Enhancing Wraparound with Evidence Based Practices Using the Managing and Adapting
Practice (MAP) System Eric J. Bruns, Ph.D.
University of Washington School of Medicine, Seattle, WA
Eric Daleiden, Ph.D. and Bruce Chorpita, Ph.D. PracticeWise, LLC
26th Annual Research and Policy Conference on Children’s Mental Health
Tampa, FL March 4, 2013
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Thanks to the Institute for Innovation and Implementation at the University of Maryland School of Social Work for their partnership in development work and to Catholic Community Services of
Western Washington for their participation in the pilot testing of the Wrap + MAP idea.
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Research to Date on Wraparound
• There have been 9 controlled studies of wraparound published in peer review journals
• Results consistently indicate superior outcomes for wraparound compared to “services as usual”* – Moderate (ES = .50) effects for living situation and
community (e.g., recidivism, school attendance) outcomes
– Smaller (ES = .25 - .30) effects for behavioral, functional, and clinical outcomes
*Suter, J.C. & Bruns, E.J. (2009). Effectiveness of the Wraparound Process for Children with Emotional
and Behavioral Disorders: A Meta-Analysis. Clinical Child and Family Psychology Review, 12, 336-351
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Research to Date on Wraparound
• However: – Evaluations have shown better outcomes for alternative conditions,
when connected to effective clinical care (Bruns et al., in revision) – Study comparing Wrap to MST (Stambaugh et al., 2007) found:
• Wrap addressed the needs of more youths in the system and similar functional outcomes, but
• Better clinical outcomes for MST and shorter length of intervention for MST
• Implication: The lack of specificity about how to use research evidence in wraparound may reduce – Clinical/functional effectiveness – Efficiency – Family and team member perception of quality of options
*Suter, J.C. & Bruns, E.J. (2009). Effectiveness of the Wraparound Process for Children with Emotional
and Behavioral Disorders: A Meta-Analysis. Clinical Child and Family Psychology Review, 12, 336-351
A call to action
• “It is time to finally develop and test a model in which the community based strengths and potent delivery systems of wraparound are united with the empirical strength of evidence-based interventions, to promote and protect mental health in children and their families”
– John Weisz et al., The American Psychologist (p.645).
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Big ideas to Enhance Wraparound
1. Generate evidence based strategies that fit the youth and family’s needs during the wraparound planning process
2. Support clinicians to use effective practices that connect to the youth and family’s priority needs
3. Coordinate family and youth partners, mentors, and other allies to support appropriate EBP use
4. Monitor progress and practice more consistently and change plans as needed
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Big Ideas Proposed enhancement Mechanisms for achieving Hypothesized effects Generate evidence based strategies that fit the youth and family’s needs during planning and delivery
Support clinicians to use effective therapies that connect to the youth and family’s priority needs
Individuals serving in peer, community, natural support roles have poorly defined roles or are not engaged at all
Monitor progress and practice more consistently and change plans as needed
Big ideas to Enhance Wraparound
The question is: HOW?
What is an approach to EBP that
would work for wraparound?
The MAP Proposal: Organize EBP into a Knowledge Management Approach
See the evidence base as knowledge and not simply products…
Organize libraries of common practices and processes with empirical support
Build information resources and tools
Coordinate delivery systems to support practitioners to generate ideas for addressing perennial questions with the “best evidence” and to self-correct over time
Why might this work? • Identified practices will fit wraparound youths (RMAP;
Bernstein et al., 2013)
• A state that tried a version of this showed better outcomes (HI; Daleiden et al., 2006)
• MAP can “go to scale” and yield positive outcomes (LA; Southam-Gerow et al., 2013)
• Modular EBP yielded better progress than standard EBT and usual care in a RCT (MATCH; Weisz et al., 2012)
• Knowledge and use of support practices is associated with better treatment quality in school-based services (SMH; Stephan et al., 2012)
• Supported practices predict progress better within a coordinated service model (MST; Denneny & Mueller, 2012)
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Big Ideas Proposed enhancement Mechanisms for achieving Hypothesized effects Generate evidence based strategies that fit the youth and family’s needs during planning and delivery
Use MAP tools to generate a broader array of research-based options that fit the youth and family’s needs
Support clinicians to use effective therapies that connect to the youth and family’s priority needs
When therapeutic needs are identified, ensure clinicians use effective treatment elements that connect to the youth and family’s strengths and preferences
Individuals serving in peer, community, natural support roles have poorly defined roles or are not engaged at all
Parent and youth partners, mentors, behavioral specialists, and others serve as “care extenders,” provide appropriate follow-on support to treatment strategies
Monitor progress and practice more consistently and change plans as needed
Use a structured tool to monitor progress and practices consistently and use the information to revise plans as needed
What are the MAP tools
and resources?
