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Universal:

Tier 2

Tier 3/Tertiar

y

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” health promotion

and prevention interventions,

broad based assessment

activities Mental Health Promotion

and Prevention, Anti-Stigma

and Awareness , Primary

Care .

) Home, School or Community

Based Group or Individual

Supports

Hospital Level Care,

Placements out of School,

Home, Community,

Children’s Mental Health in A Public Mental Health Triangle Model:

Intensive Family to Family or

Peer Support. RENEW/Wrap

Family and Youth Support and Education

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 Provider-driven Family-driven

Source of solutions Professional and agencies Child, family, and their support

team

Relationship Child and family viewed as a

dependent client expected to

carry out instructions

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 Individualized for each child

and family

Access to services Limited by agency’s menus,

funding streams, and staffing

schedules

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

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.

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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: 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.

Family-Centered: Professionals seen almost as

“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.

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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:

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

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?

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?

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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.

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?

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 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

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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

Resources

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 Participation 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?

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:

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

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

Youth Guided

Strengths-Based

Family-Driven

Needs-Driven

Individualized

Culturally Relevant

Unconditional

Community-Based

Team-Based

Accountable

Accessible

Outcome-Based

Cost- Effective

Flexible

Promoting Self-sufficiency

Comprehensive

Collaborative

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The Research Base: Challenges

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.

Eleven National Published Pre-Post Studies

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 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.

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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.

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Phase 1:

Engagement and futures planning:

-Orient Families to Renew Process

-Highlight Roles

-Describe how RENEW helps

the family

Phase 2:Team

Development- 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