Wraparound

The Wraparound Process is an intensive, individualized care management process for youths with serious or complex needs. Wraparound was initially developed in the 1980s as a means for maintaining youth with the most serious emotional and behavioral problems in their home and community. During the wraparound process, a team of individuals who are relevant to the well-being of the child or youth (e.g., family members, other natural supports, service providers, and agency representatives) collaboratively develop an individualized plan of care, implement this plan, and evaluate success over time. The wraparound plan typically includes formal services and interventions, together with community services and interpersonal support and assistance provided by friends, kin, and other people drawn from the family’s social networks. The team convenes frequently to measure the plan’s components against relevant indictors of success. Plan components and strategies are revised when outcomes are not being achieved.

The process of engaging the family, convening the team, developing the plan, implementing the plan, and transitioning the youth out of formal wraparound is typically facilitated by a trained care manager or “wraparound facilitator,” sometimes with the assistance of a family support worker. The wraparound process, and the plan itself, is designed to be culturally competent, strengths based, and organized around family members’ own perceptions of needs, goals, and likelihood of success of specific strategies.

History

Wraparound was initially developed in the 1980s as a means for maintaining youth with the most serious emotional and behavioral problems in their home and community. In recent years, however, it has been applied within many child-serving settings as a way to improve outcomes for children and adolescents with serious emotional disturbance, autism spectrum disorders and behavioral disorders. For example, it has been used as a means to facilitate permanency outcomes for youth involved in the child welfare system, to reduce recidivism for youths involved in the juvenile justice system, and to improve academic success for youths in the special educational system.

During the wraparound process, a team of individuals who are relevant to the well-being of the child or youth (e.g., family members and other natural supports, service providers, and agency representatives) collaboratively develop an individualized plan of care, implement this plan, and evaluate success over time. The wraparound plan typically includes formal services and interventions, together with community services and interpersonal support and assistance provided by friends, kin, and other people drawn from the family’s social networks. The team convenes frequently to measure the plan’s components against relevant indictors of success. Plan components and strategies are revised when outcomes are not being achieved.

The process of engaging the family, convening the team, developing the plan, implementing the plan, and transitioning the youth out of formal wraparound is typically facilitated by a trained care manager or “wraparound facilitator,” sometimes with the assistance of a family support worker. The wraparound process, and the plan itself, is designed to be culturally competent, strengths based, and organized around family members’ own perceptions of needs, goals, and likelihood of success of specific strategies.

Wraparound has been implemented nationally for over 20 years and presented as a promising practice in many publications. However, specification and consistent implementation of the model has occurred only in the past few years. In some states, Wraparound is a term applied to in-home behavioral support services. The wraparound process, however, as recently specified, is conceived of a four phase process: Engagement and team preparation, Initial plan development, plan implementation, and transition. The full description of the activities that typically take place in each of these phases can be found in “Phases and Activities of the Wraparound Process,” a document available on the website of the National Wraparound Initiative [] . Pennsylvania's Department of Public Welfare has adopted this methodology for at risk youth. [http://www.dpw.state.pa.us/ServicesPrograms/Autism/AutismRsrc/003676342.htm]

Training and Technical Assistance

Many communities and programs have been trained and coached by experts on the wraparound process to successfully implement the wraparound process. Typical curricula include initial 4 day training sessions for staff (e.g., facilitators and parent partners) followed by shadowing of experienced staff, and in-vivo coaching. Supervisors also receive a series of human resource development activities so they can collect data about staff performance and support staff over the long term via intensive group and individual supervision, as well as ongoing coaching.

Summary of Published Controlled Studies of the Wraparound Process

STUDY 1: Randomized control study (18 months) of youth in child welfare custody in Florida: 54 in wraparound vs. 78 in standard practice foster care.

References: Clark, Lee, Prange, & McDonald, 1996; Clark et al., 1998.

RESULTS: 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.

STUDY 2: Matched comparison study (18 months) of youth in child welfare custody in Nevada: 33 in wraparound vs. 32 receiving MH services as usual

References: Bruns, Rast, Walker, Bosworth, & Peterson, 2006;
Rast, Bruns, Brown, Peterson, & Mears (in submission).

RESULTS: 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 significantly 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 attendance, school disciplinary actions, and grade point averages. No significant differences were found in favor of the comparison group.

STUDY 3: Randomized control study (18 months) of “at risk” and juvenile justice involved (adjudicated) youth in Ohio: 73 in wraparound vs. 68 in conventional services

Reference: Carney & Buttell, 2003.

RESULTS: Study supported the hypothesis that youth who received wraparound services were less likely to engage in subsequent at-risk and delinquent behavior. The youth who received wraparound services did not 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.

