setting: school-based

Duration: 9 months

N = 44 [2 groups: WIN (n = 25) WAIS (n = 19)]

Age: not reported

Sex: 11% female

Race/Ethnicity:86% Caucasian, 7% African American, 7% Other

ROLES: positive change (statistical significance not reported)

CBCL, TRF, CAFAS data pro-vided only for baseline


(Eber et al., 1996b)*


Emotional and Behavioral Disability Partnership Initiative


Setting: state-wide in Illinois


N = 81 (at baseline) [with attrition: CBCL (n=25), FACES (n=46) CAFAS, TRF, ROLES (not reported)]

Age: 7-19, M = 14.64

Sex: 18% female


CBCL: significant improve-ment for females on inter-nalizing scale; no significant improvements for males and females on externalizing and males on internalizing

TRF: no significant changes

CAFAS: significant improve-ments in performance and mood scales only; not signifi-cant: behavior, thinking, and drugs

FACES: significant improve-ment for both adaptability and cohesiveness

ROLES: positive change (statistical significance not reported)

10






(Eber & Hyde, 2006)


Illinois Positive Behavior Interventions and Supports


Setting: public schools in Illinois

Duration: outcomes mea-sured at 3 months

N = 22 students with EBD

Age: not reported

Sex: not reported


Study used internal assessment instruments to compare findings at intake to 3 months:

-Reported need for behavioral supports in classroom decreased

-No change reported in classroom behaviors

-Significant improvements in academic performance

-Reported improvements in emo-tional and behavioral functioning at home (not at school)

-No reported improvements in functioning for medical/safety, social, or spiritual functioning

-Significant reduction in 3 out of 10 high-risk behaviors

-Parents were significantly more satisfied with program after 3 months

(Hyde et al., 1995)


Family Preserva-tion Initiative of Baltimore City

Lead Agency: Child Welfare

Setting: urban

Duration: M = 9.73 months

N = 70 SEBD youth

Age: 9-21, M = 15.97

Sex: 36% female

Race/Ethnicity:

67% African Ameri-can, 33% Caucasian

Costs: lower than out-of-state residential placement ($269/day vs. $216/day)

ROLES: shift from 20% to 88% of youth with living situation no more restrictive than group home

Critical behaviors (suspension, hospitalization, suicide attempts, arrests) assessed post only


11






(Illback, Nel-son, & Sanders, 1998)

Book chapter

(Illback et al., 1993)*

Journal article

Kentucky IMPACT Program


Setting: rural and urbanDuration: 16.43 months

N = 954 SEBD youth

With attrition: CBCL (N=431) ROLES (N=953)

Age: 0-21

Sex: 29.1% female


CBCL: significant improvement on total, internalizing, external-izing, and social competence scales

ROLES: significant decrease in participants in hospital place-ments, but also significant in-crease in residential placements

(Kamradt et al., 1998; Sey-bold & Gilbert-son, 1998)


(Kamradt, 1996)*

Paper presentationCited in (Bur-chard et al., 2002)

Wraparound Milwaukee Pilot Project update


Setting: initially residential treat-ment center then community, urban


N = 25 SEBD youth placed in residen-tial services

Age: M = 14.36

Sex: 36% female

Race/Ethnicity: 52% Caucasian, 44% African American, 2% Hispanic

Living situation: At the end of the two-years, the majority of youth had transition to less restrictive living situations: home (n=10), foster home (n=11), residential (n=2), corrections (n=2)

School performance: 21 partici-pants were rated as improved

Costs: wraparound service plan less than 1/3 cost of residential placement


(Kamradt et al., 2005)

Book chapter

(Kamradt, 2000; Kamradt & Meyers, 1999)

Journal articles

Wraparound Milwaukee


Setting: Milwau-kee County, WI, urban

Duration: at least 12 months

N = 1031 SEBD youth receiving wraparound

With attrition: CBCL (n=383); YSR (n=278); CAFAS (n=543)

Age: M = 14.2

Sex: 20% female

Race/Ethnicity: 65% African Ameri-can, 27% Cauca-sian, 7% Hispanic, 1% Native American

CBCL: Significant reductions in mean T-scores from intake (73) to 6 months (64) to 12 months (55)

YSR: Significant reductions in mean T-scores from intake (56) to 6 months (50) to 12 months (45)

CAFAS: Significant reductions in total scores from intake (74) to 6 months (60) to 12 months (54)

Demograph-ics not reported, but available from previ-ous report (Kamradt & Meyers, 1999)

12






(Kutash et al., 2002)

Journal article

School, Family, and Community Partnership


Setting: school-based

Duration: 2 years

N = 23 ED students

With attrition: N = 15

Age: M = 11.7

Sex: 13% female

Race/Ethnicity:78% Caucasian

CBCL: no significant improve-ments on total, internalizing, and externalizing

CAFAS: no significant improve-ments

WRAT-III: no significant improve-ments reading & math

Discipline referrals: significant decrease

% of day in special education: no change

Absences: no change

Fidelity: significantly related to reading scores but no other outcomes

Initially study had a matched comparison group but dropped due to high and differential attrition

Fidelity measure

(Levison-John-son & Gravino, 2006)


Monroe County Youth and Family Partnership

Lead Agency: Interagency

Setting: Monroe County, NY

Duration: not reported

N = 84; 2 cohort groups: n = 29 & n = 55

Age: not reported

Sex: not reported


CAFAS: Functioning from intake to “most recent CAFAS scores” was measured. 69% of group 1 (and 71% of group 2) showed im-provements in CAFAS Total Scores


(Lyman & de Toledo, 2002)


Family Advocacy, Stabilization, and Support Team (FASST)


Setting: inten-sive home-based program in Massachusetts


N = 79 SEBD youth

Age: 4-19

Sex: not reported


CAFAS: Reductions in mean total scores from intake (98) to dis-charge (80)

GAF: Increase in mean scores from intake (49) to discharge (56)


13






(Robbins & Collins, 2003)


Bridges Project school-based wraparound


Setting: schools in rural Kentucky

Duration: 12 months

N = 324 SEBD students


Age: M = 12.4

Sex: 28% female


CBCL: decrease in mean total problems from baseline (71) to 12 months (62)

CAFAS: improved mean total scores from baseline (104) to 12 months (79)

School indicators: higher grades, fewer suspensions/detentions


Large attrition due to incom-plete data for post-treatment

(Taub et al., 2006; Taub & Pearrow, 2007)


Coordinated Fam-ily Focused Care Initiative

Lead Agency: Interagency

Setting: 5 sites in Massachusetts

Duration: en-rolled for at least 6 months

Reports present data from two overlapping samples

Sample 1: N = 159 youth with SEBD at risk of residential placement

Sample 2: N = 377; 6 months (n=343) & 12 months (n=163)

Age: not reported

Sex: not reported


Repeated measures analyses re-vealed significant improvements for the following scales:

Sample 1:

CAFAS Total Score: intake (142.9) to 9 months (101.7)

Child symptoms (YOQ): intake (101.6) to 6 months (92.9)

BERS: intake (98.7) to 6 months (104.5)

Sample 2:

CAFAS School Scale: intake (26.7) to 12 months (22.3)

BERS: improvements in all domains (except School) at 6 months

School disciplinary data: No im-provements at 6 months

Fidelity measure

(Toffalo, 2000)

Journal article

Nonprofit service agency providing wraparound


Setting: rural Pennsylvania


N = 33 SEBD youth


Age: 4-7, M = 8.78

Sex: 39% female


CBCL: significant improvement on total scale score

Fidelity metric: not significantly related to outcomes; how-ever metric was not specific to wraparound (mean # treatment hours provided/mean # of hours prescribed)


14





(Vernberg et al., 2004; in press; 2006

Journal articles

Intensive Mental Health Program a school-based program with home and service coordination


Setting: Lawrence, Kansas


N = 58 SED elementary school students

N = 50 with attrition

Age: 5-13, M = 9.6

Sex: 27% female

Race/Ethnicity: 70% Caucasian, 16% African American, 8% Native Ameri-can, 4% Biracial

CAFAS: average statistical (and clinical) significant improvements from intake to discharge on total scores. 42 of 50 enrolled students showed clinically significant im-provement

CAFAS: statistical improvements on CAFAS subscales: school per-formance, home performance, behavior, moods, self-harm, thinking; no improvements on community performance, mate-rial needs, and family / social support

BASC: Average ratings moved from “clinically significant” to “at risk” for total behavioral functioning

Fidelity measure (see (Randall, et al., in press)

(Yoe et al., 1996)*

Journal article

Vermont’s Wrap-around Care Initiative


Setting: urban & rural settings


N = 40 SEBD youth

Age: 7-20, M = 16

Sex: 48% female


ROLES: significant decrease in mean level of restrictiveness and increase in community place-ments

QAIC: significant decreases in to-tal, externalizing, internalizing, and abuse related problems, but not public externalizing prob-lems.


Note. SEBD = serious emotional and behavioral disorders

Outcome measures abbreviations:

BASC = Behavior Assessment System for Children; BERS = Behavioral and Emotional Rating Scale; CAFAS = Child and Adolescent Functioning Scales; CBCL = Child Behavior Checklist; DAIC = Daily Adjustment Indicator Checklist; FACES = Family Adaptability and Cohesiveness Evaluation Scales; FSQ = Family Satisfaction Questionnaire; GAF = Global Assessment of Functioning; QAIC = Quarterly Adjustment Indicator Checklist; ROLES = Restrictiveness of Living Environment Scale ; SCICA = Semi-structured Clinical Interview for Children and Adolescents; SCRS = Self-Control Rating Scale; SSRS = Self-Control Rating Scale; TRF = Teacher Report Form; WRAT-III = Wide Range Achievement Test; YOQ = Youth Outcomes Questionnaire; YSR = Youth Self Report.

*Report included in a previous review

15





(Bickman et al., 2003)*

Journal article

(Bickman et al., 2002)

Federal report

Department of Defense managed care delivery of wraparound


Setting: generally rural across 16 states

Duration: 6 months

N = 612 SEBD youthWith attrition: N = 111 2 Groups: wrap-around (n=71) Treatment as Usual (n=40)

Age: 4-16, M = 12.2

Sex: 42% female


Service utilization for case management, in-home treat-ment, and nontraditional services higher for Wrap & lower disconti-nuity of care

Pre-post data (CBCL, YSR, VFI) reported significant improve-ments over time, but amount of improvement equal across groups

7-wave longitudinal measures (Ohio Scales) reported no signifi-cant improvements over time, and no differences between groups

Costs were significantly higher (42%) for Wrap group

Analyses only available in federal report

Insufficient data to cal-culate effect sizes

(Bruns et al., 2006)

Journal article

(Rast et al., 2007)

Unpublished manuscript

(Peterson et al., 2003; Rast et al., 2003)


Wraparound in Nevada

Lead agency: Child Welfare

Setting: urban & rural

Duration: 18 months

N = 67 SEBD youth in custody of child welfare

2 Groups: wrap-around (n = 33) and traditional case management + mental health services (n = 34)

Age: M = 11.9 years

Sex: 49% female


Wraparound group showed greater improvements than com-parison over time for:

-CBCL Total Score (d = 0.71)

-CAFAS Total Score (d = 0.25)

-ROLES Score (d = 0.62)

-School GPA (d = 0.28)

-School disciplinary (d = 0.57)

No differences between groups were found for

-School attendance

-Juvenile Justice involvement

Used multi-level model-ing to ana-lyze changes between groups over time

Fidelity mea-sure

Table 4. Quasi-Experimental Group Comparison Studies on Wraparound Process

16





(Hyde et al., 1996)*

Journal article

Family Preserva-tion Initiative of Baltimore City, Inc.


Setting: urban

Duration: 6 – 36 months

N = 107 SEBD youth

4 Groups: 2 received wraparound either fol-lowing (WR, n=25) or instead of residential treatment (WD, n=24); 2 received traditional services and measured before receiving wrap-around (PW, n=39) or did not receive wrap-around (NW, n=19)

With attrition: N = 69 WR (n=21) WD (n=24) PW (n=14) NW (n=10)

Age: M = 17.28

Sex: 25% female

Race/Ethnicity: 63% African American

Community adjustment rat-ing in “good” range: Higher for wraparound groups WR had higher % in good range than PW (d=0.76) and NW (d=1.53) and WD higher than PW (d=0.72) and WD (d=1.49)

% of youth with more than 10 days community involve-ment: WR higher than PW (d=0.53) and NW (d=1.94); WD higher than PW (d=0.28) and NW (d=1.69)


(Pullmann et al., 2006)

Journal article

Connections Program in Clark County, WA

Lead agency: Juvenile Justice

Setting: not re-ported

Duration: M = 11.2 months (range: 1 to 24.5 months)

N = 204 juvenile offend-ers with SEBD

2 groups: youth in Con-nections Program (n = 106) and a historical comparison group (n = 98)

Age: M = 15.2 years

Sex: 31% female

Race/Ethnicity: 88% White

Analyses demonstrated lower recidivism for wrap-around group for:

-Any type of offense (d = 0.25)

-Felony offense (d = 0.26)

-Whether they served in detention (d = 0.85)

For those who did serve in detention,

-Number of days served in detention (d = 0.66)

-Number of times served in detention (d = 0.76)

Cox regres-sion time-to-event analyses

CONTINUED: Table 4. Quasi-Experimental Group Comparison Studies on Wraparound Process

17





(Resendez, 2002)


Riverside County Department of Mental Health provided “flex-ible wraparound funding”


Setting: not reported

Duration: not reported intake to discharge

N = 485 SEBD youth

2 groups: receiving flexible funds (n=284) and a group receiving services but not flex-ible funds (n=201)With attrition: flex funds (n=60), attrition for comparison not reported

Age: M = 13 years

Sex: majority male

Race/Ethnicity: ma-jority White

CAFAS: significant improve-ment in total scores from intake to discharge for flexible funds (71 to 51) and non-flex-ible funds (73 to 50); there were no between group differ-ences

Insufficient data avail-able to calculate effect sizes

(Stambaugh et al., 2007)

Journal article

(Reay et al., 2003; Stam-baugh et al., 2008)


Nebraska Family Central System of Care


Setting: Rural

Duration: Months in treatment dif-fered for wrap-around (M=15), MST (M=5.5), and wrap + MST (M=10.2) groups

N = 320 SEBD youth

3 Groups: wraparound (n=213), MST (n=54), both (n=53)

With attrition: 6 months (n=285), 12 months (n=230), 18 months (n=202)

Age: M = 12 years (4 to 17.5 years)

Sex: 27% female

Race/Ethnicity: 90% White, 4% American Indian, 6% Other (11% Hispanic)

CBCL: significant improve-ment in total scores from intake to 18 months for all groups. Significant Group x Time interaction effect with the trajectory of the MST group showing significantly greater improvement than wraparound group.

CAFAS: significant improve-ment in total scores from intake to 18 months for all groups; however, there were no significant between group differences

Linear mixed models

No control group

Insufficient data avail-able to calculate effect sizes

Fidelity measure

CONTINUED: Table 4. Quasi-Experimental Group Comparison Studies on Wraparound Process

Note. SEBD = serious emotional and behavioral disorders. Outcome measures abbreviations: CAFAS = Child and Adolescent Functioning Scales; CBCL = Child Behavior Checklist; ROLES = Restrictiveness of Living Environment Scale; TRF = Teacher Report Form; VFI = Vanderbilt Functional Impairment Scale; YSR = Youth Self Report.


18





(Carney et al., 2003)

Journal article

Juvenile Delinquency Task Force Implementa-tion Commit-tee (JDIC) demonstration project

Lead Agency: Juvenile Jus-tice

Setting: Urban

Duration: 18 months

N = 307 youth referred to court or adjudi-cated and/or entered children’s services for delinquent behaviors

With attrition: N=1412 groups: wraparound (n=73) and conven-tional services (n=68)

Age: M = 14.8

Sex: 38% female

Race/Ethnicity: 50% Caucasian48% African American1% Biracial

Wraparound group missed less school (d=0.48), suspended less (d=0.48), less likely to run from home (d=0.46), less assaultive (d=0.47), and less likely to be stopped by police (d=0.51), but conventional services more likely to have a job (d=-0.39).

