Residential Treatment vs. Wraparound
The U.S. Surgeon General has referenced the issue of treatment of children for mental health issues, specifically residential treatment centers (RTCs) and other alternative treatments. The 1999 Mental Heath—A report of the Surgeon General states, “Residential treatment centers (RTCs) are the second most restrictive form of care (next to inpatient hospitalization) for children with severe mental disorders. In the past, admission to an RTC was justified on the basis of community protection, child protection, and benefits of residential treatment (Barker, 1982). However as of today, none of these justifications have stood up to research scrutiny. In particular, youth who display seriously violent and aggressive behavior do not appear to improve in such settings, according to limited evidence (Joshi & Rosenberg, 1997).”
Although used by a relatively small percentage (8%) of treated children, nearly one-fourth of the national outlay on child mental health is spent on care in these settings (Burns et al., 1998). However, there is only weak evidence for their effectiveness.
Looking at all types of residential treatment programs, the Surgeon General’s Report indicates areas of concern including:
1. “criteria for admission;
2. inconsistency of community-based treatment established in the 1980’s
3. costliness of such services (Friedman & Street, 1985);
4. the risks of treatment, including failure to learn behavior needed in the community;
5. possibility of trauma associated with the separation from the family;
6. difficulty reentering the family or even abandonment by the family;
7. victimization by RTC staff; and
8. learning of antisocial or bizarre behavior from intensive exposure to other disturbed children (Barker, 1998).”
In a discussion of newer community based interventions, the Surgeon General’s report states:
• “Of these interventions, the most convincing evidence of effectiveness is for home-based services and therapeutic foster care…”
The home-based services section describes the strong record of effectiveness for home-based services, which provide very intensive services within the homes of children and youth with serious emotional disturbances.
The major goal for the home-based service is:
1. to prevent an out-of-home placement (i.e., in foster care, residential, or inpatient treatment);
2. preserve the family’s integrity and prevent unnecessary out-of-home placements;
3. put adolescents and their families in touch with community agencies and individuals, thus creating an outside support system; and
4. strengthen the family’s coping skills and capacity to function effectively in the community after crisis treatment is completed
A panel member for the Report states that there are opportunities to develop
and apply evidence-based treatments in systems of care including
1. intensive case management,
2. Wraparound services, and
3. multisystemic therapy.
All three evidence-based treatments prescribe principles and general processes but allow flexibility of adaptation to strengths and needs of individual children and families, and those that involve families and practitioners in the development of the interventions and have produced encouraging results. However, beyond these three, few evidence-based treatments have been developed and tested with diverse populations in natural settings.
Youth Violence: A Report of the Surgeon General (2001)
There have been several popular juvenile justice approaches to preventing further criminal behavior in youths including boot camps, residential programs,
milieu treatment, behavioral token programs, and waivers to adult court. However, all have shown to be consistently ineffective.
• While some residential programs appear to produce positive effects on youth as long as they remain in the institutional setting, research indicates consistently that these effects diminish once young people leave.
• Justice systems that prevent youth violence can be effective when the focus is on providing services vs. instituting greater penalties.
• One promising justice system approach has been Wraparound services, meaning comprehensive services that are tailored to individual youths, as opposed to trying to fit youths into predetermined or inflexible programs.
• Evaluations of Wraparound Milwaukee have shown reductions in recidivism and arrests during the year following participation.
Youth Law Center and Barth, R.P. Institutions vs. Foster Homes: The Empirical Base for a Century of Action (2002) states, “Very little scientific evidence was
found to support previous claims that group care does a better job of achieving the major goals of the child welfare system.” than family foster care.
• The review indicates that there is virtually no evidence to indicate that group care enhances the accomplishment of any of the goals of child welfare services:
o it is not more safe or better at promoting development,
o it is not more stable, it does not achieve better long-term outcomes, and
o it is not more efficient as the cost is far in excess of other forms of care.
“New models of care need to continue to be developed. There is no empirical reason to return to large residential facilities to care for children entering placements at the point of a family emergency or for those remaining in child welfare services for a longer time. There is no new or old evidence to indicate that shelter care, or group care in general, is a sound approach to caring for most children entering child welfare services. Group care should only be considered for those children who have the most serious forms of mental illness and self-destructive behavior.”
Intervention Models for Foster Children
To date, there are only two intervention models that have demonstrated effectiveness for the treatment of foster children:
2. Therapeutic Foster Care intervention.
Wraparound: Hewitt Clark and his associates (1995 and 1996) at the University of South Florida developed the Fostering Individualized Assistance Program (FIAP) to provide individualized wraparound supports and services to foster children with emotional/behavioral disturbance (EBD) and their families (biological, adoptive, and foster).
o The primary program goal was to improve permanency outcomes for foster children.
o The children served in the FIAP were the most challenging 10 percent of children within the foster care system.
o The children in this study were between 7 and 12 years old, had been in out-of-home placement an average of 2.6 years and had an average of four placement changes prior to entering the FIAP study.
A random assignment study was designed to evaluate the effectiveness of the FIAP (Clark, Lee, Prange, and McDonald, 1996). The research design compared children receiving services that were standard practice (SP), with those who received FIAP.
The outcome variables evaluated in this study were: placement settings and change rates, runaway status and incarceration. The summarized results are as follows:
o FIAP children were significantly less likely to change placements than were those in the SP group during the intervention
o Both groups showed significant improvement in their emotional and behavioral adjustment over time
o FIAP boys had significantly lower rates of delinquency and fewer externalizing behaviors than their SP counterparts
o Older FIAP youths were significantly more likely than their SP peers to be in permanency settings with their parents, relatives, adoptive parents, or living on their own
o The subset of children who had histories of incarceration and running away, spent fewer days per year, on average, on runaway or incarceration status during the post intervention period than did the SP children.”
A comprehensive discussion of Wraparound is included in the document entitled Systems of Care – Promising Practices in Children’s Mental Health – Promising Practices in Wraparound for Children with Serious Emotional Disturbance and Their Families (1998, Volume IV), a publication of Child, Adolescent and Family Branch, Division of Knowledge Development and Systems Change, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S.
Department of Health and Human Services.
o Chapter III: Three Wraparound Models as Promising Approaches, by Sybil K. Goldman, M.S.W., and Leyla Faw, B.S., includes a description of EMQ Children & Family Services’ Wraparound Program in Santa Clara County.
o EMQ Children & Family Services Program UPLIFT -- EMQ’s Wraparound program in detail, and program outcomes.
Finally, the President’s New Freedom Commission on Mental Health – Achieving the Promise: Transforming Mental Health Care in America – Final Report July 2003, states: “An exemplary program that expressly targets children with serious emotional disturbances and their families, Wraparound Milwaukee strives to integrate services and funding for the most seriously affected children and adolescents... Most program participants are racial or ethnic minority youth in the child welfare and juvenile justice systems. Wraparound Milwaukee demonstrates that the seemingly impossible can be made possible: children’s care can be seamlessly integrated. The services provided to children not only produce better clinical results, reduce delinquency, and result in fewer hospitalizations, but are cost-effective.” (Page 35)
o Under the heading End Unnecessary Institutionalization, the report states,
“The Commission calls for swiftly eliminating unnecessary and inappropriate institutionalization that severely limits integrating adults with serious mental illnesses and children with serious emotional disturbances into their communities.” (Page 45)