Evaluation and Program Planning 33 (2010) 4–10

Systems of care, featherless bipeds, and the measure of all things

Sharon Hodges a,*, Kathleen Ferreira b, Nathaniel Israel c, Jessica Mazza d

a Department of Child and Family Studies, Louis de la Parte Florida Mental Health Institute, College of Behavioral and Community Sciences, University of South Florida,

13301 Bruce B. Downs Blvd., MHC 2439, Tampa, FL 33612, United Statesb Department of Child and Family Studies, Louis de la Parte Florida Mental Health Institute, College of Behavioral and Community Sciences, University of South Florida,

13301 Bruce B. Downs Blvd., MHC 2433, Tampa, FL 33612, United Statesc Evidence Based Training Academy, San Francisco Department of Public Health, Community Behavioral Health Services, Child, Youth and Family System of Care,

1380 Howard, Fifth Floor, San Francisco, CA 94103, United Statesd Department of Child and Family Studies, Louis de la Parte Florida Mental Health Institute, College of Behavioral and Community Sciences, University of South Florida,

13301 Bruce B. Downs Blvd., Tampa, FL 33612, United States

A R T I C L E I N F O

Article history:

Received 1 October 2007

Accepted 7 November 2007

Keywords:

System of care

System of care definition

Values and principles

Children’s mental health

A B S T R A C T

For more than 20 years, the system of care philosophy has comprised a central strategy of service reform

in children’s mental health at the federal, state, tribal, and local levels. System of care terminology has

become widely used in many different service sectors but often without a shared understanding of what

a system of care is. This manuscript, the feature article for this special issue of Evaluation and Program

Planning, briefly traces the history of the system of care movement, discusses the more widely used

definitions in the field of children’s mental health, and offers an expanded version of the definition that

takes into account the complex nature of systems of care. This manuscript was the product of a process

used by the Case Studies of System Implementation research team to identify established system of care

communities for inclusion in the research study. The purpose of this manuscript is to describe the

process the research team engaged in while developing the revised definition and to open a public

dialogue about how to characterize the essential properties of a system of care.

� 2009 Elsevier Ltd. All rights reserved.

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1. Introduction

Plato’s definition of human as animal, biped and featherless wascelebrated in ancient Greece. As the story goes, Diogenes of Sinopedemonstrated his dissent by plucking a fowl and bringing it intothe lecture room with the words, ‘‘Here is Plato’s human being.’’(Laertius, 1979). The dialogue of ancient Greek philosophersregarding the essential properties of human beings and otherfeatherless bipeds provides useful, if humorous, impetus forexploring the definition of systems of care, our understanding ofthe essential properties of this concept, and its impact on the fieldof children’s mental health.

The system of care concept was initially defined by Stroul andFriedman in 19861 in response to the crisis of inadequate andfragmented services for children with serious emotional distur-bance. For more than 20 years, the system of care philosophy has

* Corresponding author. Tel.: +1 813 974 6460; fax: +1 813 974 7563.

E-mail addresses: hodges@fmhi.usf.edu (S. Hodges), kferreira@fmhi.usf.edu

(K. Ferreira), nathaniel.israel@sfdph.org (N. Israel).1 ‘‘A comprehensive spectrum of mental health and other necessary services

which are organized into a coordinated network to meet the multiple and changing

needs of severely emotionally disturbed children and adolescents.’’ (Stroul and

Friedman, 1986).

0149-7189/$ – see front matter � 2009 Elsevier Ltd. All rights reserved.

doi:10.1016/j.evalprogplan.2007.11.002

comprised a central strategy of service reform in children’s mentalhealth at the federal, state, tribal, and local levels. The impact of thesystem of care concept is evidenced by the use of this term as areferent in the Surgeon General’s report on children’s mentalhealth (U.S. Department of Health and Human Services, 1999) andthe report of The President’s New Freedom Commission on MentalHealth (2003). It has been used to frame federal and statelegislation (Comprehensive Services Act, 1992; Public Law 102-321, 1992; The California AB 377 Evaluation Project, 1988;Vermont Act 264, 1988) through funding and regulatory mechan-isms that enable providers to work with families in a morecollaborative, culturally sensitive manner. It is present in courtrulings mandating services for children and youth with seriousemotional disturbance (Felix v. Cayetano Consent Decree, 1993;Katie A. v. Bonta, 2002; Rosie D. v. Romney, 2006).