Wraparound group somewhat less likely to be arrested (d=0.23) somewhat more likely to be incar-cerated (d=-0.18)

(Clark et al., 1998)*

Book chapter

(Clark et al., 1997)


(Clark et al., 1996)

Journal article

Fostering Individualized Assistance Pro-gram (FIAP)

Lead Agency: Child Welfare

Setting: foster care in Florida

Duration: not reported

N = 132 SEBD youth in foster care

2 groups: FIAP (n=54) and standard practice (SP) foster care (n=78)

With attrition: SP (n=77)

Age: 7-15

Sex: 40% female

Race/Ethnicity: 62% Caucasian, 33% African American, 5% Hispanic & biracial

Permanency status: FIAP group significantly more likely to live in permanency-type setting following program

Significantly fewer days on run-away and fewer days incarcerated for FIAP

No group differences on rate of placement changes, days absent, & days suspended

DISC conduct disorder: FIAP males showed significantly less, but FIAP females significantly more

Delinquency score: FIAP males demonstrated significantly less

YSR (n=43) & CBCL (n=41)

Internalizing & Total scores: no re-peated measures differences; yet significantly smaller % boys (not girls) in clinical range for FIAP

Externalizing: repeated measures showed significant improvement over time for boys not girls, plus significantly smaller % of FIAP group in clinical range

Table 5. Experimental Randomized Controlled Trial Studies on Wraparound Process

19





(Evans et al., 1998)*

Book chapter

(Evans et al., 1998)

Evaluation report

(Evans et al., 1996)

Journal article

Family Centered Intensive Case Management (FCICM)– similar to wraparound and Family Based Treatment (FBT)


Setting: rural New York home-based and foster care

Duration: 12 months

N = 42 SEBD youth2 Groups: FCICM (n=27) and FBT (n=15)

Differential attri-tion among measures

Age: 5-13, M = 9

Sex: 10% female

Race/Ethnicity: 83% Caucasian, 5% African American, 5% Native Ameri-can, 5% Biracial, 2% Hispanic

CAFAS (n=31): significant im-provement for FCICM overtime on behavior and moods subscales but not role performance and cogni-tion

CBCL (n=28): no significant im-provements for FCICM vs. FBT overtime on total, internalizing, and externalizing scales

FACES (n=35): no significant differ-ences between groups

Piers-Harris (n=23): no significant differences between groups

TRF: dropped due to missing data

Insuffi-cient data available to calcu-late effect sizes

(Rast et al., 2008)

Paper Presen-tation

Wraparound as implemented by child welfare caseworkers or by wraparound facilitators hired and supported by an allied mental health agency.

Lead agency: Child Welfare

Setting: Urban and suburban Oklahoma

Duration: 18 months

N = 108 youth with high level of behav-ioral health needs.

3 Groups: Wrap-around imple-mented by case-workers (CW Wrap; n=36), Wraparound implemented by MH (MH Wrap; n=36), treatment as usual (n=36).

Age: 3-17

Sex: Not reported

Race: Not reported

Permanency: Significantly more days in permanency placement and a higher percent of youth in permanency placement at 12 and 18 months for both CW Wrap and MH wrap than TAU

Residential: Fewer placement changes for CW Wrap than either MH Wrap or TAU; Lower restric-tiveness for both wrap groups than TAU

Behaviors: Greater reduction in problem behaviors as reported by the Ohio Scales for CW Wrap than MH Wrap or TAU

Functioning: Greater reduction in CAFAS scores for CW Wrap than MH Wrap or TAU

Caregiver Strain: Greater reduc-tion for CW Wrap than MH Wrap or TAU

Insuffi-cient data available to calcu-late effect sizes

Fidelity measure

Note. SEBD = serious emotional and behavioral disorders. Outcome measures abbreviations: CAFAS = Child and Adolescent Functioning Scales; CBCL = Child Behavior Checklist; DISC = Diagnostic Interview Schedule for Children; FACES = Family Adaptability and Cohesiveness Evaluation Scales; TRF = Teacher Report Form; YSR = Youth Self Report.


CONTINUED: Table 5. Experimental Randomized Controlled Trial Studies on Wraparound Process

20


& Yoe, 1995; Bruns, Suter, Force, & Burchard, 2005; Clarke, Schaefer, Burchard, & Welkowitz, 1992; Copp, Bordnick, Traylor, & Thyer, 2007; Eber & Hyde, 2006; Eber, Osuch, & Redditt, 1996a; Eber, Osuch, & Rolf, 1996b; Hyde, Woodworth, Jordan, & Burchard, 1995; Illback, Neill, Call, & Andis, 1993; Kamradt, Kostan, & Pina, 1998; Kam-radt & Meyers, 1999; Kutash, Duchnowski, Sumi, Rudo, & Harris, 2002; Levison-Johnson & Gravino, 2006; Lyman & de Toledo, 2002; Robbins & Collins, 2003; Seybold, 2002; Taub & Pearrow, 2007; Tof-falo, 2000; Vernberg et al., 2004; Yoe, Santarcan-gelo, Atkins, & Burchard, 1996). As such, they con-ducted within subjects comparisons across time, typically measuring outcomes at intake and 6 to 12 months later (M = 11.63 months, SD = 5.39). The advantage of this design over the qualitative case study design is that it includes larger (and ideally more representative) samples and often employs standardized measures of outcomes. However, due to lack of comparison groups, these studies cannot confirm that any observed changes occurred as a result of wraparound. Consequently, they provide evidence that wraparound may be associated with positive outcomes but do not of-fer the same level of confidence as provided by comparison studies.

Rather than discuss each of these 22 studies individually, key characteristics about the stud-ies and findings were summarized. Just over half of these studies (n = 13) were published in peer-reviewed journals. Although all studies indicated that the participants received wraparound, the interventions were fairly heterogeneous with re-gard to setting, participants, and the types of out-comes measured. It should be noted that three of the studies used different samples to evaluate the same wraparound initiative (Wraparound Milwau-kee, Kamradt et al., 1998; 2005; Seybold, 2002). Many of the interventions provided services in the home and community, though several others also (or exclusively) took place in schools (e.g., Eber et al., 2006). Most of the youth participants were re-ported to have SEBD, yet referral problems ranged from imminent risk of hospitalization to impaired functioning at school. Some interventions served primarily child or adolescent groups, while others simply targeted anyone 21 years or younger.

Examining outcome analyses from the pretest-posttest no comparison studies, approximately one

third (n = 7) did not conduct any tests of statis-tical significance and reported primarily positive effects. Of the studies that did conduct statistical analyses, significant positive effects were found for youth living situation (e.g., youth were able to return to their communities following wraparound) and reported number of negative behaviors. Oth-er findings were more difficult to interpret due to the range of measures used. Examining two of the most commonly used measures revealed mixed results. The ten studies that used the Child Behav-ior Checklist ([CBCL] Achenbach & Rescorla, 2001) were evenly split between showing significant im-provements (n = 5) and no improvement or mixed findings (n = 5). Nine studies used the Child and Adolescent Functional Assessment Scale ([CAFAS] Hodges, Wong, & Latessa, 1998) with only slightly more than half finding statistically significant im-provements in functioning (n = 5). Burchard and colleagues (2002) noted that there was some evi-dence for greater improvements at home than at school (Clarke et al., 1992; Eber et al., 1996b; Kutash et al., 2002; Yoe et al., 1996), however the null findings in the schools could be attributed to the relatively low power of these studies.

Quasi-Experimental Studies Five quasi-experimental studies that compared

outcomes for youth enrolled in a wraparound ini-tiative compared to usual care were identified. These studies (Bickman et al., 2003; Bruns, Rast, Peterson, Walker, & Bosworth, 2006; Hyde et al., 1996; Pullmann et al., 2006; Resendez, 2002) ad-opted pretest-posttest, comparison group designs without random assignment. This design exerts a greater level of control over the independent variable (i.e., provision of wraparound) than ei-ther of the previously discussed designs, allowing the researcher to be more confident that changes in outcome may be attributed to the intervention. This does not mean that this type of design allows one to unequivocally make causal inferences. Yet quasi-experimental design represents a major leap forward in methodology compared to single group design, thus each of these studies was re-viewed individually.

The earliest of these quasi-experimental stud-ies was conducted in urban Baltimore with chil-dren returned or diverted from residential out-of-

21


state placements (Hyde et al., 1996). The authors examined outcomes for four groups: (a) youth who received wraparound after returning from residential placement (Wrap+Return or WR), (b) youth who received wraparound as an alterna-tive to residential placement (Wrap+Diversion or WD), (c) youth who received traditional services during the year prior to the wraparound program initiating (Prior to Wrap or PW), and (d) children who received traditional services instead of wrap-

around (No Wrap or NW). The authors stressed that the four groups were not equivalent (e.g., PW group was older, WD had not experienced residential placement), and thus they cautioned against making direct comparisons. A community adjustment scale was developed for this study to provide a single rating of several relevant indi-cators (restrictiveness of the youth’s living situ-ation, school attendance, job/job training atten-dance, and serious problem behaviors). Children received ratings of “good” if they were living in regular community placements, attending school and/or working for the majority of the week, and had fewer than three days of serious behavior problems during the course of a month.

After approximately two years of wraparound, 47% of the wraparound groups (WR and WD) re-ceived a rating of good community adjustment,

compared to 8% of children who received tradi-tional mental health services. Unfortunately, high rates of attrition in the non-wraparound groups further compound the problem that the groups were not equivalent at baseline. As the authors stated, “this is not a comparison study” (Hyde et al., 1996, p. 70), so perhaps the biggest contri-butions are the identification of these groups for future comparison studies and the creation of a measurement tool that directly assessed the key indicators important to providers and families.

Bickman and his colleagues have conducted experimental evaluations of systems of care at Fort Bragg, NC (Bickman et al., 1995) and Stark County, OH (Bickman et al., 1997). More recently, they completed a quasi-experimental study on a demonstration project of wraparound through the Department of Defense (Bickman et al., 2003). A managed care company oversaw the demonstra-tion, organizing the delivery of services hierarchi-cally with professionals at the family level (case managers), program level (care managers), and system level (clinical management committee). The demonstration group (n = 71) received both traditional (e.g., psychotherapy, psychiatric hos-pitalization) and nontraditional services (e.g., respite, recreation services, therapeutic foster homes). A comparison group (n = 40, treatment as usual) was formed from families referred to the demonstration project but who refused to partici-pate or were ineligible because the demonstra-tion group had different exclusionary criteria.2 Outcomes for the two groups were assessed from baseline to six months later.

The authors’ findings included (a) largely no baseline differences between the two groups, (b) higher utilization of “wraparound services” (e.g., case management, in-home supports, and nontra-ditional services) for the demonstration group, (c) higher costs for the demonstration group (primar-ily due to this group remaining in treatment lon-ger), and (d) no consistent differences between the groups on the outcome measures. Limita-

2. Exclusionary criteria for the demonstration that were not exclusionary criteria for TAU included: requiring long-term residential care, history of treatment resistant drug use, persistent antisocial behavior not resulting from a treatable men-tal disorder, developmental or cognitive disorder that negatively impacts treatment, conviction/adjudication for sexual perpetration, and being amenable to treatment.

22


tions of this study include the short time span (6 months) and whether the demonstration project truly followed the wraparound process. The au-thors stated that the services were community-based, included informal services, and included availability of flexible funding. However, they were not aware if any of the remaining seven ele-ments had been followed. Strengths include the similarities between the groups at baseline, use of standardized measures, adequate power, and sophisticated data analyses.

Another quasi-experimental study (Resendez, 2002) compared groups of youth who did (n = 284) or did not (n = 201) receive “flexible wrap-around funding” (p. 243) while receiving mental health services from the same agency. Flexible funds were primarily directed toward financial aid as well as recreational and social supports. The average amount of flexible funds allotted was $155.81. Participants’ functioning and impairment was measured at baseline and six months later. Like the previously reviewed study, significant improvements were found for both groups over time, but no between-group differences were de-tected. Limitations include high attrition for the flexible funds group, relatively short time span (6 months), and weak manipulation of the indepen-dent variable. With the only difference between groups being an award ranging from $5 to $200, a significant difference on functioning scores seems unlikely. The main strength of this study was the assessment of the impact of a single wraparound element: Flexible Resources and Funding. As re-searchers begin to question the importance of the hypothesized components of wraparound, dis-mantling studies (that investigate the impact of specific components or principles) similar to this one will be important. However, it is questionable whether this study truly meets criteria for inclu-sion in this review of wraparound, given our inclu-sion criteria.

Pullmann and colleagues (2006) conducted a two-year longitudinal matched comparison study of youth involved in the juvenile justice system and receiving mental health services. Overall, 110 youth enrolled in wraparound were compared to 98 receiving conventional mental health services. Youths in the comparison group were three times more likely to commit a felony offense during the follow up period than youths in the wraparound

group. Among youth in the wraparound program, 72% served detention “at some point in the 790 day post identification window” (p. 388), while all youth in the comparison group served deten-tion. Of youth in the wraparound program who did serve detention, they did so significantly less of-ten than their peers. Wraparound youth also took three times longer to recidivate than those in the comparison group. According to the authors, a previous study by Pullmann and colleagues showed “significant improvement on standardized measures of behavioral and emotional problems, increases in behavioral and emotional strengths, and improved functioning at home at school, and in the community” (p. 388) among youth in the wraparound program.

The final wraparound vs. control condition quasi-experimental study was a matched com-parison pilot study conducted to demonstrate the effectiveness of the Wraparound in Nevada (WIN) program for youth in custody of the child welfare system due to abuse or neglect. Thirty-three youth with SEBD receiving wraparound were compared to a sample of 34 youth receiving tra-ditional mental health services. The comparison group was matched on location, age, severity of emotional and behavioral symptoms, and resi-dential placement. Findings from this pilot study were presented in a policy paper on wraparound (Bruns et al., 2006), two conference proceedings (Peterson, Rast, Gruner, Abi-Karam, & Earnest, 2003; Rast, Peterson, Earnest, & Mears, 2003), and a manuscript currently under review that was shared by the authors (Rast, Bruns, Brown, Peter-son, & Mears, 2007). After 18 months, approxi-mately 82% of youth in WIN moved to less restric-tive environments, compared to 38% of comparison group youth, yielding a large estimated effect (d = 0.93). In addition, family members were identi-fied to provide care for 11 of the 33 youth in the wraparound group (33.3%) compared to only six in the comparison group (17.6%). Mean scores on the CAFAS for youth in wraparound decreased sig-nificantly across all waves of data collection (6, 12, 18 months) in comparison to the traditional services group. More positive outcomes were also found for the wraparound cohort on school at-tendance, school disciplinary actions, and grade point averages. No significant differences were found in favor of the comparison group.

23


In addition to the positive impact found for wraparound, the study also reported fidelity data from the Wraparound Fidelity Index (WFI; Bruns et al., 2005). Scores from the WFI were quite high compared to other programs nationally (Bruns et al., 2006; Bruns, Leverentz-Brady, & Suter, in press). These results provide information for the field about the level of adherence that may be necessary to achieve outcomes such as those ob-served for the wraparound-enrolled youths in this study.

In addition to the five studies described above that compared outcomes for youth enrolled in wraparound to treatment as usual conditions, a unique quasi-experimental study was conducted (Stambaugh et al., 2007) that compared n = 213 children receiving wraparound to n = 54 youths receiving Multisystemic Therapy (MST; Henggeler, Schoenwald, Rowland, & Cunningham, 2002) in a single system of care in rural Nebraska. (A third group received a combination of MST and wrap-around.) Although MST and wraparound have been conceptually compared (Burns, Schoenwald, Bur-chard, Faw, & Santos, 2000), this study provided a unique opportunity to contrast the two approaches empirically. MST has a more established evidence base than wraparound and meets criteria as an empirically supported treatment for children with conduct problems (Brestan & Eyberg, 1998). Re-sults showed that both groups showed significant improvements in functioning as assessed by the CAFAS and behavior as assessed by the CBCL, and similar downward trajectories in scores for each of these measures. Rates of improvement in be-havior problems were significantly better for the MST group; however, rates of improvement in child functioning over time were the same for the two groups.

