Does Wraparound Care Coordination Improve Outcomes in Adolescents with Behavioral Health Problems?

Study Measures Effectiveness of Community Support for Teens With Serious Emotional Disorders

We can answer the question posed in the title right away:

Yes, wraparound services improve outcomes for teens with behavioral health problems. And there’s one segment of the teenage population wraparound services help most.

Before we dive into the data and details provided by a recent study that examined close to three decades of data on wraparound services – called A Systematic Review and Meta-analysis: Effectiveness of Wraparound Care Coordination for Children and Adolescents – we’ll offer a quick history of wraparound services, share the fundamental principles of wraparound care, and describe how the wraparound process typically works in communities around the country.

First, though, a definition.

Here’s how one of the first peer-reviewed journal articles on wraparound services defines the approach:

“Wraparound is a philosophy of care that includes a definable planning process involving the child and family that results in a unique set of community services and natural supports individualized for that child and family to achieve a positive set of outcomes.”

That definition, elucidated in 1998, still represents the core principles of wraparound care. The initial goal of wraparound care was to help support adolescents and youth at-risk of involvement with the juvenile justice system, adolescents and youth with emotional and behavioral disorders, and other adolescents and youth whose various personal challenges prevented their successful development, education, and ability to fully participate in school and home life.

Wraparound Services in 2021

Those goals from 1998 remain the same today. Over the past twenty years, though, wraparound service coordinators – i.e. the people responsible for implementing wraparound programs at the ground level – have clarified and simplified the language used to describe wraparound care. An updated definition of a 21st century approach to wraparound care reads like this:

“Wraparound services provide a comprehensive, holistic, youth and family-driven way of responding when children or youth experience serious mental health or behavioral challenges. Wraparound puts the child or youth and family at the center. With support from a team of professionals and natural supports, the family’s ideas and perspectives about what they need drive all of the work.”

That’s what wraparound is: a child- and family-centered way to support youth with significant behavioral or emotional problems. It’s important to note that the concept of wraparound arose when mental health professionals and social workers realized that many youth, adolescents, and families faced near-insurmountable obstacles when seeking support. For example, before wraparound care, a teacher might send a troubled teen to a school counselor. The counselor might refer the teen to a psychiatrist. The psychiatrist might refer the child to outpatient treatment. Finally, clinicians at the outpatient facility might refer them to residential treatment.

In many cases, families lost their way in this fragmented system. That means the teen in need may never have received the life-changing support and care they needed. Obstacles to support include transportation, cost, knowledge, trust in the process, and stigma, among others.

Wraparound care coordinators work to connect the dots between the various modes of support available in the community. They synthesize the process. They work with families and teens to develop a realistic and practical suite of supports and services. Most importantly, those supports and services are based on the family’s vision and goals of what success looks like for them, in their lives, in the community in which they live.

Wraparound Care for Teens: Core Principles

In the paper we cite above – Promising Practices In Wraparound For Children With Serious Emotional Disturbance and Their Families Wraparound – pioneering wraparound theorists Barbara J. Burns and Sybil K. Goldman identified the following core principles of wrapround care.

Ten Fundamental Elements That Define Wraparound Support

1. Family Voice and Choice

This is first on the list because it’s the foundation of the wraparound philosophy. During all phases of the wraparound process, family and caregiver input drives the nature, manner, and location of the support. Families identify their values and goals. Then, wraparound coordinators help them live their values and realize their goals within their own community.

2. Team Oriented

A wraparound team is made up of people chosen and/or agreed upon by the family. The team commits to supporting the teen in need. The commitment may be formal or informal. It may include teachers, family members, sports coaches, members of the clergy, social workers, or other concerned and committed adults. In the case of teens in the custody of a state agency, that agency includes people who will be part of the teen’s life after the formal involvement of the state agency.

3. Strength Based

Wraparound coordinators identify “the capabilities, knowledge, skills, and assets of the child and family, their community, and other team members” in order to create a support plan that validates the experience and wisdom people already involved in the life of the teen. The goal is to build support based on the assets present in the community, rather than focus on eliminating deficits present in the community. Respect is key. Each member of the team plays an important role in helping the teen and family meet their self-defined needs and goals.

4. Personalized Plan

A personalized plan is the manifestation of the first three principles: Family Choice, Team Oriented, and Strength Based. The family collaborates with the wraparound coordinator to define the goals of the plan. The coordinator and family agree on the members of the team. The team then identifies the ways they can support the teen – their strengths – and all of this goes into the plan.

5. Resilience

Another way of saying this is “unconditional commitment” on the part of the wraparound team to the teen in need.  If a family or teen involved in a wraparound plan encounters undesirable events or experiences unwanted, unpredicted, or negative outcomes, the wrapround team does not see them as failures or mistakes. Rather, they see them as indicators that the wraparound plan needs revision. No one gets kicked out of wraparound. When obstacles appear, the plan changes. The coordinator adapts the plans to give the teen and family their best chance at success.

6. Results Oriented

The wraparound coordinator regularly reviews the goals and desired outcomes of the wraparound plan. The goals are always measurable. For instance, a teen may strive for improved school attendance, improved grades, decreased disciplinary or behavior problems, and improved family functioning. If these goals are unmet, the team revises the plan in order to meet the goals.

