In school young "Rob's" misbehavior was so disruptive he spent
more time in detention than in the classroom. Out of school his antisocial
conduct escalated to brushes with the law and attempted suicide. His parents
were at their wit's end when a juvenile court judge remanded their son to a
program for children with behavioral problems.
After meeting with the Family Support Team of the Southwest Detroit
Wraparound program, Rob had an epiphany. For the first time he discovered that
how he acted on his feelings made a huge difference to his life.
"I f----d up," said a defiant Rob, a teenager diagnosed with
hyperactivity and bipolar disorder. "But coming here was awesome,"
he told an intake counselor at the Southwest Detroit Wraparound program."
Most places treat you like a nothing. Here they really care."
Wraparound, as the word implies, provides services that build constructive,
community-based relationships and support networks between children with
emotional or behavioral difficulties and their families, teachers, and other
caregivers (see Wraparound Programs Arose as Institutional Alternataive).
Wraparound programs maintain that the family's perspective should have the
most prominent place in the design of mental health services for an individual
child and that care decisions should be based on tapping into a child's
Since 1996 the Detroit program has served more than 20 children and
families each year in its blue-collar, ethnically diverse section of the city.
Treatment is available for anyone up to age 22 who has mental health problems;
is involved in multiple systems such as child welfare, mental health,
substance abuse, special education, or juvenile justice; and is deemed to be
at risk of removal from the community. About half of Wraparound program
clients are court referred. Most require psychiatric medications.
"The most professionally gratifying aspect of working with Wraparound
is knowing you have the financial resources to do the kind of work you were
trained to do as a child psychiatrist," Jan Bow, M.D., told
Psychiatric News. Bow is medical director of Southwest Counseling
Solutions (SWCS), part of a community mental health agency that coordinates
the Southwest Detroit Wraparound program. The program operates with an annual
budget of $338,000 from the Detroit-Wayne County Community Mental Health
Besides financial resources, Bow credits the success of Wraparound to a
dedicated staff and the ability to engage multiple systems to improve
children's lives. She oversees a staff of seven psychiatrists; three are child
psychiatrists who work as part-time consultants for Wraparound. It also
contracts with psychiatrists at local mental health clinics and in private
(Physicians don't work directly for Wraparound partly because of the
process by which children/families come into the program. In Michigan it is
through referral to the community mental health team, which reviews and
determines whether they meet entry criteria.)
Once psychiatrists are assigned to a case, they become clinical supervisors
and make the final decisions on treatment issues. They also help supervise
social workers, who provide therapy to patients.
Each patient assigned to a psychiatrist has a resource coordinator and
therapist-social worker who arrange with community service organizations to
provide patients with everything from food, clothing, or housing to legal
services for those caught up in the criminal-justice system.
Patients also have access to teams of professionals representing child
welfare, mental health, substance abuse, special education, juvenile justice,
and other agencies. They can even have individualized tutoring, often
unavailable in community mental health settings.
"Because the program is needs driven and emphasizes strengths, not
pathology, it creates a safe and open environment that encourages children and
families to speak their minds, "Carlynn Perkins, L.M.S.W., project
director for SWCS, told Psychiatric News.
A special feature of Wraparound is its close contact with schools. If a
child is sick and failing in school, a parent advocate or resource coordinator
goes to the school to talk with teachers and find out why the child is doing
poorly. If deemed necessary, the parent advocate or resource coordinator will
arrange for after-school supervision of the child. They might also arrange for
enrollment in a boys' or girls' club if they think it would benefit them.
"Visiting a child's school can be especially helpful," Bow
said, as many of the parents she deals with seldom visit the school or get
feedback from teachers on their child's behavior.
She believes it is important to give parents choices about their child's
treatment, a key part of the Wraparound philosophy. For example, if they want
their child to get off medication, she may tell them to go ahead and contact
her in a week to let her know how the child is doing. Then she follows up with
the teacher to see if the child is acting up or has skipped school.
Bow will not start a child on medication without a report from the school,
which she feels is critical. Her staff has a detailed protocol describing when
medication is needed or should be discontinued.
She believes the key to a successful Wraparound program is to have everyone
involved with it talk about each case and coordinate their efforts."
That has worked out really well," she said.
Jeanette Scheid M.D., Ph.D., an assistant professor of psychiatry at
Michigan State University, agrees. She has been a contractual psychiatric
consultant for several Wraparound programs in Michigan.
"When Wraparound is done with fidelity to the model, it is a really
good way to approach working with kids and families," she told
She maintained that the best work gets done when each member takes
responsibility for what he or she is supposed to do, and group members hold
themselves accountable for the results. When team members are not in sync in
terms of seeing to the needs and strengths of the child and family, then the
process doesn't work optimally.
She noted that one problem that may hinder this teamwork goal is the way in
which some team members may view the psychiatrist involved. "I do think
that there is a general bent within the world of nonpsychiatrist mental health
providers to view what the doc does as medical and therefore separate from any
of the work that they are doing together with the kid, family, and
team," she said. Many people feel that psychiatrists are only interested
in seeing the case from a narrow viewpoint, that is, focusing on psychiatric
symptoms and medication management, and are not interested in working with the
team and seeing the child and family from a more inclusive point of view.
Unfortunately, this view of psychiatrists, along with some of the
difficulties of providing mental health care in the 21st century, "can
get in the way of collaborative care," she said.
Information on the National Wraparound Initiative is posted at<www.rtc.pdx.edu/nwi/>.▪