Though the authors speculate that the results indicate greater benefit of using specific models such as MST as opposed to more general care coor-dination models such as wraparound, it is difficult to conclude that the results demonstrate the su-periority of MST to wraparound, given that youth in the MST group were selected based on meet-ing criteria for MST while wraparound was used to support a much larger number of youth and fami-lies with a much more diverse set of needs. Thus, though statistical controls were used in between-group comparisons, the two groups were inher-

ently non-equivalent at baseline by definition. Nonetheless, the paper points to an important direction in wraparound outcomes studies, and provides interesting information about the types of outcomes that might be achieved for youth re-ceiving care through these two models in a single system of care, as well as potential methods for organizing a system of care to meet the needs of a diverse group of youth and families.

Experimental Studies Four randomized trials (Carney & Buttell,

2003; Clark, Lee, Prange, & McDonald, 1996; Ev-ans, Armstrong, Kuppinger, Huz, & McNulty, 1998; Rast, Vetter, & Poplin, 2008) constitute the wrap-around evidence base employing experimental designs. Experimental studies provide the stron-gest protections against threats to internal va-lidity, thus allowing researchers to draw more confident connections between interventions and outcomes. However, one cannot assume that the findings will necessarily generalize to other set-tings or environments (referred to as external va-lidity). This is a particularly noteworthy point for the randomized studies reviewed here because they represent specific groups of children receiv-ing wraparound in several different contexts, including a foster care-based program (Clark et al., 1996; 1997; 1998), an intensive case manage-ment approach (Evans et al., 1996; Evans, Arm-strong, Kuppinger, Huz, & Johnson, 1998; Evans, Armstrong, Kuppinger, Huz, & McNulty, 1998), a program for adjudicated or court-referred youths (Carney & Buttell, 2003), and a program for youth involved with the child welfare system (Rast et al., 2008). These programs were deemed consis-tent enough with the wraparound process to be included in the evidence base (Burchard et al., 2002); however the findings may not generalize to wraparound programs in other settings.

Clark and his colleagues (Clark et al., 1996; Clark et al., 1998) conducted the most frequently cited empirical outcome study on wraparound. Participants included children in foster care ran-domly assigned to either the Fostering Individual-ized Assistance Program ([FIAP] n = 54) or standard practice foster care (n = 78). The program pro-vided individualized services for children in foster care with the primary goals being to achieve an ef-

24


fective permanency plan and improve behavioral outcomes. Findings from this study demonstrated significantly fewer placement changes for chil-dren in the FIAP program, fewer days on runaway, fewer days incarcerated (for subset of incarcerat-

ed youths), and older children were signifi-cantly more likely to be in a permanency plan at follow-up. No group differences were found on rate of placement chang-es, days absent, or days suspended. Sig-nificantly fewer boys in the treatment program met crite-ria for conduct dis-order compared to the children in stan-dard practice foster care, but signifi-cantly more girls in the treatment group were diagnosed with conduct disorder. No group differences were found for in-ternalizing disor-ders, but boys in the treatment program

showed significantly greater improvement on ex-ternalizing problems than the comparison group. Taken together, the findings provided moderate evidence for better outcomes for the wraparound program, though the differences appear limited to boys and externalizing problems.

The second randomized clinical trial (Evans et al., 1996; Evans, Armstrong, Kuppinger, Huz, & Johnson, 1998; Evans, Armstrong, Kuppinger, Huz, & McNulty, 1998) assigned children referred for out-of-home placements to either family centered intensive case management (n = 27) or treatment foster care (family based treatment, n = 15). The case management program largely followed the elements of the wraparound process by providing individualized, team-based, and comprehensive services and supports. Significant group differ-ences in favor of the case management program

were found for behavioral and mood functioning. No differences were found with regard to other types of functioning (role performance or cogni-tion), behavior problems (internalizing and ex-ternalizing), family cohesiveness, or self-esteem. Probably the most serious limitation of this study is the small sample size, plus further loss of data on many of the outcome measures. As a result, the study had very low power to detect differ-ences between the groups.

A third randomized clinical trial (Carney & But-tell, 2003) evaluated the effectiveness of a wrap-around program designed to reduce recidivism of adjudicated or court referred youths. Participants included 141 youths (out of 500 invited to partici-pate) randomly assigned to a team-based wrap-around program (n = 73) or conventional services (n = 68) after being referred to juvenile court. The two groups were followed for 18 months. Youths receiving wraparound were absent from school less often, suspended from school less often, ran away from home less frequently, and were less assaul-tive than those in the conventional services group. However, youths receiving conventional services were more likely to obtain a job, and no differ-ences were found for subsequent arrests or incar-ceration. Thus, though the “weight of evidence” from this study indicates better interim outcomes for the wraparound condition, the study’s pro-posed ultimate outcomes—subsequent arrests and incarceration—were not found to be significantly impacted by assignment to wraparound.

The most recent randomized trial is currently being completed in the context of the Oklahoma child welfare system (Rast et al., 2008). Though this study is not yet complete, interim findings have been reported at the annual research con-ference of A System of Care for Children’s Men-tal Health: Expanding the Research Base hosted by the University of South Florida Research and Training Center for Children’s Mental Health (one of the sources for this review). Participants were 108 children in the child welfare system who were nominated for the study because they were high users of behavioral health services. These children were randomly assigned to three groups (each n = 36): (1) wraparound facilitation conducted by the child welfare caseworker; (2) wraparound conducted by a facilitator employed by a local mental health center; or (3) services as usual. Re-

Though there may not yet be

sufficient evidence in peer-reviewed journals to state that wraparound

consistently results in better outcomes.... the evidence base is encouraging and certainly growing.

25


sults found that the group of children and youths receiving wraparound experienced fewer school and residential placement disruptions, more days overall in a permanency setting, and improved behavioral and functional outcomes, when com-pared to the services as usual group. There was also a trend toward better outcomes for children in the group for which the wraparound process was facilitated by the child welfare caseworker, as opposed to the group for which wraparound was implemented by the local mental health center.

DiscussionThis review was intended to present results

from the full range of outcome studies on wrap-around as a way to both (1) evaluate the weight of the evidence as well as (2) explore the methodol-ogies used. Overall, the findings from this review are encouraging with respect to the potential for wraparound to have a positive impact on youth and families. Though the majority of the studies that have been published and that were reviewed here have serious methodological limitations, there is a growing body of more rigorous research on wrap-around that is now emerging. This includes exper-imental and quasi-experimental studies recently completed or nearly completed (e.g., Pullmann et al., 2006; Rast et al., 2008), as well as additional randomized studies that are now underway, such as an NIMH sponsored study of wraparound com-pared to intensive case management for youth in the child welfare system in Clark County, Nevada (Walker & Bruns, 2006). Though there may not yet be sufficient evidence in peer-reviewed journals to state that wraparound consistently results in better outcomes than alternative treatments for specific populations, the evidence base is encour-aging and certainly growing.

At the same time, if advocates of wraparound hope to provide convincing evidence that wrap-around is an effective process for meeting the needs of children with SEBD, a number of meth-odological limitations must be addressed. First, more studies on wraparound are needed that uti-lize rigorous methodological design and appropri-

ate comparison groups. This includes comparing wraparound to traditional control groups (e.g., treatment as usual) as well as conceptually rel-evant alternatives. For example, although wrap-around developed as a less restrictive substitute for residential placements, no studies that direct-ly compared these two interventions were found.3 Without question, increasing the number of stud-ies that included randomized selection of partici-pants would be a major benefit to the field.

Second, many of the studies provided incom-plete data on participant demographics and out-comes. As noted in one previous narrative review (Burchard et al., 2002), few of the reviewed stud-ies specified how participants were selected for inclusion. Most likely, the researchers chose youth based on staff nominations or simply by using all available data. More care needs to be taken in fu-ture studies to specify how samples were selected in order to determine if they are truly represen-tative of their programs or children with SEBD in general. Similarly, several studies presented de-tailed findings only when the effects were statisti-cally significant. In order to better synthesize the evidence base, it is crucial for authors to include basic information (e.g., means, standard devia-tions, effect sizes) for all analyses.

Third, outcomes were measured on average from 3 to 36 months after baseline, often as post-

3. Although Hyde and her colleagues (1996) examined outcomes for youth assigned to both wraparound and residential treatment, comparisons were explicitly not conducted.

26


tests with children still engaged in services. A goal of wraparound is to create long-standing changes in the youth in family. Thus, more longitudinal fol-low-ups are necessary to see if changes last be-yond the end of treatment.

And fourth, one cannot conclude that all re-viewed studies offered equivalent versions of wraparound. The programs varied on a number of factors including setting, target population, stated goals, and outcomes measured. Only seven (19%) of the studies reported systematic assessment of the degree to which wraparound was delivered as intended (Bruns et al., 2006; Bruns et al., 2005; Kutash et al., 2002; Rast et al., 2008; Stambaugh et al., 2007; Taub & Pearrow, 2007; Vernberg et al., 2004). Without evaluating the fidelity of an intervention, it is difficult to determine if the program offers wraparound or merely “wannabe wraparound” (Walker & Bruns, 2003). Fortunate-ly, it appears that recent studies of wraparound have more consistently reported results of fidel-ity assessment using tools that are widely avail-able. The accumulation of evaluation results that include reports of fidelity assessments will facili-tate interpretation of the results as well as help synthesize findings across studies.

ConclusionsAs summarized above, this review of wrap-

around outcomes studies yielded a large number of publications describing a wide array of target populations and study designs, most of which were far from rigorous. Regardless, because of the diverse ways in which wraparound is applied for children and families, it is important to keep a “catalog” of the breadth of the overall evidence base on this model, especially in the absence of a well-developed set of randomized controlled studies. By presenting this summary in this way, we hoped to provide a format that can be updat-ed over time, and create a resource for program developers, administrators, practitioners, and re-searchers who wish to seek out published studies on a specific target population or context in which wraparound has been implemented. This review can also serve as a tool for answering more specific research questions, such as typical trajectories in behavioral or functional improvement over time, or the relationship between wraparound fidelity

and outcomes. Finally, with greater recognition of the broad range of wraparound outcomes studies, perhaps more local evaluators will be encouraged to publish their results, and/or design their evalu-ations to feature greater rigor, integrate fidelity assessment, and otherwise help the field move forward.

While the goal was to be exhaustive, we rec-ognize that this review may not include all rel-evant wraparound outcomes studies. As a result, we are continuing to search for additional gray literature not identified by the inclusion criteria used for this review (e.g., unpublished local eval-uation reports). Such findings will likely expand our understanding of outcomes typically found for systems as well as children and families and may facilitate a future exercise of benchmarking com-monly measured outcomes such as behavior, func-tioning, and residential placement.

In addition, as results emerge from the con-trolled studies of wraparound currently underway, a more systematic appraisal of the quality of the wraparound evidence base is needed, which will make reviews such as this one more complete as well as “evidence based” unto itself. At that point, we can also identify the specific gaps in the literature (e.g., specific target populations, specific types of outcomes), beyond simply noting that “more needs to be done.” Finally, we need to translate the results of quasi-experimental and experimental studies into a meta-analysis that can generate average effect sizes for different types of outcomes, as determined by between group comparisons of wraparound and control groups. Given that we have now identified 8-10 unique studies that provide some type of ability to generate estimates of the size of effects of im-plementing wraparound, this can be an immedi-ate next step that further informs the field about wraparound’s potential for positive impact on the lives of children and families.

ReferencesAchenbach, T. M., & Rescorla, L. A. (2001). Manu-

al for ASEBA school-age forms & profiles. Bur-lington, VT: University of Vermont, Research Center for Children, Youth, & Families.

*Anderson, J. A., Kooreman, H. E., Mohr, W. K., Wright, E. R., & Russell, L. A. (2002). The

27


28


Dawn Project: How it works, who it serves, and how it’s evaluated. In C. C. Newman, C. J. Liberton, K. Kutash & R. M. Friedman (Eds.), The 14th Annual Research Conference Proceedings, A System of Care for Children’s Mental Health: Expanding the Research Base (pp. 59-62). Tampa, FL: University of South Florida, The Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children’s Mental Health.

*Anderson, J. A., Wright, E. R., Kooreman, H. E., Mohr, W. K., & Russell, L. A. (2003). The Dawn Project: A model for responding to the needs of children with emotional and behavioral chal-lenges and their families. Community Mental Health Journal, 39, 63-74.

Aos, S., Lieb, R., Mayfield, J., Miller, M., & Pen-nucci, A. (2004). Benefits and costs of pre-vention and early intervention programs for youth. Olympia, WA: Washington State Insti-tute for Public Policy.

*Bartley, J. (1999). Exploratory study of a model for evaluating wrap-around services: Charac-teristics of children and youth exhibiting vari-ous degrees of success. Dissertation Abstracts International, 60, 354.

*Bickman, L. (2002). Mental health wraparound demonstration evaluation: Report to the United States Congress: Submitted to: United states Department of Defense, Health Affairs, TRICARE Management Activity (TMA), and Health Program Analysis and Evaluation.

Bickman, L., Guthrie, P. R., Foster, E. M., Lam-bert, E. W., Summerfelt, W. T., Breda, C. S., et al. (1995). Evaluating managed mental health services: The Fort Bragg experiment. New York: Plenum Press.

*Bickman, L., Smith, C., Lambert, E. W., & An-drade, A. R. (2003). Evaluation of a congres-sionally mandated wraparound demonstra-tion. Journal of Child & Family Studies, 12, 135-156.

Bickman, L., Summerfelt, W. T., & Noser, K. (1997). Comparative outcomes of emotionally disturbed children and adolescents in a system of services and usual care. Psychiatric Servic-es, 48, 1543-1548.

Brestan, E. V., & Eyberg, S. M. (1998). Effective psychosocial treatments of conduct-disordered children and adolescents: 29 years, 82 studies, and 5,272 kids. Journal of Clinical Child Psy-chology, 27, 180-189.

*Brothers, C., McLaughlin, S. C., & Daniel, M. (2006). Building community connections with project T.E.A.M.: A comparison of at-risk cau-casian and minority youth. In C. Newman, C. J. Liberton, K. Kutash & R. M. Friedman (Eds.), The 18th Annual Research Conference Proceedings, A System of Care for Children’s Mental Health: Expanding the Research Base (pp. 171-173). Tampa, FL: University of South Florida, The Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children’s Mental Health.

*Bruns, E. J., Burchard, J. D., & Yoe, J. T. (1995). Evaluating the Vermont system of care: Out-comes associated with community-based wraparound services. Journal of Child & Fam-ily Studies, 4, 321-339.

Bruns, E.J., Leverentz-Brady, K.M., & Suter, J.C. (in press). Is it wraparound yet? Setting fidelity standards for the wraparound process. Journal of Behavioral Health Services and Research.

*Bruns, E. J., Rast, J., Peterson, C., Walker, J. S., & Bosworth, J. (2006). Spreadsheets, ser-vice providers, and the statehouse: Using data and the wraparound process to reform systems for children and families. American Journal of Community Psychology, 38, 201-212.

*Bruns, E. J., Suter, J. C., Force, M. M., & Bur-chard, J. D. (2005). Adherence to wraparound principles and association with outcomes. Journal of Child and Family Studies, 14, 521-534.

Bruns, E. J., Walker, J. S., Adams, J. S., Miles, P., Osher, T. W., Rast, J., et al. (2004). Ten principles of the wraparound process. Port-land, OR: National Wraparound Initiative, Re-search and Training Center on Family Support and Children’s Mental Health, Portland State University.