Although it originated in the field of children’s mental health,the term ‘system of care’ is now in use across the United States as acommon referent for other public child-serving sectors such aseducation (No Child Left Behind Act of 2001), child welfare (U.S.Department of Health and Human Services, 2003; U.S. Departmentof Health and Human Services: Administration for Children andFamilies, 2003), and juvenile justice (Skowyra & Cocozza, 2006).Given the time and distance this concept has traveled since itsinception, we should consider whether there exists a common and

S. Hodges et al. / Evaluation and Program Planning 33 (2010) 4–10 5

shared understanding of systems of care. We might also considerwhether the definition for systems of care, like Plato’s definition ofhuman, should be expanded to provide a more comprehensiveunderstanding of this concept in its current use and application.

The purpose of this paper is to describe the process that ourresearch team used for defining systems of care and to open apublic dialogue about how to characterize the essential propertiesof this concept. An expanded definition of systems of care wasdeveloped by the authors as part of a national investigation ofsystem of care implementation funded through the Research andTraining Center for Children’s Mental Health (2004). This paperreviews the existing definitions for systems of care and presents anexpanded definition that attempts to capture the complexity anddynamics of ongoing system development. The authors analyze thecomponents of their definition for the purpose of articulating alogic regarding the essential properties of the system of careconcept. The authors believe that clarity around the definition willincrease fidelity of system of care implementation across diverseand evolving community contexts. Readers should note that theprocess and results described in this paper reflect the point in timeat which this research study was initiated and aspects of thedefinition may have since evolved.

The immediate question raised by such an undertaking is,‘‘What use is a definition, much less a redefinition?’’ Practically,defining a concept facilitates the efficient communication of a setof information. Definitions provide a basis for common under-standing of phenomena. For systems of care, clarity about theconcept of systems of care facilitates our understanding of thepurpose and goals of such a system reform as well as ourevaluation of its impact (Rosenblatt, 1998). As a scientificenterprise, defining a concept also opens it to logical, empirical,and experiential challenges. These challenges may serve ascatalysts for re-examination and revision of the content and scopeof a concept, as well as its lawful relations with other concepts. Thishas practical implications for service providers and families to theextent that new definitions of concepts are translated intostructures, decision rules, and new concepts that are translatedinto novel action.

There are a number of reasons that this is an appropriatejuncture to examine the definition of systems of care. The concepthas been redefined since 1986, and multiple versions are currentlyin use. The initial concept of systems of care was redefined in anupdated monograph by Stroul and Friedman (Stroul & Friedman,1994). The Center for Mental Health Services (CMHS) hassubsequently articulated a definition for systems of care thatincludes processes for family and youth involvement as well ascultural competence.2 Second, the term ‘‘systems of care’’ issometimes used without specific reference to its definition, such asin the report of The President’s New Freedom Commission onMental Health (2003) and the No Child Left Behind Act (2001),implying shared understanding of its meaning. System of careimplementation has been funded in 144 communities nationwidethrough the federal Comprehensive Community Mental HealthServices for Children and Their Families program (Substance Abuseand Mental Health Services Administration, 2008), making thisterm part of the lexicon of a broad range of public agencies andcommunity-based organizations that may not know either itshistory or the issues surrounding the development of the concept.

2 ‘‘A system of care is a coordinated network of community-based services and

supports that is organized to meet the challenges of children and youth with serious

mental health needs and their families. Families and youth work in partnership

with public and private organizations so services and supports are effective, build

on the strengths of individuals, and address each person’s cultural and linguistic

needs. A system of care helps children, youth, and families function better at home,

in school, in the community, and throughout life’’ (Center for Mental Health

Services, 2006).

Although the concept has been further operationalized by Pires(2002) and Stroul and Blau (2008), such common usage acrossmultiple settings assumes a shared meaning of this term that mayor may not be widely held. Finally, recent advances in the scientificunderstanding of complexity and systems development (Holland,1995; Plsek, 2003) as well as rapidly shifting demographic,political, and funding landscapes indicate that this is an opportunetime to examine the definition of systems of care in the currentcontext.