Getting down to the building blocks of
“what works”
Incredible
Years PCIT
Defiant
Children
Parent Training
Commands Commands Attending
Time Out
Rewards
Time Out
Protocols
Families
Practice Elements
Managing and Adapting Practice (MAP)
• Three main innovations:
– PracticeWise Evidence Based Services (PWEBS) Database • Method for a practitioner to use the database of common treatment
elements
– Practitioner Guides • Codified clinical supports
– Clinical Dashboard • Feedback tool to monitor process and progress of treatment
– Supported by an on-line resource library and user interface called PracticeWise (www.practicewise.com)
This tells you the practice elements associated with those treatment types.
Objectives:
to increase the amount of positive attention provided to the child, even if the child has misbehaved at other times during the day
to teach the caregiver to attend to positive behaviors
to promote the child’s sense of self-worth
Steps:
Provide rationale Emphasize the importance of providing positive attention to the child.
Elicit the caregiver’s opinion about how attention affects behavior and people’s motivation to do a good job.
Have the caregiver describe his or her best and worst “managers” and the caregiver’s motivation to work for each.
Lead the caregiver to recognize that how he or she was treated affected the caregiver’s desire to work.
Discuss how the child’s behavior may be affected by the caregiver’s behavior towards the child and how the child’s desire to behave can be increased by improving the caregiver-child relationship.
Set aside one-on-one time for caregiver and child
Encourage the caregiver to set aside a block of time (e.g., 10 minutes) each day devoted to joining the child in an activity the child has chosen.
Teach caregiver to provide positive and descriptive commentary
Show the caregiver how to demonstrate sincere interest in the child’s activities while they are playing.
Instruct the caregiver to provide enthusiastic descriptive (e.g., “You are drawing a tree”) and/or positive (e.g., “I like the way you stacked the blocks”) commentary and praise regarding the child’s behavior.
Encourage caregiver to engage in child’s activity
Suggest that the caregiver become actively involved in the play activity by imitating the child’s behavior in order to demonstrate approval.
Restrict criticism, questions, and commands
It is important that the child lead the activity; that is, the caregiver should refrain from making suggestions, asking questions, and criticizing the child.
Allow the child to use his or her imagination (e.g., coloring the green or making up new rules to a game) without caregiver input about the “correct” way to do things.
Anticipate difficulties When the procedure is initially implemented, the child may engage in negative behavior that characterizes the usual caregiver-child interaction. When this occurs, the caregiver should:
consistently ignore negative behavior by looking away;
refrain from scolding the child so as to avoid providing negative attention for misbehavior;
end one-to-one time if disruptive behavior continues or is dangerous.
Over time, however, it is expected that consistent positive attending will result in decreased negative behavior and increased positive caregiver-child interactions.
Attending
Use This When:
To improve the quality of the caregiver-child relationship.
Practitioner Guide
For CaretakerFor Caretaker
One 2-sided page per practice
During Session Before Session
Remind client and obtain commitment
Review dashboard to assess progress and practice history
Review notes on previously assigned homework
Identify next practice(s) that will be the focus
Review the Practice Guide(s)
Establish session plan and choose rehearsal activity
Check in with supervisor if needed
After Session Record progress
ratings and practice(s) performed
Review Practice Guide(s) to determine if any steps were missed that should be covered next time
Note any homework that was assigned
Note any new stressors or obstacles
Check in with supervisor if needed
The Session Planner (Clinical Event Structure)
Process
Guide
© 2012 PracticeWise, LLC
Opening
• Check In, Identify a Strength
• Review Earlier Skills/Homework
• Set Agenda
Working
• Advise, Instruct, Or Guide
• Rehearse
• Repeat
Closing
• Review
• Assign Homework
• Reward
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Big Ideas Proposed enhancement Mechanisms for achieving Hypothesized effects Generate evidence based strategies that fit the youth and family’s needs during planning and delivery
Use MAP tools to generate a broader array of research-based options that fit the youth and family’s needs
• Use PWEBS searches at strategic points in planning process
• Use Practice Guides to help family and team members understand options
Support clinicians to use effective therapies that connect to the youth and family’s priority needs
When therapeutic needs are identified, ensure clinicians use effective treatment elements that connect to the youth and family’s strengths and preferences
• Train and coach wraparound-affiliated clinicians on MAP system and treatment elements
• Certify clinicians in MAP
Individuals serving in peer, community, natural support roles have poorly defined roles or are not engaged at all
Parent and youth partners, mentors, behavioral specialists, and others serve as “care extenders,” provide appropriate follow-on support to treatment strategies
• Modify select MAP treatment elements to “care extension” strategies
• Orient/train support staff in care extender model
• Clinicians/team include follow-on support strategies in wraparound plans
Monitor progress and practice more consistently and change plans as needed
Use a structured tool to monitor progress and practices consistently and use the information to revise plans as needed
• Facilitators trained to use team-level dashboard
• Clinicians trained to use MAP clinical dashboard
• Supervisors trained to use dashboards in supervision
What will
this do?
