Newsletter > Volume3 > Issue2

Description of Wraparound and Case Example

From the Encyclopedia of Behavior Modification and Cognitive Behavior Therapy, Volume Three, Educational Applications

Wraparound is a philosophy of care with a defined planning process used to build constructive relationships and support networks among students and youth with emotional or behavioral disabilities (EBD) and their families. Major features of wraparound are that it is community based, culturally relevant, individualized, strength based, and family centered. Wraparound plans are comprehensive and address multiple life domains across home, school, and community, including living environment; basic needs; safety; and social, emotional, educational, spiritual, and cultural needs. Another defining feature of wraparound is that it is unconditional; if interventions are not achieving the outcomes desired by the team, the team regroups to rethink the configuration of supports, services, and interventions to ensure success in natural home, school, and community settings. In other words, students do not fail, but plans can fail. Rather than forcing a student to fit into existing program structures, wraparound is based on the belief that services and supports should be flexibly arranged to meet the unique needs of the students and their families.

As teams of community members and extended family from partnerships with mental health providers, educators, and other professionals, wraparound teams often have to create services that may not have existed as part of a community-based continuum of care, such as respite or in-home interventions. Services are created on a "one student at a time" basis to support success as defined by the student, family, teacher, and others who spend the most time with or have the most responsibility for the student As teams problem solve how to effectively meet students' needs, they combine supports for natural activities (e.g., child care, mentoring, making friends) with traditional interventions (e.g., behavioral interventions, specialized reading instruction, medication). Wraparound teams also arrange services for the adults who care for the student. For example, teams have assisted family members in accessing basic living supports, such as transportation, stable housing, recreation opportunities, and social supports. A parent may be better able to focus on a home-based behavior change plan if stress about being evicted from an apartment is alleviated. Teams can also provide supports for teachers who may be challenged with meeting the unique needs of a student A behavior support plan to change problem behavior at school may be- more likely to succeed if the teacher has a designated person (e.g., school psychologist, counselor) who models the instruction of the replacement behavior or how to naturally deliver the reinforcement in the context of a classroom.

A skilled facilitator works closely with the youth and family to assemble a team based on their unique strengths and the student's identified needs. Extended family and other natural support persons ensure that the team represents the culture and values of the family. Team members who have skills in areas of need (e.g., behavior specialist, vocational counselor, mental health clinician) or resources and credibility to support the family (e.g., minister from their church, extended family, friends) collectively prioritize needs, design interventions, and plan access to needed supports and services. Similar to person-centered planning in its focus on quality of life determined by the student and family, the wraparound process creates a context in which the perspectives of all team members are blended to reach identified goals. The focus is to ensure that those who spend the most time with the student have full ownership of and commitment to the outcomes and are invested in the interventions used to achieve the outcomes. Under these conditions, wraparound teams can establish a context where effective interventions are likely to be developed and implemented with success.

RESEARCH BASIS

Wraparound did not develop from a formal change theory but emerged as practitioners sought alternatives to medically based models that had resulted in large numbers of students being placed in overly restrictive settings away from their natural supports. The wraparound theory of change that emerged is consistent with psychosocial child development theories, such as social-ecological theory, social learning theory, and systems change theory.

Wraparound has become a predominant tool for implementing interagency systems of care. The system of care concept was developed in the mid-1980s as a response to (a) a dearth of mental health and other services for students; (b) the fragmentation of services across mental health, education, child welfare and juvenile justice services; and (c) the history of poor outcomes for students with emotional disturbance and their families. The key idea behind the development of a system of care was a coordinated network of community-based services that is organized to meet student and family needs rather than agency needs.

Early research with wraparound involved case studies of students with significant mental health diagnoses and histories of neglect and abuse who were returned to their home communities from residential placements during the 1980s and early 1990s. Stabilization within families and improvement in student-family functioning were reported in these early case studies.

States and communities, with support from grants awarded primarily by national mental health agencies, have attempted to create systems of care that integrate the multiple agencies that historically have been separate and therefore confusing and ineffective to those trying to access services. Descriptive studies of system of care communities that apply the wraparound philosophy and process indicate positive outcomes, such as reductions in use of restrictive placements, stabilized living environments, increases in family and student satisfaction, and decreased use of restrictive special education placements. Student and family outcomes reported by these descriptive studies have included improvements in emotional and behavioral functioning and in school attendance, academic performance, and post-school adjustment indicators.

Although a descriptive research base for wraparound has emerged over the past 10 years, only a few experimental studies have been conducted. The "whatever it takes" approach of building unique services and supports around natural and extended family members presents challenges for researchers attempting to clearly define the process and identify factors that allow precise measurement of the integrity of the philosophy. Although there is agreement on the general philosophy and key features described here; there is a wide variance of program structures. A juvenile justice program using wraparound may use a higher rate of in-home and community-based interventions, whereas school-initiated wraparound connected with school-wide systems of positive behavior supports (PBS) may be more focused on improving functioning at school and therefore more likely to focus on connecting family and school personnel in consistent application of proactive behavior-based interventions. Both types of wraparound-based programs may be adhering to the value base and processes of wraparound, but the resulting interventions, as well as the student outcomes studied may vary.

