Wrap-around services: An analysis of community-based mental health services for children
Furman, Rich
TOPIC. Wrap-around services-individualized, community-based mental health services for children in their homes and schools-for children with severe emotional and behavioral disorders.
PURPOSE. To conduct an analysis of the social policy antecedents that culminated in wraparound services in one state and consider the development of one state’s implementation and relevant value issues.
SOURCES. Policy and historical literature; the first author’s experience as a director of a large wrap-around program.
CONCLUSIONS. While the advent of wrap-around services and the expansion of Medicaid represent significant steps forward in the treatment of children with mental health problems, outcome studies of these services are sorely needed.
Search terms: Children’s mental health, child welfare policy, wrap-around
Wrap-around services – individualized community– based mental health services for children in their homes and schools-have in many states become an integral component of the service delivery system for children with severe emotional and behavioral disorders (Brown & Hill, 1996). In Pennsylvania, wrap-around services are used to prevent hospitalization and maintain children in least restrictive school and family settings. As children’s mental health historically has been a neglected area of policy analysis (Allen-Meares, 1997), few studies exist. Since wrap-around services are starting to proliferate throughout the United States (VanDenBerg, 2000b), an analysis of the development of these services on state and local levels can help inform policy makers and practitioners as they develop these services. The purpose of this article is to analyze the social policy antecedents that culminated in wrap-around services in Pennsylvania.
The Advent of Children’s Mental Health
The social factors that resulted in the 1989 expansion of the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) provision of Title XIX of the Social Security Act of 1935 paved the way for a viable funding stream for wrap-around services. Recognizing emotional disorders as conditions that should be covered under Medicaid, this expansion of Title XIX represents one of the most significant, yet often unrecognized, pieces of legislation in the history of children’s mental health policy.
Many of the problems that are now viewed as mental health issues were attributed to different factors at various times. For example, prior to 1850, mentally ill adults and children were often not seen as ill, but as morally deficient (Nurcombe & Partlett, 1994). As the conception of children’s problems began to change, the manner in which we have cared for them has shifted as well. The idea of children’s mental health policy was inconceivable until very recent times for two main reasons. First, throughout most of history, children were viewed as mere property parents could deal with as they pleased (Postman, 1992). This changed somewhat during the mid-19th century, when children were removed from poor immigrant families that were seen as unstable or too poor to provide for their children’s well-being (Axinn & Levin, 1982; Boyer, 1978). Their health, well-being, and general welfare were not seen as subjects of social policy any more than was the welfare of cattle: Both were viewed as property (De Mause, 1976). Since children were private property, their well-being was seen as being the responsibility of their parents and outside the public domain (Stone, 1977).
Childhood, as viewed by the middle class in postindustrial societies, is largely a social construction of the modern era (Postman, 1992). Today, childhood is seen as a special time of life, a preparation for the emotional and physical challenges of adulthood. The child’s primary “vocation,” if you will, is healthy growth and development (Elkind, 1994). This has not always been the case. Less than 100 years ago, children labored slavishly for dozens of hours a week (Cunningham, 1995).
The history of this transformation from child as property to full human status is complex, uneven, and in many ways unresolved. That is, shifts in how a child is viewed and valued are often followed by shifts in policy and programming. For instance, before the advent of child-labor laws, activists and reform movements began to view the child as worthy of protection and care (Otis, 1995). Institutions were created to prevent child abuse well before child-labor laws were enacted.
Additionally, the labeling of children’s emotional and behavioral concerns as mental health problems is a relatively recent construction, with its origins in the early part of the 20th century. Historically, children’s behavioral problems have been attributed to moral deficits in the child or lack of skills in their parents (Elizur & Minuchin, 1989). The pathology of a child was not seen in medical or psychological terms, but in terms of the immorality of a child or his/her family. The goal of “treatment,” however rationalized, was to help families understand that they must adopt values more congruent with those of the middle class (Devore & Schlesinger, 1991).