2. Review of definitions currently in use

The system of care concept was conceived as an organizationalphilosophy that involves collaboration across agencies, families,and youth for the purpose of improving access to an expandedarray of coordinated community-based services and supports forchildren with serious emotional disturbance (SED) and theirfamilies (Stroul, 1993; Stroul & Friedman, 1986). Historically, thisconcept emerged from the work of Knitzer (1982) in her seminalbook, Unclaimed Children. In response to Unclaimed Children, theChild and Adolescent Service System Program (CASSP) of theNational Institute of Mental Health (1983) undertook thedevelopment and description of the system of care model, andthis effort resulted in the widely read monograph, A System of Care

for Severely Emotionally Disturbed Children and Youth (Stroul &Friedman, 1986). These early efforts to conceptualize systems ofcare shared a focus on the need to create systemic change in child-serving organizations in order to expand and improve servicedelivery (Hernandez & Hodges, 2003; Lourie, Katz-Leavy, DeCarolis, & Quinlan, 1996). Both Knitzer and Stroul and Friedmanplaced an emphasis on issues related to the organization anddelivery of community-based services that relied on interagencycollaboration in order to provide community-based care in lessrestrictive settings. Early definitions of systems of care focused onorganizational change and the reduction of ‘‘bureaucratic turf andother organizational barriers’’ as a central concept (Lourie et al.,1996, p. 105).

The term ‘‘system of care’’ appears, at first glance, to have acommon and accepted meaning. A closer look at the definition andits uses indicates that the definition has changed over time, both inits explicit definition and its use in policy documents. Thedefinition of systems of care was first expanded in a follow-upmonograph by Stroul and Friedman (1994). In this monograph, theoriginators introduced person- and family-first language in thecore definition and added cultural competence to the Core Valuesthat describe the operational philosophies of a system of care(Stroul & Friedman, 1994, p. xii). This revised definition has beenwidely adopted and was cited in the Surgeon General’s Report onMental Health (U.S. Department of Health and Human Services,1999). In more recent documents widely distributed by CMHS,authors have paraphrased and re-worded the original definition.These new definitions (Pires, 2002, p. 4; Stroul, 2002, p. 3) 3 arecited as the 1986 Stroul and Friedman definition, but do notinclude reference to serious emotional disturbance. These occur-rences indicate that there has been some ‘drift’ from the originaldefinition of a system of care. Definition drift and variation cancreate challenges to a field’s shared meaning of the concept.

Even more fundamental changes to the definition wereincorporated into the official definition of systems of care usedby CMHS, the agency that administers the funding and oversightfor the Comprehensive Community Mental Health Services forChildren and Their Families program (Center for Mental Health

3 ‘‘A comprehensive spectrum of mental health and other necessary services

which are organized into a coordinated network to meet the multiple and changing

needs of children and their families.’’

S. Hodges et al. / Evaluation and Program Planning 33 (2010) 4–106

Services, 2006). This definition of systems of care is substantiallymore explicit regarding how services are to be delivered and theintended outcomes of a coordinated service delivery process. Suchchanges indicate that oversight bodies adapt the definition of thisconcept to the changing understanding of the essential propertiesof systems of care. The system of care definitions discussed abovecan be compared with regard to the populations each identifies asaffected by systems of care, the system response, and mode ofsystem response (see Table 1). Taken together, these observationsindicate that the definition of a system of care has changed overtime. However, the process by which this happens is rarely publicor beholden to formal scientific scrutiny.

It should be noted that there are comprehensive discussions ofsystem of care components, most notably Pires’ (2002) System of

Care Primer and the more recent System of Care Handbook by Strouland Blau (2008). This discussion was purposely restricted todefinitional statements that began, ‘‘A system of care is. . .’’ and didnot analyze detailed descriptions of systems of care that provideinsight into the concept.

3. Developing an expanded definition of systems of care

The expanded definition of systems of care presented belowwas developed for a national research study funded through theResearch and Training Center for Children’s Mental Health (2004).The study used a multi-site embedded case study design to identifystrategies that local communities undertake in implementingcommunity-based systems of care. Site selection criteria requiredthe identification of established systems of care specifying thatparticipating systems must have: an identified local population(s)of youth with serious emotional disturbance; clearly identifiedgoals for this population that are consistent with systems of carevalues and principles; active implementation of strategies toachieve these goals; outcome information demonstrating progresstoward these goals; and demonstrated sustainability over time.