A further complication is that many programs and models referred to as wraparound do not adhere to the key assumptions and features. Consistent training approaches and tools to measure fidelity of implementation are needed to advance the research agenda. Further research will help to reliably define the wraparound process and develop a theoretical framework linking the process, the actual interventions, and student functioning (outcomes). This theoretical framework could facilitate experimental studies. Testing of this theory can then proceed.

RELEVANT TARGET POPULATION

Wraparound was originally developed for students who had experienced significant system failures and were in residential or other restrictive placements outside of their families and communities. Initially, wraparound was used by agencies to bring students in the custody of child welfare who had been placed out of state back into their home communities by developing unique plans for one student at a time. These early wraparound plans redirected resources to provide supports directly to families while developing inclusive social opportunities and effective behavioral interventions designed in collaboration with the student and family. Some states went beyond the child welfare population and began applying the unconditional wraparound process to bringing students placed by mental health, education, and juvenile justice back into their states and communities. These early applications of wraparound focused primarily on the most seriously affected students with histories of abuse, neglect, substance abuse, criminal activity, and unstable living. Application of wraparound with these severely challenged populations required significant shifts in practice approaches. It greatly emphasized supporting the adults who cared for the student and building multiple life domain supports and interventions across home, school, and community environments.

Since 1993, the Center for Mental Health Services (CMHS) has funded grants in more than 85 states and local communities, including tribal sites and territories, to build systems of care. The wraparound process is the tool used in most of these grant-funded communities, where the target population is students with a DSM diagnosis and their families. This has increased the number of students receiving a wraparound process initiated by the mental health system. More recently, wraparound has been applied to students with EBD in schools and other populations at risk of residential placement. For example, demonstration projects to reduce residential placements have led some school districts to convert school social worker positions into "wrap facilitator" positions. The integration of the strength-based, family-centered wraparound process into school programs benefits students who routinely have not yet been involved with other systems.

COMPLICATIONS

The primary support systems for students with EBD and their families include special education, mental health, child welfare, and juvenile justice. These systems have historically operated independently from each other, with different structures, tools, and philosophies. Differences in eligibility criteria, definitions, policies, and assessment processes create challenges for practitioners attempting to create seamless systems of support for students with EBD and their families. The system of care concept which has been widely disseminated since 1986, provided practitioners with a framework of a full continuum that was flexible and community based but did not include a definition of how practices would have to change to ensure successful student and family outcomes in community-based settings. Wraparound emerged from the need to have a significant change in the design of supports, services, and interventions for individual students and their families. This shift in practice for professionals working with students with EBD and their families presented a challenge to individual systems and to the coordination of supports across settings, life domains, and family members. Moving from deficit-based models to a strength-based, family-centered, approach requires training, practice, and hands-on guidance as professionals change their meeting protocols and communication patterns with families and learn to identify the real needs of the student and family. The following case summary illustrates how a school that was implementing school-wide systems of PBS initiated a comprehensive wraparound process for an individual student. In addition to describing the process and outcomes for the student, descriptions of system struggles and outcomes with learning and applying the wraparound process are provided.

CASE ILLUSTRATION

Readiness for Wraparound. "Lamar," a third grader, was identified as having lying and stealing behaviors by the targeted intervention team at his school. Disrespectful behavior toward adults and peers, disruptive classroom behavior, and a decrease in grades and academic performance were also identified as problematic. These school personnel had received school-wide PBS training and were currently implementing school-wide and targeted group PBS interventions. They had some initial training on behavior support plans and function of behavior and were aware of the wraparound process for students with significant needs but had not yet received specific training in the process. In October, the principal, social worker, and resource teacher had a meeting with Lamar's mother (at school) and discussed the increased problem behavior they were experiencing at school. They hoped to engage Lamar's mother in addressing these problem behaviors but became frustrated, as they experienced her as not responsive. They said she sat passively and offered little information. In completing a strengths and needs checklist (provided by the school's PBS coach), Lamar's mother indicated that Lamar did not participate in activities in the community (she did not fill out that portion of the checklist). She did share that she worried about him in the apartment building and going out to play with other kids. The school social worker gave Lamar's mother a list of resources she could pursue for community-based supports. The school personnel reported to the PBS coach that they did not want to pursue the development of a wraparound team because they felt the mother was not open to a wraparound process. They decided to include Lamar in the group behavioral intervention available in the school, where identified students received increased monitoring and reinforcement for the three schoolwide expectations. The PBS coach encouraged the school personnel to participate in an upcoming wraparound training for PBS schools, as the coach suspected the school team was uncertain about how to engage this parent in a collaborative process.

Lamar's problem behaviors continued to be a concern for the school's targeted intervention team. In February, the team agreed to revisit the option of wraparound, with more direct support from the PBS coach in engaging the mother. At the same time, the team began a case study evaluation (CSE) for special education. In addition, an EBD classification and placement were discussed as a possibility.

