The Evidence Base for Wraparound and Strengths-Based Approaches

1. The Evidence Base for Wraparound and Strengths-Based Approaches Eric J. Bruns, Ph.D. University of Washington School of Medicine (ebruns@uw.edu) National Wraparound Initiative (www.wrapinfo.org) Washington State Children’s MH Evidence Based Practices Institute (http://depts.washington.edu/pbhjp) Presented at the CASSP 25th Anniversary Systems of Care Program Annual Meeting of the American Academy of Child and Adolescent Psychiatry October 26, 2009 Honolulu, Hawaii

2. Acknowledgments • The work described in this presentation has been funded by a variety of sources, including: • The Child, Adolescent, and Family Branch of the Center for Mental Health Services, SAMHSA • The National Institute of Mental Health (R34 MH072759; R41 MH077356) • The American Institutes for Research and National Technical Assistance Partnership • The Maryland Child Mental Health and Innovations Institute • The presenter received support to travel to Honolulu to today’s meeting and is receiving an honorarium. He has no conflict of interest to disclose.

3. John D. Burchard, University of Vermont (1936-2004)

4. Wraparound Process Principles • Family voice and choice • Team-based • Natural supports • Collaboration • Community-based • Culturally competent • Individualized • Strengths based • Unconditional commitment and persistence • Outcome-based Walker, Bruns, Adams, Miles, Osher et al., 2004 (see www.wrapinfo.org)

5. The Strengths Perspective… • “The Strengths Perspective obligates workers to understand that, however downtrodden… individuals have survived (and thrived). They have taken steps, summoned up resources, and coped. We need to know what they have done, how they have done it, what they have learned from doing it, and what resources (inner and outer) were available in their struggle to surmount their challenges. As helpers, we must tap into that work, elucidate it, find and build on its possibilities.” • Saleeby (1992), pp. 171-172

6. Practices involved in strengths-based service delivery • An Empowering orientation • Services are provided in ways that build on family members’ strengths and empower them to do things for themselves • Cultural competence • Including understanding and valuing a family’s culture as a source of strength • A relationship-based approach • That works to develop a supportive relationship between program staff and family members, and that… • Strengthens families • By improving relationships within and across families • Active partnering • Between family members and program staff

7. Practices involved in strengths-based service delivery (cont’d) • Community orientation • Including sensitivity to community history and • Knowledge of community-based providers • A family-centered approach • That includes the entire family rather than focusing on a specific individual • Goal-orientation • That helps families not only with immediate crises but also with identifying and realizing long-term goals • Individualization of services • To address specific family needs • Based on a review by Green, McAllister, & Tarte (2004) that includes Dunst et al., 1994; Herman, Marcenko, & Hazel, 1996; Kagan & Shelley, 1987; Koren, DeChillo, & Friesen, 1992

8. Strengths-Based Services & Supports(Adapted from Green et al., 2004) PHILOSOPHY ENGAGEMENT OUTCOMES Family and youth efficacy and empowerment Engagement in Strategies and Services Strengths Based Services & Supports Better Follow-through with services/ strategies Relationships and social support Relationships with Helpers Other family outcomes Child/youth outcomes

9. Is there Evidence for Strengths-Based Services? • Staudt, Howard, & Drake, 2001 • Few evaluations of SBS • Existing studies not rigorous enough to determine whether outcomes are due to strengths perspective or delivery of additional services • Directives of the strengths perspective not adequately operationalized or measured • Concluded that “the strengths perspective is more a value stance than a unique practice model” (p.19)

10. Making Progress: Operationalization • E.g., The ADMIRE framework (Franz, 2008) • Attitude • Discovery • Mirroring • Intervention • Recording • Evaluation • See also: • Nissen, 2006 (Juvenile Justice) • Rawanda & Brownlee, 2009 (Social Work)

11. Making Progress: Measurement • Assessment based on strengths • Behavioral and Emotional Rating Scale (Epstein & Sharma, 1998); Child and Adolescent Needs and Strengths (CANS; Lyons et al.) • Degree of strengths orientation in practice • Strengths-Based Practices Inventory (SBPI; Green, McAllister, & Tarte, 2004) • Assessment tools to assist planning and provision of services • E.g., Personal Strengths Grid (Cox, 2008)

12. Making Progress: Empirical Support • Cox, 2006, Randomized control study of child MH therapists • Strengths-based assessment (SBA)  higher parent satisfaction and fewer missed appointments than assessment as usual • Use of SBA + therapist strengths orientation  improved child functioning outcomes • Green et al., 2004, cross-sectional study of family support programs: • Greater strengths orientation as assessed by the SBPI  family empowerment and social support • but not better child behavior or improved parent skills