Bruns, E. J., Woodworth, K., Froelich, P. K., & Burchard, J. D. (1994). User’s manual to the Vermont system for tracking progress data

29


entry and graphing programs for creation of multi-axial life events timelines and behav-ioral adjustment tracking graphs. Burlington, VT: University of Vermont.

Burchard, J. D., Bruns, E. J., & Burchard, S. N. (2002). The Wraparound approach. In B. J. Burns & K. Hoagwood (Eds.), Community treatment for youth: Evidenced-based inter-eventions for severe emotional and behav-ioral disorders (pp. 69-90). New York: Oxford University Press.

*Burchard, J. D., Burchard, S. N., Sewell, R., & VanDenBerg, J. (1993). One kid at a time: Evaluative case studies and descriptions of the Alaska Youth Initiative Demonstration Project. Washington, DC: Substance Abuse and Mental Health Service Administration, Center for Mental Health Services.

Burns, B. J. (2002). Reasons for hope for children and families: A perspective and overview. In B. J. Burns & K. Hoagwood (Eds.), Community treatment for youth: Evidence-based inter-ventions for severe emotional and behavioral disorders (pp. 3-15). New York: Oxford Univer-sity Press.

Burns, B. J., Goldman, S. K., Faw, L., & Burchard, J. D. (1999). The wraparound evidence base. In B. J. Burns & S. K. Goldman (Eds.), Systems of Care: Promising Practices in Children’s Mental Health, 1998 Series (Vol. IV). Washington, DC: Center for Effective Collaboration and Prac-tice, American Institutes for Research.

Burns, B. J., Schoenwald, S. K., Burchard, J. D., Faw, L., & Santos, A. B. (2000). Comprehen-sive community-based interventions for youth with severe emotional disorders: Multisytemic Therapy and the Wraparound process. Journal of Child and Family Studies, 9, 283-314.

*Carney, M. M., & Buttell, F. (2003). Reducing ju-venile recidivism: Evaluating the wraparound services model. Research on social work prac-tice, 13, 551-568.

*Clark, H. B., Boyd, L. A., Lee, B., Prange, M. E., Barrett, B., Stewart, E. S., et al. (1997). Indi-vidualized service strategies for children with emotional/behavioral disturbances in foster care: Summary of practice, findings, & sys-

temic recommendations. In C. J. Liberton, K. Kutash & R. M. Friedman (Eds.), The 9th Annu-al Research Conference Proceedings, A System of Care for Children’s Mental Health: Expand-ing the Research Base (pp. 137-142). Tampa, FL: University of South Florida, Florida Mental Health Institute, Research and Training Center for Children’s Mental Health.

*Clark, H. B., & Clarke, R. T. (1996). Research on the wraparound process and individualized services for children with multi-system needs. Journal of Child and Family Studies, 5, 39-54.

*Clark, H. B., Prange, M. E., Lee, B., Stewart, E. S., McDonald, B. B., & Boyd, L. A. (1998). An individualized wraparound process for children in foster care with emotional/behavioral dis-turbances: Follow-up findings and implications from a controlled study. In M. H. Epstein, K. Kutash & A. Duchnowski (Eds.), Outcomes for children and youth with emotional and behav-ioral disorders and their families: Programs and evaluation best practices (pp. 513-542). Austin, TX: Pro-ED, Inc.

*Clarke, R. T., Schaefer, M., Burchard, J. D., & Welkowitz, J. W. (1992). Wrapping community-based mental health services around children with a severe behavioral disorder: An evalua-tion of project wraparound. Journal of Child & Family Studies, 1, 241-261.

Cohen, J. (1992). A power primer. Psychological Bulletin, 112, 155-159.

*Copp, H. L., Bordnick, P. S., Traylor, A. C., & Thy-er, B. A. (2007). Evaluating wraparound servic-es for seriously emotionally disturbed youth: Pilot study outcomes in Georgia. Adolescence, 42, 723-732.

*Cumblad, C. (1996). The pathways children and families follow prior to, during, and after contact with an intensive, family-based, so-cial service intervention in urban settings. Unpublished doctoral dissertation, Northern Illinois University, DeKalb.

*Eber, L., & Hyde, K. L. (2006). Integrating data-based decisionmaking into the wraparound process within a system of school-wide posi-tive behavior supports (PBS). In C. Newman,

30


C. J. Liberton, K. Kutash & R. M. Friedman (Eds.), The 18th Annual Research Conference Proceedings, A System of Care for Children’s Mental Health: Expanding the Research Base (pp. 147-152). Tampa, FL: University of South Florida, The Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children’s Mental Health.

*Eber, L., Osuch, R., & Redditt, C. A. (1996). School-based applications of the wraparound process: Early results on service provision and student outcomes. Journal of Child & Family Studies, 5, 83-99.

*Eber, L., Osuch, R., & Rolf, K. (1996). School-based wraparound: How implementation and evaluation can lead to system change. In C. J. Liberton, K. Kutash & R. M. Friedman (Eds.), The 8th Annual Research Conference Proceed-ings, A System of Care for Children’s Mental Health: Expanding the Research Base (pp. 143-147). Tampa, FL: University of South Florida, Florida Mental Health Institute, Research and Training Center for Children’s Mental Health.

*Evans, M. E., Armstrong, M. I., & Kuppinger, A. D. (1996). Family-centered intensive case man-agement: A step toward understanding indi-vidualized care. Journal of Child and Familiy Studies, 5, 55-65.

*Evans, M. E., Armstrong, M. I., Kuppinger, A. D., Huz, S., & Johnson, S. (1998). A randomized trial of family-centered intensive case man-agement and family-based treatment: Final report. Tampa, FL: University of South Flori-da.

*Evans, M. E., Armstrong, M. I., Kuppinger, A. D., Huz, S., & McNulty, T. L. (1998). Preliminary outcomes of an experimental study compar-ing treatment foster care and family-centered intensive case management. In M. H. Epstein & K. Kutash (Eds.), Outcomes for children and youth with emotional and behavioral disor-ders and their families: Programs and evalua-tion best practices (pp. 543-580).

Farmer, E. M. Z., Dorsey, S., & Mustillo, S. A. (2004). Intensive home and community inter-ventions. Child and Adolescent Psychiatric Clinics of North America, 13, 857-884.

Friedman, R. M., & Drews, D. (2005). Evidence based practices, systems of care, & individ-ualized care. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, Department of Child & Family Stud-ies. The Research and Training Center for Chil-dren’s Mental Health.

Henggeler, S. W., Schoenwald, S. K., Rowland, M. D., & Cunningham, P. B. (2002). Serious emotional disturbance in children and adoles-cents: Multisystemic Therapy. New York: Guil-ford Press.

Hodges, K., Wong, M. M., & Latessa, M. (1998). Use of the Child and Adolescent Functional As-sessment Scale (CAFAS) as an outcome mea-sure in clinical settings. Journal of Behavioral Health Services and Research, 25, 325-336.

*Hyde, K. L., Burchard, J. D., & Woodworth, K. (1996). Wrapping services in an urban setting. Journal of Child & Family Studies, 5, 67-82.

*Hyde, K. L., Woodworth, K., Jordan, K., & Bur-chard, J. D. (1995). Wrapping services in an urban setting: Outcomes of service reform in Baltimore. In C. J. Liberton, K. Kutash & R. M. Friedman (Eds.), The 7th Annual Research Conference Proceedings, A System of Care for Children’s Mental Health: Expanding the Research Base (pp. 255-260). Tampa, FL: Uni-versity of South Florida, Florida Mental Health Institute, Research and Training Center for Children’s Mental Health.

*Illback, R. J., Neill, T. K., Call, J., & Andis, P. (1993). Description and formative evaluation of the Kentucky IMPACT Program for children with serious emotional disturbance. Special Services in the Schools, 7, 87-109.

*Illback, R. J., Nelson, C. M., & Sanders, D. (1998). Community-based services in Kentucky: De-scription and 5-year evaluation of Kentucky IMPACT. In M. H. Epstein, K. Kutash & A. Duch-nowski (Eds.), Outcomes for children and youth with emotional and behavioral disor-ders and their families: Programs and evalua-tion best practices. (pp. 141-172). Austin, TX: Pro-ED, Inc.

*Kamradt, B. (1996). The 25 Kid Project: How Mil-waukee utilized a pilot project to achieve buy-

31


in among stakeholders in changing the system of care for children with severe emotional problems. Paper presented at the Washington Business Group on Health.

*Kamradt, B. (2000). Wraparound Milwaukee: Aid-ing youth with mental health needs. Juvenile Justice, 7 (1), 14-23.

*Kamradt, B., Gilbertson, S. A., & Lynn, N. (2005). Wraparound Milwaukee: Program description and evaluation. In M. H. Epstein, K. Kutash & A. J. Duchnowski (Eds.), Outcomes for chil-dren and youth with emotional and behavioral disorders and their families (2nd ed., pp. 307-328). Austin, TX: Pro-Ed.

*Kamradt, B., Kostan, M. J., & Pina, V. (1998). Wraparound Milwaukee: Two year follow-up on the Twenty Five Kid Project. In C. J. Liberton, K. Kutash & R. M. Friedman (Eds.), The 10th Annual Research Conference Proceedings, A System of Care for Children’s Mental Health: Expanding the Research Base (pp. 225-228). Tampa, FL: University of South Florida, Florida Mental Health Institute, Research and Training Center for Children’s Mental Health.

*Kamradt, B., & Meyers, M. J. (1999). Curbing violence in juvenile offenders with serious emotional and mental health needs: The ef-fective utilization of wraparound approaches in an American urban setting. International Journal of Adolescent Medicine & Health, 11, 381-399.

Kazdin, A. E. (2002). Research design in clinical psychology (4th ed.). Needham Heights, MA: Allyn and Bacon.

*Kutash, K., Duchnowski, A. J., Sumi, W. C., Rudo, Z. H., & Harris, K. M. (2002). A school, fam-ily, and community collaborative program for children who have emotional disturbances. Journal of Emotional & Behavioral Disorders, 10, 99-107.

*Levison-Johnson, J., & Gravino, G. (2006). Us-ing data for continuous quality improvement in an integrated setting. In C. Newman, C. J. Liberton, K. Kutash & R. M. Friedman (Eds.), The 18th Annual Research Conference Pro-ceedings, A System of Care for Children’s Mental Health: Expanding the Research Base

(pp. 325-328). Tampa, FL: University of South Florida, The Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children’s Mental Health.

Lipsey, M. W., & Wilson, D. B. (2001). Practical meta-analysis. Thousand Oaks, CA: Sage Pub-lications.

*Lyman, D. R., & de Toledo, B. A. (2002). RiskRisk factors and treatment outcomes in a strate-gic intensive family program. In C. Newman, C. J. Liberton, K. Kutash & R. M. Friedman (Eds.), The 14th Annual Research Conference Proceedings, A System of Care for Children’s Mental Health: Expanding the Research Base (pp. 55-58). Tampa, FL: University of South Florida, The Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children’s Mental Health.

*Myaard, M. J. (1998). Applying behavior analysis within the wraparound process. In C. J. Liber-ton, K. Kutash & R. M. Friedman (Eds.), The 10th Annual Research Conference Proceed-ings, A System of Care for Children’s Mental Health: Expanding the Research Base (pp. 235-242). Tampa, FL: University of South Florida, Florida Mental Health Institute, Research and Training Center for Children’s Mental Health.

*Myaard, M. J., Crawford, C., Jackson, M., & Ales-si, G. (2000). Applying behavior analysis within the wraparound process: A multiple baseline study. Journal of Emotional & Behavioral Dis-orders, 8, 216-229.

National Advisory Mental Health Council. (2001). Blueprint for change: Research on child and adolescent mental health. Washington, DC: Author.

New Freedom Commission on Mental Health. (2003). Achieving the promise: Transforming mental health care in America. Rockville, MD: Author.

*Peterson, C., Rast, J., Gruner, L., Abi-Karam, N., & Earnest, L. (2003). Comparing function-al outcomes of wraparound and traditional mental health and child welfare services. In C. Newman, C. J. Liberton, K. Kutash & R. M. Friedman (Eds.), The 16th Annual Research Conference Proceedings, A System of Care

32


for Children’s Mental Health: Expanding the Research Base (pp. 307-311). Tampa, FL: Uni-versity of South Florida, The Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children’s Mental Health.

Petticrew, M., & Roberts, H. (2006). Systematic reviews in the social sciences: A practical guide. Oxford: Blackwell Publishing.

*Pullmann, M. A., Kerbs, J., Koroloff, N., Veach-White, E., Gaylor, R., & Sieler, D. D. (2006). Juvenile offenders with mental health needs: Reducing recidivism using wraparound. Crime & Delinquency, 52, 375-397.

Randall, C. J., & Biggs, B. K. (in press). Enhanc-ing therapeutic gains: Examination of fidelity to the model for the Intensive Mental Health Program. Journal of Child & Family Studies.

*Rast, J., Bruns, E. J., Brown, E. C., Peterson, C. R., & Mears, S. L. (2007). Outcomes of the wraparound process for children involved in the child welfare system: Results of a matched comparison study. Unpublished manuscript.

*Rast, J., Peterson, C., Earnest, L., & Mears, S. L. (2003). Service process as a determinant of treatment effect – the importance of fidelity. In C. Newman, C. J. Liberton, K. Kutash & R. M. Friedman (Eds.), The 16th Annual Research Conference Proceedings, A System of Care for Children’s Mental Health: Expanding the Research Base (pp. 311-315). Tampa, FL: Uni-versity of South Florida, The Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children’s Mental Health.

*Rast, J., Vetter, J., & Poplin, E. (2008, February). Wraparound in Oklahoma: Preliminary results of a randomized study. Paper presented at the 21st Annual Research Conference: A System of Care for Children’s Mental Health, Louis de la Parte Florida Mental Health Institute, Tampa, FL.

*Reay, W. E., Garbin, C. P., & Scalora, M. (2003). The Nebraska evaluation model: Practice and policy decisions informed by case and program specific data: What we have learned from Fort Bragg, Stark County, and Len Bickman. In C. Newman, C. J. Liberton, K. Kutash & R. M. Friedman (Eds.), The 15th Annual Research

Conference Proceedings, A System of Care for Children’s Mental Health: Expanding the Re-search Base (pp. 49-52). Tampa, FL: University of South Florida, The Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children’s Mental Health.

*Resendez, M. (2002). The relationship between flexible wraparound funds and mental health outcomes. In C. Newman, C. J. Liberton, K. Kutash & R. M. Friedman (Eds.), The 14th Annual Research Conference Proceedings, A System of Care for Children’s Mental Health: Expanding the Research Base (pp. 243-246). Tampa, FL: University of South Florida, The Louis de la Parte Florida Mental Health Insti-tute, Research and Training Center for Chil-dren’s Mental Health.

*Robbins, V., & Collins, K. (2003). Building bridges of support in eastern Kentucky: Outcomes of students receiving school-based wraparound. In C. Newman, C. J. Liberton, K. Kutash & R. M. Friedman (Eds.), The 15th Annual Research Conference Proceedings, A System of Care for Children’s Mental Health: Expanding the Research Base (pp. 202-205). Tampa, FL: Uni-versity of South Florida, The Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children’s Mental Health.

*Seybold, E. D. (2002). Treatment of external-izing behavior disorders in a comprehensive, continuum-of-care program. Dissertation Ab-stracts International, 63, 2074.

*Seybold, E. D., & Gilbertson, S. A. (1998). Reli-able change: Measuring treatment effective-ness of the Wraparound Milwaukee program. In C. J. Liberton, K. Kutash & R. M. Friedman (Eds.), The 10th Annual Research Conference Proceedings, A System of Care for Children’s Mental Health: Expanding the Research Base (pp. 207-212). Tampa, FL: University of South Florida, Florida Mental Health Institute, Re-search and Training Center for Children’s Men-tal Health.

*Stambaugh, L. F., Mustillo, S. A., Burns, B. J., Stephens, R. L., Baxter, B., Edwards, D., et al. (2007). Outcomes from wraparound and Multisystemic Therapy in a Center for Mental Health Services system-of-care demonstration

33


site. Journal of Emotional and Behavioral Dis-orders, 15, 143-155.

