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Orientation to Child and Family Team Practice and the Pennsylvania Youth and Family Institute

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Title: Orientation to Child and Family Team Practice and the Pennsylvania Youth and Family Institute


1
Orientation to Child and Family Team Practice
and the Pennsylvania Youth and Family Institute
  • Jim Rast, Ph.D.
  • John VanDenBerg, Ph.D.
  • December, 2007

2
This Pennsylvania Effort
  • Pennsylvania has a long history of successful
    collaboration and programs to support children
    and their families.
  • Through the PYFI, VVDB is committed to
    developing capacity to provide, coach and train
    sites with a commitment to implementing Child and
    Family Teams processes (high fidelity wraparound)
    in PA
  • VVDB is partnering with the PYFI, participating
    Counties, and State Level partners to help this
    transformation succeed

3
Wraparound
  • Wraparound and wraparound are not the same thing.
  • PA uses the term wraparound differently than
    almost every other state.
  • Arizona had other uses for the term wraparound
    and chose to use the term child and family
    teams to describe the process of integration and
    individualization used at the practice level

4
Development of Wraparound
  • Grassroots Development
  • General Principles
  • Applied in many different ways
  • Creativity and advances
  • 200,000 children in 1999
  • Initial Results
  • Life changing success stories
  • Strong support
  • Mixed evaluation results
  • Research shows results match fidelity

5
Defining Wraparound
  • Steps to Define Wraparound
  • Duke meeting on principles
  • National Wraparound Initiative
  • Who they are
  • Process used
  • Products produced
  • Wraparound Fidelity Assessment System

6
Wraparound Process
  • Is a Process for Supporting Youth and Families
    that
  • Is defined by 10 principles of how the process is
    implemented
  • Is done in four phases and related activities
    that describe what is to be done and
  • Fits the four components of the theory of change
    that explains why it works.

7
Principles for Wraparound
  • Family Voice and Choice
  • Team Based
  • Natural Supports
  • Collaboration (and Integration)
  • Community Based
  • Culturally Competent
  • Individualized
  • Strengths Based
  • Persistence
  • Outcome Based and Cost Responsible

8
Phases and Activities, and Skill Sets
  • NWI phases and activities
  • Vroon VanDenBerg specific skill sets for
    wraparound facilitators, coaches and family
    support partners
  • VVDB performance based training and coaching
    products
  • Credentialing and Quality Improvement
  • Used and been in over 35 sites across North
    America.
  • Sites using these products report greatly
    improved outcomes and more satisfied families and
    staff.

9
Impact on CAFAS Scores after 6 Months
10
Impact of Fidelity
11
Breakdown of Fidelity Scores
12
Impact on CAFAS Scores after 18 Months
13
The Theory of Change is
  • Is why we do wraparound
  • Is what about wraparound that makes it work
  • Is what differentiates it from other service
    coordination processes
  • Defines expectations for what we hope to
    accomplish through wraparound

14
Theory of Change for Wraparound Why Does
Wraparound Work?
Self Efficacy
NEEDS
Efficacy
Natural Support System
Integrated Plan
15
Theory of Change for Wraparound Why Does
Wraparound Work?
Wraparound addresses the priority needs
identified by the youth and family
Self Efficacy
NEEDS
Efficacy
Natural Support System
Integrated Plan
16
Families are not Fully Engaged
  • Research finds that
  • Up to 60 of families drop out of services before
    they are finished
  • Children from vulnerable populations are less
    likely to stay in treatment

17
The Challenge of Full Family Engagement
  • Why do families drop out?
  • Treatment is stressful
  • Treatment seems irrelevant
  • Poor relationship with therapist
  • Concrete obstacles
  • Time, transportation, child care, other priorities

18
Wraparound Supports Engagement
  • Addresses family prioritized needs
  • Plans for needed support
  • Family-centered and youth guided
  • Culturally competent
  • Strengths- and community based
  • Creative and Individualized
  • Teams brainstorm how to mobilize professional,
    natural, and community supports to meet unique
    needs