Factors that were once attributed to moral deficits and family dysfunction are now understood to have biological etiologies. For example, modern psychiatry has made great strides in helping destigmatize mental illness in children. The treatment of children with mental health issues is now seen as necessitating interventions on the biological, psychological, and social levels, regardless of the cause of the problem (Stroul & Friedman, 1986). State-of-the-art care frames families not as causes of problems or as hurdles to overcome, but as resources in the treatment of children with mental health problems (Young, 1990).
Social Policy Context
The stock market crash of October 24, 1929, marked the beginning of a new era in American society (Moroney, 1991). For perhaps the first time, many Americans recognized that the poor could be socially disadvantaged as a result of the malfunctioning of society (Piven & Cloward, 1993). Previously, the American system of social provisions, including mental health services, could be characterized as individualist (Gilbert & Terrell, 1998) or residual (Wilensky & Lebeaux, 1958) in nature. The residual perspective views social welfare as a safety net, which should help individuals only as a last resort. It places responsibility on individuals and their families for meeting their needs, not on government. In this world view, social welfare is seen as the domain of religious institutions or the voluntary sector, who are the payers and providers of services (Estes, 1988).
With the widespread recognition of the failings of the American economy, a new view began to emerge in social policy- the collectivist (Gilbert & Terrell, 1998) or institutional perspective (Wilensky & Lebeaux, 1958). The institutional perspective contends that institutions of social welfare are necessary components of modern capitalist societies. In fact, it is posited that one of the key reasons for Roosevelt’s adoption of the New Deal was to derail the various radical movements, which were gaining strength during the 1930s (Gil, 1990; Piven & Cloward, 1993).
Although the Great Depression shifted American social policy toward the institutional provision of social welfare, great ambivalence has always existed in the body politic as to the appropriateness of governmental social intervention (Janson, 1997). Another much disputed area in social welfare has been between those who support federal intervention and those who see social welfare as the providence of the state, or even municipal government (Gilbert & Terrell, 1998). The dynamic tension created as a result of this debate has been responsible in part for the patchwork nature of children’s mental health policy (Kutash, Duchnowski, & Sondheimer, 1984).
One of the key social responses to the Great Depression was the adoption of the Social Security Act of 1935. This legislation marks the first significant move toward the development of the American welfare state (Dolgoff & Feldstein, 1980). Through subsequent revisions, it paved the way for public funding of health, and later mental health, services.
Title XIX, signed into law by President Johnson on July 30, 1965, was a major expansion of the Social Security Act. Trattner (1994) asserts that the original purpose of Title MX was to end “charity medical care” by giving the financially indigent access to medical health insurance. Before Title XIX, the poor often received substandard medical care only at public hospitals, which often were overcrowded and not able to meet many specific needs. Medicaid, as the program was titled, allowed recipients access to any doctor who would accept the payment, thus expanding choice of care for public assistance recipients. The title provided funds to states to pay for health care for those on public assistance, and if funding was sufficient, for others in need.
In spite of its problems, the act had a key provision, EPSDT, that created a funding stream for poor children with health disorders and, later, mental health disorders. EPSDT declared that disabled children who were eligible for Medicaid were entitled to any service that was “medically necessary.” Originally, the EPSDT provision provided poor children with immunization, equipment, and services designed to allow them to remain in their homes and schools. For instance, EPSDT funds were used to build wheelchair ramps in the homes of physically disabled children.
Mental Health Policy
For most of history, the mentally ill have not been viewed as sick but as morally bankrupt, deviant, or undesirable (Elizur & Minuchin, 1989). Foucault (1965) traces the beginning of the “medicalization” of such undesirables to the development of the Hopital Generale in France in 1656. Before this, the mentally ill were warehoused in asylums, maintained in jails, or even sent down the river on ill-fated “ships of fools.”
