The Wraparound Process: An Overview
I. Description and definition of Wraparound
Wraparound is an approach to treatment that has evolved over the past 15 years through efforts to help families with the most challenging children function more effectively in the community. More specifically, it is a definable planning process that results in a unique set of community services and natural supports that are individualized for a child and family to achieve a positive set of outcomes. While most of the development of wraparound has focused on families who have children with severe emotional and behavioral problems, the approach has also been used for these problems with 'emancipated' adolescents and with families who have family members who are experiencing severe and/or chronic physical illnesses and developmental disabilities. Wraparound has been implemented in the mental health, education, child welfare and juvenile justice sectors.
The philosophy that spawned wraparound is relatively simple: identify the community services and supports that a family's needs and provide them as long as they are needed. However, while the initial philosophy behind wraparound was relatively simple, the development and implementation of the intervention is complex. One reflection of the efforts toward better definition is the reference to wraparound as an intervention rather than a service. The more common label of a 'wraparound service' is often interpreted as a specific service or an array of categorical services. For example, some agencies have declared that they have offered wraparound if they provided respite or individualized services, even though many essential elements of the approach were lacking; e.g., the parents were not involved in the decision-making process. Other agencies have described their intervention as wraparound because they utilized funding from two separate agencies, even though all families received the same array of services. There has also been the misconception that wraparound can be administered outside the community in residential treatment centers or psychiatric hospitals, even though wraparound was conceived as and is intended to be an alternative to institutionalization. In short, there has not always been the awareness that wraparound is a comprehensive approach that requires a specific set of values, elements, and principles, all of which have to be in place.
In the latter half of the 1980's, efforts to implement wraparound began to spread as many state and county public services agencies began to explore new ways to provide community-based services to children with severe mental health challenges. By 1990, the wraparound approach had been established as a viable alternative to residential treatment, with many advocates expressing the belief that wraparound was more youth and family friendly, less costly and more effective than traditional services. Since that time there has been a remarkable expansion in the utilization of the wraparound approach. Results of a 1998 survey of the United States and its territories suggests that the current number of youth with their families engaged in wraparound could be as high as 200,000 (Faw, 1999).
Coinciding with the rapid proliferation of wraparound has been concern for more uniform definitions and practice standards, as well as measurement of fidelity to the intervention. The essential elements and requirements for practice are listed below. These elements and principles provide the foundation for service provision, as well as training, supervision, and assessment of fidelity to the Wraparound approach.
Essential Elements of Wraparound
Requirements for Practice
The elements and practice principles listed above provide the framework for the two main components of the wraparound intervention. The first component is a family-centered decision-making process that identifies those services and supports that will help meet the family's needs. The second component is the actual array of services and supports that are implemented. Operating together, these two components provide the primary active ingredients of the wraparound intervention.
II. Research on Wraparound
For the purposed of this review, fifteen studies were identified which attempted to assess the effectiveness of the wraparound approach: two qualitative case studies, nine pre-post studies, two quasi-experimental studies and two studies involving randomized clinical trials. Overall, the research base on Wraparound remains undeveloped in comparison to many child and family interventions; nonetheless, significant evidence supports wraparound's effectiveness.
The first case study in the review was an extensive retrospective analysis that included personal interviews with approximately 75 key informants who were involved with 10 youth who had been receiving wraparound through the Alaska Youth Initiative (Burchard, Burchard, Sewell & VanDenBerg, 1993). One to two years after entry to wraparound, all the youth were still residing in the community. Five youth were no longer requiring services, four youth still receiving services with a stable adjustment and adjustment of the remaining youth was very unstable. The other case study consisted of a retrospective analysis of eight child welfare families that had been receiving the wraparound intervention (Cumblad, 1996). During the time that these families received wraparound (mean duration 3 years), there no longer was any evidence of abuse or neglect and none of the children were removed from their parents. At the time the study was conducted, all the children were in more stable family environments. In addition, none of the children were exhibiting the high-risk behaviors that led to their referral for wraparound.
The nine pre-post studies provide preliminary evidence that positive outcomes are correlated with wraparound. While the case studies provide a rich base of subjective information on a few children and families, these nine studies provide data from empirically based measures on hundreds of children and families. Taken together, the findings of these nine pre-post studies provide evidence that the majority of these children were able to maintain a stable adjustment in the community. The clearest evidence is that studies show almost all of the children were living in the community months and sometimes years after they entered wraparound. This alone is a significant finding. Research demonstrates that a large percentage of children with severe emotional and behavioral problems who receive 'traditional services' are eventually placed in more restrictive programs outside their communities. This is evidenced by the findings of the National Adolescent and Child Treatment Study, which found that 32% of the children and adolescents who were 'discharged successfully' from 28 different residential treatment centers where either readmitted to a residential program or incarcerated in a correctional facility within 12 months of discharge (Greenbaum et al., 1996). After six years the recidivism rate was 75%.