STUDY 4: 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

Reference: Pullmann, Kerbs, Koroloff, Veach-White, Gaylor, & Sieler, 2006.

RESULTS: Youths in the comparison group were three times more likely to commit 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 served detention. And 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 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.

STUDY 5: 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.

References: Evans, Armstrong, & Kuppinger, 1996; Evans, Armstrong, Kuppinger, Huz, & McNulty,1998

RESULTS: 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.

STUDY 6: Quasi-experimental (6 months) study in Department of Defense demonstration site of youths with serious mental health issues: 71 in wraparound group vs. 40 in comparison group (study refusers/ineligible youths).

Reference: Bickman, Smith, Lambert, & Andrade, 2003

RESULTS: Findings included higher utilization of “wraparound services” (e.g., case management, in-home supports, and nontraditional services) for the demonstration group, higher costs for the demonstration group (primarily due to this group remaining in treatment longer), and no consistent differences between the groups on outcome measures (e.g., behavior, functioning, caregiver strain, perceived social support, family environment). Limitations of this study include the short time span (6 months) and whether the demonstration project truly followed the wraparound process. Authors stated the “wrap” condition had access to informal services and flexible funding, but authors did not assess “wrapness” and stated that, “there is no evidence that the content or the quality of the services were different for the Wraparound children.” (p.151)

STUDY 7: 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.

Reference: Hyde, Burchard, & Woodworth, 1996.

RESULTS: Primary outcome was a single rating that combined several indicators: restrictiveness of youth living situation, school attendance, job/job training attendance, 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, compared to 8% of youths in traditional MH services. Limitations of the study include study attrition and group non-equivalence at baseline.

STUDY 8: Quasi-experimental (multiple-baseline case study) of four youths referred to wraparound because of serious mental health issues in rural Michigan.

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

RESULTS: 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 interactions, 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 wraparound.

References

*Bruns, E.J., Rast, J., Peterson, C., Walker, J., Bosworth, J. (2006). Spreadsheets, service 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.

*Burchard JD, Bruns EJ, & Burchard SN (2002). The wraparound approach. In Community treatment for youth: Evidence-based interventions for severe emotional and behavioral disorders. Edited by Burns BJ, Hoagwood K. New York, Oxford University Press.

*Burns BJ & Goldman SK (Eds) (1999). Promising practices in wraparound for children with severe emotional disorders and their families. Systems of care: Promising practices in children's mental health, 1998 series: Volume IV. Washington, DC, Center for Effective Collaboration and Practice, American Institutes for Research.

*Eber, L. (2003). The Art and Science of Wraparound. Bloomington, IN: Forum on Education at Indiana University.

*Eber, L. (2005). Wraparound: Description and Case Example. In Sugai, G. & Horner, R. (2005) Ed., Encyclopedia of Behavior Modification and Cognitive Behavior Therapy: Educational Applications. 1601-1605. Thousand Oaks: Sage.

*Eber, L., Nelson, C.M., & Miles, P. (1997). School-based wraparound for students with emotional and behavioral challenges. Exceptional Children, 63(4), 539-555.

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

*Kendziora K, Bruns E, Osher D, et al (Eds) (2001). Wraparound: Stories from the field. Systems of care: Promising practices in children's mental health, 2001 series: Volume I. Washington, DC, Center for Effective Collaboration and Practice, American Institutes for Research.

*Walker, J.S. & Bruns, E.J. (2006). Building on practice-based evidence: Using expert perspectives to define the wraparound process. Psychiatric Services, 57(11), 1579-1585.

*Walker JS, Koroloff N, & Schutte K (2003). Implementing high-quality collaborative Individualized Service/Support Planning: Necessary conditions, Portland OR: Research and Training Center on Family Support and Children's Mental Health.

Extra References for Review of Outcomes Studies

*Bickman, L., Smith, C., Lambert, E. W., & Andrade, A. R. (2003). Evaluation of a congressionally mandated wraparound demonstration. Journal of Child & Family Studies, 12, 135-156.

*Carney, M. M., & Buttell, F. (2003). Reducing juvenile recidivism: Evaluating the wraparound services model. Research on Social Work Practice, 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 strategies 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 disturbances: 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 behavioral 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 Management: A Step Toward Understanding Individualized 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 intensive case management. In Epstein, M.H. (Ed); Kutash, K (Ed); et al. (1998). Outcomes for children and youth with emotional and behavioral 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(1), 67-82.

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

*Pullmann, M. D., Kerbs, J., Koroloff , N., Veach-White, E., Gaylor, R., & Sieler, D. (2006). Juvenile 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. (submitted May 2007). Impact of the wraparound process in a child welfare system: Results of a matched comparison study. Social Work Research.

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