John D. Burchard

The role of individualized care in a service delivery system for children and adolescents with severely maladjusted behavior

Individualized care is a total system of care that is tailored to a child with severely maladjusted behavior. The services are unconditional, flexible, child and family focused, and interagency coordinated. The services follow the child until the child is adjusting in a normalized, mainstream environment. Individualized care is illustrated through two different projects. One is theAlaska Youth Initiative where individualized care was used to return children from out-of-state, residential programs. The other isProject Wraparound where it was used to prevent children from being removed from their families. This paper begins with the principles of individualized care and then describes the ecological, multilevel assessment process that coincides with the delivery of services. A case example from Project Wraparound is provided for clarification. Following the case example is a discussion of the need for evaluation data with some suggested strategies for documenting effectiveness. The final section focuses on two barriers to the implementation of individualized care. One is the tendency to think in terms of component programs rather than individualized services. The other barrier is the competition for scarce resources. Strategies are presented for overcoming both barriers.

Comprehensive community-based interventions for youth with severe emotional disorders: Multisystemic therapy and the wraparound process

Two comprehensive community-based interventions for youth with severe emotional disorders are contrasted and compared. The interventions are multisystemic therapy (MST)—a brief but intensive, clinician-provided, and home-based treatment; and wraparound—a long-term approach to planning and coordinating the provision of both formal and informal services in the community. Both approaches are spreading rapidly across the country. As this occurs, it is important for families, clinicians, and policymakers to have sufficient information to understand the requirements and the research base for each. This paper provides a description of both MST and wraparound across multiple dimensions (i.e., origin, theory, target population, principles, role of family, cultural competence, staffing, training, quality monitoring, costs, and the evidence base). The respective similarities and differences are discussed and options for utilizing both for selected youth and families who require intensive and long-term care are explored briefly.

Evaluating the vermont system of care: Outcomes associated with community-based wraparound services

Evaluation of innovative community-based interventions is becoming a high priority for child and adolescent mental health service system research. The present study examined outcomes for a sample of Vermont children (N=27) experiencing emotional and behavioral problems and receiving individualized, wraparound services. One year after initiation of wraparound care, incidence of negative behaviors rated as placing a child at risk of removal from the community had decreased significantly, compliance behavior had increased, and a significant decline in Total Problem Behavior scores on the Child Behavior Checklist was observed. In addition, though 70% of the participants had previously required inpatient or residential treatment, 89% were maintained in the community after one year of services, and the total cost of services was less than that of out-of-state residential care. Although further comparative research is needed, this study suggests that for many of these children, wraparound services may be a more efficient intervention than long-term psychiatric hospitalization or residential treatment.

Wrapping community-based mental health services around children with a severe behavioral disorder: An evaluation of project wraparound

During the past two decades there has been a significant increase in community-based mental health and educational services for children and youth with serious emotional and behavioral problems and their families. However, in the vast majority of programs there are no reliable longitudinal data on the adjustment of the children that are served. Project Wraparound was a community-based individualized treatment program which served children and youth with severely maladjusted behavior and their families by providing intensive home and school-based services. The purpose of this paper is to provide a longitudinal analysis of client and family adjustment data. Data on client adjustment within the home and characteristics of the home environment were obtained at intervals of 3 months, 6 months, and 1 year. Data on client adjustment in school was obtained at four points over a period of 2 years. The results from 19 cases indicate that substantial change occurred on measures of the home environment and client adjustment in the home with no significant change in adjustment in the school. Implications of the findings are discussed.

Wraparound care in vermont: Program development, implementation, and evaluation of a statewide system of individualized services

Over the past decade, there has been a dramatic shift in the provision of mental health services to children, adolescents, and their families. This shift has been marked by a movement away from restrictive treatment options toward the development of comprehensive community-based systems of care designed to keep the most challenging children in their homes, schools, and communities. Based on a model of intensive case management referred to as Wraparound Care, Vermonts statewide approach emphasizes aggressive outreach, use of the least restrictive treatment options, and care that is flexible, unconditional, and child- and family-centered. We chart the development of Vermonts Wraparound Care Initiative and present residential, educational, and behavioral outcome data for a cohort of 40 youth receiving Wraparound Care over a 12-month period. The results showed that after 12-months, youth who had been previously removed from their homes or were at imminent risk of such removal, were residing in significantly less restrictive community-based living arrangements and exhibiting significantly fewer problem behaviors than at intake. These results are discussed in light of recent national studies and previous studies on similar cohorts of Vermont youth receiving Wraparound Care.