As the study commenced in 2004, the research team consideredthat the system of care concept was in wide use, but the precisemeaning of the concept was not always clear. The team decidedthat establishing a shared understanding of this concept among theinvestigators would support careful and thoughtful adherence tothe site selection criteria as well as reliability in the collection andanalysis of data. Because the study focused on the dynamics ofsystem development, it was necessary to consider a definition ofsystems of care that allowed for systems change over time. Themethod used by the investigators to develop their definition forsystems of care is summarized in the four steps below. Thisoccurred over several months and was more iterative than thesequential steps suggest.

(1) A review of the literature was conducted to establish how thesystem of care concept was being used within and outside thefield of children’s mental health. This review suggested that the1986 and 1994 Stroul and Friedman definitions were the mostfrequently referenced in public documents. The investigatorsused the 1994 definition as their initial point of reference.

(2) Deconstruction of the 1994 Stroul and Friedman definition inan effort to understand its essential properties and relevance tothe system-level unit of analysis proposed in the study. Theinvestigators sought a definition that more explicitly addressedthe growing understanding of systems as socially constructed,reflective of multiple perspectives, and embedded in multiplecontexts.

(3) Identification of essential properties of a system of care thatincorporate the notion of change over time and accommodate asystem-level unit of analysis that is inclusive of the collabor-ating partners and agencies responsible for serving children

with serious emotional disturbance and their families. To dothis, the investigators reviewed the study’s criteria foridentifying established systems of care and considered theessential properties necessary for a system of care to meetthese criteria. This process resulted in the development of asystem of care definition that they believed to incorporate theessential properties.

(4) Review of the literature for each of the essential properties inthe new definition and development of a shared understandingof the meaning of those properties in the context of theirresearch.

The product of this undertaking was a definition for systems ofcare that expands, yet remains consistent with, the 1994 Stroul andFriedman definition. This definition was referenced regularly bythe research team as it proceeded through site selection, theiterative processes of data collection and data analysis, and thereporting of results. This new definition states:

‘‘A system of care is an adaptive network of structures,processes, and relationships grounded in system of care valuesand principles that provides children and youth with seriousemotional disturbance and their families with access to andavailability of necessary services and supports across admin-istrative and funding jurisdictions’’ (Hodges, Ferreira, Israel, &Mazza, 2006).

4. Analysis of essential properties of systems of care

The act of defining determines the limits of a concept, but howcan it be determined whether the properties of a definitionadequately describe its meaning? The Hodges et al. definitionpresented above proved useful for its intended research purpose,but the question remains as to whether it is robust enough to beapplied beyond the boundaries of this research more broadly todetermine whether a broader set of service delivery entitiespossess the necessary qualities of a system of care. A process isneeded to determine whether the definition of a concept actuallyincorporates all of its essential properties.

Plato’s definition of human was completely accurate, butequally insufficient in stating a human’s essential properties. Inmathematics or formal logic, the truth of a proposition is checkedby analyzing the meaning of its terms. Are certain features of adefinition necessary to its meaning? Are others non-essential? Theprocess of analyzing the essential properties of a definitioninvolves evaluating whether these properties are necessary andsufficient conditions for belonging to the concept being defined. Itintroduces a formal reasoning about whether the properties usedto define a concept are, in fact, essential. For example, consider thedefinition of a square as a quadrilateral with all sides of equallength and four right angles summing to 3608. How does ourunderstanding of the concept of ‘‘square’’ change if the property ofit being a quadrilateral is removed from the definition? Upon quickreflection, the quality of four-sidedness is essential to thedefinition of a square, as is the property of equal sides. But whatabout the property stating that the sum of its angles equals 3608?This quality is an accurate statement, but unnecessary because thesum of any four angles created by a quadrilateral will always equal3608. The stipulation that these be right angles, however, preventsthe square from being a parallelogram and is therefore essential.

Let us apply a similar process to the Hodges et al. definition ofsystems of care in an effort to determine whether its componentterms are in fact essential to the properties of systems of care. Thisanalysis will explore the component terms across three dimen-sions: (1) whether the presence of the component is necessary tocreate the concept we call systems of care; (2) whether the

Table 1Comparison of system of care definitions currently in use.