*Stambaugh, L. F., Mustillo, S. A., Burns, B. J., Stephens, R. L., Baxter, B., Edwards, D., et al. (2008). Results from a Center for Mental Health Services (CMHS) demonstration of inte-grated wraparound and Multisystemic Therapy. In C. Newman, C. J. Liberton, K. Kutash & R. M. Friedman (Eds.), The 20th Annual Research Conference Proceedings, A System of Care for Children’s Mental Health: Expanding the Re-search Base. Tampa, FL: University of South Florida, The Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children’s Mental Health.

Stroul, B. (2002). Systems of care: A framework for system reform in children’s mental health [Issue Brief]. Washington, DC: National Tech-nical Assistance Center for Children’s Mental Health.

*Taub, J., Banks, S., Smith, K. T., & Breault, C. (2006). Strengths, psychological and func-tional adjustment over time in a multi-site wraparound initiative. In C. Newman, C. J. Liberton, K. Kutash & R. M. Friedman (Eds.), The 18th Annual Research Conference Pro-ceedings, A System of Care for Children’s Mental Health: Expanding the Research Base (pp. 345-348). Tampa, FL: University of South Florida, The Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children’s Mental Health.

*Taub, J., & Pearrow, M. (2007). School function-ing for children enrolled in community-based wraparound services. In C. Newman, C. J. Li-berton, K. Kutash & R. M. Friedman (Eds.), The 19th Annual Research Conference Pro-ceedings, A System of Care for Children’s Mental Health: Expanding the Research Base (pp. 323-326). Tampa, FL: University of South Florida, The Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children’s Mental Health.

*Toffalo, D. A. D. (2000). An investigation of treat-ment integrity and outcomes in wraparound services. Journal of Child & Family Studies, 9, 351-361.

Tolan, P. H., & Dodge, K. A. (2005). Children’s

mental health as a primary care and concern: A system for comprehensive support and ser-vice. American Psychologist, 60, 601-614.

U. S. Department of Health and Human Services. (1999). Mental health: A report of the Surgeon General. Rockville, MD: Author.

U. S. Department of Health and Human Services. (2000). Report of the Surgeon General’s con-ference on children’s mental health: A nation-al action agenda. Washington, DC: Author.

U. S. Department of Health and Human Services. (2005). Cooperative Agreements for the Com-prehensive Community Mental Health Services for Children and Their Families Program (SM-05-010). Retrieved September 2, 2005, from http://www.systemsofcare.samhsa.gov.

VanDenBerg, J. (1999). History of the wraparound process. In B. J. Burns & C. K. Goldman (Eds.), Systems of care: Promising practices in chil-dren’s mental health, 1998 series (Vol. IV, pp. 1-8). Washington, DC: Center for Effective Col-laboration and Practice, American Institutes for Research.

*Vernberg, E. M., Jacobs, A. K., Nyre, J. E., Pud-dy, R. W., & Roberts, M. C. (2004). Innova-tive treatment for children with serious emo-tional disturbance: Preliminary outcomes for a school-based intensive mental health pro-gram. Journal of Clinical Child and Adolescent Psychology, 33, 359-365.

*Vernberg, E. M., Roberts, M. C., Jacobs, A. K., Randall, C. J., Biggs, B. K., & Nyre, J. E. (in press). Outcomes and findings of program evaluation for the Intensive Mental Health Program. Journal of Child & Family Studies.

*Vernberg, E. M., Roberts, M. C., Randall, C. J., Biggs, B. K., Nyre, J. E., & Jacobs, A. K. (2006). Intensive mental health services for children with serious emotional disturbances through a school-based, community oriented program. Clinical Child Psychology and Psychiatry, 11, 417-430.

Walker, J. S., & Bruns, E. J. (2003). Quality and fidelity in wraparound [Special issue]. Focal Point, 17 (2).

Walker, J.S. & Bruns, E.J. (2006). Building on practice-based evidence: Using expert per-

34


spectives to define the wraparound process. Psychiatric Services, 57, 1579-1585.

Weisz, J. R., Sandler, I. N., Durlak, J. A., & Anton, B. S. (2006). A proposal to unite two different worlds of children’s mental health. American Psychologist, 61, 644-645.

*Yoe, J. T., Santarcangelo, S., Atkins, M., & Bur-chard, J. D. (1996). Wraparound care in Ver-mont: Program development, implementa-tion, and evaluation of a statewide system of individualized services. Journal of Child & Family Studies, 5, 23-37.Table 1 Participant demographics reported by wraparound out-come studies

AuthorsJesse Suter is a faculty member at the Univer-sity of Vermont with interests in the research, development, and evaluation of community- and school-based programs for preventing and re-sponding to emotional and behavioral challenges. He was introduced to wraparound by working with John Burchard on the Wraparound Fidelity Index, and he continues to work on the Wraparound Eval-uation and Research Team with two other former

students of John’s: Eric Bruns and Kristen Lever-ntz-Brady.

Eric Bruns is a clinical psychologist and Associate Professor at the University of Washington School of Medicine in Seattle. He spends much of his professional life conducting research on innova-tive community-based models for helping youth and families with complex needs, including fam-ily treatment drug courts, treatment foster care, parent support programs, and the wraparound process. He is a lead developer of the Wraparound Fidelity Assessment System and, with Janet Walk-er, co-directs the National Wraparound Initiative.

Suggested Citation:

Suter, J., & Bruns, E. J. (2008). A narrative review of wraparound outcome studies. In E. J. Bruns & J. S. Walker (Eds.), The re-source guide to wraparound. Portland, OR: National Wraparound Initiative, Research and Training Center for Family Support

and Children’s Mental Health.

National Trends in Implementing Wraparound: Results from the State Wraparound Survey, 2007

One of the most frequently cited studies on the wrap-around process is a national survey conducted in 1998

examining wraparound implementation across the U.S. This study (Faw, 1999), conducted by Duke University and the Georgetown National Technical Assistance Center for Chil-dren’s Mental Health and published in the Burns & Goldman (1999) monograph on wraparound, used surveys of state mental health directors to estimate that wraparound was available in 80%- 90% of states and U.S. territories. Based on estimates provided by 24 of the responding 49 states and territories, the authors also estimated that as many as 200,000 youth may be served by the wraparound process annually.

Though the number of youth served by wraparound was impressive, the study also found that fewer than half the states had any defined standards for wraparound imple-mentation, that only about half had dedicated resources to support wraparound training and professional development, and that few states measured fidelity or were conducting program evaluation. The authors concluded that there was a “lack of a concurrent definition” of wraparound at the time of the survey, and that results pointed to “a need for a defi-nition as well as an established set of standards” (p.64).

Nearly 10 years later, Dr. Faw (now Dr. Stambaugh) part-nered with the National Wraparound Initiative (NWI) and the University of Washington Division of Public Behavioral Health & Justice Policy, to conduct a follow up of the 1998 survey. With wraparound having indeed become better un-


April Sather, Research CoordinatorWraparound Evaluation & Research Team

Leyla Stambaugh, Research PsychologistRTI International




2


derstood and standards more consistently estab-lished in the intervening years, the purpose of the new study was to gain an updated and more refined estimate of the number of wraparound initiatives and participating youth. As with the original study, the intent was also to better un-derstand how wraparound implementation was being supported in different places across the country, and collect qualitative information about implementation successes, barriers, and lessons learned. In the rest of this article, we will pres-ent an overview of the methods and results from this nine-year follow-up to the State Wraparound Survey.

MethodsA 17-item survey about wraparound implemen-

tation in the respondent’s home state was cre-ated, based on the original 13-item survey used in 1998. This survey was mailed to Children’s Mental Health Directors (as identified by the National As-sociation of State Mental Health Program Direc-tors or NASMHPD) in all 50 states, 4 U.S. territo-ries, and the District of Columbia.

For this update to the original 1998 study, wrap-around was defined using more precise language, using descriptions based on the model specifica-tion work of the National Wraparound Initiative (Walker & Bruns, 2006). Specifically, respondents were asked to report on initiatives in their state that adhered to the following definition:

Wraparound is a team-based process to de-velop and implement individualized service and support plans for children with serious emotional and behavioral problems and their families. Wrap-around implementation is typically facilitated by a trained wraparound facilitator or care coordina-tor, who works with a team of individuals relevant to the youth and family. The wraparound process also ideally includes the following characteris-tics:

Efforts are based in the community;

Services and supports are individualized to meet specific needs of the children and families;

The process is culturally competent and strengths-based;

1.

2.

3.

Teams have access to flexible funding;

Family and youth perspectives are sought and prioritized;

Team members include people drawn from family members’ natural support network;

The wraparound plan includes strategies that draw on sources of natural support;

The team monitors progress on measur-able indicators of success and changes the plan as necessary.

Respondents could complete the survey on-line, via hard copy, or via email. Respondents that did not return surveys were sent two email reminders, after which they were reminded by phone calls from the study team. For approxi-mately 10 states whose identified respondent did not respond to email or phone reminders, the research team contacted colleagues in the state for potential alternate respondents who would be adequately knowledgeable about wraparound im-plementation in the state to complete the survey. Five states’ surveys were completed through this mechanism.

ResultsResponse rates. Surveys were ultimately com-

pleted for 47 states, one territory, and D.C., for a total return rate of 89.1% (49 out of 55 possible states and territories). This is the same overall return rate as for the 1998 survey, when 46 states, two territories and D.C. responded. (For conve-nience sake, we will refer to responding states, territories, and D.C. collectively as “states” in the rest of this report.).

Numbers of programs and youth served. Of the 49 states who responded to the survey, 87.8% (n = 43) reported having some sort of wrap-around program in their state in 2007. This is ex-actly the same number and percent that reported wraparound availability in 1998. Of the 43 states reporting a wraparound initiative, 42 gave esti-mates of the number of children served state-wide. Among states that could provide estimates, a total of 98,293 children were estimated to be served by wraparound, in a reported 819 unique

4.

5.

6.

7.

8.

3

Chapter 3.4: Bruns, Sather, & Stambaugh

programs across the 43 responding states. The mean number of youth served in states reporting wraparound programs was 2,337, and the median was 852.5. This is compared to a mean of 3,802 in 1997 (median 1,162).

There were wide variations in the number of children served per state, which was very posi-tively skewed and ranged from 66 to 18,000 (SD = 3,676). Five states (North Carolina, Arizona, Kentucky, Maine, and Florida) reported over 5,000 youth served annually, while there were also five states reporting fewer than 100 youth served an-nually and 21 that reported under 1000 served annually. There were also vast differences in the number of unique wraparound initiatives or pro-grams estimated to be operating in each state, which ranged from 1 to 134 (SD = 30.5). Five states

(Georgia, Ohio, Michigan, Illinois, and Indiana) re-ported at least 50 unique wraparound programs in the state.

Statewide or local implementation. In 2007, 60% of states with wraparound projects (26 of 43) reported that wraparound is a statewide effort, as opposed to 17 (40%) which were implemented through one or more local effort(s). This is a de-crease in reported state wraparound initiatives from 1998, when 81% of states (35 of 43) reported that wraparound was a statewide effort. States reporting statewide implementation reported a mean of 3,227 youth served (SD = 4367) versus only 946 youth served (SD = 1366) for states with local implementation only (t(39) = 2.47; p<.05). Overall, 13 of the 16 states serving 2,000 or more

youth via wraparound reported having a statewide wraparound initiative.

Not surprisingly, states with statewide imple-mentation also had a higher mean number of wraparound programs. States with statewide im-plementation reported a mean of 22.5 (SD = 36.2) unique wraparound programs in the state com-pared to 14.3 (SD = 18.9) for states with local im-plementation only. At the same time, about half (7/16) of the states serving 2,000 or more youth reported only one “unique wraparound program or initiative” in the state, and all of these states said that wraparound is a statewide initiative. This suggests that the reported number of wrap-around programs in a state may be influenced by semantics, with some respondents considering a statewide initiative to be a single program, with others reporting unique programs in terms of local catchment areas, counties, or lead provider agen-cies implementing wraparound within an overall statewide effort.

Agencies taking part in wraparound initia-tives. Figure 1 presents the percent of states for which different child-serving agencies were re-ported to be involved in the state’s wraparound initiative(s), both in 1998 as well as 2007. As shown, the agencies most frequently involved in implementing wraparound efforts in 2007 were, in order of frequency: (1) Mental Health (100%); (2) Child Welfare (90%); (3) Juvenile Justice (90%); and Education (81%). These agencies were repre-sented at similar rates in wraparound initiatives in 1998. However, more states are reporting active involvement by health, substance abuse, and de-velopmental disabilities agencies in 2007 than was reported in 1998. Overall, in 2007 a mean of 5.26 (SD = 1.69) agencies were reported to be involved in the state wraparound initiative(s), compared to 4.67 (SD = 1.62) in 1998, a marginally significant difference (t (39) = 1.704; p < .10).

We also investigated whether statewide im-plementation of wraparound was associated with greater number of agencies involved. Indeed, states reported to be implementing wraparound statewide were found to have a mean of 5.54 agencies involved (SD = 1.56), compared to 4.94 (SD = 1.77) for states in which wraparound was being implemented locally. This difference, how-ever, was not significant.

Agencies in lead role. The agencies most

4


Figure 1. Agencies Involved with State Wraparound Initiatives

1998

2007

1998

2007

0

20

40

60

80

100

Perc

ent

of S

tate

s

Menta

l Hea

lth

Child

Welf

are

Educ

ation

Juve

nile J

ustic

e

Health

Subs

tanc

e Abu

se

Dev.

Disa

biliti

es

1b. Agencies in Lead Role in State Wraparound Initiatives

0

20

40

60

80

100

Perc

ent

of S

tate

s

Menta

l Hea

lth

Child

Welf

are

Educ

ation

Juve

nile J

ustic

e

Health

Subs

tanc

e Abu

se

Dev.

Disa

biliti

es

1a. Agencies Involved in State Wraparound Initiatives

often identified as taking the lead role in wrap-around efforts were: (1) Mental Health (93%); (2) Child Welfare (52%); (3) Juvenile Justice (24%); and Education (24%). As shown in Figure 1, child welfare, juvenile justice, and developmental dis-abilities were all much more likely to be in a lead role in 2007 than in 1998. However, it is impor-tant to note that more agencies in general were reported to be in a “lead role” in 2007 than in 1998.

Wraparound by any other name. In 2007, 76% of states reported that terms other than “wraparound” were used to describe their pro-grams. This was compared to only 54% of states in 1998. The most common terminologies used for wraparound-type initiatives in 2007 were: (1) Child & Family Teams (34% of states had at least one program that used this term); (2) Care Coor-dination/Coordinated Services (14%); (3) Individu-alized Treatment Plan or Individualized Service Agreement (14%); and (4) Team (or Family) Deci-sion Making (14%). Other reported terms included:

Children’s System of Care Initiative, Family Cen-tered Practice, Intensive Community Based Treat-ment & Supports, and Family Support Teams.

Wraparound standards. The 2007 survey showed that 23 of the 41 states (56%) with wrap-around programs (and that responded to the item) reported having some type of written standards for wraparound. This is an increase in use of writ-ten standards for wraparound from 1998, when 17 states (40%) reported having written standards.

Though this increase may be viewed as a positive change toward greater accountability, it should be noted that many of the respondents who provided details said that standards were from a training entity or that are incorporated into a fidelity scale that is being used in the state. Thus, the number of states that have incorpo-rated practice standards directly into provider or agency contracts or reimbursement codes is likely to be much fewer than the 23 that reported hav-ing some type of standards.

