Wraparound Programs Succeed in Helping Troubled Youth

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 Original article: 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 strengths.

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 Agency.

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 practice.

(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 Psychiatric News.

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/>.▪