Stroul and Friedman (1986) Stroul and Friedman (1994) Pires (2002) and Stroul (2002) CMHS (2006)

Population [describes individuals

affected by Systems of Care]

[The multiple and changing

needs of] severely emotionally

disturbed children and

adolescents

[The multiple and changing

needs of] children and

adolescents with severe

emotional disturbances

and their families

[The multiple and changing

needs of] children and their

families

[The challenges of] children

and youth with serious mental

health needs and their families

System Response [describes

activities of system response]

Comprehensive spectrum of

mental health and other

necessary services

Comprehensive spectrum of

mental health and other

necessary services

Comprehensive spectrum of

mental health and other

necessary services

Community-based services and

supports [that] build on strengths

of individuals and address each

person’s cultural and linguistic needs

Mode of System Response

[describes organization

of system response]

A coordinated network A coordinated network A coordinated network A coordinated network [in which]

families and youth work in

partnership with public and private

organizations

S. Hodges et al. / Evaluation and Program Planning 33 (2010) 4–10 7

contributions of this component aid our understanding of systemsof care; and (3) whether removing the component from thedefinition would create something other than a system of care.Using this logic, the authors will reflect upon why each componentterm was included in their definition of systems of care andwhether these terms seem to be essential properties of theconcept. For ease of presentation, the 10 component terms of theHodges et al. definition are organized by the population affected, the

system response, and mode of system response (see Table 2).

4.1. Population affected by the system of care

4.1.1. Children and youth with serious emotional disturbance and

their families

The population of children and youth affected by systems ofcare is included in this definition because the authors believe that aclearly specified population is necessary in order for communitiesto successfully identify and monitor system outcomes as well asimplement strategies intended to achieve those outcomes. At itsinception, the system of care movement identified this populationas children with serious emotional disturbance (Knitzer, 1982;Stroul & Friedman, 1986). The current federal definition (Center forMental Health Services, 2005) describes this population as childrenand youth under 22 years of age who have a diagnosable mentalhealth disorder that results in reduced functioning in home, schoolor community settings or requires multi-agency intervention, andwhose disability must have been present or is expected to bepresent for at least 1 year. However, it should be noted thatcommunities adopt their own population definitions, sometimeschoosing a population of focus of particular concern in theircommunities such as underserved and inappropriately servedchildren and youth or those at risk of out-of-home placement.Although reference to SED is missing from some definitions (Pires,2002; Stroul, 2002), the authors believe that federal children’smental health policy remains focused on children and youth withSED and that the definition of systems of care should clearly reflectthis. Inclusion of families as part of this population definitionreflects the importance placed on serving children in the context oftheir families.

Table 2Domains of Hodges et al. definition.

Population [describes individuals affected by systems of care]

System response [describes activities of system response]

Mode of system response [describes organization of system response]

4.2. System response

4.2.1. Access and availability

Access refers to a child’s/family’s ability to enter, navigate, andexit appropriate services and supports as needed (Center forMental Health Services, 2003; Center for Mental Health Services,2004; Farmer, Burns, Phillips, Angold, & Costello, 2003). Avail-ability includes services and supports in sufficient range andcapacity to serve these needs (Stroul, Lourie, Goldman, & Katz-Leavy, 1992; U.S. Department of Health and Human Services,2003a). Availability of services and supports also speaks to thespecificity of the system and its ability to provide appropriate care.The parameters of care include the ability to enter services, get careas needed, and exit services at appropriate times. Care is not trulyaccessible if it is not available, in the same way that sitting in ahospital waiting room is not the same as seeing a doctor. Withoutaccessible and available care, a central purpose of a system of careis lost, and its ability to improve child and family outcomes is nolonger viable. The properties of accessibility and availability arethus integral to a definition of a system of care, and a system of carecannot exist without accessible and available services.

4.2.2. Necessary services and supports

The authors believe that the primary goal of a system of care isto provide individualized care through a broad array of servicesand supports. The word ‘‘necessary’’ emphasizes the provision ofwhatever services and supports are needed for an individual childand his or her family. This implies a certain flexibility of systemresponse and is in contrast to providing care from a standard set ofservices and supports that may or may not meet individual need.The types of services and supports in this definition should beunderstood to include both formal and informal (Hernandez,Worthington, & Davism, 2005; Lazear & Pires, 2002) as well astraditional and non-traditional (Burchard, Bruns, & Burchard,2002). The authors intend this definition to be respectful of familyreliance on social networks in seeking help (Srebnik, Cauce, &Baydar, 1996) as well as collaboration between professional andnatural helpers as critical components of care (Apple et al., 1997;Lazear & Pires, 2002). The explicit inclusion of services and

Hodges et al. (2006)

Children and youth with serious emotional disturbance and their families

Access to and availability of necessary services and supports across

administrative and funding jurisdictions

An adaptive network of structures, processes, and relationships grounded

in system of care values and principles

S. Hodges et al. / Evaluation and Program Planning 33 (2010) 4–108

supports in the definition is essential because without these, theneeds of children and their families cannot be addressed.

