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Literature Review on Wraparound as an Exemplary Practice The emergence of the Wraparound process as an alternative paradigm to the traditional treatment planning processes for children and adolescents with emotional and behavioral disorders is described by Van Den Berg, et al. (1996). This research compares current practices in the field to the Wraparound process and describes procedures to aid communities in the implementation of the Wraparound process. Positive results were reported for individualized Wraparound strategies among foster children with confirmed emotional/behavioral disturbances and their families by McDonald et al. (1995). Malysiak et al. (1998) examine the theoretical and paradigmatic basis to better define fidelity in a Wraparound approach to service delivery, drawing on team discussion data with seven families in Tampa, FL, follow-up interviews with 56 of these participants, and a review of case files. The literature is examined in an effort to clarify terms and suggest a paradigmatic and theoretical base for Wraparound. Results suggest that Wraparound is an emerging collaborative model based in systems theory. This research also proposes steps in clarifying the process of implementation and evaluation of the Wraparound approach that can contribute to better definitions for treatment fidelity. Research on Wraparound as an intervention is also abundant. Family-centered policy and practice has generally used expert models that define families with children with serious emotional disturbances as dysfunctional. Wraparound engages these families as decision-making participants using naturally occurring strengths to ìwrapî individualized supports around the child & family. Malysiak (1997) posits that Wraparoundís principles can be used to descriptively identify and ensure the integrity of the collaborative model. Wraparound as described by Handron et al. (1998) is a strengths-based, family-driven orientation role that focuses on the uniqueness of each child and family. The professionalís role in Wraparound is to offer an historical perspective and clinical practice implications for family nurses or service providers as other disciplines are explored. This case study demonstrates how structural family therapy may be used as a theoretical framework in concert with the Wraparound process. Another case study by Epstein (1997) on the actions of professional social workers and family workers in a family support program designed with a Wraparound philosophy (Kaleidoscope, Inc, a nonprofit child welfare organization in Chicago, IL) found that more than 33 percent of a social workerís day is devoted to indirect care activities (e.g., writing reports, attending meetings, & collateral contacts) and that family workers spend more of their time working directly with families. Finally Carney et al. (1997) and Rosenblatt (1996) define the individualized Wraparound processes for children with the most challenging emotional/behavioral disturbances and their families, and provide an overview of the state of research. It is argued that the future of Wraparound depends on carefully defining the process, including how to best integrate Wraparound services with reforms based on the principles of a comprehensive system of care. A strong commitment must be made at all levels to the process of accumulating knowledge and building and creating innovative research along with programs. As an intervention, Wraparound was demonstrated to be effective in Ontario with children ages 2 to 15 with moderate to severe emotional difficulties who would have needed residential care if not provided with Wraparound services as an alternative. The approach was to provide participants with services they requested. Parents identified in-home help, stress reduction and individual (one-on-one) services as the major contributors to success. The program was demonstrated to be cost-effective with cases averaging 17% of the mean cost of local community out-of-home placements (Brown, 1996). A Wraparound service model in Baltimore, MD targeting 25 severely maladjusted youth resulted in one youth being returned home and 24 being diverted from out-of-state residential treatment centers to Wraparound services (Hyde, 1996). In an evaluation of a community-based treatment program in rural New England using a Wraparound model, the research examined adjustment to home and school among children with severe emotional and behavioral problems. The Child Behavior Checklist and the Teacher Report Form provided standardized information on the severity of problems according to parents and classroom teachers. The Wraparound services included intensive home and school-based services. The results indicated substantial improvement in child functioning in the home though these results were not found in the school (Clarke, 1992). Keller (1999) describes a technology transfer initiative in which network therapy (a version of Wraparound) was used in substance abuse treatment utilizing peer and family support in New York City. Following counselor training that included a didactic seminar, role-playing, use of videotaped illustrations, and clinical supervision, counselors implemented the NT approach. Using a comparison group, Keller et al found that network therapy patients had significantly less positive urinalysis (UAs) than comparison group patients. In 1994 a Community-Initiated Wraparound services model called Breakthrough for Families targeting the most hard-to-reach families, i.e., those struggling with parental substance abuse, youth at high risk, and other complex needs cutting across existing categorical programs, reported strong positive outcomes (Ray, 1998). In addition to describing the positive outcomes for treatment versus comparison groups in the Fostering