Using positive reinforcement to suppress behavior: some experimental comparisons with sibling conflict*

Sibling conflict was used as a prototype problem behavior to compare the relative suppressive effects of two positive reinforcement procedures: reinforcement of a specific alternative behavior and omission training or differential reinforcement of other behavior (DRO). A total of 6 families containing 16 children served as subjects. The procedures were compared within individual families. The major findings were: (a) both procedures reduced the frequency of conflict, relative to baseline by approximately 50%, (b) there was no significant difference in the degree of suppression, produced by these two positive reinforcement procedures, (c) on nights when they were alone, mothers were able to carry out both procedures equally well and with comparable effects to nights when an experimenter was also present in the home, (d) although the percentage of conflict was reduced equally by both procedures, other behaviors were differentially affected, i.e., “appropriate interaction” was increased significantly more by the specific alternative response reinforcement procedure than by the DRO procedure and “no interaction” only showed a significant decline from baseline during the specific alternative response reinforcement procedure, (e) generalized suppression of conflict was observed on nights of the week when neither reinforcement procedure was in effect, (f) parents were able to extend the DRO procedure during a follow-up phase to 2-hr periods of the day and the percentage occurrence of sibling conflict continued to decline during this period.

Wrapping services in an urban setting

Efforts to reform services for children and their families in Baltimore City have included providing Wraparound services to youth returned or diverted from out-of-state residential treatment. We briefly present the history and evolution of the system reform efforts in Baltimore City that were necessary to support the implementation of a Wraparound model of service delivery. The characteristics of the Wraparound service model is presented along with the referral pathway of the youth into the service system, the components of the service delivery system and an overview of step-down services and linkages utilized to transition the youth. Data are presented that demonstrate the level of community adjustment of a subset of the 121 youth served through the Wraparound model in contrast to the level of community adjustment achieved by nonequivalent comparison groups. We discuss the use of “report card” type of outcome measures, its user-friendly features, limitations, and the developmental steps needed to refine it further.

Improving accountability in a service delivery system in children's mental health

Abstract A Vermont legislator who served on the House Appropriations Committee once remarked, “If human service agencies were forced to compete in the private sector, most of them would go out of business in less than a year — their product is people and they have no idea what happens to them after they are served.” This article begins with a discussion of the increasing concern for public agency accountability and some of the limitations of more traditional program evaluation methods for meeting this need. Three methods are described that have been utilized to monitor the progress of children receiving services within a public service delivery system. The methods include the measurement of daily adjustment, residential and educational service tracking, and an approach for integrating and displaying individual case information related to child behavior, life and family events, services received, and service costs. A description and illustration of each method is followed by a brief discussion of issues related to implementation and utilization. Future developments, which include methods to track units of service and youth and parent satisfaction, are also discussed.

Impact of Respite Care Services for Families With Children Experiencing Emotional and Behavioral Problems

In this article we discuss the results of a controlled, longitudinal study of the short-term effectiveness of respite care services for families with children experiencing emotional and behavioral disturbance (EBD). Results indicated that 33 families caring for a child with EBD who received respite care experienced significantly better outcomes overall than did 28 families in a wait-list comparison group, including fewer incidents of out-of-home placement, greater optimism about caring for the child at home, reductions in some areas of caregiving stress, and lower incidence of negative behaviors expressed in the community. However, significant between-group differences were not found for several other variables, and regression analyses suggested that more intensive allocation of service hours was necessary to have a more pervasive impact. The results support the hypothesis that moderate amounts of respite services benefit families with children experiencing EBD but suggest that respite plus other individu...

Foster parents teaching foster parents: Communication and conflict resolution skills training

The purpose of the present study was to examine a model of foster parent training in which specific therapeutic parenting skills (communication and conflict resolution) were taught to foster parents by other previously trained foster parents. A comparison was made of how well these skills were learned under this condition as compared to when instructors were mental health professionals. Pre-to posttest measures revealed that foster parents who received training from either the professional or nonprofessional staff showed greater acquisition of these skills than did a comparison group of untrained foster parents, and that trained foster parents and professional staff did not differ substantially in their ability to transmit these skills.