Quasi-experimental studies consist of one study that compared the community adjustment outcomes of different groups of subjects who received wraparound and residential treatment services and one within-subject study that employed a multiple baseline design. The group study was conducted under the auspices of the Family Preservation Initiative in Baltimore (Hyde, Burchard & Woodworth, 1996). This study found that after two years of the inception of wraparound a "good" adjustment rating was obtained by 47% of those who received wraparound and 8% of those who received residential treatment only. Given the rather stringent criteria required (e.g., 85% school attendance or 35 hrs/week of vocational activity) for classification in the "good" adjustment category, the results are very promising. However, a major limitation was that only 42% of the group that received residential treatment alone were able to be located for inclusion in this retrospective study.
In the second quasi-experimental study, four youths with histories of chronic offending who were receiving services through the wraparound approach were studied (Myaard, in press). Baseline behaviors consisted of low rates of compliance and appropriate peer interaction in all four participants and high rates of physical aggression, alcohol and drug use, and extreme verbal abuse in three participants. In each case marked behavioral improvement occurred shortly after the beginning of wraparound. Results were interpreted as providing strong evidence that wraparound was responsible for the participants' behavioral change.
Randomized Clinical Trials
The research base on wraparound includes two randomized clinical trials, one conducted in New York and a second in Florida. In the New York study (Evans, Armstrong & Kuppinger, 1996 and Evans, Armstrong, Kuppinger, Huz & Johnson, 1998), 42 children who were referred to out-of-home placements were assigned to either treatment foster care (n=15) or family-centered intensive case management (n=27). The latter condition (FCCM) employed most of the values and elements of the wraparound process. The results showed more favorable outcomes for the children that received wraparound. This was evidenced by a greater decline in behavioral symptoms, lower overall impairment, and fewer externalizing, social problems and thought problems.
In the Florida study (Clark et al., 1998), 131 youths in the foster care system were randomly assigned to either wraparound foster care (n=54) or standard foster care (n=77). One of the major findings of this study was fewer placement changes and fewer days absent from school for the wraparound group. In addition, the boys in the wraparound group showed lower rates of delinquency and better externalizing adjustment than the boys in standard foster care. Also, the older wraparound youths were more likely to achieve a permanent living arrangement in the community (with their parents, relatives, adoptive parents, or living on their own).
Fidelity Assessment and Association with Outcomes
Ensuring treatment fidelity in children's and family services is becoming an increasingly important issue in both service delivery and research. With respect to the Wraparound approach, this work has been urgent because of the complex nature of service delivery within the Wraparound approach, the need for QA within programs, concerns about the proliferation of programs that are not truly adherent to the Wraparound model, and the need for a reliable and valid tool to measure the nature of wraparound interventions in future large-scale outcome studies (Burchard, Bruns, & Burchard, 2002). Until recently, the primary attempts to measure fidelity have been programs' QA procedures that combine techniques such as open-ended interviews, record reviews, and supervision of providers (Bruns, 1999). More recently, the Wraparound Observation Form (WOF; Epstein, et al., 1998) was developed, using independent observers to validate that elements of the wraparound process were occurring at the child and family team level. While this approach is limited by an observer effect and requires on-site personnel, it can provide useful feedback for training and supervision.
Although it is still under development, the most widely adopted approach to measuring fidelity to Wraparound is the Wraparound Fidelity Index (WFI; Bruns, Suter, Force, and Burchard, 2002). The intent of the WFI is to assess the adherence to the Elements and Practice Principles listed above for an individual family through the use of a standardized, rating-scale checklist that is administered in an interview format. Parents, Youth, and Resource Facilitators respond to items on a three-point scale, where 2=Yes, 1=Sometimes or Somewhat, and 0=No. Taken together across informants, a full profile of adherence to the 10 Elements is constructed for the family. Administration of the appropriate WFI forms yields Total Fidelity scores and Element scores for individual families, which can then be aggregated within a site or program to create an Overall Fidelity Score for the site, as well as a profile of Element scores. WFI data can be turned into reports that allow for improvement of service delivery at a site or jurisdictional level, as well as an individual family level. The WFI Total Fidelity Score has been found to have good test-retest reliability and internal consistency across as well as within individual respondents. Construct validity studies have revealed significant correlations between WFI scores and fidelity ratings of an on-site expert who utilized intensive record review and multiple interviews to assess fidelity for individual families.
Perhaps most interestingly, WFI scores
have been found to
be significantly associated with child and family outcomes, including
behavioral strengths ratings, child functioning, restrictiveness of
placement changes, and parent satisfaction with the child's progress
al., 2002). This preliminary study also found that Wraparound fidelity
measured via the WFI was more likely to predict future outcomes than be
associated with concurrently assessed outcomes. Such findings support
hypothesis that, within complex service delivery approaches such as
fidelity to family-centered, team-driven practice principles (such as
specified in the Wraparound approach) mediates the relationship between
participation in a system of care and child and family outcomes. Such
also provided additional support for the construct validity of the WFI.
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Adjustment ratings were based on a combination of residential and behavioral data. See Hyde, Burchard, and Woodworth (1996) for full definitions.