4.2.3. Across administrative and funding boundaries

The predominance of categorical administrative and fundingboundaries is identified as a key challenge to providing care tochildren with serious emotional disturbance and their families(Pires, 2002; Stroul & Friedman, 1994; The President’s NewFreedom Commission on Mental Health, 2003). The authorsbelieve that access and availability to services and supportswithout administrative and funding restrictions is essential tocoordination and collaboration across service providers. Withoutthis essential property, services and supports would lack integra-tion.

4.3. Mode of system response

4.3.1. Network

This property refers to the quality of linkages across people,organizations or communities (Capra, 2002; Schensul, LeCompte,Trotter, Cromley, & Singer, 1999). Its inclusion is intended tocapture the mode of service response as comprised of multipleinterconnected elements. The concept of a network is present ineach of the definitions reviewed for this paper. In the Hodges et al.definition, this concept is intended to capture the idea that thesystem is made up of an integrated web of structures, processesand relationships. System linkage across people, organizations, andcommunities is believed to support the capacity of the system toprovide an individualized and non-linear response to the needs ofchildren and families. The qualities of linkage and integration canbe contrasted with the fragmentation and disconnectedness acrosspeople, agencies, and communities that would exist in the absenceof a network within a system of care.

4.3.2. Adaptive

The concept of adaptation describes the type of network withinthe system and conveys an ability of the system to be responsive tochanging environment and context. In this use, adaptationincorporates the ideas of action, reaction, and learning over time(Holland, 1995). This property was included in the definitionbecause systems have been observed to respond to environmentsthat are constantly changing across multiple domains such asfunding arrangements, political will, system leadership, andstaffing (Hernandez & Hodges, 2003). The adaptive behaviors ofsystems of care are characterized by action and reaction among themultiple interconnected elements of these systems over time. It isimportant to note these adaptive responses were considered valueneutral by the authors. For example, action, reaction and learningmay produce system upheaval as well as stability. Adaptation isconsidered an essential property because it accounts for thedynamic nature of systems of care and allows for system changeover time. Without adaptation, systems would rapidly becomeobsolete in a changing environment.

4.3.3. Structures

This term incorporates specified roles, responsibilities, andauthorities that denote organizational boundaries and enable anorganization to perform its functions (Bolman & Deal, 1997; Plsek,2003; Thierry, Koopman, & de Guilder, 1998). Checkland (1993)described structures as being permanent or changing slowly overtime. The authors believe that structures help to organize thefunctioning of the system and allow values to be translated into arange of actions. This includes the physical arrangement andlocation of staff across child-serving sectors, organizationalhierarchies, the defining of catchment areas, and rules regardingdecision-making and communication. Structures are essential

because they create uniformity around how business is conductedwithin the system. Removing the concept of structures from thedefinition would create a system that lacks routine functions,making it difficult to translate values and goals into actions.

4.3.4. Processes

Processes are methods and procedures for carrying outorganizational activities and often involving sequences or sets ofinterrelated activities that enable an organization to perform itsfunctions (Bolman & Deal, 1997; Plsek, 2003; Thierry et al., 1998).Specific processes vary across systems and may change over time(Checkland, 1993). System of care processes might includestrategic planning, supervision of staff, authorization of services,care coordination, and conflict resolution. Processes are guides tothe range and sequence of behaviors by which people meet systemgoals. The authors consider processes as critical to the dailyoperation of a system and believe their absence would likely stallefficient activity of the system.

