Children’s Mental Health in
A Public Mental Health Triangle Model:
Hospital Level Care,
Placements out of School,
Home, Community,
Intensive Family to Family or
Peer Support. RENEW/Wrap
Home, School or Community
)
Based Group or Individual
Supports
Family and Youth
Support and
Education
Mental Health Promotion
and Prevention, Anti-Stigma
and Awareness , Primary
Care .
Tier
3/Tertiar
y
Tier 2
2-5% of
population:
complex challenges,
require highly
individualized support
15% of population:
Less complex individual
and/or group supports,
therapies
80% of population:
Universal:
“universal” health promotion
and prevention interventions,
broad based assessment
activities
Some of What We Know:
History of poor outcomes for children/youth with
emotional/behavioral disturbance and their families
Schools are spending significant resources to address the needs
of the students who need Tier 3 supports, often with limited
positive outcomes. This cost and issue decreases with
investment in PBIS.
Special education identifications are up in many districts
Suspension rates are too high
Restrictive placements are too high
Intervention…
Needs to happen sooner for many youth/families
Gets tougher with each system failure
When MTSS are in place…it saves $ and students.
(Kate Salvati, SLC)
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Engagement is an Intentional and
Active Intervention
Failed Interventions are Never
Neutral (Eber)
Engaging Families in MTSS
 Tier
1: Familiar and “easiest”
 Tier 2: Unfamiliar and challenging
 Tier 3: We have a context, but
rarely engage at the highest level
of mutual trust and high
performance
Paradigm Shift in Service Delivery Systems for Children and Youth with Emotional Disturbance
From Osher, Trina W. and David M. Osher. The Paradigm Shift to True Collaboration with Families. Journal of Child and Family Studies,
Vol. 11, No. 1, March 2002, pp. 47-60.
Paradigm
Provider-driven
Family-driven
Source of solutions
Professional and agencies
Relationship
Child and family viewed as a
dependent client expected to
carry out instructions
Child, family, and their support
team
Partner/collaborator in decision
making, service provision, and
accountability
Orientation
Isolating and “fixing” a
problem viewed as residing in
the child or family
Ecological approach enabling
the child and family to do better
in the community
Assessment
Deficit oriented
Strengths based
Expectations
Low to modest
High
Planning
Agency resource based
Access to services
Limited by agency’s menus,
funding streams, and staffing
schedules
Individualized for each child
and family
Comprehensive and provided
when and where the child and
family require
Outcomes
Based on agency function and
symptom relief
Based on quality of life and
desires of child and family
2
Family Engagement
Stages of Family Team Development

Professional Centered: Professionals are the
experts. At Tier 3, families may be viewed as a hostile
and resistive force, in the way of achieving professional
goals. At Tier 1, families may be fundraisers or popcorn
makers (little policy impact). At Tier 2, families are ?

Family Focused:
Professionals are the experts,
families may be helpers or allies. Professional knows
best, decides both the rules and the roles for team
members. Focus is on getting the family/community to
ally toward the professionals’ goals.
Stages of Family Team Development

Family Allied: Tier 3:

Family-Centered: Professionals seen almost as
Families are viewed as the
customer, professionals strive to attune the
services/structure to the needs and desires families. Tier
1 and 2: Families are seen as colleagues who have
knowledge and ideas but that choice may be limited by
what folks “internally” know is available or allowed.
Collaborative but not equal.
“employees” of the family- families are the experts and
professionals exist to support them and their role as the
primary agent in helping their children reach their goals.
3
The Team Stage

Team Centered:
Decision making with a full team
of school, community, and family. Team strengths and
resources are collected and used to select strategies
most likely to work, at all levels. Planning and
intervention rest on the combined skills and flexible
resources of a diversified and committed team. Decision
making rests with the collective power of the team
working together, without shame or blame, in a
supportive manner.
At “TEAM”- we know we are
there when:


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Families play an active role in planning,
implementation and evaluation of
interventions at all 3 levels.
Family Voice: why does the school run this
way? How can we together make it run
better?
Families with students supported at all 3
Tiers are actively engaged in MTSS
Activity: Assessing Stages



What stage of Team Development are
most of the teams you work with currently
at? What roles do outside resources,
including families, play at each tier?
Think about 3 ways in which you might
help your teams move to the next “level”.
Move into groups- i.d. 3 solid strategies to
advance toward a “team centered” model
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Some Barriers to Team

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Often, policies and rules of individual agencies are
barriers to full engagement- name some.
Families and professionals may both have had multiple
negative experiences that they bring to the table
Service and support teams are a “false/forced”
construct- not the way relationships normally develop
Members of a team may not all have a common goal
Finding and incorporating natural and community
supports can be difficult- strategize.
Some agencies may have limits on employee time due to
billing constraints
FUNCTION: Why do it? How?


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It’s all about function- and data
Definitions- for example, who is defining
what a welcoming environment and
climate feels like within the school? Who
defines the “hat policy”?
Data- how are families reacting to
changes within the school? What do they
know? How can they contribute?
Tier 1: Universal




How are parents engaged at Tier 1? Who
is engaged? (reflective of community?)
What are the benefits of parent
engagement at Tier 1?
What are the challenges of parent
engagement at Tier 1?
What can you do better?
5
Tier 2:Targeted




What are the functions of your Tier 2
team?
How are parents engaged at Tier 2?
What skill sets/perspective can parents
offer at Tier 2?
What processes are in place to incorporate
parent perspective into planning and
implementing interventions and supports?
Tier 2, Targeted Cont’d.


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What decision making roles do parents
have in regard to behavior/”discipline”?
What data do parents access and give
input about?
What are the barriers to parent
engagement at Tier 2?
What can be done better? What will you
do next?
Tier 3: Intensive



How are we doing engaging parents at
Tier 3? Are we hitting high performance as
teams at Tier 3?
What are some successful strategies for
parent engagement at Tier 3?
What can be done better? What will be
done next?
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Activity



Family Engagement Checklist- Muscott
and Mann (2004) from Epstein (2003) and
Fullen (1991)
How is your school doing, if you look at it
through the lens of this tool?
What could or should be modified about or
added to this tool? (10 years old now)
Team Member Strategies: Who do We Need
to Be?






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Listeners first and above all
Equals in power and responsibility
NOT saviors or martyrs (Tier 2 and 3 especially)
Communicators: Open, honest, constant and clear
Informed about resources and open to non-traditional
approaches
Respectful of differences of culture and values
Understanding of each other’s limits and limitations
Tools for building family
engagement: Tier3

Hear their story –



Set a time to meet that works for them
Begin with a conversation, not a “meeting”
Use active listening skills such as



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Clarification, empathizing, reframing, mirroring, summarizing
Help elicit/identify strengths
Make a conscious effort to remain non-judgmental
Accept hospitality!!!!
Use a Person Centered Planning “Mapping”
approach
7
The Unique Culture of
Intergenerational Poverty

Skills learned to survive poverty are not the same as the
skills that make us successful in school- examples?
Cultural elements most often decried by providers: the
“big screen tv” issue- entertainment in poverty
Families who are “in for what they can get”
Hospitality as an element of family culture.
Fluid lines of family definition
“Retro- Rich”

Ruby Payne: The Culture of Poverty

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Resources

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PIC, GSFFCMH, NAMI NH
Muscott and Mann 2004 Tool
Parent Professional Partnership- National
Federation of Families for Children’s
Mental Health
Takeaways
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Scenario:
-You struggled in school and dropped out in 10th grade so you could
work and help your family
-You have a family history of mental illness
-You have been out of work for 8 months
-Your car needs brakes and isn’t inspected
-Your assistance check was unexpectedly $500 less this month
-You can’t pay rent and you are at risk of being evicted
-Your son was just suspended for the 8th time and the school wants you
to come to a meeting…
How are you feeling now??
(Thanks and credit to Kate Salvati, Strafford Learning Center)
Scenario:




You manage to get a ride to the meeting from a
neighbor
You arrive on time but everyone else is already at the
table talking
You are still thinking about the food shortfall you will
have this month
The room is full of professionals:



Teacher, principal, guidance counselor, school psychologist, special ed.
teacher, behavior specialist, truancy officer, Special Ed. Director and 2
others that you didn’t catch
They are having a “Manifestation Determination”
meeting – it sounds serious but you don’t know what it
means
And how are you feeling now??
Scenario Continued:
The meeting starts with everyone talking about all the trouble your son is
causing at school and in the community
The team spends 45 minutes giving examples of what he has been doing
wrong
They tell you the next time he gets in trouble at school you will have to come
pick him up
They tell you to call the police the next time he leaves the house without
permission
They tell you that you have to get him to school even when he refuses (he’s
5’10 and 180 lbs)or you can be filed against for educational neglect
They ask you if you have gotten him to counseling like they told you to last
time
They ask you if you have any questions
How are you feeling now??
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Do You Feel Engaged?
Is Your
Energy for
Participatio
n in Future
Meetings
Very High
Right Now?
Are You Very Excited to Answer the Phone?
Activity: Initial
Engagement
You have just received word that
you will now be working with the
most difficult and “notorious”
family that your school and agency
support. What 3 things can you do
right away to ensure that your
efforts to engage with this family
are more successful than past
efforts?
What is Wraparound?

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Wraparound is a planning process, based in a
clear set of values and principles.
Wraparound teams have dynamic rather than
static membership.
Wraparound is a process that begins with the
strengths of individual youth and families.
Wraparound is not a service or set of services.
Wraparound is a good tertiary level planning
intervention
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



What is Wraparound?
Wraparound is a process that is child
centered and family focused
Wraparound connects families to supports
and services in their communities, and
always includes a mix of public, private,
and natural supports.
Wraparound is a process that respects
families’ culture and values.
Wraparound is led by a trained facilitator.
Wraparound Is Not:

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A specific set of services offered
A typical team meeting
Any meeting held without family or youth
An immediate or quick solution
A crisis intervention or response
A standing interagency team
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Wraparound in Simplest Terms

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Work until it works.
When barriers arise--- People haven’t failed- the
plan has failed.
Strengths plus Needs= Actions
Voice and choice.
If it doesn’t feel like help, it probably isn’t.
No shame, no blame
Activity: Reframing



Reframe our own perspective on family
challenges
Reframe the words we use to describe
youth and families
Reframe deficits and challenges as
strengths
Critical Elements of High Fidelity Wraparound


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Youth Guided
Strengths-Based
Family-Driven
Needs-Driven
Individualized
Culturally Relevant
Unconditional
Community-Based
Team-Based

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Accountable
Accessible
Outcome-Based
Cost- Effective
Flexible
Promoting Self-sufficiency
Comprehensive
Collaborative
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The Research Base: Challenges

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Wraparound is considered a promising practice; more research
projects using control groups (not receiving wraparound) need to be
done to establish it as a true evidence based practice.
Wraparound is not yet “manualized”- there are recognized national
trainers and several curricula, but no standard manual.
Many kinds of planning are being done with families that are called
wraparound but may or may not include all of the “critical elements”
that have been widely agreed upon as necessary to good
wraparound.
Fidelity measures vary.
Wraparound is not fully and well defined…but we are getting closer.
Most EBPs are not designed for children- wraparound is, but is not
manualized.
The Research: What has Been Done
from: Burchard, JD, Bruns, E.J, & Burchard, SN (2002) The Wraparound Process and B.
Burns, K. Hoagwood, & M. English. Community Based Interventions for Youth, NY:
Oxford University Press


Fifteen studies have been done: two
qualitative case studies, 11 pre-post
studies, two quasi experimental studies,
two studies involving clinical trials.
This research is not sufficient to qualify
wraparound as an evidence based practice
in the strictest definition of the term, but
is significantly promising.