Interesting differences emerged for states

5


States with Written Standards (n = 23)

States without Written Standards (n = 18)

Statewide wraparound initiative 74%** 44%

Local initiative(s) only 26% 56%

In-state resources for training and professional development

74% 61%

No such state resources 26% 39%

Fidelity is monitored in the state 83%** 50%

Fidelity is not monitored 17% 50%

Mean number of agencies involved (SD)

5.65 (1.37) * 4.78 (1.87)

Mean number of programs (SD) 25.4 (34.2) 12.7 (25.6)

Mean number of youth served (SD) 2914 (4274) 1823 (2852)

Table 1. Characteristics of States with and without Written Standards for Wraparound Implementation

**p < .05; *p < .1

with standards versus those without standards. (See Table 1.) First, among states with writ-ten standards, more reported having statewide wraparound initiatives (74%) than among states without standards (44%) (chi-square (1) = 3.69; p=.05). Second, as shown in Table 1, 83% of states with written standards reported formal fidelity monitoring in the state, versus only 50% of states without standards (chi-square (1) = 4.96; p<.05) Third, states with written standards also reported more agencies being involved in their wraparound initiative than states without written standards, 5.65 on average versus 4.78 (t(39) = 1.73; p<.1). Finally, states with written standards also tend-ed to have more sites implementing wraparound in their state (25.4 versus 12.7 on average); and served more youth overall (2,914 versus 1,823).

Implementation resources. In the current survey, 71% of states that reported having wrap-around in their state also reported that there were in-state resources available for wraparound training and professional development. Though fewer than three-fourths of states reported hav-ing in-state resources for training, 97% of states reported having some sort of in-service training in the last 5 years. This is compared to 86% in 1998. Interestingly, unlike existence of standards, availability of in-state resources for wraparound implementation did not differ significantly for

states with statewide versus local wraparound initiatives.

Fidelity measurement. Of the 42 states that responded, 28 (67%) stated that fidelity measure-ment was conducted. As shown in Table 2, wheth-er states collected fidelity data did not differ by statewide versus local implementation. Among states that measured fidelity, a higher percent-age reported having standards for wraparound, compared to the percentage among states not measuring fidelity (68% versus 31%; chi-square (1) = 4.96; p<.05). States that measured fidelity were also more likely to have an in-state training and TA resource (75% versus 61%), but this differ-ence was non-significant. In summary, states that measured wraparound fidelity were more likely to have written standards and in-state resources for training and professional development. Whether a state measures fidelity does not appear to relate to the existence of statewide vs. local initiatives.

Evaluation. In 2007, 42 states responded to an item inquiring about whether a formal evaluation had been conducted in the state on one or more of its wraparound programs. Thirty-one respondents reported that one had been conducted (74%). This is in comparison to only 9 of 31 states (29%) that responded affirmatively to this item in 1998. As shown in Table 3, states that reported formal evaluation were more likely to have a statewide

States Reporting Fidelity Measurement

(n = 28)

States without Fidelity Measurement (n = 14)

Statewide wraparound initiative 61% 64%


Written standards for wraparound 68% 31%

No written standards 32% 69%*


75% 61%


Table 2. Characteristics of States that Report Conducting Fidelity Monitoring

*p < .05

6


wraparound initiative, to have written standards, and to measure fidelity of implementation. The only significant difference among these, however, was for measurement of fidelity (chi-square (1) = 3.018; p<.05).

Responses to open-ended questions. Respon-dents were asked “what lessons have you learned from your experience with implementing wrap-around in your state?” Thirty-six of the 43 states reporting wraparound programs responded to this item, providing a total of 92 unique statements. As shown in Table 4, over two-thirds of these state-ments were related to three issues: Maintaining fidelity (n=28), ensuring stakeholder buy-in and engagement (n=18) and maintaining active family and youth participation and engagement (n=17). After these, funding/sustainability (n=13), inter-agency collaboration (n=8), outcomes (n=6), and definitional issues regarding wraparound (n=4) were all identified as themes.

Regarding the topic of maintaining quality and fidelity, the majority (n=15) of statements emphasized the importance of training, quality assurance, and maintaining fidelity to the wrap-around model. For example, one respondent re-

ported “Fidelity processes are very important but are time consuming and it is difficult to find funds to support the process.” Others reported that staff training and coaching were important for ensuring certain aspects of the model were achieved, such as using a strengths based approach or including natural supports on teams and in plans.

In other statements (n=5), respondents noted specific types of data collection necessary to sup-port wraparound implementation. For example, one respondent stated, “treatments should be monitored for congruence to the plan, otherwise you end up with two distinct plans/approaches.” Finally, n=5 respondents reported specific ap-proaches in their state for ensuring fidelity, train-ing, and/or support. Examples included using national experts, developing local training enti-ties, and/or efforts to train and mobilize family advocates. One respondent gave this advice: “uti-lize technical assistance from the “experts,” but don’t be afraid to challenge them to look ‘outside the box’ of unique characteristics of your local area.”

Of the 18 statements pertaining to stakeholder engagement and buy-in, the vast majority simply

States with Written Standards (n = 23)

States without Written Standards (n = 18)

Statewide wraparound initiative 65% 55%


Written standards for wraparound 61% 36%

No written standards 39% 64%

Fidelity is monitored in the state 74%* 45%

Fidelity is not monitored 26% 55%


74% 55%


Table 3. Characteristics of States with and without Recent or Ongoing Formal Wraparound Evaluation

*p < .1

7


8


emphasized the need to “build community buy-in and meaningfully engage stakeholders before implementing wraparound.” Stakeholders were

identified broadly as individuals such as partner agency leaders and middle managers, as well as partner agency staff and members of the provider

Theme N Statements

Percent of Total (n=96)

Fidelity and Quality Assurance 28 30%

General – important to maintain fidelity 15 16%

Developed specific methods for monitoring 5 5%

Specific models for Training/Professional Dev. 5 5%

Problems with staffing/turnover 3 3%

Buy-in/Stakeholder Engagement 18 19%

Community & Stakeholders engagement 16 17%

Staff engagement and buy-in 2 2%

Family & Youth Voice 17 18%

Importance of having family/youth engagement 9 10%

Family members as Facilitators/Trainers 5 5%

Family Voice at the Service Delivery Level 3 3%

Funding Needs/Cost 13 14%

General – fiscal issues 8 9%

Importance of flex funds 5 5%

Interagency Collaboration 8 9%

Methods to develop/importance of 8 9%

Outcomes 6 6%

Importance of and difficulty documenting 6 6%

Defining Wraparound 4 4%

General concerns 4 4%

Total 94 100%

Table 4. Summary of Statements (n=94) Coded from Qualitative Data in Response to the Question “What Lessons Have you Learned About Implementing Wraparound in Your State”

9


community.In a related theme, n=17 statements pertained

to the importance of youth and family member participation at the community as well as en-gagement at the individual family level. Most of these statements underscored the importance of this buy-in and participation across all levels of effort, but a number (n=5) also referred to the importance of or local efforts to train youth and family members as navigators, facilitators, and support partners.

Respondents’ statements related to fund-ing and sustainability were very diverse. Five of the 13 statements in this theme highlighted the importance of flexible funding to implementing wraparound on the ground level. The remaining open-ended feedback provided a range of insights, including the following statements:

“Seed funding is artificial. Better to make agencies commit to blending funds and re-capturing savings.”

“Financial support for families’ involve-ment is hard to come by, but it is very im-portant.”

“Whenever you share funds, you share ac-countability.”

“Need to set up payment mechanisms very carefully so that they do not become un-wieldy as program services grow.”

“The importance and difficulty of blended funding… we struggle when children fit many funding silos.”

“Joint funding gave communities the ini-tiative to create other funding sources.”

“Fundraising is critical key to sustainabil-ity.”

“Need to ensure that planning activities with the model are reimbursed through ei-ther Medicaid or state funding.”

Eight statements presented suggestions, chal-lenges, and lessons learned about creating infra-structure for collaboration. For example, “train-ing [is needed] on how to integrate different plans from different systems into a single plan of care.” And, “although it has been a positive process for coordinating services among multiple agencies,

•

•

•

•

•

•

•

•

[wraparound] has not been able to address the development of specialized services and supports that are not available within traditional funding streams.” Another respondent noted that “The team approach is what sustained wraparound through funding cuts, leadership changes, and overall changes in our system.”

The remaining coded statements fell into two categories. Regarding outcomes (n=6), most re-spondents lamented not having better ability to measure and document outcomes. One was much more specific, stating that, “we have been doing ‘low fidelity wraparound’ for 15 years. It is costly and we have little data to demonstrate effective-ness.” Finally, four respondents provided respons-es related to understanding the wraparound model. One simply said that “understanding what ‘wraparound’ is, is a challenge,” while another said, “after seven years, communities still struggle with the term.” Another stated, “the wraparound process should be considered as a strategy, not as a model—the strategy is more adaptable to each specific community and populations, while the model is more restricted and less flexible.”

DiscussionThis paper presents some basic results of a

follow-up survey about the scope and nature of wraparound implementation nationally. Identical to 1998 results, 49 states returned a survey and 43 (88%) reported one or more wraparound efforts in their state. Among the six states that reported no wraparound availability in 2007, four also report-ed no wraparound in 1998. Only one state—Virgin-ia—reported having wraparound in 1998 but not in 2007, and follow up conversations with officials in Virginia reveal that a state wraparound confer-ence and initiation of two wraparound efforts oc-curred in late 2007. Thus, the official number of states implementing wraparound in 2007 might be more accurately reported as 44 of 49.

Though the number of states reporting wrap-around implementation may be stable or increas-ing, the total estimated number of youth served nationally was found to be lower than the 1998 estimate of 200,000. This is likely due to the more stringent definition of wraparound used in the 2007 survey, which was provided in order to ensure that estimates of wraparound reflect im-

10


plementation of a more specific model, such as that defined by the National Wraparound Initia-tive (Walker & Bruns, 2006). Though the definition presented in the 2007 survey includes components of the previous description, it also specifies, for example, that wraparound features a specific in-dividual who serves as a care coordinator or facili-tator, that there is a team, and that certain ac-tivities are occurring, such as engaging sources of natural support, monitoring progress on measur-able indicators of success, and regularly review-ing and changing an individualized wraparound plan. In general, movement in the past decade toward viewing wraparound as a definable team-based care coordination model for youth with the most serious and complex needs (rather than a philosophy of care for all youth with behavioral and emotional concerns) is likely to have led to lower estimates of total enrolled youth.

Such shifts in conceptualization may also be responsible for the reduction in the percent of states reporting statewide wraparound efforts, from 81% in 1998 to 58% in 2007. In 2007, with wraparound being conceived as a model as well as a philosophy, more state informants are reporting that wraparound is available through local provid-ers, programs, and initiatives.

At the same time, however, the percent of states reporting existence of standards for imple-mentation has increased, from 40% to 56%. Though having a statewide wraparound initiative is signifi-cantly associated with existence of standards, it is not just states with statewide wraparound ini-tiatives that are reporting existence of standards:

A number of states that reported that wraparound is overseen by local efforts nonetheless reported having state standards. In general, this trend to-ward use of standards probably reflects recent emphasis on defined and/or manualized “evi-dence based practices,” more specific descrip-tions of the wraparound process, and a growth in literature on system and program conditions required to implement wraparound (e.g., Bruns, Suter, & Leverentz-Brady, 2006; Walker, Koroloff, & Schutte, 2003). Thus, there seem to be trends toward addressing a concern that was prominent in the children’s services field in the late 1990s: that wraparound was not well-enough specified to be implemented consistently and subjected to re-search (Clark & Clarke, 1996; Rosenblatt, 1996).

Along with greater prominence of standards, a number of seemingly positive trends were ob-served from the 2007 survey results. For example, states are reporting a greater number of agencies being actively involved in wraparound implemen-tation, and a greater diversity of child-serving sys-tems taking a lead role, including child welfare, juvenile justice, and education. This latter finding likely reflects the expansion of the wraparound model toward serving a more diverse set of pur-poses and populations (see John VanDenBerg’s article on this phenomenon elsewhere in this Re-source Guide). In addition, results show that 71% of states providing wraparound have in-state re-sources for wraparound training and professional development, 67% report measuring fidelity, and 97% have had some sort of training provided in the past five years (an increase from 86% in 1998). Perhaps not surprisingly, all the trends reported above, particularly involvement of multiple agen-cies and fidelity monitoring, are associated with the presence of written standards for wraparound implementation, and nearly all of these associa-tions are statistically significant.

Finally, 74% of states report having conducted formal evaluation of their wraparound initiative(s) in 2007, compared to only 31% in 1998. States with formal evaluation studies were significantly more likely to report measuring fidelity as well. This finding may speak to a greater overall attention to evaluation in these states; however, it may also mean that the evaluation that is being conduct-ed in these states is largely focused on fidelity or implementation assessment, more so than out-

11


comes. This hypothesis is supported by responses to open-ended questions in which many respon-dents reported difficulty in collecting outcomes data and documenting outcomes in general.

Implications & Recommendations. Extrapo-lating from current results leads us to an estimate of over 800 wraparound programs nationally, serv-ing approximately 100,000 youth and their fami-lies. As mentioned above, this number is lower than was derived from the 1998 survey. The es-timate may be considered more accurate, how-ever, given that it is based on a more stringent definition based on work done in the interven-ing decade to better specify wraparound (Walker & Bruns, 2006). Unfortunately, the definitional change makes it difficult to determine trends in numbers of youths served via the wraparound pro-cess over time. The fact that the same number of states report implementation of wraparound in 2007 as did in 1998, however, suggests that efforts to deploy wraparound (however it may be concep-tualized) have been relatively stable over the past 10 years. But it remains difficult to say with any real certainty.

Nonetheless, if accurate, the estimate pro-vided from this survey would mean that wrap-around is being employed far more often than other prominent community-based treatment models for youth with serious and complex needs. This includes five times as many youth as multi-systemic therapy (MST; Henggeler et al., 1998), which is estimated to serve 19,000 youths; three times more youth than Functional Family Therapy (FFT; Alexander, Pugh, Parsons, & Sexton, 2000), which is estimated to serve 30,000 youth annu-ally; and many times more youth than Multidi-mensional Treatment Foster Care (MTFC; Cham-berlain & Reid, 1998), which is estimated to serve 1,000 youth annually (Evidence-Based Associates, 2008).

This is probably not surprising, given that wraparound is conceived as a system-level inter-vention that has the capacity to serve children with a range of concerns, as opposed to MST, FFT, and MTFC, which are tailored to serve children who meet specific eligibility criteria. But none-theless, one major implication of the current re-search is that the wraparound process, even with the greater specification and narrowing of its defi-nition, is quite extensively implemented relative

to other community-based models for the same population. As such, it deserves significant atten-tion from researchers and developers so that the likelihood of its successful deployment for these many youth is as likely as possible. Given that MST, FFT, and MTFC generally are considered to have been tested through more rigorous research than wraparound, this implication becomes all the more important.

Fortunately, far from a reluctance to deal with these issues, results of this study show that there has been an increase in the attention paid to wraparound quality and fidelity over the past de-cade. Results indicate that use of state-level stan-dards, in-state train-ing and TA resources, fidelity monitoring, evaluation, and oth-er implementation supports are all on the rise. This is also being reflected in an increase in the number and rigor of research studies on wraparound in the past five years (see review by Suter and Bruns in this Re-source Guide).

At the same time, however, few-er states report that their wraparound initiatives are be-ing overseen at the state level. This may be unfortunate, because results suggest state-wide initiatives are associated with greater de-ployment of standards, active involvement by more agencies, and more consistent fidelity and quality monitoring. Even if counties or local pro-grams are now more likely to oversee wraparound efforts, it may be advantageous for states to be in the business of overseeing implementation ef-forts in some way, such as through establishment of standards and/or monitoring of adherence to standards of quality.

A final conclusion to take from the open-end-ed question posed to respondents is that wrap-

In 2007, nearly every state and approximately

100,000 children and their families

had some involvement with the wraparound

process.

