Family voice with informed choice: coordinating wraparound with research-based treatment for children and adolescents

A Phenomenological Exploration of Families' Experiences of the Mental Health System of Care in the Monadnock Region

Accessing mental health treatment in rural locations is a unique challenge for families with youth experiencing adverse mental health conditions. Families often experience a variety of difficulties accessing and negotiating changes within the system of care. This study aimed to understand the experiences of families and their youth in navigating the mental health system in a rural community. Interpretative phenomenological analysis was used to examine how participants interpret their experiences within the local system of care. Qualitative interviews were conducted with eight families. Results included five main themes: youth experience, family experience, access to a system of care, relationships between stakeholders, and larger societal beliefs. Families highlighted their experiences accessing the local care system and their hope for strengthening community access and partnerships. Findings indicate that prioritizing family voices should be encouraged by local systems.

A landscape assessment of the activities and capacities of evidence-to-policy intermediaries (EPI) in behavioral health

BACKGROUND

A significant gap exists between the production of research evidence and its use in behavioral health policymaking. Organizations providing consulting and support activities for improving policy represent a promising source for strengthening the infrastructure to address this gap. Understanding the characteristics and activities of these evidence-to-policy intermediary (EPI) organizations can inform the development of capacity-building activities, leading to strengthened evidence-to-policy infrastructure and more widespread evidence-based policymaking.

METHODS

Online surveys were sent to 51 organizations from English-speaking countries involved in evidence-to-policy activities in behavioral health. The survey was grounded in a rapid evidence review of the academic literature regarding strategies used to influence research use in policymaking. The review identified 17 strategies, which were classified into four activity categories. We administered the surveys via Qualtrics and calculated the descriptive statistics, scales, and internal consistency statistics using R.

RESULTS

A total of 31 individuals completed the surveys from 27 organizations (53% response rate) in four English-speaking countries. EPIs were evenly split between university (49%) and non-university (51%) settings. Nearly all EPIs conducted direct program support (mean = 4.19/5 [sd = 1.25]) and knowledge-building (4.03 [1.17]) activities. However, engagement with traditionally marginalized and non-traditional partners (2.84 [1.39]) and development of evidence reviews using formal critical appraisal methods (2.81 [1.70]) were uncommon. EPIs tend to be specialized, focusing on a group of highly related strategies rather than incorporating multiple evidence-to-policy strategies in their portfolios. Inter-item consistency was moderate to high, with scale α's ranging from 0.67 to 0.85. Ratings of respondents' willingness to pay for training in one of three evidence dissemination strategies revealed high interest in program and policy design.

CONCLUSIONS

Our results suggest that evidence-to-policy strategies are frequently used by existing EPIs; however, organizations tend to specialize rather than engage in a breadth of strategies. Furthermore, few organizations reported consistently engaging with non-traditional or community partners. Focusing on building capacity for a network of new and existing EPIs could be a promising strategy for growing the infrastructure needed for evidence-informed behavioral health policymaking.

Clinical Update: Child and Adolescent Behavioral Health Care in Community Systems of Care

OBJECTIVE

The objective of this Clinical Update is to review the principles, structures, processes, and outcomes of community systems of care as they pertain to the delivery of behavioral health care to children and adolescents METHOD: A search of the literature on this topic from 2002 was initially conducted in 2016 and repeated in 2019 and 2021, yielding 1,604 English-language citations. These citations were supplemented by references suggested by topic experts and identified through Web searches, increasing the yield to 1,684 total citations, of which 1,184 were unduplicated. After sequential review by Update authors at title/abstract and then full-text levels, the citations were winnowed to 156 based on relevance to the topic.

RESULTS

The systems of care approach, arising in the 1980s, expanded child and adolescent behavioral health care from the core services of psychotherapy, medication management, inpatient psychiatric services, and residential treatment to include home- and community-based treatment and support services; promotion, prevention, and early intervention programs; and specialized services for very young children and youth and young adults of transition age. These services and supports are delivered by a large multidisciplinary workforce and are governed by key principles, including a biopsychosocial case conceptualization; family-driven, youth-guided, strengths-based, and trauma-informed care. Services in the least restrictive setting; continuity of care across transitions; a public health framework for service delivery; promotion of wellness and resilience; and elimination of health disparities. Challenges to systems of care implementation include funding availability, workforce shortages, deficiencies in cross-systems collaboration, and variability in insurance coverage. Although controlled studies have failed to provide convincing evidence of favorable outcomes from the whole systems of care approach, uncontrolled research has demonstrated increased access to care, positive clinical and functional outcomes, improved family functioning, and reductions in costs, particularly when research is focused on specific behavioral health problems, specific interventions such as Wraparound care, or highly specified groups of youth.