Pinel’s traitement moral became in America “moral treatment” or “moral management,” a psychologically oriented therapy that relied on an orderly, disciplined asylum and coercive medical directives to cause patients to internalize normal social behaviors and values (Grob, 1994). It became the rationale and foundation for the growth of hospitals and asylums for the insane in the United States throughout the late 18th and early 19th centuries.
Treatment of the mentally ill was similar throughout the history of the American colonies and into the early days of the union. Many states responded by building hospitals that were intended as safe havens for those unable to function in society. Due to a lack of political commitment, the social dislocation of the industrial revolution, and the general stresses of urban life, by the 1920s the state hospital was “an asylum in name only” that merely warehoused patients (Karger & Stoesz, 1998, p. 339). The mentally ill fared no better in the middle of the century. Sterilization and invasive surgery (the lobotomy) became norms during the 1930s and 1940s (Mechanic, 1969). Further, perhaps the most frequently used method of treating mental illness during the first half of the century was psychoanalysis (Grob, 1994). Psychoanalytic theory posited that unresolved conflicts emanating from a patient’s family history lead to mental illness. This intrapsychic orientation paved the way to biomedical and behavioral science advancements of the later part of the century.
Perhaps the greatest impetus for change in mental health policy and practice occurred in response to World War II. Nearly one in four soldiers was rejected from military service for psychological reasons (Trattner, 1974). Further, return of “shell-shocked” veterans mandated a dear social response to care for men who had served. Grob (1994) eloquently reflects on the impact of World War 11:
The growth in the mental health professions was given impetus by World War II. Psychologists, for example, found that the exigencies of war created new opportunities for practical and applied services…. The relative shortage of trained psychiatrists and the presence of thousands of neuropsychiatric cases among war returning servicemen, moreover, led the Veterans Administration to create joint doctoral training programs with a number of universities in order to increase dramatically the number of clinical psychologists and thus alleviate professional staff shortage. (p. 237)
In response, the Mental Health Act of 1946 was enacted, establishing the National Institute of Mental Health (NIMH) (Karger & Stoesz, 1998). The creation of NIMH (with its agenda to end custodial care), the advent of psychotropic medication, President Kennedy’s receptiveness to mental health reform, and the postwar econon-dc boom made possible the adoption of the Community Mental Health Centers Act of 1963. The passage of this legislation marked the beginning of the deinstitutionalization movement.
Children’s Mental Health
Expansion of the Community Mental Health Centers Act of 1963 added an array of services that advocates hoped would be provided. The architects of the community mental health movement envisioned preventive services provided to children in their schools, to identify and treat those at risk for developing mental health problems (Karger & Stoesz, 1998). However, full funding of these programs never materialized. As the war in Vietnam progressed, and as America became more polarized, mental health and other social services became less of a priority. In essence, during the Nixon administration, the “War on Poverty,” social services, and mental health programs lost ground to the war in Southeast Asia, with its fiscal and political consequences (Axinn & Levin, 1982). Children’s mental health remained a neglected area of social policy.
Public law 94-142, the Individual With Disabilities Education Act, was important legislation in the development of children’s mental health policy. Passed in 1975, this federal legislation mandated that all children receive a free, appropriate public education regardless of the level or severity of their disability. It provided funds to assist states in the education of students with disabilities and required that states make sure these students receive an individualized education program based on their unique needs in the least restrictive environment possible (ARC, 2000). This legislation contributed to the development of community-based mental health services by mandating appropriate care for disabled children within the context of their schools.