12


around implementation remains challenging for states, communities, and providers. Though the majority of comments suggested that wraparound is viewed as a major asset to states and their communities, many respondents noted the diffi-culty of maintaining fidelity to wraparound com-ponents such as flexible funds, individualization, and team-based coordination in the face of siloed systems, staff turnover, and limited and increas-ingly inflexible resources. It may be that, over the years, the accumulation of implementation fail-ures related to such barriers is what has led to the term “wraparound” being used less and less frequently (as was found in this survey), in favor of finding new names for team-based individual-ized care programs that are less associated with past disappointments.

ConclusionThe State Wraparound Survey is one part of a

broad research agenda to better identify national trends and challenges regarding wraparound im-plementation. Though the research base on wrap-around is progressing, it has been slow to develop due to its individualized and grassroots nature. Wraparound is also conceived as both a systems intervention as well as a strategy for working with individual children and families (Stroul, 2002; Walker, Bruns, & Penn in press), making it all the more challenging to implement. In general, much more research is needed on what factors lead to high-quality implementation of wraparound and improved health and well-being for the individu-als who are engaged in it. This is particularly im-portant when one considers that, in 2007, nearly every state and approximately 100,000 children and their families had some involvement with the wraparound process.

Though 100,000 may seem like a large num-ber, one possible implication of the current study could be that far too few children and youth re-ceive wraparound. According to the most recent estimates, there are 5-8 million youths with a serious emotional disturbance (SED) nationally (Costello, Messer, Bird, Cohen, & Reinherz, 1998; Friedman, Katz-Leavey, Manderscheid, & Sond-heimer, 1998),and about one out of five of these youth receives mental health services of any kind (Kataoka, Zhang, & Wells, 2002). This means that,

at best, assuming no overlap in treatments re-ceived per youth, only 1-2% of youths with SED are engaged in the wraparound process and another 1% in one of the other intensive community-based treatments mentioned above. As for those 20% of youths with SED who receive some kind of service, our findings raise questions about the nature of supports provided to these youth, given that over 90% apparently do not receive wraparound or one of these other intensive community-based treat-ments. Though not all youth with SED require the intensity of wraparound, MST, FFT, or MTFC, it is unlikely that so few as 2-3% annually would ben-efit from engagement in one of these models.

References

Bruns, E.J., Suter, J.C., & Leverentz-Brady, K.M. (2006). Relations between program and sys-tem variables and fidelity to the wraparound process for children and families. Psychiatric Services, 57, 1586-1593.

Burns, B. J., & Goldman, S. K. (Eds.). (1999). Sys-tems of care: Promising practices in children’s mental health, 1998 series: Volume IV. Promis-ing practices in wraparound for children with severe emotional disorders and their families. Washington, DC: Center for Effective Collabo-ration and Practice, American Institutes for Research.

Clark, H. B., & Clarke, R. T. (1996). Research on the wraparound process and individualized services for children with multi-system needs. Journal of Child and Family Studies, 5, 1-5.

Costello, E.J., Messer, S.C., Bird, H.R., Cohen, P., & Reinherz, H.Z. (1998). The prevalence of serious emotional disturbance: A re-analysis of community studies. Journal of Child and Fam-ily Studies, 7, 411-432.

Faw, L. (1999). The state wraparound survey. In B.J. Burns & S.K. Goldman (Eds.), Systems of Care: Promising practices in children’s mental health, 1998 series: Volume IV. Promising prac-tices in wraparound (pp. 79-83). Washington, DC: Center for Effective Collaboration and Practice, American Institutes for Research.

Friedman, R., Katz-Leavey, J., Manderscheid, R., & Sondheimer, D. (1998). Prevalence of seri-

13


ous emotional disturbance: An update. In R. Manderscheid & M. Henderson (Eds.). Mental health, United States (pp.110-112). Rockville, MD: USDHHS, Substance Abuse and Mental Health Services Administration.

Kataoka, S.H., Zhang, L., & Wells, K.B. (2002). Unmet need for mental health care among U.S. children: Variation by ethnicity and insur-ance status. American Journal of Psychiatry, 159, 1548-1555.

Rosenblatt, A. (1996). Bows and ribbons, tape and twine: Wrapping the wraparound process for children with multi-system needs. Journal of Child and Family Studies, 5(1), 101-117.

Stroul, B. (2002). Issue Brief: Systems of Care – A Framework for System Reform in Children’s Mental Health. Washington, DC: National TA Center for Children’s Mental Health.

Walker, J.S., & Bruns, E.J. (2006). Building on practice-based evidence: Using expert per-spectives to define wraparound process. Psy-chiatric Services, 57, 1579-1585.

Walker, J.S., Bruns, E.J., & Penn, M. (2008). In-dividualized services in systems of care: The wraparound process. In B. Stroul & G. Blau (Eds.). The System of Care Handbook: Trans-forming Mental Health Services for Children, Youth, and Families. Baltimore: Brookes.

Walker, J. S., Koroloff, N., & Schutte, K. (2003). Implementing high-quality collaborative In-dividualized Service/Support Planning: Nec-essary conditions. Portland OR: Research and Training Center on Family Support and Chil-dren’s Mental Health.

AuthorsEric Bruns is a clinical psychologist and Associate Professor at the University of Washington School

of Medicine in Seattle. He spends much of his professional life conducting research on innova-tive community-based models for helping youth and families with complex needs, including fam-ily treatment drug courts, treatment foster care, parent support programs, and the wraparound process. He is a lead developer of the Wraparound Fidelity Assessment System and, with Janet Walk-er, co-directs the National Wraparound Initiative.

April Sather works with Eric Bruns at the Univer-sity of Washington, with the Wraparound Evalua-tion & Research Team. April coordinates various research activities and works closely with the Wraparound Fidelity Assessment System develop-ment and training.

Leyla Stambaugh, Ph.D., conducted the first na-tional survey of wraparound in the U.S. in 1999. She recently completed postdoctoral training with Barbara J. Burns, Ph.D., at Duke University, during which she examined wraparound outcomes from a CMHS system of care site in Nebraska. In 2007, she joined the Child and Family Program at RTI International as a Research Psychologist.

Suggested Citation:

Bruns, E. J., Sather, A., & Stambaugh, L. (2008). National trends in implementing wraparound: Results from the state wrap-around survey, 2007. In E. J. Bruns & J. S. Walker (Eds.), The resource guide to wrap-

around. Portland, OR: National Wraparound Initia-tive, Research and Training Center for Family Sup-port and Children’s Mental Health.

Summary of the Wraparound Evidence Base: April 2010 Update

Wraparound is a team-based planning process intended to provide coordinated, holistic, family-driven care to

meet the complex needs of youth who are involved with multiple systems (e.g. mental health, child welfare, juve-nile justice, special education), at risk of placement in insti-tutional settings, and/or experiencing serious emotional or behavioral difficulties (Walker & Bruns, 2008). Wraparound provides an “on the ground” mechanism for ensuring that core system of care values will guide planning and produce individualized, family-driven and youth-guided support that is community based and culturally competent (Stroul & Friedman, 1996).

In the children’s services field, there is broad consen-sus that for youth and families with multiple and complex needs, the wraparound paradigm is an improvement over more traditional service delivery methods that are unco-ordinated, professional-driven, deficit-based, and overly reliant on out of home placement. This is reflected in wrap-around’s widespread adoption nationally and worldwide. A 2007 survey shows that 91% of U.S. states have some type of wraparound initiative, with 62% implementing some type of statewide initiative. Over 100,000 youth nationally are esti-mated to be engaged in a well-defined wraparound process (Bruns, Sather, & Stambaugh, 2008).

Regardless of how popular an intervention is with provid-ers or families, or how well it conforms to current values of care, such criteria can not be used as the sole basis for pol-icy making or treatment decision making. In the current era


Jesse C. Suter, Research Assistant ProfessorUniversity of Vermont




2


of “evidence-based practice,” decisions regarding how we invest our scarce health care resources —as well as decisions about what treatment ap-proaches will be used with a given youth or family —must also be based on evidence derived from properly designed evaluations. After all, youth with complex needs may be served via a range of alternative approaches, such as via traditional case management or through uncoordinated “ser-vices as usual” (in which families negotiate ser-vices and supports by themselves or with help of a more specialized provider such as a therapist). Other communities may choose to invest in an array of more specialized office- or community-based evidence-based practices that address spe-cific problem areas, in the absence of wraparound care coordination. And of course, many commu-nities continue to allocate significant behavioral health resources to out-of-community options such as residential treatment, group homes, and inpatient hospitalization. The range of options in which states and localities may invest, combined with resource limitations, demands that we de-velop evidence for what models work for which youth under which conditions.

Increasingly, investment in wraparound is backed by controlled research. As of 2003, when the first meeting of the National Wraparound Ini-tiative was held, there were only three controlled (i.e., experimental or quasi-experimental) studies of wraparound effects published in peer-reviewed journals. As of 2010, there are now nine con-trolled, published studies. Several of these newer studies include fidelity data as well as cost data, increasing our understanding of wraparound’s po-tential for impact and what is required to achieve that impact. In addition, the first meta-analysis of wraparound has now been published (Suter & Bruns, 2009). As a result of this expansion in controlled research, as well as the greater avail-ability of dissemination materials, Wraparound is currently being reviewed for inclusion in the Sub-stance Abuse and Mental Health Services Admin-istration (SAMHSA) National Registry of Evidence-based Programs and Practices (NREPP).

Kazdin (1999) says there are four criteria for assessing the status of an intervention’s evi-dence base: (1) A theory to relate a hypothesized mechanism to a clinical problem; (2) Basic re-search to assess the validity of the mechanism;

(3) Outcome evidence to show that a therapeutic approach changes the relevant outcomes; and (4) Process-outcome connections, which display the relationships between process change and clinical outcomes.

With respect to criteria 1 and 2, for youth and families with complex and overlapping needs, the theory of change for wraparound (Walker, 2008) provides rationale (with supportive basic research) for why wraparound treatment planning is likely to be more effective than services provided in the absence of this process. Some of the specific mechanisms of change include better treatment acceptability and youth/family engagement; bet-ter teamwork; an emphasis on problem solving; and an emphasis on increasing optimism, hope, self-efficacy, and social support.

For condition 4, research is increasingly show-ing associations between system-, organizational, and team-level fidelity and child and family out-comes. Bruns et al. (2005; 2006; 2008) as well as other authors (e.g., Walton & Effland, 2010) have shown that communities that adhere more closely to the wraparound principles as assessed via mea-sures such as the Wraparound Fidelity Index tend to show more positive outcomes. On the flip side, communities with better developed system sup-ports for wraparound tend to demonstrate higher fidelity scores. (You can see an entire section in the Resource Guide to Wraparound on this evi-dence).

Ultimately, however, it is outcomes evi-dence from rigorous studies (criterion no.3) that is most relevant to evaluating an interven-tion’s evidence base. As described in our review of wraparound research, as of 2008, we found 36 published outcomes studies of wraparound. How-ever, only a small number of these (n=7) were controlled studies that used random assignment or some type of comparison group design. In 2009, we published a meta-analytic review of these seven studies (Suter & Bruns, 2009). This analy-sis found that, on average across these studies, significant effects of wraparound were found for all four outcome domains we examined, including living situation, youth behavior, youth function-ing, and youth community adjustment. Mean ef-fect sizes across these domains (calculated as the difference between wraparound and control group means at posttest divided by the pooled standard

3

Chapter 3.5: Bruns & Suter

1 Two notes on the studies included in Tables 1 and 2 and the Suter & Bruns (2009) meta-analysis are worth making. First, one study included in Table 1 (Myaard et al., 2000) studied outcomes for N=4 youths participating in wraparound with outcomes assessed using a multiple baseline experimental design. Given this research design, this study is worthy of inclusion in a review of rigorous wraparound studies; however, due to its unique multiple baseline design, this study was not included in the 2009 meta-analysis nor are its outcomes included in Table 2. Second, one of the studies included in the meta-analysis (Bickman et al., 2003) presented evidence indicating that the “wraparound” condition that was evaluated did not conform to the principles or practice model of wraparound and was not meaningfully different from the comparison condition. Thus, while this study was included in the meta-analysis to be conservative, it is not included in Table 1 or 2.

deviation, or Cohen’s d) ranged from .25 to .59, with the largest effects found for living situation outcomes (e.g., youth residing in less restrictive, community placements and/or greater stability of placement). The mean effect size across all out-comes was .33–.40, depending on whether studies for which effect sizes were imputed were includ-ed (d=.33) or excluded (d=.40). These effect sizes are quite similar to effects found for established EBPs implemented under “real world” conditions and compared to some type of alternative treat-ment condition (Weisz, Jensen-Doss, & Hawley, 2006).

As of 2010, there have been nine controlled studies of wraparound that have been pub-lished in peer reviewed publications. In the rest of this document, we present a summary of each of these studies (Table 1), followed by a summary of all significant behavioral outcomes found across the controlled studies (Table 2).1

Though many of these studies have signifi-cant methodological weaknesses, the “weight of the evidence” of these studies indicates superi-or outcomes for youth who receive wraparound compared to similar youth who receive some al-ternative service. On the strength of these stud-ies, as well as others currently being completed, it is likely that wraparound will increasingly be referred to as an “evidence-based” process in the future.

At the same time, much more wraparound re-search is needed. The diversity of contexts in which wraparound is implemented (e.g., for youths from birth to transition age as well as adults, and in con-texts as varied as mental health, juvenile justice, child welfare, and schools) demands more effec-tiveness studies, so that we can better understand for which individuals and in what contexts wrap-around is most likely to be effective. The many ways in which wraparound can be implemented

also demand an expansion of the implementation research base on wraparound. For example, what are outcomes and costs of achieving different lev-els of fidelity? What modifications to the practice model achieve the best results? What training, coaching, and supervision yield the best fidelity, staff, and youth and family outcomes? What is needed at the organizational and system level to support high-quality wraparound implementation? Though the wraparound research base continues to grow, so does the list of questions for which we seek answers.

References

References for Outcomes ReviewBruns, E. J., Rast, J., Walker, J. S., Peterson, C.

R., & Bosworth, J. (2006). Spreadsheets, ser-vice providers, and the statehouse: Using data and the wraparound process to reform systems for children and families. American Journal of Community Psychology, 38, 201-212.

Carney, M. M., & Buttell, F. (2003). Reducing ju-venile recidivism: Evaluating the wraparound services model. Research on Social Work Prac-tice, 13, 551-568.

Clark, H. B., Lee, B., Prange, M. E. & McDonald, B. A. (1996).Children lost within the foster care system: Can wraparound service strate-gies improve placement outcomes? Journal of Child and Family Studies, 5, 39-54.

Clark, H. B., Prange, M. E., Lee, B., Stewart, E. S., McDonald, B. B., & Boyd, L. A. (1998). An individualized wraparound process for children in foster care with emotional/behavioral dis-turbances: Follow-up findings and implications from a controlled study. In M. H. Epstein, K. Kutash & A. Duchnowski (Eds.), Outcomes for children and youth with emotional and behav-

References continued on p. 6

4


Study Citations Outcomes

Child Welfare

Randomized control study (18 months) of youth in child welfare custody in Florida: 54 in wraparound vs. 78 in standard practice foster care.

Clark, Lee, Prange, & McDonald, 1996;

Clark et al., 1998.

Significantly fewer placement changes for youths in the wraparound program, fewer days on runaway, fewer days incarcerated (for subset of incarcerated youths), and older youths were significantly more likely to be in a permanency plan at follow-up. No group differences were found on rate of placement changes, days absent, or days suspended. No differences on internalizing problems, but boys in wraparound showed significantly greater improvement on externalizing problems than the comparison group. Taken together, the findings provided moderate evidence for better outcomes for the wraparound program; however, differences appear somewhat limited to boys and externalizing problems.