CONCLUSION

Health professionals who are educated in the systems of care approach can improve access to and quality of behavioral health care for children and adolescents with behavioral health needs.

Shared decision-making for youth psychotherapy: A preliminary randomized clinical trial on facilitating personalized treatment

OBJECTIVE

Engaging youth and caregivers as active collaborators in the treatment planning process is a patient-centered approach with the potential to facilitate the personalization of established evidence-based treatments. This study is the first randomized clinical trial to evaluate shared decision-making (SDM) to plan youth psychotherapy.

METHOD

Forty youth (7-15 years; 33% ethnic minority) were randomly assigned to psychosocial treatment planned using SDM (n = 20) or planned primarily by the clinician (n = 20). In the SDM condition, clinicians guided youth and caregivers through a collaborative treatment planning process that relies on research findings to inform three primary decisions: (a) treatment target problem(s), (b) treatment participants, and (c) treatment techniques. Assessments occurred at baseline, following treatment planning, midtreatment, and post-treatment.

RESULTS

Youth and caregivers in the SDM condition reported significantly greater involvement in the treatment planning process compared to their counterparts in the clinician-guided condition (U = 123.00, p = .037; U = 84.50, p = .014, respectively) and SDM caregivers reported significantly lower decisional conflict (U = 72.00, p = .004) and decisional regret (U = 73.50, p = .020). Supporting the feasibility of successful SDM implementation, there were no significant differences between conditions on treatment length, satisfaction with decisions, or engagement. There were no significant diagnostic or symptom differences between conditions.

CONCLUSIONS

Planning psychosocial treatments in collaboration with youth and caregivers is a promising way to support youth and caregiver autonomy and plan evidence-based treatments that are responsive to patient preferences, culture, and values. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Racial and Ethnic Disparities in Pediatric Mental Health-Related Emergency Department Visits

OBJECTIVES

To test the hypotheses that (1) rates of mental health-related concerns presenting to pediatric emergency departments (ED) have increased (2) rates are increasing more in minority than nonminority youth.

METHODS

We performed a 5-year retrospective cohort study of youth with mental health-related ED visits using the Pediatric Health Information System. We calculated rates of mental health-related visits, in aggregate and by race/ethnicity. The Poisson model was used to generate incidence rate ratios of unique mental health-related visits each year using census data as the population denominator.

RESULTS

There were 242,036 mental health-related visits that met the inclusion criteria, representing 160,656 unique patients. Approximately 7% of unique patients had 3 or more mental health-related visits, differing by race/ethnicity (8.75% non-Hispanic [NH]-Black vs 7.01% NH-White; adjusted odds ratio 1.14 [1.03, 1.26]). Overall, there were 42.8 mental health-related ED visits per 100,000 US children. The NH-Black children had higher rates of visits per 100,000 children compared with NH-Whites (66.1 vs 41.5; adjusted relative risk, 1.54 [1.50-1.59]). Mental health-related visits increased from 2012 to 2016 (33.31 [32.92-33.70] to 49.94 [49.46-50.41]). Every racial/ethnic group experienced an increase in rate of presentation over the study period; Hispanics experienced a significantly larger increase compared with NH-White children (P < 0.05).

CONCLUSIONS

Mental health-related ED visits among children are increasing overall, disproportionally affecting minority children. The NH-Black children have the highest visit rates, and rates among Hispanics are increasing at a significantly higher rate when compared with NH-Whites. These results indicate need for increased capacity of EDs to manage mental health-related complaints, especially among minority populations.

Expect the Unexpected: A Qualitative Study of the Ripple Effects of Children's Mental Health Services Implementation Efforts

Background

Strategies to implement evidence-based interventions (EBIs) in children's mental health services have complex direct and indirect causal impacts on multiple outcomes. Ripple effects are outcomes caused by EBI implementation efforts that are unplanned, unanticipated, and/or more salient to stakeholders other than researchers and implementers. The purpose of the current paper is to provide a compilation of possible ripple effects associated with EBI implementation strategies in children's mental health services, to be used for implementation planning, research, and quality improvement.

