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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.

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Presentation on theme: "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."— Presentation transcript:

1 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 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 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 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 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 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 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 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 9 Impact on CAFAS Scores after 6 Months

10 10 Impact of Fidelity

11 11 Breakdown of Fidelity Scores

12 12 Impact on CAFAS Scores after 18 Months

13 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 14 Efficacy Theory of Change for Wraparound Why Does Wraparound Work? Integrated Plan Natural Support System Self Efficacy NEEDS

15 15 Theory of Change for Wraparound Why Does Wraparound Work? Wraparound addresses the priority needs identified by the youth and family Efficacy Integrated Plan Natural Support System Self Efficacy NEEDS

16 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 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 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 19 Theory of Change for Wraparound Why Does Wraparound Work? Wraparound strengthens youth and families confidence that they can create positive change in their lives Efficacy Integrated Plan Natural Support System Self Efficacy NEEDS

20 20 Self-Efficacy is the belief in one’s 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 21 Theory of Change for Wraparound Why Does Wraparound Work? Wraparound strengthens the social support system that helps the youth and family succeed Efficacy Integrated Plan Natural Support System Self Efficacy NEEDS

22 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 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 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 25 Theory of Change for Wraparound Why Does Wraparound Work? Wraparound creates an integrated and simplified plan for the whole family Efficacy Integrated Plan Natural Support System Self Efficacy NEEDS

26 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 27 Children with Behavioral Health Disorders Across Systems

28 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. Today’s mental health care system is a patchwork relic—the 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 Chairman President’s New Freedom Commission on Mental Health

29 29 Tyler Family Marge, 38 Evan, 39 Billy, 14 Sam, 12 Sally, 12 Major Strengths, Family Culture: Parents married 17 years Marge’s 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 30 Major Needs of Tyler Family From the more detailed description of the Tyler family list concerns or risk factors

31 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 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 33 Typical Plans for Tyler Family

34 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 don’t you see that would make this family rate a higher number?

35 35 26 Helpers and 12 Plans School (5) Technical School (2) Child Welfare (1) Juvenile Justice (1) Children’s 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 Children’s MH Tx Plans 2 Adult MH Tx Plans Bailey Center Plan Employment Services 33 Treatment Goals or Objectives

36 36 Collaborative Efforts in Tyler’s Town 1. 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. 2. School Superintendent and United Way are leading an interagency effort for substance abuse prevention. 3. Local Health Department has a grant and steering committee to decrease teenage Pregnancy. 4. Child Welfare has a mandated interagency coalition that is planning for multi-agency involved children and youth. 5. Children’s Mental Health has co-located staff at child welfare supporting family preservation and family group decision making. 6. Adult Mental Health and Adult Addictions Services are in same agency. 7. There is a grassroots effort to develop more church involvement in supporting children and families.

37 37 Your Collaboration Is your communities more, the same, or less collaborative than the Tyler’s town?

38 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 Dad’s 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 39 Monthly Appointments for the Tylers Child Welfare Worker 1 Marge’s Psychologist 2 Marge’s Psychiatrist ? Billy’s therapist 4 Billy’s restitution services 4 Appointments with Probation and School 2 Family Based 4 Therapeutic Support Staff12 Evan’s anger management 4 Children’s Psychiatrist 1 Other misc. meetings:, Housing, Medical 5 AA Meetings16 Also, consider daily schedule (School, tech center, and vocational training) and the dozen or more calls from the schools each month.

40 40 Comments from the Files: Parents don’t respond to school’s 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 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 42 Help isn’t help unless it is asked for!* Sometimes people need help even though they don’t 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 don’t see the plan is theirs? *Quote from Help: The Original Human Dilemma (pub. By Harper, 2004), author is Garret Keizer

43 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 44 Going From Collaboration to Integration is a Needed Shift Collaboration: Agencies are familiar with each other’s 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 other’s 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 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 46 First: Crisis Stabilization Before team building, stabilize immediate crises with safety plan for Billy’s criminal behavior, Marge’s suicidal behavior and maintenance of Evan’s 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 47 Initial Tyler Wraparound Team All of the immediate family (5) Marge’s Parents (2) Twin’s behavioral staff from school Probation Officer Child Welfare Case Worker Marge’s business co-owner Evan’s AA Sponsor Care Coordinator Family Support Partner 14 total, team can change over time… Later, teachers, therapists, vocational staff, others in consulting roles

48 48 Next, Prioritize Needs and Plan Notice that needs are addressed in sequence with integrated approach to selection of need priority, with family in control of final decisions with court approval 1. Billy’s thefts – highly individualized plan using the “cool” grandfather to help stop criminal behavior, do individualized restitution to victims, and build on Billy’s strengths 2. 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 3. Plan to stabilize twin’s 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” 4. Support Marge’s business efforts to keep income rolling in 5. Continued Vocational Services for Evan, with team support of job finding And so on, over a year (predicted)

49 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 1000’s 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 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 51 Permanency

52 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 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 54 Stability of School Placement

55 55 Summary of Results Outcome (Data Source) Positive Direction CompDHS WrapNC Wrap Average Number of Days in Permanency Setting (KIDS)792*63* Percent of Youth in Permanent Placement 12 to 18 months (KIDS)4.1%55.7%**29.5%* Change in Number of Residential Moves per Six Months (KIDS) *0 Number of Schools in Six Month Period (Caregiver Survey)2.01.2*1.4 Changes in Restrictiveness of Living Scale (KIDS) **-.32* Change Level of Family and Caregiver Stress (Caregiver Survey) **+ 3.6 Change in Level of Youth Problems (Ohio Scales) **+1.8 Change in Level of Youth Functioning (Ohio Scales) **- 1.1 Change in Level of Impairment (CAFAS) **-10.5 Reduction in Medicaid Spending (OHCA)$75,383$400,906**$222,384*

56 56 Impact on Medicaid Spending

57 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 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 59 Barriers to High Fidelity Wraparound in PA 1. In small groups, assign a recorder with good hand writing (the notes will be turned in) 2. 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) 3. Prioritize the list and choose the top barrier (5 minutes) 4. Then (most important) make a recommendation for removing the top barrier. (10 minutes)

60 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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