Matched comparison study (18 months) of youth in child welfare custody in Nevada: 33 in wraparound vs. 32 receiving MH services as usual

Bruns, Rast, Walker, Bosworth, & Peterson, 2006;

Rast, Bruns, Brown, Peterson, & Mears, 2007

After 18 months, 27 of the 33 youth (approximately 82%) who received wraparound moved to less restrictive environments, compared to only 12 of the 32 comparison group youth (approximately 38%), and family members were identified to provide care for 11 of the 33 youth in the wraparound group compared to only six in the comparison group. Mean CAFAS scores for youth in wraparound decreased signifi-cantly across all waves of data collection (6, 12, 18 months) in comparison to the tra-ditional services group. More positive outcomes were also found for the wraparound cohort on school attendance, school disciplinary actions, and grade point averages. No significant differences were found in favor of the comparison group.

Matched comparison study (12 months) of N=210 youth in child welfare custody in Los Angeles County: 43 discharged from Wraparound vs. 177 discharged from group care.

Rauso, Ly, Lee, & Jarosz, 2009

Initial analyses for a larger matched sample of youth (n=102 wraparound vs. n=210 for group care) found that 58% (n=59) of youth discharged from wraparound had their case closed to child welfare within 12 months, compared to only 16% (n=33) of youth discharged from group care. Of those youth who remained in the care of child welfare for the full 12 months follow-up period (n=43 for wraparound vs. n=177 for group care), youth in the wraparound group experienced significantly fewer out of home placements (mean = 0.91 compared to 2.15 for the comparison group). Youth in the wraparound group also had significantly fewer total mean days in out of home placements (193 days compared to 290). During the 12-months follow-up, 77% of the Wraparound graduates were placed in less restrictive settings while 70% of children who were discharged from RCL 12-14 were placed in more restrictive environments. Mean post-graduation cost for the wraparound group was found to be $10,737 com-pared to $27,383 for the group care group.

Table 1. Summary of Nine Published Experimental and Quasi-Experimental Outcomes Research Studies of Wraparound**

**NOTE: The research selected for inclusion in this Table includes the nine experimental and quasi-experimental out-comes research studies published in peer-reviewed journals relevant to the wraparound process (8 controlled studies and 1 multiple-baseline study). Studies are organized by the population studied. These include four studies of youths served through the child welfare system, two studies of youths served because of their involvement in (or risk of involvement in) juvenile justice, and four studies of youths served because of their intensive mental health needs.

5



Child Welfare

Matched comparison study (6 months) of N=126 youths involved in the child welfare system in Clark County, NV: 96 in wraparound vs. 30 in traditional child welfare case management.

Mears, Yaffe, & Harris, 2009

Youth in the wraparound group approach showed significantly greater im-provement in functioning (d=.50) as assessed by the Child and Adolescent Functional Assessment Scale (CAFAS) compared to youth receiving tradi-tional child welfare services. Youth in the wraparound group also showed significantly greater movement toward less restrictive residential place-ments (d=.71) as assessed by the Restrictiveness of Living Environment Scale (ROLES). More wraparound youth experienced a placement change during the 6 month follow up (23% vs. 49%); however, this was due to youth in the wraparound group being more likely to move to less restrictive place-ments during the study period. No differences were found for child behav-ior as assessed by the CBCL, school, or juvenile justice outcomes.

Juvenile Justice

Randomized control study (18 months) of “at risk” and juvenile justice involved (adjudicated) youth in Ohio: 73 in wraparound vs. 68 in conventional services

Carney & Buttell, 2003

Study supported the hypothesis that youth who received wraparound ser-vices were less likely to engage in subsequent at-risk and delinquent be-havior. The youth who received wraparound services were less likely to miss school unexcused, get expelled or suspended from school, run away from home, or get picked up by the police as frequently as the youth who received the juvenile court conventional services. There were, however, no significant differences, in formal criminal offenses.

Matched comparison study (>2 years) of youth involved in juvenile justice and receiving MH services: 110 youth in wraparound vs. 98 in conventional MH services

Pullmann, Kerbs, Koroloff, Veach-White, Gaylor, & Sieler, 2006

Youths in the comparison group were three times more likely to com-mit a felony offense than youths in the wraparound group. Among youth in the wraparound program, 72% served detention “at some point in the 790 day post identification window” (p. 388), while all youth in the comparison group were subsequently served in detention. Of youth in the Connections program who did serve detention, they did so significantly less often than their peers. Connections youth also took three times longer to recidivate than those in the comparison group. According to the authors, a previous study by Pullman and colleagues also showed “significant improvement on standardized measures of behavioral and emotional problems, increases in behavioral and emotional strengths, and improved functioning at home at school, and in the community” (p. 388) among Connections youth.

Mental Health

Randomized control study (12 months) of youths referred to out-of-home placements for serious mental health problems in New York State: 27 to family centered intensive case management (wraparound) vs. 15 to treatment foster care.

Evans, Armstrong, & Kuppinger, 1996;

Evans, Armstrong, Kuppinger, Huz, & McNulty,1998

Significant group differences were found in favor of the case management/ wraparound program for behavioral and mood functioning. No differences were found, however, with respect to behavior problems (internalizing and externalizing), family cohesiveness, or self-esteem. No differences found in favor of the TFC group. Overall, small sample size plus loss of data on many of the outcome measures resulted in the study having very low power to detect differences between groups.

Table 1. (CONTINUED) Summary of Nine Published Experimental and Quasi-Experimental Outcomes Research Studies of Wraparound**

6



Mental Health

Quasi-experimental (24 months) study of youths with serious mental health issues in urban Baltimore: 45 returned or diverted from residential care to wraparound vs. 24 comparison youths.

Hyde, Burchard, & Woodworth, 1996

Primary outcome was a single rating that combined several indicators: re-strictiveness of youth living situation, school attendance, job/job training at-tendance, and serious problem behaviors. Youths received ratings of “good” if they were living in regular community placements, attending school and/or working for the majority of the week, and had fewer than three days of serious behavior problems during the course of previous month. At 2-year follow-up, 47% of the wraparound groups received a rating of “good,” com-pared to 8% of youths in traditional MH services. Limitations of the study include substantial study attrition and group non-equivalence at baseline.

Experimental (multiple-baseline case study) study of four youths referred to wraparound because of serious mental health issues in rural Michigan.

Myaard, Crawford, Jackson, & Alessi (2000).

The multiple baseline case study design was used to evaluate the impact of wraparound by assessing whether outcome change occurred with (and only with) the introduction of wraparound at different points in time. The authors tracked occurrence of five behaviors (compliance, peer interac-tions, physical aggression, alcohol and drug use, and extreme verbal abuse) for each of the youths. Participants began receiving wraparound after 12, 15, 19, and 22 weeks. For all four participants, on all five behaviors, dramatic improvements occurred immediately following the introduction of wrap-around.

Table 1. (CONTINUED) Summary of Nine Published Experimental and Quasi-Experimental Outcomes Research Studies of Wraparound**

ioral disorders and their families: Programs and evaluation best practices (pp. 513-542). Austin, TX: Pro-ED, Inc.

Evans, M. E., Armstrong, M. I., Kuppinger, A.D. (1996). Family-centered intensive case man-agement: A step toward understanding indi-vidualized care. Journal of Child and Family Studies, 5, 55-65.

Evans, M. E., Armstrong, M. I., Kuppinger, A. D., Huz, S., & McNulty, T. L. (1998). Preliminary outcomes of an experimental study comparing treatment foster care and family-centered in-tensive case management. In M. H. Epstein, K. Kutash, & A. Duchnowski (Eds.), Outcomes for children and youth with emotional and behav-ioral disorders and their families: Programs and evaluation best practices. (pp. 543-580). Xviii, 738 pp.

Hyde, K. L., Burchard, J. D., & Woodworth, K. (1996). Wrapping services in an urban setting. Journal of Child & Family Studies, 5, 67-82.

Mears, S. L., Yaffe, J., & Harris, N. J. (2009). Evaluation of wraparound services for severely emotionally disturbed youths. Research on so-cial work practice, 19, 678-685.

Myaard, M. J., Crawford, C., Jackson, M., & Ales-si, G. (2000). Applying behavior analysis within the wraparound process: A multiple baseline study. Journal of Emotional & Behavioral Dis-orders, 8, 216-229.

Pullmann, M. D., Kerbs, J., Koroloff , N., Veach-White, E., Gaylor, R., & Sieler, D. (2006). Ju-venile offenders with mental health needs: Reducing recidivism using wraparound. Crime and Delinquency, 52, 375-397.

Rast, J., Bruns, E. J., Brown, E. C., Peterson, C. R., & Mears, S. L. (2007). Impact of the wrap-around process in a child welfare system: Re-sults of a matched comparison study. Unpub-lished program evaluation.

Rauso, M., Ly, T. M., Lee, M. H., & Jarosz, C. J.

References continued on p. 8

References (CONTINUED)

Section 1: Statistically Significant (p<.05) Behavioral Outcomes

Outcome Effect Size Citation

Less assaultive 0.30 Carney & Buttell, 2003, p. 561

Ran away less 0.45 Carney & Buttell, 2003, p. 561

Suspended from school less 0.47 Carney & Buttell, 2003, p. 561

Missed less school 0.47 Carney & Buttell, 2003, p. 561

Less likely to be picked up by police 0.49 Carney & Buttell, 2003, p. 561

Less likely to be suspended from school 0.22 Clark et al., 1998, p. 529

Less likely to spend more time incarcerated 0.31 Clark et al., 1998, p. 529

Fewer days on runaway 0.34 Clark et al., 1998, p. 528

Residing in more permanency-type settings 0.17 Clark et al., 1998, p. 526

Less likely to spend time on runaway 0.22 Clark et al., 1998, p. 529

Less likely to experience a high number of placement changes

0.25 Clark et al., 1998, p. 529

Improved behavioral functioning on CAFAS 0.61 Evans et al., 1998, p. 566

Improved moods / emotions on CAFAS 0.61 Evans et al., 1998, p. 566

Improved overall functioning on CAFAS 0.50 Mears et al., 2009, p. 682

Residing in less restrictive placements 0.71 Mears et al., 2009, p. 682

Reduced recidivism for any offense 0.25 Pullman et al., 2006, p. 386

Reduced recidivism for felony 0.26 Pullman et al., 2006, p. 388

Fewer days served in detention 0.66 Pullman et al., 2006, p. 388

Fewer episodes in detention 0.75 Pullman et al., 2006, p. 388

Less likely to serve in detention 0.85 Pullman et al., 2006, p. 388

Table 2. Summary of All Behavioral Outcomes for the Wraparound Process with Supporting Citations from Eight Controlled Studies

7


Note on effect sizes: The effect size reported for these outcomes is the standardized mean difference, typically referred to as Cohen’s d (1988). Effect sizes were calculated as the difference between wraparound and control group means at posttest divided by the pooled standard deviation. Effect sizes were generated using an effect size program created by Wilson (2004) and presented such that positive values always indicated positive results for youth receiving wraparound relative to youth in control groups. All effect sizes were adjusted using Hedges’ small sample size correction to create unbiased estimates (Hedges & Olkin, 1985). The magnitude of effects is typically interpreted using Cohen’s (1988) guides for small (0.20), medium (0.50), and large (0.80) effects.

Section 1: Statistically Significant (p<.05) Behavioral Outcomes


Improved school GPA 0.69 Rast et al., 2007, p. 22

Improved overall functioning on CAFAS 0.69 Rast et al., 2007, p. 20

Fewer disciplinary actions 0.95 Rast et al., 2007, p. 22

Moved to less restrictive living environments 1.09 Rast et al., 2007, p. 21

Fewer emotional and behavioral problems on CBCL

0.86 Rast et al., 2007, p. 19

Fewer out-of-home placements 0.84 Rauso et al., 2009, p. 65

More stable living environment 0.57 Rauso et al., 2009, p. 66-67

Residing in less restrictive placements 0.98 Rauso et al., 2009, p. 66

Section 2: Behavioral Outcomes That Were Not Statistically Significant, But with Positive Effect Sizes


Less likely to be arrested 0.23 Carney & Buttell, 2003, p. 561

Less likely to be in clinical range on CBCL or YSR 0.23 Clark et al., 1998, p. 532

Fewer unexcused absences 0.50 Rast et al., 2007, p. 22

Combined rating indicating lower restrictiveness of placement, improved school attendance, and fewer negative behaviors.

0.68 Hyde et al., 1996, p. 78

Table 2. (CONTINUED) Summary of All Behavioral Outcomes for the Wraparound Process with Supporting Citations from Eight Controlled Studies

8


(2009). Improving outcomes for foster care youth with complex emotional and behavioral needs: A comparison of outcomes for wrap-around vs. residential care in Los Angeles County. Emotional & Behavioral Disorders in Youth, 9, 63-68, 74-75.

Other ReferencesBickman, L., Smith, C., Lambert, E. W., & An-

drade, A. R. (2003). Evaluation of a congres-

sionally mandated wraparound demonstra-tion. Journal of Child & Family Studies, 12, 135-156.

Bruns, E. J., Leverentz-Brady, K. M., & Suter, J. C. (2008). Is it wraparound yet? Setting fidelity standards for the wraparound process. Journal of Behavioral Health Services and Research, 35, 240-252.

Bruns, E. J., Sather, A., & Stambaugh, L. (2008). National trends in implementing wraparound:

References (CONTINUED)

9


Results from the state wraparound survey, 2007. In E.J. Bruns & J.S. Walker (Eds.), Re-source guide to wraparound. Portland, OR: National Wraparound Initiative, Research and Training Center for Family Support and Chil-dren’s Mental Health.

Bruns, E. J., Suter, J. S., Force, M. D., & Burchard, J. D. (2005). Adherence to wraparound prin-ciples and association with outcomes. Journal of Child and Family Studies, 14, 521-534.

Bruns, E. J., Suter, J. S, & Leverentz-Brady, K. (2006). Relations between program and sys-tem variables and fidelity to the wraparound process for children and families. Psychiatric Services, 57, 1586-1593.

Kazdin, A. E. (1999). Current (lack of) status of theory in child and adolescent psychotherapy research. Journal of Clinical Child Psychology 28, 533–543.

Stroul, B. A., & Friedman, R. M. (1996). A system of care for children and youth with severe emo-tional disturbances. Washington, DC: CASSP Technical Assistance Center, Center for Child Health and Mental Health Policy, Georgetown University Child Development Center.

Suter, J. C. & Bruns, E. J. (2009). Effectiveness of the Wraparound Process for Children with Emotional and Behavioral Disorders: A Meta-Analysis. Clinical Child and Family Psychology Review, 12, 336-351.

Walker, J. S. (2008a). How, and why, does wrap-around work: A theory of change. In E. J. Bruns & J. S. Walker (Eds.), The resource guide to wraparound. Portland, OR: National Wrap-around Initiative, Research and Training Cen-ter for Family Support and Children’s Mental Health.

Weisz, J. R., Jensen-Doss, A., & Hawley, K. M. (2006). Evidence-based youth psychotherapies versus usual clinical care: A meta-analysis of direct comparisons. The American Psycholo-gist, 61, 671-689.

AuthorsEric Bruns is a clinical psychologist and Associate Professor at the University of Washington School of Medicine in Seattle. He spends much of his professional life conducting research on innova-tive community-based models for helping youth and families with complex needs, including fam-ily treatment drug courts, treatment foster care, parent support programs, and the wraparound process. He is a lead developer of the Wraparound Fidelity Assessment System and, with Janet Walk-er, co-directs the National Wraparound Initiative.

Jesse Suter is a faculty member at the Univer-sity of Vermont with interests in the research, development, and evaluation of community- and school-based programs for preventing and re-sponding to emotional and behavioral challenges. He was introduced to wraparound by working with John Burchard on the Wraparound Fidelity Index, and he continues to work on the Wraparound Eval-uation and Research Team with two other former students of John’s: Eric Bruns and Kristen Lever-ntz-Brady.

Suggested Citation:

Bruns, E. J., & Suter, J. C. (2010). Summary of the wraparound evidence base. In E. J. Bruns & J. S. Walker (Eds.), The resource guide to wraparound. Portland, OR: Nation-al Wraparound Initiative.

Theory and Research: Chapter 3.1 How, and Why, Does ...

Documents

Transcript of Theory and Research: Chapter 3.1 How, and Why, Does ...