Methods

Participants were identified via expert nomination and snowball sampling. Online surveys were completed by 81 participants, each representing one of five roles: providers of mental health services to children or youth, researchers, policy makers, caregivers, and youth. A partially directed conventional content analysis with consensus decision making was used to code ripple effects.

Results

Four hundred and four unique responses were coded into 66 ripple effects and 14 categories. Categories include general knowledge, skills, attitudes, and confidence about using EBIs; general job-related ripple effects; EBI treatment adherence, fidelity, and alignment; gaming the system; equity and stigma; shifting roles, role clarity, and task shifting; economic costs and benefits; EBI treatment availability, access, participation, attendance, barriers, and facilitators; clinical process and treatment quality; client engagement, therapeutic alliance, and client satisfaction; clinical organization structure, relationships in the organization, process, and functioning; youth client and caregiver outcomes; and use of EBI strategies and insights in one's own life.

Conclusions

This research advances the field by providing children's mental health implementers, researchers, funders, policy makers, and consumers with a menu of potential ripple effects. It can be a practical tool to ensure compliance with guidance from Quality Improvement/Quality Assurance, Complexity Science, and Diffusion of Innovation Theory. Future phases will match potential ripple effects with salient children's mental health implementation strategies for each participant role.

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.

Evidence Based Practice in Systems of Care for Children with Complex Mental Health Needs

Purpose: Community-based social work with families and youth with complex behavioral health needs highlights challenges to incorporating empirical evidence into routine practice. This article presents a framework for integrating evidence in community-based Systems of Care for these children and their families.Method: This article reviews research on various approaches to integrating evidence into children's behavioral health and community-based care and contextualizes it within dominant paradigms of Systems of Care (SoC) and Wraparound principles.Results: Based on this review, this article proposes the Evidence-Based Practice in Systems of Care (EBP in SoC) model. The model describes how to incorporate evidence into every aspect of community-based SoCs for children with mental health concerns.Discussion and Conclusion: Discussion of the model will focus on implications of using the framework for practitioners, mental health organizations, communities, and state and federal administration and policymaking.

State-Community System of Care Development: an Exploratory Longitudinal Review

The system of care (SOC) philosophy evolved into a framework to support access to effective behavioral health services for children. This study explored the use of the System of Care Implementation Survey (SOCIS) to monitor SOC development during one Midwestern state's federal planning and expansion grants. Utilizing a translational framework, results showed that despite fluctuations in SOC factor implementation over time, state and local SOCs had mid-level development. Further, inferential analysis of select factors indicated that outreach and access to services and the skilled provider network were significantly worse over time. Significant improvement in the treatment quality was documented but not sustained. Changes for Family Choice and Voice and Collaboration were not statistically significant. Variability in survey participation limited the evaluation. Refinement of evaluation methods is needed to monitor progress and to manage SOC development.

Common Elements of Childhood Universal Mental Health Programming

Despite the availability of multiple mental health prevention and promotion programs for children, challenges related to their dissemination limit their reach and impact. This review identifies the most common practice elements of effective childhood universal mental health programming for children ages 3-11, based on a structured interpretation and coding of program manuals and descriptions in peer-reviewed articles. Across a range of program goals and targeted outcomes, psychoeducation and problem solving emerged as the most common practice elements, followed by social skills training, insight building, and communication skills. These skills were largely taught via role-plays and modeling. Synthesizing what we know from the universal mental health programming literature has potential to facilitate dissemination of information to inform the development, adaptation or adoption of programs for children.

The role of the outer setting in implementation: associations between state demographic, fiscal, and policy factors and use of evidence-based treatments in mental healthcare

Background

Despite consistent recognition of their influence, empirical study of how outer setting factors (e.g., policies, financing, stakeholder relationships) influence public systems’ investment in and adoption of evidence-based treatment (EBT) is limited. This study examined associations among unmodifiable (e.g., demographic, economic, political, structural factors) and modifiable (e.g., allocation of resources, social processes, policies, and regulations) outer setting factors and adoption of behavioral health EBT by US states.