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Big Ideas Proposed enhancement Mechanisms for achieving Hypothesized effects Generate evidence based strategies that fit the youth and family’s needs during planning and delivery
Use MAP tools to generate a broader array of research-based options that fit the youth and family’s needs
• Use PWEBS searches at strategic points in planning process
• Use Practice Guides to help family and team members understand options
• Greater range of options for family/team
• Options are based on evidence for effectiveness
• Family/team better engaged, more hopeful, more satisfied
Support clinicians to use effective therapies that connect to the youth and family’s priority needs
When therapeutic needs are identified, ensure clinicians use effective treatment elements that connect to the youth and family’s strengths and preferences
• Train and coach wraparound-affiliated clinicians on MAP system and treatment elements
• Certify clinicians in MAP
• Treatments better fit youth clinical needs
• Better communication with wraparound team about purpose of therapy
• Treatments more focused • Treatments more effective
Individuals serving in peer, community, natural support roles have poorly defined roles or are not engaged at all
Parent and youth partners, mentors, behavioral specialists, and others serve as “care extenders,” provide appropriate follow-on support to treatment strategies
• Modify select MAP treatment elements to “care extension” strategies
• Orient/train support staff in care extender model
• Clinicians/team include follow-on support strategies in wraparound plans
• Better role definition for persons in support roles
• More effective teamwork • Treatment strategies more
effective • Support staff more satisfied
and show greater self-efficacy
Monitor progress and practice more consistently and change plans as needed
Use a structured tool to monitor progress and practices consistently and use the information to revise plans as needed
• Facilitators trained to use team-level dashboard
• Clinicians trained to use MAP clinical dashboard
• Supervisors trained to use dashboards in supervision
• More frequent progress review • Better teamwork/problem
solving • Shorter self-correction cycles • Understanding of transition • Shorter wraparound episodes
One Idea = Ensure connection to a
MAP Therapist
© 2012 PracticeWise, LLC
Wrap Facilitator
…as well as…
Parent Partner
Youth Specialist
MAP Therapist
Clinical
Dashboard
Codified
Clinical
Procedures (PG)
Service Literature
(PWEBS)
Biger idea:
Fully coordinated process
© 2012 PracticeWise, LLC
Wrap Facilitator
…as well as…
Parent Partner
Youth Specialist
MAP Therapist
Plan of Care
Clinical
Dashboard
Team Meeting
Codified
Procedures (PG)
Service Literature
(PWEBS)
Family/Collateral
Communication
Direct
Communication
Initial response is encouraging
• 88% of MAP therapists who work in wraparound contexts agreed combining Wrap and MAP would promote positive outcomes
• 90% of wraparound providers (N=21) in our pilot site “agreed” or “strongly agreed” that combining Wrap and MAP would promote positive outcomes
• 88% of wraparound facilitators and family peer support partners who used PWEBS to facilitate plan development agreed that it improved the options available to planning
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General
Services
Research
Local
and Community
Evidence
Family Story
and Timeline
Causal
Mechanism
Research
Priority
Needs &
Goals
Strategies,
Supports, and
Treatments
Service
Setting
Client
Progress
Treatment
Integrity
MAP Therapist
Resources
& Supports
Wraparound
Team/
Process
Wraparound
Facilitator
•Engagement
•Teamwork
•Goal Setting
•Integrated Plan
of Care
•Collateral
Communication
•Social Support
Satisfaction
and Wrap
Fidelity
•Service
Literature
•Searchable
Database
•Codified
Procedures
•Clinical
Dashboard
Peer Support
Worker
Evidence-based Wraparound Care Coordination
Model?
Adapted with Permission from EBS System Model, © 2012 PracticeWise, LLC
Next steps
• Preparation for pilot test:
– Developing MAP training content for individuals in wraparound roles
– Adapting training on relevant treatment elements to care extenders (e.g., peer supports, mentors, behavioral support specialists)
– Developing wraparound team-level progress and practice dashboard
• Tests of feasibility, parent and provider perceptions, and teamwork outcomes
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For more information
• PracticeWise: www.practicewise.com
• Wraparound Evaluation and Research Team: www.wrapinfo.org
• Eric Bruns: [email protected]
• Eric Daleiden: [email protected]
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