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Eleven
National
Published
Pre-Post
Studies

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Improvement in self-control
Improvements in home, school, and community,
role performance
Decrease in problem behaviors
85% decrease in arrests
Improvement in permanency
Decrease in hyperactivity
Decrease in abuse related behaviors
Decrease in substance use
Decrease in hospital admissions
Decrease in out-of-home placements.
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Research: Pre Post Studies

This can be compared to the findings of
the National Adolescent and Child
Treatment study, which found that of
children with SED who received only
“traditional” services via residential
facilities and were discharged successfully,
32% were placed back in residential or
incarcerated within 12 months. After 6
years, recidivism was 75%.
National Published Studies
Two Randomized Published Studies

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Increase in home, school, community
functioning
Improved permanency
Decrease in days and number of suspensions
Decrease in runaway behavior
Decreased incarceration (2.6 times less likely)
Decrease in delinquency and conduct disorder
Decrease in problem behavior.
Issues with the Evidence


It is not clear that the “wraparound” being done
in each of these trials and projects was exactly
the same– i.e. it is not clear that there was
fidelity to a single practice model.
Often, “values” and adherence to them are
taken as fidelity measures, as opposed to
objective, quantifiable elements that can be
clearly seen as present or absent.
14
What Does the Research Add Up To?
Fidelity to a Practice Model= Better Outcomes for
Children and Families.
 Critical Elements of a “good” wraparound
process (i.e. one that will result in good
outcomes) have been developed and are largely
agreed upon by experts and practitioners in the
field. The Portland University Research and
Training Center has published these critical
elements and they are becoming widely used.
Common shortcomings in Wraparound– nationally and
in New Hampshire
•Failing to incorporate full complement of important individuals on
the wraparound team.
•Failing to engage the youth in community activities the youth does
well, or activities that will allow him or her to develop appropriate
friendships
•Failing to use family/community strengths to plan and implement
services
•Failing to use natural supports, such as extended family members
and community members
•Lack of flexible funds to help implement innovative ideas that
emerge from the ongoing team planning process
•Inconsistent outcome & satisfaction assessment
• Under use of trained facilitators- facilitators experience a
decrease in confidence and skills.
From patterns of WFI element and item scores (Bruns, 2004)
Family Engagement as a Critical Element in
Wrap/RENEW


Defining “Family”: a family unit is defined
by its members, and each family defines
itself
Can include bio or adoptive parents, foster
parents, partners, siblings, extended
family, friends who provide extended
support to a child or primary caregiver:
may be fluid.
15
Phase 1:
Engagement
and futures
planning:
-Orient Families
to Renew
Process
-Highlight Roles
-Describe how
RENEW helps
the family
Phase
2:Team
Developmen
t- Initial
Planning:
-Youth Present
Futures Plan to
Family
--Engage Family
during Team
Development
Phase
Phase 3:
Implementat
ion and
Monitoring:
-Family has
roles during
implementation
and Monitoring
-Family
celebrates
Successes
Phase 4:
Transition:
-Family has a
role in
transition
planning
-Family has a
role in
connecting
youth to follow
up supports
The Wraparound Process and its Current
Place within the Research Base on
Treatments for Children, Youth, and
Families
Eric J. Bruns, Ph.D.
Acting Assistant Professor
University of Washington Department of
Psychiatry and Behavioral Sciences
Division of Public Behavioral Health and
Justice Policy Division of Public Behavioral
Health and Justice Policy
ebruns@u.washington.edu
Grand Rounds
University of Washington Division of Child
& Adolescent Psychiatry
Children’s Hospital and Regional
Seattle, Washington
February 4, 2005
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