Systematic Review and Meta-analysis: Effectiveness of Wraparound Care Coordination for Children and Adolescents.

OBJECTIVE: Wraparound is a common method for coordinating care for children and adolescents with serious emotional disorders (SED), with nearly 100,000 youths served annually in the United States. The current systematic review and meta-analysis estimated effects on youth outcomes (symptoms, functioning, school, juvenile justice, and residential placement) and costs. METHOD: A literature search identified 17 peer-reviewed and gray literature studies meeting criteria, which were coded on characteristics of sample, design, implementation, and outcomes. Random effects modeling was conducted using Comprehensive Meta-Analysis Version 3.0. Effect sizes were calculated using Hedges g. Homogeneity of effects were assessed using Q statistics. RESULTS: Medium-sized effects favored Wraparound-enrolled youths for costs (g = 0.391, CI = 0.282-0.500, p < .001), residential outcomes (g = 0.413, CI = 0.176-0.650, p = .001), and school functioning (g = 0.397, CI = 0.106-0.688, p = .007); small effects were found for mental health symptoms (g = 0.358, CI = 0.030-0.687, p = .033) and functioning (g = 0.315, CI = 0.086-0.545, p = .007). Larger effects were found for peer-reviewed studies, quasi-experimental designs, samples with a larger percentage of youths of color, and Wraparound conditions with higher fidelity. CONCLUSION: Results indicate positive effects for Wraparound, especially for maintaining youths with SED in the home and community. However, many studies showed methodological weaknesses, and fidelity measurement was largely absent, suggesting a need for additional research. Nonetheless, the results should aid decisions around resource allocation, referral practices, and system partnerships among child psychiatrists and other behavioral health professionals.

Psychometrics, Reliability, and Validity of a Wraparound Team Observation Measure.

Wraparound is a widely-implemented team-based care coordination process for youth with serious emotional and behavioral needs. Wraparound has a positive evidence base; however, research has shown inconsistency in the quality of its implementation that can reduce its effectiveness. The current paper presents results of three studies used to examine psychometrics, reliability, and validity of a measure of wraparound fidelity as assessed during team meetings called the Team Observation Measure (TOM). Analysis of TOM results from 1,078 team observations across 59 sites found good overall internal consistency (alpha = .80), but constrained variability, with the average team rated as having 78% of indicators of model adherent wraparound present, 11% absent, and 11% not applicable. A study of N=23 pairs of raters found a pooled Kappa statistic of .733, indicating substantial inter-rater reliability. Higher agreement was found between external evaluators than for pairs of raters that included an external evaluator and an internal rater (e.g., supervisor or coach). A validity study found no correlation between the TOM and an alternate fidelity instrument, the Wraparound Fidelity Index (WFI), at the team level. However, positive correlations between mean program-level TOM and WFI scores provide support for TOM validity as a summative assessment of site- or program-level fidelity. Implications for TOM users, measure refinement, and future research are discussed.

Effectiveness of the wraparound process for children with emotional and behavioral disorders: a meta-analysis.

Wraparound is a team-based service planning and coordination process intended to improve outcomes for children and youth with serious emotional and behavioral disorders and support them in their homes, schools, and communities. Given the substantial resources devoted to implementing wraparound, a meta-analysis of outcome studies was conducted to better understand current empirical support for this process. A literature search identified seven studies between 1986 and 2008 that documented the effects of youth receiving wraparound compared to control groups. Mean treatment effects across outcome domains ranged from medium for youth living situation (0.44) to small for mental health outcomes (0.31), overall youth functioning (0.25), school functioning (0.27), and juvenile justice-related outcomes (0.21). The overall mean effect size across studies was 0.33. Interpretation of results was complicated by the lack of consistent documentation of implementation fidelity across studies and conditions, variations in target population and intended outcomes, and methodological concerns. The authors conclude that, though the published wraparound research base is expanding and findings are largely positive, it continues to be in a preliminary state of development. However, there are insufficient data to support calls for wraparound's acceptance or dismissal based on the strength of existing studies.

Is it wraparound yet? Setting quality standards for implementation of the wraparound process.

The wraparound process has increasingly been used as a mechanism to plan and coordinate services for children with behavioral health needs and their families. This has led to growing interest in assessing wraparound implementation against standards for quality. However, there has been little consideration of how best to establish such benchmarks or guidelines. Using both a norm-referenced and criterion-referenced approach, this study established preliminary criteria for assessing the adequacy of wraparound implementation using the Wraparound Fidelity Index, version 3, a multi-informant interview that assesses conformance to wraparound principles. The evaluation system was then applied to ten wraparound programs and 11 different study samples assessed via the Wraparound Fidelity Index version 3 in research studies. The system was constructed to discriminate different wraparound conditions assessed in research studies while still being attainable by the ten established wraparound programs. Implications for evaluating wraparound programs and for setting fidelity benchmarks in behavioral health services research are discussed.

Relations between program and system variables and fidelity to the wraparound process for children and families.

OBJECTIVE: Past research and experience have indicated that characteristics of organizations and service systems influence the quality of mental health services delivery. The study aimed to illuminate such associations by examining the relationship between a set of program- and system-level variables and fidelity to the wraparound model for children and families. METHODS: A measure of fidelity to the wraparound process for children and families (the Wraparound Fidelity Index) was administered to families receiving services in eight mental health agencies across the United States. Program administrators at each agency also completed by telephone a standardized interview for assessing program and system conditions hypothesized to influence quality of implementation (Program Administrator version of the Wraparound Fidelity Index). Regression analyses were used to assess the relationship between program and system variables and fidelity. RESULTS: Results of interviews with program administrators revealed substantial variation across programs in the number and type of program and system supports for wraparound implementation. Regression analyses found a significant association between the number of organizational and system supports and Wraparound Fidelity Index scores. CONCLUSIONS: Results support the hypothesized relationship between program and system conditions and the quality of service delivery. Results also highlight the importance of engineering the system and organizational context (maintaining low caseload sizes, establishing interagency partnerships, and implementing accountability mechanisms) in order to provide a solid foundation for high-quality wraparound to children and families.