Starting the Wraparound Process by Hearing the Family's Story. The social worker and the PBS coach met with Lamar's mother at her home with the purpose of engaging her in the wraparound process while obtaining information for the social history component of the CSE. Much of this meeting focused on the complex needs of the family. Lamar's mother was losing her eyesight and had lost much of her independence; there was very little support in place for the family, which consisted of the mother, Lamar, and his younger brother, age 5 years. Lamar's mother shared her concern that Lamar seemed isolated at home and that she was fearful about letting the boys out to play, as she might not be able to find them due to her visual impairment. The PBS team later noted that meeting with the mother in her apartment (this was offered as an option that she chose) and focusing on what she perceived to be the needs of the family (instead of just focusing on problem behavior at school) helped establish a different context for moving forward with a collaborative plan between home and school. The school was now able to see the unique needs and strengths from the family perspective, and Lamar's mother was beginning to see the school as a potential partner that could help her to problem solve some of her concerns as a parent.

Identifying Strengths and Needs Together as a Team. Following this initial conversation, a wraparound planning meeting occurred at school with Lamar and his mother. Strengths identified for Lamar included being helpful at home, enjoying playing piano and guitar, a sense of humor with peers, being very good at art, volunteering and contributing to class discussions, being good with hands-on activities, and liking things that are laminated. The mother's strengths included keeping her sons safe, enjoying reading with the boys, being insightful about Lamar's behavior, and wanting to attend college.

The team identified that Lamar had no peer contact outside of school. This was a great concern to his mother. His decreasing academic performance was a concern to everyone. It was also discovered that Lamar failed his eye screening and needed an eye examination. The team recognized that the mother also needed community supports regarding her disability. At this meeting, the team began to examine the lying and stealing behavior, which was of concern to the teacher. Analyzing the problem behavior as a team, they clarified that the lying consisted primarily of exaggerated stories about his life, and the stealing involved things such as pencils, Post-It notes, and other school supplies. Lamar's mother shared that she felt Lamar's behavior was due to his sense of being helpless about his life circumstances.

Designing Interventions to Meet Identified Needs and Build on Strengths. To help increase Lamar's sense of belonging and confidence, the team identified several after-school options for Lamar, one of which was an after-school open gym program at school that Lamar had expressed a desire to attend. However, the family did not have transportation. The principal offered to contact another family that could provide transportation for Lamar so that he would be able to get home from open gym. The school team arranged for the eye examination, and the principal and the social worker offered to provide' transportation. The resource teacher agreed to begin doing some curriculum adaptations to ensure academic success in the classroom. The social worker agreed to assist Lamar's mother in investigating the local community-based network for more resources for the family, specifically regarding the mother's visual impairment.

The teacher agreed to provide increased prompts and instruction about "good manners" and respectful voice and words. Lamar would be able to laminate his artwork as an incentive when he met school-wide expectations per his "Check and Connect" card.

Outcomes. In April, the team determined that the curriculum adaptations were successful. His teacher reported that although Lamar knew the work was different from that of his peers, he saw his grades get better and began to feel and act more confident. He then received his glasses, which further increased his academic success, confidence, and behavior. School personnel described him as "a new person." Lamar and his mother reported satisfaction with Lamar's participation in open gym now that the transportation problem was solved. The team reported positive changes, including that he appeared to be happier, had become popular among peers, and interacted with them appropriately. They reported that his use of "respectful tone and words" with adults and peers had increased with prompts and reinforcers. In May, the teacher reported to the team that the disrespectful behavior was increasing again, and the team decided to increase the prompts and reminders about the end-of-year activities available as incentives though the school-wide PBS system. After the team meeting, the mother shared with the social worker that a few weeks earlier, Lamar had overheard her crying on the phone about her increasing blindness. She shared with the wrap coach and the social worker that she had not discussed her deteriorating condition with him, as she herself was confused and fearful. She believed that his recent behavior at school was related to this incident at home.

Ongoing Monitoring and Revision of the Plan. The CSE determined that Lamar had a learning disability, which was already addressed with the curriculum adaptations. A functional behavior assessment completed by the district behavior specialist as part of the CSE indicated that Lamar seemed to be avoiding academic work by acting out in class. As the school year ended, the team planned for Lamar's transition to fourth grade in a new building. Because they were concerned that he had had difficulty in the past making friends and adjusting to transitions, a visit to the fourth-fifth grade center was planned to engage the center in the wrap process and establish relationships with adults who could provide the positive prompts and reinforcement Lamar needed at school. The strategies that were needed to maintain academic and behavior success would be shared through a wraparound team meeting, and the behavior specialist would remain involved with the team at the new school. Lamar's mother connected with an agency that specialized in assisting those with visual handicaps to become more independent in the community. Further connections for her with a broader network of community supports would be pursued with support from this agency. Community supports for Lamar's mother would be added to the wrap team as she is assisted in developing relationships with persons in the community.

-- Lucille Eber

See also: Contextual Fit (Vol. Ill), Person-Centered Planning (Vol. I), Positive Behavior Support (Vol. Ill), Systems of Care (Vol. Ill)