19
Theory of Change for Wraparound Why Does
Wraparound Work?
Self Efficacy
Wraparound strengthens youth and families
confidence that they can create positive change
in their lives
NEEDS
Efficacy
Natural Support System
Integrated Plan
20
Self-Efficacy
  • is the belief in ones capabilities to organize
    and execute courses of action required to produce
    given attainments
  • plays the central role in the cognitive
    regulation of motivation
  • People with high self-efficacy are more likely to
    expend more effort, and persist longer
  • Low self-efficacy often results in poor task
    planning, as well as increased stress.
  • people with high self efficacy often take a wider
    picture of a task in order to take the best route
    of action

21
Theory of Change for Wraparound Why Does
Wraparound Work?
Self Efficacy
Wraparound strengthens the social support system
that helps the youth and family succeed
NEEDS
Efficacy
Natural Support System
Integrated Plan
22
What or Who are Natural Supports
  • Natural supports are community resources
    available for use by youth and families within
    which are consistent with their cultural beliefs
    and practices.
  • Natural supports may involve individuals outside
    the immediate family and a variety of informal
    supports found in the neighborhood or larger
    community.
  • Natural resources are external to the child and
    family and, once accessed through active
    affiliation, become part of the child's and
    family's strengths.

23
Research on Impact of Natural Supports
  • positively impact chronic disease related health
    behaviors
  • increase compliance to routine medical care
  • improved health for older people with chronic
    conditions
  • decrease postnatal depression for new mothers
  • decrease depression in older women
  • positive natural supports decrease drug use
  • positive natural supports decrease HIV risk
    behaviors
  • decrease punitive punishment from parents
  • increase coping, resilience and sustainability
    for caregivers

24
What Natural Supports Do for Caregivers
  • Natural Supports may support and influence
    improved and sustained care-giving by
  • Creating situations to observe and learn about
    effective parenting from people the family trusts
  • Providing a sense of attachment and someone to
    talk to during tough times
  • Someone to trust and provide respite from many
    types of demands of care giving
  • Providing access to resources and material goods
  • Providing coping resources

25
Theory of Change for Wraparound Why Does
Wraparound Work?
Self Efficacy
Wraparound creates an integrated and simplified
plan for the whole family
NEEDS
Efficacy
Natural Support System
Integrated Plan
26
Seriousness of the Problem
Prevalence of Serious Emotional Disturbance (SED)
Population Proportions (9 to 17 year-olds)
5-9 Youth with SED extreme functional
impairment 9-13 Youth with SED, with substantial
functional impairment 20 Youth with any
diagnosable disorder
27
Children with Behavioral Health Disorders Across
Systems
28
Fragmented System
  • Yet, for too many Americans with mental
    illnesses, the mental health services and
    supports they need remain fragmented,
    disconnected and often inadequate, frustrating
    the opportunity for recovery. Todays mental
    health care system is a patchwork relicthe
    result of disjointed reforms and policies.
    Instead of ready access to quality care, the
    system presents barriers that all too often add
    to the burden of mental illnesses for
    individuals, their families, and our communities.
  • Michael F. Hogan, Ph.D. 2003 Chairman
  • Presidents New Freedom Commission on Mental
    Health

29
Tyler Family
  • Marge, 38
  • Evan, 39
  • Billy, 14
  • Sam, 12
  • Sally, 12
  • Major Strengths, Family Culture
  • Parents married 17 years
  • Marges parents alive and in the area, care about
    the family
  • Marge has entrepreneur skills in area of home
    cleaning business
  • Family has history of surviving adversity using
    their wits
  • Evan has over a year of sobriety after a decade
    of untreated alcoholism
  • Children provide active support to each other
  • Family culture prioritizes educational goals
  • Billy knows what cool is

30
Major Needs of Tyler Family
  • From the more detailed description of the Tyler
    family list concerns or risk factors

31
Major Needs of the Tyler Family
  • Billy
  • Serious Juvenile Justice involvement
  • Breaking and entering, shoplifting, thefts of all
    types
  • Two years behind in school but lots of potential
  • Twins (Sam and Sally)
  • Bi-polar, extreme mood swings.
  • In child welfare custody in a specialized foster
    home
  • School is having problems controlling behaviors
    and engaging them in lessons
  • All school behavior plans have failed, and school
    is suggesting home bound instruction
  • Evan
  • Verbally and physically abusive to children
  • unemployed, unable to hold job due to self
    described Stubborn attitude about authority
  • Recovering from severe alcoholism
  • Marge
  • Family history of major depression (untreated)
  • Suicidal ideation which is likely to result in
    death.