In 1983, the NIMH began to focus considerable energy on the problem of children’s mental illness through the development of the Children and Adolescent Service System Program (CASSP) (Burns et al., 1995; Friedman & Kutash, 1992). The values and principles of the burgeoning program were articulated in the Core CASSP Principles, which have greatly influenced the provision of mental health services to children (VanDenBerg, 2000a). The “Core Principles” include five types of service (Pennsylvania Department of Public Welfare, 2000):
1. Child-centered: Services that meet the individual needs of the child
2. Family-focused: Services that recognize the family is the primary support system for the child
3. Community-based: Whenever possible, services are delivered in the home and use community resources
4. Culturally competent: Services recognize and respect the behavior, ideas, attitudes, customs, language, rituals, ceremonies, and practices of the family’s ethnic group
5. Least restrictive/least intrusive: Services take place in settings that are the most natural for the child and family and are the least restrictive and intrusive to meet the needs of the child and family
While significantly influential, CASSP’s ability to influence the system of providers was hampered by a familiar problem within children’s mental health services-a lack of specifically designated funding (Furman, 1997). This funding problem was addressed in 1989, when Congress expanded the EPSDT provision of Medicaid (Social Security Administration, 1989). Addressing the disparity between physical and mental health services, the provision mandated that children with emotional problems be provided any medically necessary service. Many states began to tap into Medicaid funding for children’s mental health services through EPSDT (Orland & Foley, 1996). States received matching funds for children’s mental health services, provided that children met Medicaid eligibility and were diagnosed with a mental health condition that impaired their social functioning (medical necessity). The development of EPSDT as a viable funding stream, and the adoption of CASSP principles by various states, led increasingly to the infusion of CASSP values into wrap-around services.
Pennsylvania, however, was not one of the states that voluntarily decided to take advantage of this funding. This was most likely due to the Department of Human Service’s reluctance to provide the matching funds required to draw down federal dollars and its fear of opening the floodgates to treating additional children with mental health problems.
Pennsylvania wrap-around services. In 1993, under extreme pressure to settle litigation brought to the Pennsylvania high court by advocates for children with special needs, the state capitulated. The response was the creation of Pennsylvania’s system of services known as EPSDT wrap-around. The advent of these services has meant that children previously treated in long-term residential programs are now able to remain with their families and live within their communities (VanDenBerg & Grealish, 1996). By providing intensive support services in their schools, many children with serious mental health problems are able to stay in regular classrooms. Many of these children were placed in special education classrooms in the past, where educational expectations often were far below their educational capacities (Gates, 2000). When special education services are required, wrap-around workers are able to provide services in the context of these classrooms.
Wrap-around services, for all their benefits, have created some very real problems and limitations. First, wrap-around, in the form it has taken in Pennsylvania, is not the flexible model of noncategorical services that was envisioned originally. Services frequently are provided in a cookie-cutter manner, in which the capacities and structures of the service-providing agencies provide a more significant influence over service provision than do the needs of individual children and families. Giovannoni (1997) contends that such categorical services often lead to inappropriate and ineffective care for children. VanDenBerg (2000b) also suggests that such dynamics may lead to negative outcomes with children.
Second, there has been concern that the overreliance on Therapeutic Staff Support (TSS)-bachelor’s-level paraprofessionals working in a child’s home up to 40 hours per week-has led to the disempowerment and disengagement of some families. TSS workers implement behavioral plans designed by therapists or behavioral consultants that are part of the wrap-around team. They provide behavioral reinforcement and document the results of the intervention (Cautilli & Skinner, 1997). TSS workers provide structure activities to children in order to meet their behavioral goals. However, the overreliance on TSS workers, in large part due to attractive reimbursement rates, can lead to the TSS workers taking over discipline and other parental functions. The first author of this study noted 20 instances over a 2-year period where this dynamic occurred. Further, it is possible that once these services are removed, children will return to behavioral and emotional baselines, as family dynamics have not been improved – or, in some cases, have worsened.
Value Considerations
Values are preferences, or what we deem as good. Perlman (1976) defines a value as a cherished belief, an emotionally invested preference. How we view people, and what is important to us about what happens to them, greatly affects how services are delivered (Levy, 1973). Therefore, to understand social programs, movements, and policies, it is imperative to understand their underlining values (Levy). This section seeks to provide an understanding of the role that values have played in the development of wrap-around services and the congruence of these values to nursing and other helping professions.