13. Wraparound Process Principles • Family voice and choice • Team-based • Natural supports • Collaboration • Community-based • Culturally competent • Individualized • Strengths based • Unconditional commitment and persistence • Outcome-based Walker, Bruns, Adams, Miles, Osher et al., 2004 (see www.wrapinfo.org)

14. Wraparound • Principles: A philosophy or approach to service delivery (broadly defined and applicable to any practice) • Practice: A defined, team-based, individualized practice model for planning and implementing services and supports for youth and families with the most complex needs • System: Characteristics of a system or program that are necessary to support implementation per the wraparound principles and practice model

15. What is Wraparound? • Wraparound is a family-driven, youth guided, team-based process for planning and implementing services and supports. • Through the wraparound process, teams create plans that are geared toward meeting the unique and holistic needs of children and youth with complex needs and their families. • The wraparound team members (e.g., the identified youth, his or her parents/caregivers, other family members and community members, mental health professionals, educators, and others) meet regularly to implement and monitor the plan to ensure its success.

16. For which children and youth is the wraparound process intended? • Youth with needs that span home, school, and community • Youth with needs in multiple life domains • (e.g., school, employment, residential stability, safety, family relationships, basic needs) • Youth for whom there are many adults involved and they need to work together well for him or her to succeed

17. For which youth in a system of care? More complex needs Most Intensive intervention level Full Wraparound Process 2% 3% Targeted Intervention Level 15% Targeted and Individualized Services Prevention and Universal Health Promotion Level 80% Less complex needs

18. Who is served by wraparound?An example from Washington State • Of the 116,209 served by CA, JRA, and/or MHD in 2003 (smaller circles), about 9 percent (4,030) of these children and youth received MH services from two or more administrations: • 3,547 From CA and MHD • 368 From JRA and MHD • 35 From CA and JRA • 80 From CA, MHD, and JRA

19. Why should we find a different way to work with these youth and their families? • In Fiscal Year 2002, over 126,000 children and youth received services from three DSHS programs: CA, JRA, and|or MHD. • 44,900 of these children and youth received at least one mental health service from one of the systems during that year. • Collectively, the mental health services for those 44,900 young people cost $169 million. • Half of that expenditure ($81 million) was spent on the 9 percent who received mental health care from two or more programs.

20. Why should we find a different way to work with these youth and their families? • In 2003, of the 39,361 children and youth who used mental health services one program (CA, JRA, or MHD), 14 percent spent some time in treatment or placement away from home. • In 2003, of the 4,030 children who used mental health care from two or three administrations, 68 percent spent some time in treatment or placement away from home. • Typically, those spending time away from home are in foster care, inpatient or residential treatment, or a JRA institution.

21. Until proven otherwise, we believe that all parents want to… • Be proud of their child • Have a positive influence on their child • Hear good news about their child and about what their child does well • Provide their child a good education and a good chance of success in life • See their child’s future as better than their own • Have a good relationship with their child • Feel hopeful about their child • Believe they are good parents Laura Burger Lucas, ohana coaching, 2009; adapted from the work of Insoo Kim Berg

22. Until proven otherwise, we believe all children want to… • Have their parents be proud of them • Please their parents and other adults • Be accepted as a part of a social group • Be active and involved in activities with others • Learn new things • Be surprised and surprise others • Voice their opinions and choices • Make choices when given an opportunity Laura Burger Lucas, ohana coaching, 2009; adapted from the work of Insoo Kim Berg

23. A practice model:The Four Phases of Wraparound Phase1A Engagement and Support Phase1B Team Preparation Phase2 Initial Plan Development Phase3 Implementation Phase4 Transition Time

24. Phase 1 : Engagement and Team Preparation Care Coordinator & Family Support Partner meets with the family to discuss the wraparound process and listen to the family’s story. Discuss concerns, needs, hopes, dreams, and strengths. Listen to the family’s vision for the future. Assess for safety and make a support plan if needed Identify people who care about the family as well as people the family have found helpful for each family member. Reach agreement about who will come to a meeting to develop a plan and where we should have that meeting. Phase 1 A and B

25. Phase 2: Initial Plan Development Conduct first Child & Family Team (CFT) meeting with people who are providing services to the family as well as people who are connected to the family in a supportive role. The team will: Review the family vision Develop a Mission Statement about what the team will be working on together Review the family’s needs Come up with several different ways to meet those needs that match up with the family’s strengths Different team members will take on different tasks that have been agreed to. Phase 2