32
Pairs Activity
  • After the concerns and risk factors for the Tyler
    family are discussed brainstorm typical services
    and plan(s) for them in your county. We are
    going for typical what the average youth and
    family in their situation would get.

33
Typical Plans for Tyler Family
34
How complex is the Tyler Family?
  • Based on initial information, rate this family
    from one to ten, with one being least complex
    needs and ten being most complex needs.
  • What dont you see that would make this family
    rate a higher number?

35
26 Helpers and 12 Plans
  • School (5)
  • Technical School (2)
  • Child Welfare (1)
  • Juvenile Justice (1)
  • Childrens Mental Health (6)
  • Adult Mental Health (3)
  • Employment Services (2)
  • AA (1)
  • Housing Department (1)
  • Bailey Center (2)
  • Specialized Foster Care (2)
  • 2 IEPs (Sally and Sam)
  • Tech Center Plan
  • Permanency Plan
  • Probation Plan
  • 3 Childrens MH Tx Plans
  • 2 Adult MH Tx Plans
  • Bailey Center Plan
  • Employment Services
  • 33 Treatment Goals or Objectives

36
Collaborative Efforts in Tylers Town
  • Local Judge is chairing a restorative justice
    effort to address truancy and violence in
    schools. Juvenile Justice and law enforcement has
    major presence in local High Schools.
  • School Superintendent and United Way are leading
    an interagency effort for substance abuse
    prevention.
  • Local Health Department has a grant and steering
    committee to decrease teenage Pregnancy.
  • Child Welfare has a mandated interagency
    coalition that is planning for multi-agency
    involved children and youth.
  • Childrens Mental Health has co-located staff at
    child welfare supporting family preservation and
    family group decision making.
  • Adult Mental Health and Adult Addictions Services
    are in same agency.
  • There is a grassroots effort to develop more
    church involvement in supporting children and
    families.

37
Your Collaboration
  • Is your communities more, the same, or less
    collaborative than the Tylers town?

38
Current Services to Tyler Family
  • School has IEP for each of the twins and
    extensive behavior support and planning.
  • Billy is in a tech center but is rarely in
    school, school has offered many adaptive plans
    but none have worked.
  • Both schools call parents frequently.
  • Child welfare has substantiated Dads abuse of
    twins, has removed them from the home, created a
    strict reunification plan that includes family
    therapy and supervised visits
  • Twins are in specialized foster care with care
    and a therapist who supports the foster parents.
  • Twins are in therapy, two different therapists
    and a psychiatrist
  • TSS to help out with Billie
  • Juvenile Justice has just released Billy from
    detention over breaking and entering, Billy has
    new charges of theft,
  • Court ordered therapy
  • Restitution supervised by local youth services
    agency with a counselor and mentor
  • Housing is trying to find safer housing
  • Marge sees a psychologist occasionally in crisis
    times and has been referred to a psychiatrist,
    went once but does not want to go back.
  • Evan goes to four AA meetings a week and sees his
    sponsor twice a week, calls daily
  • Evan goes to court ordered anger management
  • Evan is working with Vocational Services on
    employment skills

39
Monthly Appointments for the Tylers
  • Child Welfare Worker 1
  • Marges Psychologist 2
  • Marges Psychiatrist ?
  • Billys therapist 4
  • Billys restitution services 4
  • Appointments with Probation and School 2
  • Family Based 4
  • Therapeutic Support Staff 12
  • Evans anger management 4
  • Childrens Psychiatrist 1
  • Other misc. meetings, Housing, Medical 5
  • AA Meetings 16
  • Also, consider daily schedule (School, tech
    center, and vocational training) and the dozen or
    more calls from the schools each month.