Methods

Multilevel models examined relationships between state characteristics, an array of funding and policy variables, and state adoption of behavioral health EBTs for adults and children across years 2002–2012, using data from the National Association for State Mental Health Program Directors Research Institute and other sources.

Results

Several unmodifiable state factors, including per capita income, controlling political party, and Medicaid expansion, predicted level of state fiscal investments in EBT. By contrast, modifiable factors, such as interagency collaboration and investment in research centers, were more predictive of state policies supportive of EBT. Interestingly, level of adult EBT adoption was associated with state fiscal supports for EBT, while child EBT adoption was predicted more by supportive policies. State per capita debt and direct state operation of services (versus contracting for services) predicted both child and adult EBT adoption.

Conclusions

State-level EBT adoption and associated implementation support is associated with an interpretable array of policy, financing, and oversight factors. Such information expands our knowledge base of the role of the outer setting in implementation and may provide insight into how best to focus efforts to promote EBT for behavioral health disorders.

Fostering Cross-Sector Partnerships: Lessons Learned From a Community Care Team

PURPOSE/OBJECTIVES

The purpose of this study was to describe lessons learned during the development and implementation of a community care team (CCT) and the applicability of this model in movement toward cross-sector team-based care coordination.

PRIMARY PRACTICE SETTING

Primary care.

FINDINGS/CONCLUSIONS

Cross-sector CCTs composed of primary care and community service providers are a care coordination approach that attends to the individual's social determinants of health, enhances the individual's capacity to manage treatment and self-care demands of multiple chronic health conditions, improves the care experience, and impacts well-being. A collaborative CCT decreased the use of acute care services and the costs of care.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

As reported in this study, use of interprofessional collaborative health care teams in planning care and services for individuals is a standard of practice for case management. Cross-sector partnerships provide the opportunity to maximize the contributions of health care and community service providers that address both chronic health conditions and social determinants of health, minimize fragmentation and costs of care, and promote collaborative care coordination. Community care teams offer sophisticated care coordination not otherwise available to medically complex high-need individuals who require assistance in navigating the medical and financial systems that exist in health care today.

Family-Based Crisis Intervention With Suicidal Adolescents: A Randomized Clinical Trial

OBJECTIVE

In current practice, treatment as usual (TAU) for suicidal adolescents includes evaluation, with little or no intervention provided in the emergency department (ED), and disposition, usually to an inpatient psychiatry unit. The family-based crisis intervention (FBCI) is an emergency psychiatry intervention designed to sufficiently stabilize suicidal adolescents within a single ED visit so that they may return home safely with their families. The objective of this article is to report efficacy outcomes related to FBCI for suicidal adolescents and their families.

METHODS

A total of 142 suicidal adolescents (age, 13-18 years) and their families presenting for psychiatric evaluation to a large pediatric ED were randomized to receive FBCI or TAU. Patients and caregivers completed self-report measures of suicidality, family empowerment, and satisfaction with care provided at pretest, posttest, and 3 follow-up time points over a 1-month period.

RESULTS

Patients randomized to FBCI were significantly more likely to be discharged home with outpatient follow-up care compared with their TAU counterparts (P < 0.001). Families randomized to the FBCI condition reported significantly higher levels of family empowerment and client satisfaction with care at posttest compared with their TAU counterparts. Gains were maintained over the follow-up period. No completed suicides were reported during the study period in either condition.

CONCLUSIONS

Family-based crisis intervention is a model of care for suicidal adolescents that may be a viable alternative to traditional ED care that involves inpatient psychiatric hospitalization.

Characteristics of Female Youth Offenders in New Zealand

Female youth offending is poorly understood, despite increased rates of such offending. Research indicates there are a range of factors that have a causal impact on the development of offending in young people. This study investigated risk factors using a retrospective file audit of 184 female youth offenders in New Zealand. The findings were classified using Bronfenbrenner's ecological model, which highlights the different contextual levels that influence behavior, including individual, family, peer, school, community, and cultural factors. The results indicate that there are significant risk factors for female youth offenders. There were high rates of mental health difficulties, drug use, histories of maltreatment, family stressors, peer issues, and school behavior problems in the cohort. There was very little difference between violent and nonviolent offenders. All the young women had risk factors affecting them at many levels. Targeted, multisystemic intervention and prevention programs are therefore needed to address female youth offending.