26. Phase 3: Plan Implementation and Refinement Based on the CFT meetings, the team has created a written plan of care. Action steps have been created, team members are committed to do the work, and our team comes together regularly. When the team meets, it: Reviews Accomplishments (what has been done and what’s been going well); Assesses whether the plan has been working to achieve the family’s goals; Adjusts things that aren’t working within the plan; Assigns new tasks to team members. Phase 3

27. Phase 4: Transition There is a point when the team will no longer need to meet regularly. Transition out of Wraparound may involve a final meeting of the whole team, a small celebration, or simply the family deciding they are ready to move on. The family we will get a record of what work was completed as well as list of what was accomplished. The team will also make a plan for the future, including who the family can call on if they need help or if they need to re-convene their team. Sometimes transition steps include the family and their supports practicing responses to crises or problems that may arise Phase 4

28. Theory of change for wraparound process Ten principles of the wraparound process • Intermediate outcomes: • Participation in services • Services that “work” for family • Short term outcomes: • Better engagement in service delivery • Creative plans that fit the needs of youth/family • Improved service coordination • Follow-through on team decisions • Family regularly experiences success/support • Long term outcomes: • Stable, home-like placements • Improved mental health outcomes (youth and caregiver) • Improved functioning in school/ vocation and community • Improved resilience and quality of life • Model adherent wraparound • Youth/Family drives goal setting • Single, collaboratively designed service plan • Active integration of natural supports and peer support • Respect for family’s culture/expertise • Opportunities for choice • Active evaluation of strategies/outcomes • Celebration of success • Intermediate outcomes: • Achievement of team goals • Increased social support and community integration • Improved coping and problem solving • Enhanced empowerment • Enhanced optimism/self-esteem Phases and Activities of the Wraparound Process From Walker (2008)

29. When wraparound is implemented as intended… • Basing plans on strengths, needs, and culture leads to more complete engagement of families • High-quality teamwork and flexible funds leads to better plans, better fit between family needs and supports, and greater integration of effort by helpers • Greater relevance, less dropout, better follow-through • As family works with a team to solve its own problems, develops family members’ skills andself-efficacy • Process focuses on developing supportive relationships • Focus on setting goals and measuring outcomes leads to more frequent problem-solving, more effective plans, greater success

30. Wraparound implementation is widespread and increasing • 87.8% of states (43 of 49) have at least one wraparound initiative • 26 states now have a statewide initiative • From estimates provided by states, 98,293 children were served by wraparound in 2008, in a reported 819 unique programs (Sather, Bruns, & Stambaugh, 2008)

31. Several factors are promoting expansion of wraparound implementation • Alignment with youth and family movements • Fills a gap in the public health continuum • Serves a central role in implementing the systems of care framework • Addresses concerns of youth with complex needs, regardless of referring agency • Facilitates shared effort by many agencies that otherwise wouldn’t work well together • Can be flexibly applied to respond to different agencies’ target populations in one state or community • The evidence base continues to expand… • Bruns, Walker, et al., in press

32. Outcomes of Wraparound Does wraparound work? For whom? What is associated with positive outcomes?

33. Is there evidence for wraparound? • Recent summaries of the evidence base skeptical and still often cited • “The existing literature does not provide strong support for the effectiveness of wraparound” (Bickman, Smith, Lambert, & Andrade, 2003; p. 138). • Farmer, Dorsey, and Mustillo (2004) recently characterized the wraparound evidence base as being “on the weak side of ‘promising’” (p. 869). • However, since 2003: • Five controlled (experimental or quasi-experimental studies) have been published • First meta-analysis published (Suter & Bruns, 2009) • First NIMH-funded studies of wraparound underway

34. Results from Nevada:Impact on Child Functioning Bruns et al. (2006)

35. Results from Clark County, WAImpact on juvenile justice outcomes • Connections (wraparound) group (N=110) 3 times less likely to commit felony offense than comparison group (N=98) • Connections group took 3 times longer on average to commit first offense after baseline • Connections youth showed “significant improvement in behavioral and emotional problems, increases in behavioral and emotional strengths, and improved functioning at home at school, and in the community” Pullman et al. (2006)

36. Results from Ohio RCT of wraparound for youth involved with JJ • Wraparound group • Missed less school • Suspended less often • Less likely to run from home • Less assaultive • Less likely to be stopped by police • However… • Between-group differences in arrests and incarceration were not significant. • (Carney & Buttell, 2003)