40
Comments from the Files
  • Parents dont respond to schools calls
  • Family is dysfunctional
  • Parents are resistant to treatment
  • Home is chaotic
  • Billy does not respect authority
  • Twins are at risk due to parental attitude
  • Mother is non-compliant with her psychiatrist,
    does not take her meds
  • Father is unemployable due to attitude
  • Numerous missed therapy sessions
  • Attendance at family therapy not consistent,
    recommend group therapy for parents

41
Mutual Perspective
  • How do the professionals involved with the Tyler
    family view this family, and their role in the
    family? Do they see their role as Rescuer
    Stabilizer Enforcer Supervisor Teacher?
  • How does the family view the professionals? Does
    the family feel that they are asking for help?
    Does the family want the same help as the help
    the professionals want to give?

42
Help isnt help unless it is asked for!
  • Sometimes people need help even though they dont
    ask for it. How can we engage them in a way that
    helps them trust us when we see a need that they
    do not see? Will any plan work if the Tylers are
    not on board or dont see the plan is theirs?
  • Quote from Help The Original Human Dilemma
  • (pub. By Harper, 2004), author is Garret Keizer

43
Cost
  • Specialized Foster Care
  • Psychiatrist
  • Psychologist
  • Therapy (Individual and Family Based)
  • Therapeutic SS
  • Tech Center
  • Vocational Training
  • School
  • Restitution
  • Per Month
  • Plus the cost of the salaries for the public
    staff and the time from AA. If there is a
    crisis, detention, or higher levels of care the
    cost goes up considerably

44
Going From Collaboration to Integration is a
Needed Shift
  • Collaboration Agencies are familiar with each
    others missions and roles, key staff work with
    each other at the child/family level, but retain
    single system decision making power and planning.
  • Integration Agencies are familiar with each
    others missions and roles, key staff work with
    each other at the child/family level, sharing
    decision making in a team format that includes
    the family, producing a single plan that meets
    all system mandates and that is owned by the
    entire team.

45
Rate your town
  • On collaboration, rate your town from one to ten,
    with ten being most collaborative?
  • On integration, rate your town from one to ten,
    with ten being most integrated?
  • If ratings were different, what are non-blaming
    or shaming reasons for the differential ratings?
    For example, staff may not be trained to
    integrate.

46
First Crisis Stabilization
  • Before team building, stabilize immediate crises
    with safety plan for Billys criminal behavior,
    Marges suicidal behavior and maintenance of
    Evans sobriety
  • Crisis planning involves prediction of worst case
    scenario, functional assessment to target plan on
    function of crisis behaviors, implement
    individualized, strengths-based, culturally
    competent prevention efforts, and plan for what
    to do if crisis occurs

47
Initial Tyler Wraparound Team
  • All of the immediate family (5)
  • Marges Parents (2)
  • Twins behavioral staff from school
  • Probation Officer
  • Child Welfare Case Worker
  • Marges business co-owner
  • Evans AA Sponsor
  • Care Coordinator
  • Family Support Partner
  • 14 total, team can change over time
  • Later, teachers, therapists, vocational staff,
    others in consulting roles

48
Next, Prioritize Needs and Plan Notice that
needs are addressed in sequence with integrated
approach to selection of need priority, with
family in controlof final decisions with court
approval
  • Billys thefts highly individualized plan using
    the cool grandfather to help stop criminal
    behavior, do individualized restitution to
    victims, and build on Billys strengths
  • Support of twins and highly individualized plan
    to gradually move toward reunification, done at
    approximately same time as 3 so that school,
    foster home, and home are consistent
  • Plan to stabilize twins school behavior using
    Marge, grandparents and others as volunteer
    aides, including accelerated plan to get Billy up
    to grade level using volunteer aides who are
    cool
  • Support Marges business efforts to keep income
    rolling in
  • Continued Vocational Services for Evan, with team
    support of job finding
  • And so on, over a year (predicted)

