Janet S. Walker

Children's Stigmatization of Childhood Depression and ADHD: Magnitude and Demographic Variation in a National Sample

OBJECTIVE To estimate the magnitude of stigmatizing attitudes toward peers with depression or attention-deficit/hyperactivity disorder (ADHD) in a national sample of children ages 8 to 18 and to examine variation in level of stigma by school location, region of the United States, grade level, race/ethnicity, or sex. METHOD Surveys were administered to 1,318 children and adolescents. Respondents were randomly assigned to depression, ADHD, or asthma conditions and were presented with a vignette about a peer with one of the conditions. Participants responded to items assessing positive and negative attributions, social distance, and family attitudes. Mean differences were tested for statistical significance and effect sizes were computed. RESULTS Respondents were more likely to make negative attributions about peers with ADHD and depression versus asthma, particularly regarding the likelihood of antisocial behavior and violence (Cohen d range 0.78-1.35, large effect sizes). Moderate effect sizes were found for preferences for social distance from peers with ADHD(d = 0.37) and depression (d = 0.45). Effects were found for perceptions of negative family attitudes toward both mental health conditions, with depression (d = 0.78) seen as even more stigmatized than ADHD (d = 0.47). The level of stigmatization was relatively constant across demographic variables, with the exception of greater stigmatization evident in Asian/Pacific Islander youths. CONCLUSIONS Across most items, both depression and ADHD were more stigmatized than asthma, with depression more stigmatized than ADHD. The perception of likelihood of violence and antisocial behavior was particularly high for both ADHD and depression, greatly exceeding the real-world association for depression.

Intervening in the Lives of Youth with Complex Behavioral Health Challenges and Their Families: The Role of the Wraparound Process

Wraparound is an individualized, team-based service planning and care coordination process intended to improve outcomes for youth with complex behavioral health challenges and their families. In recent years, several factors have led wraparound to become an increasingly visible component of service systems for youth, including its alignment with the youth and family movements, clear role within the systems of care and public health frameworks, and expansion of the research base. In this paper, we provide a review of the place of the wraparound process in behavioral health, including a discussion of the opportunities it presents to the field, needs for further development and research, and recommendations for federal actions that have the potential to improve the model’s positive contribution to child and family well-being.

Practice and Process in Wraparound Teamwork.

Collaborative family—provider teams have become an increasingly popular mechanism for creating and implementing individualized service and support plans for children and families with complex needs. In the context of childrens mental health,this type of individualized service planning is most often known as wraparound, and it has become one of the primary strategies for implementing the system of care philosophy. A consensus has been reached about the values that underlie wraparound; however, less agreement exists regarding the specific techniques or procedures that translate the value base into practices at the team level. Difficulties in reaching agreement about guidelines or standards for wraparound practice are exacerbated by the lack of a theory describing how the wraparound process produces positive outcomes. This article brings together theory and research from a variety of sources in proposing a model of effectiveness for wraparound. The model specifies relationships between team practices, processes, and outcomes. The model is then used as a basis for recommending specific practices for wraparound teamwork.

Grounded Theory and Backward Mapping: Exploring the Implementation Context for Wraparound

Within children’s mental health, there is an increasing demand for wider implementation of wraparound and other interventions that can provide comprehensive, individualized, family-driven care. Unfortunately, implementation has proven difficult because these approaches do not necessarily flourish within traditionally organized agencies and systems. This has highlighted the need for information about how mental health agencies and systems must evolve if they are to provide a hospitable implementation environment for these interventions. A first step in developing this information is through research that advances conceptual and theoretical understanding of the impact of contextual factors on implementation. At the same time, there is an immediate need for practical information to guide decision making and policy development in settings where implementation is being undertaken. This article describes a study of wraparound implementation that used a combination of qualitative strategies to meet both of these needs simultaneously. It is argued that these strategies are particularly well suited to the study of emerging practices that reflect—and help drive—transformation in mental health systems.

