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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
Grand Rounds
University of Washington Division of Child
& Adolescent Psychiatry
Children’s Hospital and Regional
Seattle, Washington
February 4, 2005