7. Community Based

The wraparound plan leverages support and community services in the most inclusive and accessible ways possible. The best plan offers services in the home community itself, which promotes community cohesion and increases a sense of belonging and trust in the teen who receives support. If those services are not available in the community, the wraparound coordinator either finds a way to bring them there or finds a way to make them easily accessible to the family and teen.

8. Cultural Competency

Wraparound coordinators and programs recognize the inherent power of “the values, preferences, beliefs, culture, and identity of the youth, family, and their community.” The goal is to understand and utilize the community and culture to support the youth, rather than impose an external value system on the child and family. In most cases, a combination of family voice and coordinator input results in a successful, culturally competent, wraparound plan.

9. Natural Supports

Think of natural support as a circle of resources available to the youth, expanding outward from the youth themselves, with the youth at the center of the circle. The first natural supports are the family and extended family. Then come friends, neighbors, and others, including people who know the family through church, clubs, sports leagues, or community organizations. Important members of the natural support team are also the teachers, paraprofessionals, specialists, and school faculty and staff who know and interact with the teen on a daily basis.

10. Collective and Collaborative

Each member of the team works together to apply their strengths to support the family and teen in need. The team decides who’s best suited to offer specific types of support, and helps them offer that support. The family and the wraparound coordinator work to create a plan that’s a seamless combination of family/teen-directed and team-directed. When the family and team disagree on goals and methods, they rely on communication, trust, and commitment to resolve issues to the benefit of the family and teen in need of support.

Since 1998, these ten principles have formed the framework for wraparound programs implemented across the U.S. These ten foundational components differentiate wraparound services from traditional interventions for youth with serious emotional or behavioral disorders.

Next, we’ll briefly describe the wraparound process.

How Wraparound Works

What we just described resonates with us, because at its core, the wraparound approach reflects the integrated approach to mental health treatment we use every day. It’s family-focused, strength-based, and data-driven. Those are core elements of any successful intervention, whether it’s for a mental health, behavioral, or addiction issue.

The core elements match our philosophy, as does the manner in which most communities implement wraparound programs. Here’s how they do it.

Phase One: Engage and Prepare

This phase is about establishing a trusting relationship between all members of the wraparound team and the family in need of support. Coordinators set the collective tone, and engage the family in the process of creating a wraparound plan. Families learn they’re going to be part of the process, and their voices will be heard. This phase should be quick, and last no longer than two weeks.

Phase Two: Create a Plan

This happens alongside Phase One. After the wraparound coordinator establishes a positive collaborative atmosphere, the family and team design a plan that incorporates the family’s strengths, the skill the support professionals, and the input of the community to meet the needs of the family. Like Phase One, Phase Two should happen quickly, so that the teen and family receive support in a timely manner.

Phase Three: Implement the Plan

This is the action phase. Everything in the plan is put into motion. The coordinator engages in an ongoing process or review, and will change the plan if goals are not met, or add new goals if goals are met ahead of time. The team and plan stays in place until goals are met and the team reaches the mutual decision that a formal wraparound program is no longer needed.

Phase Four: Transition

This final phase involves a transition from a formal wraparound program – with the input and oversight of the wraparound coordinator – to “a mix of formal and natural supports in the community.” A well-designed plan will allow a smooth transition. During transition, the natural supports present throughout the process will gradually replace the formal supports, until the teen and family are fully independent, functional, and no longer need formal wraparound support.

Those four steps mirror our approach to treatment, from assessment to aftercare. But we digress: this article is about whether wraparound care coordination improve outcomes for adolescent with serious emotional disorders, or SEDs.

We offered a simple answer above – and now we’ll share the data.

Are Wraparound Programs Effective?

We’ve shared the what and the how.

It’s time for the results from the study we mention above.

A systematic review of 17 studies published between 1991 and 2020 found that, in comparison to treatment as usual (TAU) for teens with serious emotional disorders, coordinated wraparound services led to improved:

  • Mental health symptoms
  • Mental health functioning
  • School functioning
  • Residential placement (i.e. teens either stayed at home or achieved success in an alternate living situation)

In addition, wraparound service significantly reduced the financial burden on families that previously would have relied on specialized care outside their community. That leads us to share what we hinted at in our introduction: wraparound services are most beneficial for youth of color in communities where mental health services are typically unavailable and have been traditionally underserved by the standard array of mental health supports.

In an interview with Science Daily, Dr. Eric Bruns, a researcher and study author, describes the importance of these results:

“For many years, public systems have used wraparound because it provides families with the kind of compassionate approach they say they want and need. Now we have clear results that support what many have seen in their own local systems of care. Wraparound is more effective and cost-effective than traditional services.”

Dr. Bruns also indicates that the community nature of wraparound programs – family choice and voice, collaborative teams, and a strength-based approach – might be what makes wraparound programs particularly effective in underserved communities where support for mental health issues has been lacking – or nonexistent – for decades. However, further research is needed to reach a definitive conclusion on that topic.

In the meantime, what we know is this: wraparound works for the people who need it most. The data from this latest study proves it. We’re optimistic that communities around the country will use this new information as grounds to expand their wraparound services to include as many families and teens as possible.