Impact of a Web-Based Electronic Health Record on Behavioral Health Service Delivery for Children and Adolescents: Randomized Controlled Trial

BACKGROUND

Electronic health records (EHRs) have been widely proposed as a mechanism for improving health care quality. However, rigorous research on the impact of EHR systems on behavioral health service delivery is scant, especially for children and adolescents.

OBJECTIVE

The current study evaluated the usability of an EHR developed to support the implementation of the Wraparound care coordination model for children and youth with complex behavioral health needs, and impact of the EHR on service processes, fidelity, and proximal outcomes.

METHODS

Thirty-four Wraparound facilitators working in two programs in two states were randomized to either use the new EHR (19/34, 56%) or to continue to implement Wraparound services as usual (SAU) using paper-based documentation (15/34, 44%). Key functions of the EHR included standard fields such as youth and family information, diagnoses, assessment data, and progress notes. In addition, there was the maintenance of a coordinated plan of care, progress measurement on strategies and services, communication among team members, and reporting on services, expenditures, and outcomes. All children and youth referred to services for eight months (N=211) were eligible for the study. After excluding those who were ineligible (69/211, 33%) and who declined to participate (59/211, 28%), a total of 83/211 (39%) children and youth were enrolled in the study with 49/211 (23%) in the EHR condition and 34/211 (16%) in the SAU condition. Facilitators serving these youth and families and their supervisors completed measures of EHR usability and appropriateness, supervision processes and activities, work satisfaction, and use of and attitudes toward standardized assessments. Data from facilitators were collected by web survey and, where necessary, by phone interviews. Parents and caregivers completed measures via phone interviews. Related to fidelity and quality of behavioral health care, including Wraparound team climate, working alliance with providers, fidelity to the Wraparound model, and satisfaction with services.

RESULTS

EHR-assigned facilitators from both sites demonstrated the robust use of the system. Facilitators in the EHR group reported spending significantly more time reviewing client progress (P=.03) in supervision, and less time overall sending reminders to youth/families (P=.04). A trend toward less time on administrative tasks (P=.098) in supervision was also found. Facilitators in both groups reported significantly increased use of measurement-based care strategies overall, which may reflect cross-group contamination (given that randomization of staff to the EHR occurred within agencies and supervisors supervised both types of staff). Although not significant at P<.05, there was a trend (P=.10) toward caregivers in the EHR group reporting poorer shared agreement on tasks on the measure of working alliance with providers. No other significant between-group differences were found.

CONCLUSIONS

Results support the proposal that use of EHR systems can promote the use of client progress data and promote efficiency; however, there was little evidence of any impact (positive or negative) on overall service quality, fidelity, or client satisfaction. The field of children's behavioral health services would benefit from additional research on EHR systems using designs that include larger sample sizes and longer follow-up periods.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02421874; https://clinicaltrials.gov/ct2/show/NCT02421874 (Archived by WebCite at http://www.webcitation.org/6yyGPJ3NA).

A community-based parent-support programme to prevent child maltreatment: Protocol for a randomised controlled trial

The prevention of child abuse and neglect is a global public health priority due to its serious, long-lasting effects on personal, social, and economic outcomes. The Children At Risk Model (ChARM) is a wraparound-inspired intervention that coordinates evidence-based parenting- and home-visiting programmes, along with community-based supports, in order to address the multiple and complex needs of families at risk of child abuse or neglect. The study comprises a multi-centre, randomised controlled trial, with embedded economic and process evaluations. The study is being conducted in two child-welfare agencies within socially disadvantaged settings in Ireland. Families with children aged 3-11 years who are at risk of maltreatment (n = 50) will be randomised to either the 20-week ChARM programme (n = 25) or to standard care (n = 25) using a 1:1 allocation ratio. The primary outcomes are incidences of child maltreatment and child behaviour and wellbeing. Secondary outcomes include quality of parent-child relationships, parental stress, mental health, substance use, recorded incidences of substantiated abuse, and out-of-home placements. Assessments will take place at pre-intervention, and at 6- and 12-month follow-up periods. The study is the first evaluation of a wraparound-inspired intervention, incorporating evidence-based programmes, designed to prevent child abuse and neglect within intact families. The findings offer a unique contribution to the development, implementation and evaluation of effective interventions in the prevention of child abuse and neglect. The trial is registered with the International Standard Randomised Controlled Trial Number Register (DOI 10.1186/ISRCTN13644600, Date of registration: 3rd June 2015).