4.3.5. Relationships

Relationships refer to trust-based links creating connectednessacross people and organizations (Folke, Hahn, Olsson, & Norberg,2005). Empirical evidence suggests that well-established relation-ships are critical in the process of fully implementing plannedorganizational change (Tenkasi & Chesmore, 2003). Interpersonalconnections form a basis for creating shared purpose and processesto achieve value-informed goals. These relationships allowindividuals to take risks and share scarce resources to achievecommon ends. This is critical in the fluid and highly chargedpolitical environments in which systems of care often operate. Insystems of care, these partnerships extend beyond traditionalpublic child-serving agencies to include youth and familymembers. In addition, current research in cultural competencesuggests that system relationships also include individuals andorganizations that can support access to culturally and linguisti-cally appropriate services and supports (e.g. ministers, elders, orother respected community leaders), regardless of their specificrelationship to children with serious emotional disturbance andtheir families (Research and Training Center for Children’s MentalHealth, 2005). The need for the inclusion of relationships in thisdefinition is supported by the observation that the absence oftrusting relationships is sufficient to stymie system developmentand prevent the development of a system of care that is true to itsexpressed values and principles.

4.3.6. System of care values and principles

Originally identified by Stroul and Friedman in 1986, the valuesand principles of a system of care are widely used throughout thefield of mental health and have been adopted at community, state,tribal, and federal levels. These values have changed over time toincorporate culturally competent, family-focused, and family-driven care. The inclusion of values and principles in the definitionof a system of care, particularly the emphasis on familyinvolvement and cultural competence, is considered essential bythe authors because values and principles shared across systemstakeholders establish the philosophy and parameters for opera-tion of the system. Values and principles also provide a beliefstructure for the kinds of outcomes a system is expected to achieve,making some outcomes desirable and others unacceptable. Forexample, if system partners commit to the value of servingchildren and youth in the least restrictive most clinicallyappropriate environment, then the system outcomes shouldreflect an increase in the availability of community-based careand a reduction of out-of-home placements. Strategies resulting inincreased restrictive placements for children and youth with SEDwould be considered undesirable and not in keeping with system

S. Hodges et al. / Evaluation and Program Planning 33 (2010) 4–10 9

of care values and principles. If a system values family-driven care,then system outcomes can be expected to reflect family involve-ment at all levels of decision making, from governance toindividual care. The authors believe that these values andprinciples are evident in the daily operation of a well functioningsystem of care and that their absence would create morefragmented, less individualized care, provided in more restrictivesettings with little regard for the role of families or the diversity ofthe populations served.

The Hodges et al. definition offers a number of modifications tothe existing definitions of systems of care. Among these, a notabledifference relates to values and principles in the CMHS (2006)definition. The authors concur with the primacy of the valuesspecifically articulated within the CMHS definition, but believethat all of the values and principles articulated by Stroul andFriedman (1994) should be taken together as the philosophicalfoundation of systems of care and are, in their sum, essential. Theauthors also make more explicit the concept of ‘‘network,’’ which isused in all of the definitions reviewed in this paper. Perhaps morenoteworthy, the system response, as articulated in the Hodgeset al. definition, is distinguished by its focus on access to andavailability of services and supports as well as the ability to cross-administrative and funding jurisdictions. The authors believe thatthese elements are so fundamental to systems of care that theymust be explicitly stated in the definition. Finally, the authors’explicit inclusion of adaptation as a necessary system qualityreflects recent advances in scientific understanding of complexityand system development. This new knowledge is believed to becritical to our understanding of system development over time anda key concept in the definition.

5. Discussion

This exercise of analyzing the component terms of a definitionis productive in establishing an understanding of whether and whycertain components are essential properties of the concept. Asystem, however, consists of interrelated parts coming together toform a whole. The concept of holism, taken from the Greek wordholos, suggests that as we study some aspect of human society wemust remain mindful of its relation to the whole. In research aswell as service planning and delivery, we can successfully isolatespecific elements of service systems in an effort to improve thatfunction. In an interdependent system, however, a change in onepart has ramifications for the whole. For this reason, Aristotle’sobservation that the whole is more than the sum of its parts iscritical to facilitating our understanding of the system of careconcept (Aristotle, 350 BCE/1924).