49
Benefits of an Integrated Approach for the Tyler
Family and the Town
  • Tyler family has real hope from their plan and
    process, have more energy each time a goal is
    met.
  • The professionals involved get to maximize the
    use of their own expertise. For example, which
    plan would you rather be the psychiatrist in? Or
    the teacher?
  • The professionals get to practice integration
    skills which will benefit 1000s of other
    families, trading control and autonomy for
    outcomes at the family level, and more satisfying
    jobs. Also may decrease professional turnover.
  • Taxpayers get return for their investment
  • Potential multi-generational positive effect
  • Community building a family at a time.

50
Cost
  • Not why we are here, but the real five year cost
    of Tylers was in excess of 250,000 real money
    paid by real taxpayers
  • Is the typical plan a good deal for taxpayers?

51
Permanency
52
THE Placement
  • The most important part of finding the placement
    is really getting to know the strengths, culture
    and needs of the youth.
  • Talk to the youth at length and also talk to
    people who know the youth (caregivers, former
    caregivers, teachers, etc)
  • Strengths include people who might provide some
    level of support
  • Needs focus on what it will take in an
    environment to be successful for the youth and
    what the youth wants out of life
  • Needs include the challenges that make the youth
    hard to place
  • Once you know the youth use the information to
    match to THE placement
  • Use the strengths to sell the youth to the
    placement
  • Be very honest about the challenges and needs so
    placement knows what to expect
  • Plan with the youth and placement before the
    youth arrives so the initial experience is better
  • Frequent communication and support over time to
    youth and placement once there
  • In the meantime
  • Stall
  • Use the same principles and keep working on the
    THE placement if a temporary stop is required

53
Youth Story - THE Placement
  • Youth was 16 and in lock down for shoplifting and
    AWOL from TFC. History of sexual abuse and had
    become sexually reactive. Multiple failed
    placements because of sexual and aggressive to
    other kids. No supports or visits for several
    years.
  • Strengths good with adults, motivated to
    succeed
  • Challenges around younger kids or kids in home,
    learning disability requires very structured
    situation and instructions
  • THE placement a mature couple with no other
    children in the home
  • The Results found grandmother and brother who
    want to support him but could not provide
    placement. Developed long range vision of work
    with need for supported living. Completed school
    and went to Job Corp. Will return to live with
    grandparents supported by brother until he is
    ready to go out on his own.

54
Stability of School Placement
55
Summary of Results
56
Impact on Medicaid Spending
57
Facilitator Credentialing using VVDB tools
  • Novice -- has completed 24 hours of class room
    (or E-Learning) instruction, in-class behavioral
    rehearsals, pre and post tests, and 20 hours of
    shadowing
  • Practitioner -- has a professional development
    plan, is receiving appropriate supervision and
    coaching, and has demonstrated competency using
    VVDB documentation and observation review tools.

58
VVDB Observation and Review Tools
  • Either the Supervisor/Coach or Coach actively
    reviews document products and observes key
    activities based on NWI Phases and Activities
  • Documentation Reviews SNCD Wrap Plan
    Functional Assessment Crisis Plan Progress
    Notes Transition Plan
  • Observation Reviews (live) Initial Engagement
    meeting Initial Team Meeting Follow-up Meeting

59
Barriers to High Fidelity Wraparound in PA
  • In small groups, assign a recorder with good hand
    writing (the notes will be turned in)
  • Begin the discussion by introductions. Then, list
    out top barriers which may get in the way of
    implementing wraparound as defined by the
    National Wraparound Initiative (30 minutes)
  • Prioritize the list and choose the top barrier (5
    minutes)
  • Then (most important) make a recommendation for
    removing the top barrier. (10 minutes)

60
Remember one thing
  • High Fidelity Wraparound is a process of
    integration for children and families with
    co-occurring disorders. It is specifically
    designed to lead to positive clinical outcomes
    and is based on a theory of change
  • In general, the field has greatly underestimated
    the complexity of doing a good job with
    wraparound at the supervisor and staff levels.
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