A community-based parent-support programme to prevent child maltreatment: Protocol for a randomised controlled trial

The prevention of child abuse and neglect is a global public health priority due to its serious, long-lasting effects on personal, social, and economic outcomes. The Children At Risk Model (ChARM) is a wraparound-inspired intervention that coordinates evidence-based parenting- and home-visiting programmes, along with community-based supports, in order to address the multiple and complex needs of families at risk of child abuse or neglect. The study comprises a multi-centre, randomised controlled trial, with embedded economic and process evaluations. The study is being conducted in two child-welfare agencies within socially disadvantaged settings in Ireland. Families with children aged 3-11 years who are at risk of maltreatment (n = 50) will be randomised to either the 20-week ChARM programme (n = 25) or to standard care (n = 25) using a 1:1 allocation ratio. The primary outcomes are incidences of child maltreatment and child behaviour and wellbeing. Secondary outcomes include quality of parent-child relationships, parental stress, mental health, substance use, recorded incidences of substantiated abuse, and out-of-home placements. Assessments will take place at pre-intervention, and at 6- and 12-month follow-up periods. The study is the first evaluation of a wraparound-inspired intervention, incorporating evidence-based programmes, designed to prevent child abuse and neglect within intact families. The findings offer a unique contribution to the development, implementation and evaluation of effective interventions in the prevention of child abuse and neglect. The trial is registered with the International Standard Randomised Controlled Trial Number Register (DOI 10.1186/ISRCTN13644600, Date of registration: 3 ^rd June 2015).

Provider Perspectives on Principle-Adherent Practice in Empirically Supported Interventions for Emerging Adults with Serious Mental Health Conditions

In recognition of the need to create new treatment approaches that will be appealing to and effective for emerging adults with serious mental health conditions, researchers have begun to create and evaluate programs and interventions that are specifically tailored to reflect the preferences and needs of the population. The literature that describes these new approaches-including both descriptions of interventions and guidelines based on expert consensus-expresses a high degree of agreement regarding practice principles that should guide intervention. However, beyond naming these principles, the literature provides little information about what the principles mean, or how principle-adherent practice can be recognized. This article describes a qualitative investigation of providers' understanding of principle-driven practice in the context of programs and interventions for emerging adults with serious mental health conditions. The goal was to learn about how providers conceptualize the principles that drive their practice, and how they describe principle-adherent practice.

At the Intersection of Health Information Technology and Decision Support: Measurement Feedback Systems... and Beyond

We select and comment on concepts and examples from the target articles in this special issue on measurement feedback systems, placing them in the context of some of our own insights and ideas about measurement feedback systems, and where those systems lie at the intersection of technology and decision making. We contend that, connected to the many implementation challenges relevant to many new technologies, there are fundamental design challenges that await a more elaborate specification of the clinical information and decision models that underlie these systems. Candidate features of such models are discussed, which include referencing multiple evidence bases, facilitating observed and expected value comparisons, fostering collaboration, and allowing translation across multiple ontological systems. We call for a new metaphor for these technologies that goes beyond measurement feedback and encourages a deeper consideration of the increasingly complex clinical decision models needed to manage the uncertainty of delivering clinical care.

A theory of change for positive developmental approaches to improving outcomes among emerging adults with serious mental health conditions

Recent evidence attests to the shortcomings of typical services for improving outcomes among emerging adults with serious mental health conditions (SMHCs). Researchers and providers have responded by developing new programs and interventions for meeting the unique needs of these young people. A significant number of these programs and interventions can be described as taking a positive developmental approach, which is informed by a combination of theoretical sources, including theories of positive development, self-determination, ecological systems, and social capital. To date, however, there has been no comprehensive theoretical statement describing how or why positive change should occur as a result of using a positive developmental approach when intervening with this population. The goal of this article is to propose a general model that "backfills" a theory behind what appears to be an effective and increasingly popular approach to improving outcomes among emerging adults with SMHCs.