In spite of the previously mentioned difficulties with wrap-around services in Pennsylvania, many providers have attempted to structure their services to adhere to the values and philosophy of CASSP. Many of these values are congruent with the values of the deinstitutionalization movement, as well as those of the helping professions that care for children with special needs.
The concept of adult deinstitutionalization has its parallel in children’s mental health policy and the policies associated with children’s special needs in general (Giovannoni, 1997). The philosophy underlying these policies can be referred to as “least restrictive treatment.” The very notion of wrap-around services implies that children should be cared for in the least restrictive environment possible (Bouchard & Clark, 1990). VanDenBerg and Grealish (1977) argue that, both morally and fiscally, children should not be cared for in institutions but within the context of their families, if possible, and within their natural communities.
Several social values are implied in this philosophy. First, those with mental health and emotional problems are ill, not morally deficient. This is a value that has been reinforced by scientific innovations and research over the last several decades, attributing mental health problems, at least in part, to biophysical variables. As such, individuals with mental illnesses deserve treatment for their conditions in much the same manner as those with other illnesses. Also implied in this philosophy is the valuation of diversity and nondiscrimination-those with behaviors that differ from the norm are seen to be deserving of the fruits of society, not of scorn and neglect.
Further, the social conceptions of emotional and behavioral problems of children have followed a path parallel to that of adults with mental illness. Children with various behavioral and emotional problems are understood now in professional and policy literature to be disabled (Olkin, 1997). Indeed, children with behavioral problems are often referred to as having “special needs” (Sadker & Sadker, 1991). This destigmatizing term connotes children having needs that fall outside the developmental norms of peers.
There is great congruence between these values and those of the helping professions that care for children.
For instance, providing services to children in their homes implies a respect for and belief in the importance of families. Institutionalization – separating families from the context of care -connotes levels of paternalism rejected by nursing, social work, and other helping professions, which value collaboration and community care, whenever possible (American Nurses Association [ANA], 2000; Reamer, 1993). Wrap-around program treatment plans, which involve family members and clients during all steps of treatment planning, afford a level of client self-determination that is rare in mental health services (Beauchamp & Childress, 1994). Providing clients with the opportunity to be an integral part of planning their own treatment affords them a great deal of autonomy and self-determination – key values within nursing and other helping professions (ANA; Linzer, 1996; Muyskens, 1982; Reamer).
Conclusion
The expansion of Medicaid and the advent of wraparound services represent significant steps forward in the treatment of children with mental health problems. When implemented well, wrap-around programs can harness the strengths of families and communities and curtail the use of costly and overly restrictive institutional forms of care. Wrap-around programs attempt to combat the extreme fragmentation of services that often are linked to treatment failure for children and families with multiproblems (Schorr, 1988). The value base of wrap-around programs, when they adhere to CASSP principles, are congruent with both state-of-the-art knowledge regarding the treatment of children with mental health disorders, and the values of nursing and other helping professions. Currently, implementation of wrap-around programs may at times meet these goals, yet may be uneven within or across states. Policy makers and practitioners must be certain that the wrap-around programs in their states remain highly flexible, resisting the tendency toward rigidity. States would do well to devise programs that support, and even encourage, creative treatment planning at the community level. While wrap-around programs have shown promise, outcome studies are sorely needed. With an estimated 100,000 children receiving wrap-around services in more than 30 states (VanDenBerg, 2000b), opportunities for comparative and longitudinal studies abound.
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Rich Furman, PhD, MSW, and Robert Jackson, PhD
Rich Furman, PhD, MSW, is Assistant Professor, School of Social Work, Colorado State University, Fort Collins, CO. Robert Jackson, PhD, is Associate Professor, Social Work Program, University of Washington, Tacoma.
Author contact: Furman@cahs.colostate.edu, with a copy to the Editor: Poster@uta.edu
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