Family Voice With Informed Choice: Coordinating Wraparound With Research-Based Treatment for Children and Adolescents

The wraparound process is a type of individualized, team-based care coordination that has become central to many state and system efforts to reform childrens mental health service delivery for youths with the most complex needs and their families. Although the emerging wraparound research base is generally positive regarding placements and costs, effect sizes are smaller for clinical and functional outcomes. This article presents a review of literature on care coordination and wraparound models, with a focus on theory and research that indicates the need to better connect wraparound-enrolled children and adolescents to evidence-based treatment (EBT). The article goes on to describe how recently developed applications of EBT that are based on quality improvement and flexible application of “common elements” of research-based care may provide a more individualized approach that better aligns with the philosophy and procedures of the wraparound process. Finally, this article presents preliminary studies that show the feasibility and potential effectiveness of coordinating wraparound with the Managing and Adapting Practice system, and discusses intervention development and research options that are currently under way.

Development of a Scale to Measure the Empowerment of Youth Consumers of Mental Health Services

Within the field of children’s mental health, there is increasing emphasis on the idea that young people who experience mental health difficulties should be encouraged to take an active role in shaping not only their own treatment but also mental health services and systems. The terms empowerment and, to a lesser extent, self-efficacy have been used to describe consumers’ confidence and capacity for taking on this active role. Measures of mental health empowerment and self-efficacy have been developed for adults with mental illnesses and for parents and caregivers of children with serious emotional or behavioral disorders; however, no such measure exists to assess empowerment among youth who themselves experience serious mental health difficulties. This article describes the development of the Youth Empowerment Scale—Mental Health and provides initial evidence of its reliability and validity.

Defining practice: Flexibility, legitimacy, and the nature of systems of care and wraparound

In human services, clear definition of key concepts and strategies is critical to facilitating training, implementation, and research. This article reflects on methods undertaken to specify the wraparound process for children and families, and considers lessons that may be relevant to defining the system of care concept.

Caregivers' Views on the Cultural Appropriateness of Services for Children with Emotional or Behavioral Disorders

While there is growing consensus on the need for cultural competence in childrens mental health services, research has thus far provided little concrete information about what culturally competent service provision looks like in practice. This study is a secondary analysis of quantitative and qualitative data regarding caregiver perceptions of the cultural appropriateness of services to children with severe emotional and behavioral disorders. The data were gathered from a diverse sample of caregivers for 286 children. Analysis of the qualitative data yielded a set of coding categories which reliably capture the dimensions of caregiver experience contained in descriptions of specific instances of satisfaction or dissatisfaction with services. Caregivers from diverse backgrounds were equally likely to express satisfaction or dissatisfaction with services; however, the distribution of these satisfactions and dissatisfactions across the coding categories was not the same for caregivers of different ethnic or racial communities, or for higher- versus low-income caregivers. For minority caregivers, having experienced a dissatisfaction related to respect for community/ethnic cultural values contributed significantly to overall dissatisfaction with services.

A Theory of Change for Positive Developmental Approaches to Improving Outcomes Among Emerging Adults with Serious Mental Health Conditions

Recent evidence attests to the shortcomings of typical services for improving outcomes among emerging adults with serious mental health conditions (SMHCs). Researchers and providers have responded by developing new programs and interventions for meeting the unique needs of these young people. A significant number of these programs and interventions can be described as taking a positive developmental approach, which is informed by a combination of theoretical sources, including theories of positive development, self-determination, ecological systems, and social capital. To date, however, there has been no comprehensive theoretical statement describing how or why positive change should occur as a result of using a positive developmental approach when intervening with this population. The goal of this article is to propose a general model that “backfills” a theory behind what appears to be an effective and increasingly popular approach to improving outcomes among emerging adults with SMHCs.

Community and state systems change associated with the healthy transitions initiative.

People engaged in efforts to improve services to emerging adults with serious mental health challenges have reached the conclusion that service change at the program or agency level is not sustainable without related changes at the systems or policy level. This article focuses on one set of efforts to create intentional system change at both the community and state levels. These changes were pursued by states and communities that received grants under the federally funded Healthy Transitions Initiative (HTI), with the aim of creating more effective services for emerging adults with serious mental health conditions. The article reviews the development of a measure to assess systems change efforts at the state and community levels and describes the findings that emerged when the measure was used to assess the change that occurred in the HTI sites over a period of approximately three and a half years.