37. Meta analysis of Seven Published Controlled Studies of Wraparound

38. Mean Effect Sizes & 95% Confidence Intervals

39. Findings from our meta-analysis of seven controlled studies • Strong results in favor of wraparound found for Living Situation outcomes (placement stability and restrictiveness) • A small to medium sized effect found for: • Mental health (behaviors and functioning) • School (attendance/GPA), and • Community (e.g., JJ, re-offending) outcomes • The overall effect size of all outcomes in the 7 studies is about the same (.35) as for “evidence-based” treatments, when compared to services as usual (Weisz et al., 2005) Suter & Bruns (2008)

40. Other unpublished outcomes of wraparound • Greater/more rapid achievement of permanency when implemented in child welfare (Oklahoma) • Reduced recidivism among adult prisoners • 95% survival at 27 mos post-release for “PrisonWrap” condition vs. 70% for TAU • Reduction in costs associated with residential placements (Milwaukee, LA County, Washington State, Kansas, many other jurisdictions)

41. Outcomes from Wraparound Milwaukee • After Wraparound Milwaukee assumed responsibility for youth at residential level of care (now approx 1300 per year)… • Average daily Residential Treatment population reduced from 375 placements to 70 placements • Psychiatric Inpatient Utilization reduced from 5000 days per year to under 200 days (average LOS of 2.1 days) • Reduction in Juvenile Correctional Commitments from 325 per year to 150 (over last 3 years) (Kamradt et al., 2008)

42. LA County DSS WraparoundOutcomes for N=102 wraparound graduates vs. matched group of N=210 youth discharged from Group Care (RCL12-14) Rauso et al (2009)

43. LA County DSS WraparoundOutcomes for N=102 wraparound graduates vs. matched group of N=210 youth discharged from group care (RCL12-14) Rauso et al (2009)

44. Outcomes are variable and related to implementation factors Studies indicate that Wraparound teams often fail to: • Incorporate full complement of key individuals on the Wraparound team; • Engage youth in community activities, things they do well, or activities to help develop friendships; • Use family/community strengths to plan/implement services; • Engage natural supports, such as extended family members and community members; • Use flexible funds to help implement strategies • Consistently assess outcomes and satisfaction.

45. What is the connection between wraparound fidelity and outcomes? • Provider staff whose families experience better outcomes were found to score higher on fidelity tools (Bruns, Rast et al., 2006) • Wraparound initiatives with positive fidelity assessments demonstrate more positive outcomes (Bruns, Leverentz-Brady, & Suter, 2008)

46. Fidelity’s Impact on Outcomes at a state level? WFI=69 WFI=68 WFI=80 WFI=81

47. What does it take to get high fidelity scores? • Training and coaching found to be associated with gains in fidelity and higher fidelity (Bruns, Rast, et al., 2006) • Communities with better developed supports for wraparound show higher fidelity scores (Bruns, Suter, & Leverentz-Brady, 2006)

48. Program and system supports for Wraparound(from the Community Supports for Wraparound Inventory) • Community partnership:Do we have collaboration across our key systems and stakeholders? • Collaborative action:Do the stakeholders take concrete steps to translate the wraparound philosophy into concrete policies, practices and achievements? • Fiscal policies:Do we have the funding and fiscal strategies to meet the needs of children participating in wraparound? • Service array:Do teams have access to the services and supports they need to meet families’ needs? • Human resource development:Do we have the right jobs, caseloads, and working conditions? Are people supported with coaching, training, and supervision? • Accountability:Do we use tools that help us make sure we’re doing a good job?

49. Getting to “high fidelity”Characteristics of one “high fidelity” state • Statewide training and TA center • Oversees statewide fidelity assessment using fidelity measures • Consistent availability of family partners (+ youth advocates) • Certification program for facilitators/Family Partners • Fiscal responsibility shared by multiple agencies • Referrals from multiple agencies • Care management entity (CME) that maintains MIS, develops service array, holds some risk for overall costs • Allows for flexible funding of team strategies • Encourages individualization of plans • 1915c Waiver • Professional development at SSW and in provider agencies

50. Summary • Wraparound provides an operationalization of strengths-based practice as well as the CASSP/system of care principles • Its use has been widespread due to its face validity and alignment with the family and youth movements • Evidence base has expanded to the point where discussion as an “evidence based process” makes sense • Fidelity controls and fidelity measurement is needed, as is attention to necessary system-level conditions