Why We Need Wraparound: A Short History

In honor of Mental Health Month Blog Day, I want to take a moment to appreciate how far we’ve come as a community when it comes to helping kids with complex behavioral needs, and how far we can still go. Wraparound didn’t just happen one day, it grew out of bleak necessity.

By the 1970s, mental health services for youths, children, and their families with complex behavioral needs were at a crossroads.  Funding and service changes were calling for deinstitutionalization.  At the same time, there were few good options for providing the kind of holistic, comprehensive services these children and families needed.  Before wraparound, too many children with complex behavioral health needs were being put into long-term placements outside their homes. Wraparound grew out of the continuing movement to improve behavioral health services for children, youth, and their families. Prior to the advent of wraparound, two-thirds of all children with severe emotional disturbances were not receiving appropriate services (Knitzer, 1982). These children were “unclaimed” by the public agencies responsible to serve them, and there was little coordination among the various child-serving systems.

In 1980, a lawsuit called Willie M. vs. Hunt supported the need for community-based system of care services. This set a precedent for the legal right to treatment options within the community. To address this need, Congress appropriated funds in 1984 for the Child and Adolescent Service System Program (CASSP) through the National Institute of Mental Health. It was envisioned as a comprehensive mental health system of care for children, adolescents and their families. Ongoing Federal grants supported the development of systems of care across the country. The first project named Wraparound was grounded in creative agency­ based individualized planning at the Kaleidoscope Agency in Chicago (Kendziora, 1999). The Kaleidoscope Agency’s practices grew from research on de-institutionalization and normalization efforts from Canada. Soon afterward the Alaska Youth Initiative built on the Kaleidoscope program to bring all children in out-of-state back to their home communities (Burchard, Burchard, Sewell & VanDenBerg, 1993).  Following these successes wraparound as a process was used in early programs directly targeted to keeping youths and children in their homes. States such as Alaska, Michigan, Maine, Wisconsin, Vermont and Kansas used the process to reduce the potentially harmful impact of long –term institutional placements and serve children and youth in their homes. These early pilot programs were based primarily on the key principles of individualization, unconditional care, strengths-based planning, and increasing family voice and choice.   At these early stages there was little to no standardization of the wraparound process.

By 1988, many communities had created programs they called ‘‘wraparound.” These programs varied wildly in quality and in scope. Local implementation was shaped through local innovations and policy and funding constraints.  By the mid 1990’s, efforts in several states to implement ”wraparound” had been identified as failures by implementers, evaluators, and funders. Close examination of these efforts revealed that what was called wraparound more closely resembled children’s case management with no real individualization, limited family voice and choice, no integration of services, and a focus on deficit-based services (Koroloff, Walker & Shutte, 2003).

These failed variations posed a serious threat to the continued funding of wraparound everywhere. To address this, a meeting was held at Duke University. This meeting marked the first major organized effort to provide consistency to the definition of the wraparound process (Burns and Goldman, 1998).  This meeting helped to clarify the principles, but had little direct effect on the process variation.

In 2001 a larger group of early innovators, providers, and family members came together to continue the process of defining and standardizing wraparound.   This group grew into the National Wraparound Initiative (NWI) and developed standardized principles, and described the process of wraparound through standard phases and activities (Walker and Bruns 2006).  A part of NWI -the Wraparound Evaluation and Research Team (WERT) – developed standardized fidelity measures based on pre NWI tools (Rast and Burchard, 1996) and the principles of the process (Bruns, 2007). The founding partners of VVDB, Jim Rast and John VanDenBerg, were initial core members of NWI. Many states and provinces have accepted the standardized principles and the phases and activities of the NWI as the definition of the wraparound process, and the field is becoming more consistent. 2001 was also the year that the Jason K. lawsuit in Arizona, leaning on the precedent set By Willie M., led to the inclusion of over 16,000 children and youth in the wraparound process.

The NWI principles, phases, and activities created a strong basis for standardizing wraparound practices. Their efforts are being felt on a global scale. Recently, the government of Norway (Flessen, 2007) launched a nation-wide effort to establish NWI-inspired wraparound, which is being supported by trainers from the United States and from a successful wraparound effort in Toronto, Ontario. Wraparound implementation is also beginning in New Zealand. However, there was still more work to be done.  VVDB has extended the work of NWI to define the roles of the Wraparound Facilitator and Family and Youth Support Partners through functions, action steps, and certification processes.  In addition, VVDB has defined a theory of change that explains why wraparound works which guides staff to individualize the process they use to do wraparound with individual families and provide a fidelity-based process for coaching and supervision.  VVDB has continually addressed challenges to engaging, completing, and sustaining progress and outcomes for families in wraparound.  One of the major lessons of this experience shows that success in wraparound must focus more on the youth and family than on the team.

A major focus and goal of wraparound (purposeful transition) is to prepare youth and families to get their own needs met and manage their own crisis after wraparound.  VVDB teaches that wraparound is equally about addressing current needs and preparing the family for the future. VVDB also recognizes that most people have “teams” of people who support them, but that the “teams” or “go to people” vary with different needs and few supports are involved with even most of the family’s needs. Families have many different ways they prefer to ask for and coordinate services and supports (their culture of support).  Most do not choose to have team meetings.  Managing wraparound throughout the implementation phase through team meetings does not prepare (most) families to sustain progress after wraparound. Explanations of wraparound that focus more on the team than the family miss this major element of successful wraparound. VVDB has developed competency-based training for all wraparound staff and defined roles for trainers, coaches, supervisors and wraparound process mentors (consultants and coach trainers).  VVDB has developed certification processes for each of these positions.  VVDB has also developed and continues to develop advanced training and coaching materials through ongoing implementation research.

Today, wraparound is helping families across the country. Our practices are getting stronger – along with our research base. Our communities are becoming more integrated. But we can do better. There are still programs doing “wraparound style” instead of true high fidelity wraparound. There are still consultants selling shortcuts and easy fixes instead of focusing on sustainable success. And there are still so many things we don’t fully understand.

I'm Blogging for Mental Health 2015.

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