Individualized Assistance Program (FIAP) in Florida the evaluation research also details the approach and participants in the program. To further attest to the salience of the Florida research for the Gilroy project participants, the Florida participants ranged in age from 7 to 15 at entry and had been adjudicated dependent, and averaged 2.6 years in out-of-home placement with an average of four placement changes per year. Family specialists served as clinical case managers, providing strengths-based assessment, life-domain planning, home-based services, brokered services, & follow-along monitoring & supports. While there was a significant increase in days in incarceration for both groups, there was a significantly greater likelihood that an FIAP child would achieve permanent placement. The findings support the superiority of individualized strategies of service delivery such as Wraparound for children with severe emotional and behavioral disturbances (Clark, 1996). Interventions with chronic juvenile delinquents and their families have often been unsuccessful in reducing crimes because they fail to account for the social system in which the delinquents operate. The Wraparound model described by Northey et al. (1997) includes the following premises: the quality of attachment to others affects the adolescentís behavior; interventions must take the adolescentís interpersonal interactions into account; interventions should focus on intrapsychic and interactional experiences of the adolescent, family, extended family and ìfictiveî kin networks, and the integration of these premises in a systems perspective decreases conflict in the network. The key to the model is impacting family interactions at different levels, building on family strengths, and clarifying meanings associated with problematic behavior. In addition to empirical evidence of the effectiveness of Wraparound for children and adolescent with severe behavioral and emotional disorders who may have co-occuring substance abuse issues, strong support is also found among service providers and consumer families. Support among providers and consumers has been found by Quinn (1995) who surveyed 180 direct service providers about barriers to providing services, specific service priorities for system development and how services could best be developed and implemented and found support for a Wraparound model. Telephone surveys with 20 youths receiving community-based, Wraparound services in Vermont indicated a high degree of satisfaction, sense of involvement, and feelings of unconditional care. Further, each of these variables was related to behavioral adjustment. Wraparound was also found to enhance youthsí sense of involvement and their perceptions that care was unconditional and this was strongly associated with satisfaction with services (Rosen, 1994). In Vermont the Wraparound Care Initiative providing residential, educational, and behavioral outcome data for a cohort of 40 youth receiving Wraparound care over a 12-month period were reported to show that after 12 months youth who had previously been removed from their homes or were at risk of removal were residing in significantly less restrictive community-based living arrangements and exhibiting significantly fewer problem behaviors than at intake (Yoe, 1996). The use of Wraparound approaches across a variety of educational settings to prevent out-of-school and out-of-home care was reported by Eber, et al. (1998). The researchers examined the application of a school-based Wraparound approach for the past three years by the La Grange (IL) Area Dept of Special Education. The project has been implementing a school-based individualized service network for students with emotional and behavioral disabilities that are now being integrated into larger special education, mental health, and social services systems. Students who were identified through self-contained special education classrooms were compared to students who were identified from various other school and mental health settings and were found to be less clinically involved. Perhaps the best researched approach, Choose-Get-Keep (CGK), is based on the values of psychiatric rehabilitation including consumer choice, individual planning, and consumer involvement in the rehabilitation process (Farkas & Anthony, 1989). ìThe Choose-Get-Keep Approach to Employment Support: Operational Guidelinesî manual (Danley & MacDonald-Wilson, 1996) is published by the Center for Psychiatric Rehabilitation. Earlier versions of this manual have been available for studies since the late 1980s. In addition to the technology of psychiatric rehabilitation, such as how to set goals with consumers, how to ìconnectî with consumers, how to teach skills to consumers, and how to develop resources with and for consumers (Cohen, et al., 1985; 1986; 1988; 1990) the CGK approach has been evaluated in a variety of community applications. In a multi-site comparison of the CGK approach in three psychosocial rehabilitation centers in Virginia, Georgia, and Oregon, competitive employment was achieved for 41% of 275 clients. Skills were found to increase and symptoms decreased for those who became employed (Rogers, Anthony, Toole & Brown, 1991). At Boston University, a supported education program model incorporating the CGK approach was developed and demonstrated effective for patients who were ìpsychiatrically disabled.î Employment and self-esteem significantly increased over a two and one-half year period and hospitalizations significantly decreased (Unger, Anthony, Sciarappa & Rogers, 1991). The adaptation of the CGK model for Latinos is currently being investigated (Restrepo-Toro & Spaniol, 1998).
Brown, R.A.& Hill, B.A. (1996). Opportunity for
change: exploring an alternative to residential treatment. Child Welfare,
75(1), 35-37. |