Having explored the definition of systems of care, we return tothe definition of what is human. The sophist Protagoras of Abderadefined human in the 5th century BCE claiming that, ‘‘man is themeasure of all things’’ (Poster, 2006). This statement is ofteninterpreted as an introduction of the idea of relativism, the notionthat truth is not absolute but is instead influenced by values,beliefs, and subjective interpretation. In other words, conclusionsabout the meaning of a concept should be considered within theirhistorical and cultural context. Approaching the process of definingfrom a position of relativism, we can ask, ‘‘Is any definition themeasure of all things?’’ For some concepts, perhaps. The concept ofan object such as square is concrete, and its definition can beconsidered constant. The scientific debate surrounding Pluto andthe essential properties of planets demonstrates that concepts weonce understood as concrete must be reconsidered relative to thedevelopment of new knowledge and understanding.

The definition of systems of care will never be as concrete asthat of quadrilaterals with four right angles and all sides of equallength. Comparing generalizations made in the natural sciences to

generalizations in behavioral and social sciences, Cronbach stated,‘‘Generalizations decay. At one time a conclusion describes theexisting situation well, at a later time it accounts for rather littlevariance, and ultimately is valid only as history’’ (Cronbach, 1975,p. 113). Our understanding of systems of care has changed incritical ways over the past 20 years. The involvement of familiesand our attention to cultural competence are two prime examples.The effort to conceptualize systems of care as complex andadaptive and reflect their implementation as dynamic and evolvingprocess also speaks to this point. We cannot assume that anydefinition for systems of care is the measure of all things. We do,however, have a responsibility to be as clear in our conceptualiza-tion of systems of care as our knowledge and understandingcurrently allow. Doing so contributes to clarity around the theoryof systems of care, its goals and objectives, and our expectations forsuch service system reform.

6. Conclusion

This paper has provided a revised definition of systems of careand articulated the authors’ logic around the derivation of eachcomponent. The creation of expanded or revised definitions of aconcept is driven by attempts to assimilate new experiences andobservations into our previously held ideas of a concept.Definitions, like systems, should be adaptive, and a public processof examination allows for incremental changes in our under-standing of how systems work and how key concepts are defined.Definitions can provide the basis for common understanding, butonly if there is clarity and consensus around the core componentsof the concept.

It is in the spirit of adaptation that we made our definition anddefinitional process public and recognize that by encouragingcritique in this special issue and beyond, it might be relegated to aspecies of featherless bipeds. We look forward to new observationsand perspectives that challenge us to respond to both incrementaland paradigmatic change in our conceptualizations of systems ofcare. We share the hope that this undertaking is experienced as ademocratic process whereby changes in our understanding of whatsystems are and how they operate are communicated and madeaccessible to all stakeholders, and that clarity around the conceptof systems of care can facilitate the implementation of such systemreform.

Acknowledgements

The authors would like to acknowledge the late Dr. Steve Banksfor his inspiration and thank Beth Stroul and Robert Friedman fortheir foundational work defining systems of care.

The research described in this manuscript was jointly funded bythe National Institute on Disability and Rehabilitation Research,U.S. Department of Education and the Center for Mental HealthServices, Substance Abuse and Mental Health Services Adminis-tration under grant number H133B040024. The opinions containedin this document are those of the authors and do not necessarilyreflect those of the U.S. Department of Education or SubstanceAbuse and Mental Health Services Administration.

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Sharon Hodges, PhD, MBA, is an applied organizational anthropologist and ResearchAssociate Professor in the Department of Child and Family Studies at the University ofSouth Florida. Her research focuses on collaboration and cross-sector accountability,strategic resource use among organizations and the reorganization and restructuringof agency relationships that result from voluntary local system development efforts.She has worked with systems of care for more than 15 years.

Kathleen Ferreira, MSE, is an Assistant in Research in the Department of Child andFamily Studies and a Doctoral Candidate in the College of Education at the Universityof South Florida. Her dissertation research is focused on multi-disciplinaryapproaches to mental health service delivery. Her research interests include exam-ining the development and sustainability of mental health service systems; colla-boration between multiple agencies in the mental health service system, and the roleof various stakeholder groups in the development of successful mental health servicesystems.

Nathaniel Israel, PhD, is Director of the Evidence-Based Training Academy for theChild, Youth and Family System of Care within the San Francisco Department of PublicHealth. His primary interest is intervening in systems to make them more effective forchildren, youth and families. His current work involves identifying and implementingclinical and evaluation practices that support family-directed, culturally competent,functionally effective service delivery.

Jessica Mazza, MSPH, was a member of the research team while earning her MSPHthrough the College of Public Health at the University of South Florida.