Effectiveness of wraparound versus case management for children and adolescents: results of a randomized study

In this study, we compared service experiences and outcomes for youths with serious emotional disorder (SED) randomly assigned to care coordination via a defined wraparound process (n = 47) versus more traditional intensive case management (ICM; n = 46) The wraparound group received more mean hours of care management and services; however, there ultimately were no group differences in restrictiveness of residential placement, emotional and behavioral symptoms, or functioning. Wraparound implementation fidelity was found to be poor. Organizational culture and climate, and worker morale, were poorer for the wraparound providers than the ICM group. Results suggest that, for less-impaired youths with SED, less intensive options such as ICM may be equally effective to poor-quality wraparound delivered in the absence of wraparound implementation supports and favorable system conditions.

Pediatric Community Mental Health

The emotional health and wellbeing of children and adolescents and their families is of utmost importance. Pediatricians are at the front line in identifying mental illness in children and adolescents and either linking them to resources in the community or providing treatment options themselves. Collaboration and integrative health care models is the cornerstone of effective strategies to provide access and quality mental health care to children and families in communities across the country.

Future Directions for the Implementation and Dissemination of Statewide Developmental-Behavioral Pediatric Integrated Health Care

The integration of mental health and pediatric health care services has long been a goal for both research and practice. With the advent of federal policies developed to mandate clinical efficiency across the health care spectrum, this issue is becoming more salient. Applied literature on this topic is only recently emerging, however, and there are limited contextual examples to guide program development, research, and refinement. This article presents background information relevant to the development of such a program (the Center for Advancement of Youth). The cultural and organizational contexts for the project are discussed, with particular emphasis on models for cooperation among several institutions of varying size and scope. The implications for the future of tangible research in this area are also discussed, with attention to extending lessons learned to diverse settings motivated to integrate various aspects of health care service provision.

Applying User Input to the Design and Testing of an Electronic Behavioral Health Information System for Wraparound Care Coordination

Health information technology (HIT) and care coordination for individuals with complex needs are high priorities for quality improvement in health care. However, there is little empirical guidance about how best to design electronic health record systems and related technologies to facilitate implementation of care coordination models in behavioral health, or how best to apply user input to the design and testing process. In this paper, we describe an iterative development process that incorporated user/stakeholder perspectives at multiple points and resulted in an electronic behavioral health information system (EBHIS) specific to the wraparound care coordination model for youth with serious emotional and behavioral disorders. First, we review foundational HIT research on how EBHIS can enhance efficiency and outcomes of wraparound that was used to inform development. After describing the rationale for and functions of a prototype EBHIS for wraparound, we describe methods and results for a series of six small studies that informed system development across four phases of effort-predevelopment, development, initial user testing, and commercialization-and discuss how these results informed system design and refinement. Finally, we present next steps, challenges to dissemination, and guidance for others aiming to develop specialized behavioral health HIT. The research team's experiences reinforce the opportunity presented by EBHIS to improve care coordination for populations with complex needs, while also pointing to a litany of barriers and challenges to be overcome to implement such technologies.

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.

An analysis of stakeholder views on children's mental health services

The purpose was to examine the perspectives of mental health stakeholders as a means to guide the adaptation of evidence-based treatments. The Mental Health System Ecological (MHSE) model was used to organize therapist, administrator, and parent perspectives gathered using qualitative methods. The MHSE model posits the influences of client-level, provider-level, intervention-specific, service delivery, organizational, and service system characteristics on implementation. Focus groups and interviews were conducted with community mental health stakeholders and included parents, therapists, and administrators (N = 21). Participants included 11 primarily Caucasian (90.48%) female participants, ranging in ages between 31 and 57 years. Data were analyzed according to the MHSE model. Frequency counts were tabulated for each theme and stakeholder group differences were determined using the Mann-Whitney test. Stakeholder groups mentioned needs at each level of the MHSE model. Stakeholder group differences most notably emerged with child and family themes, which included complexity of mental health issues, parenting differences, and family stressors. Stakeholders identified challenges for optimal mental health services for children across multiple levels of an ecological model. Implications of the findings are discussed, including the continued relevance of adapting mental health interventions by increasing their flexible application across multiple target problems and the promise of partnership approaches.