Journal of Child and Family Studies, VoL 5, No. 1, 1996,pp. 23-39
Wraparound Care in Vermont: Program Development, Implementation, and Evaluation of a Statewide System of Individualized Services James T. Yoe, Ph.D., t~ Suzanne Santarcangelo, Ph.D., 2 Margaret Atkins, B.S.W., 3 and John D. Burchard, Ph.D. 4
Over the past decade, there has been a dramatic shift in the provision of mental health services to children, adolescents, and their families. This shift has been marked by a movement away from restrictive treatment options toward the development of comprehensive community-based systems of care designed to keep the most challenging children in their homes, schools, and communities. Based on a model of intensive case management referred to as Wraparound Care, Vermont's statewide approach emphasizes aggressive outreach, use of the least restrictive treatment options, and care that is flexible, unconditiona~ and child- and family-centered. We chart the development o f Vermont's Wraparound Care Initiative and present residential, educational, and behavioral outcome data for a cohort of 40 youth receiving Wraparound Care over a 12-month period. The results showed that after 12-months, youth who had been previously removed from their homes or were at imminent risk of such removal, were residing in significantly less restrictive community-based living arrangements and er.hibiting significant& fewer problem behaviors than at intake. These results are discussed in light of recent national studies and 1Principal Investigator and Co-Project Director of the Evaluation of the Comprehensive Community Mental Health Services Program for Children, Macro International Inc., Atlanta, Georgia. 2Director of Children, Youth and Family Program, Clara Martin Center, Randolph, Vermont. 3Therapeutic Case Management Coordinator, Child, Adolescent and Family Unit, Vermont Department of Mental Health and Mental Retardation, Waterbury, Vermont. 4Professor, Department of Psychology, John Dewey Hall, University of Vermont, Burlington, Vermont. 5Correspondence should be directed to James T. Yoe, Macro International Inc., 3 Corporate Square, Suite 370, Atlanta, GA 30329. 23
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Yoe, Santarcangelo, Atkins, and Burchard
previous studies on similar cohorts of Vermont youth receiving Wraparound Care. KEY WORDS: wraparound care; services research; program evaluation; children; adolescents; emotional and behavioral disorders.
Recent studies have estimated that between 6% and 12% of all children and adolescents from birth to age 18 have emotional and behavioral difficulties that significantly interfere with their functioning at home, in school, and in the community (Clarke, Schaefer, Burchard, & Welkowitz, 1992; Saxe, Cross, & Silverman, 1988). Over the past two decades public child serving agencies have come under increasing criticism for being categorical, inefficient, inflexible, and largely non-responsive to the needs of children and families (Knitzer, 1982; Sax et al. 1988). Moreover, the categorical nature of child serving systems has promoted a lack of cooperation, collaboration, and coordination among public and private child serving agencies (Knitzer, 1982; Stroul & Friedman, 1986). In recognition of the unmet needs of children, adolescents, and their families, service delivery systems have begun to shift toward a model emphasizing child and family centered approaches, least restrictive community-based service options, and interagency planning and coordination. Vermont has made considerable progress in developing its state-wide Wraparound Care Initiative based on the principles of unconditional care, flexible funding, child and family centered services, and interagency collaboration. Integral to the development of Vermont's Wraparound Care Initiative was the passage of Act 264, which mandated interagency coordination and collaboration in the delivery of services to children and adolescents experiencing severe emotional or behavioral disturbance and their families. This interagency infrastructure was designed to facilitate the identification and resolution of clinical, financial, and policy issues. Local Interagency Teams were established in each of 12 social services districts. These teams provide multi-disciplinary decision making in situations where local providers, parents, or educators are unable to develop or implement a child's treatment plan. Local teams are mandated to include parent representatives, as well as local representatives from Social Services, Mental Health, and Special Education. Other persons involved in child and family service delivery are included specific to each local community. At the state level, two groups review cases as part of this mandate. First, the State Interagency Team, which is comprised of Division Directors of all child serving agencies and parent representatives, reviews cases in which a Local Interagency Team is unable to resolve the
Vermont Wraparound Care
25
fiscal or clinical challenges presented. The State Interagency Team provides information and policy concerns related to fiscal and program development to respective Commissioners and the Secretary of the Agency of Human Services. Second, the Case Review Subcommittee of the State Interagency Team reviews all cases referred for intensive or restrictive placement. In addition, Act 264 provides for a governor-appointed advisory b o a r d and a statewide definition of "severe e m o t i o n a l disturbance." A Robert Wood Johnson Foundation Grant, awarded in 1990, enabled Vermont to more aggressively develop and expand its community-based services. This expansion included the reintegration of youth into their home communities from intensive residential treatment both in and out-of-state. The Vermont Wraparound Care Initiative is more of an approach to service delivery than a specific service model or program. This approach is characterized by a commitment to: (a) child and family focused treatment; (b) strength-based versus p r o b l e m - o r i e n t e d approach; (c) unconditional care; (d) individualized service planning that is uniquely tailored to the specific needs and strengths of each child and family; (e) community-based care; (f) use of non-categorical flexible funding strategies; (g) an interdisciplinary team approach that emphasizes interagency coordination and collaboration in the planning, development, and delivery of services; (h) proactive planning for crisis; and (i) respect for the family culture and values. In an attempt to assess the effectiveness of the Wraparound Care Initiative, an evaluation and tracking system has been ongoing since its implementation in 1991. This evaluation was designed to provide a description of the children and adolescents served and to assess the effectiveness of Wraparound Care through the ongoing tracking of residential, behavioral, and service outcomes. We provide a description of this tracking and evaluation system and examine outcomes for a cohort of 40 children and adolescents enrolled in Wraparound Care over a 12-month period. Based on the underlying principles of the Wraparound approach the following hypotheses were developed: (a) Children and adolescents will move to, and/or remain in, less restrictive family-living arrangements or other community-based placements over the 12 month study period; (b) children and adolescents will move to, and/or remain in, less restrictive more mainstreamed educational settings over the 12 month study period; and (c) children and adolescents will exhibit decreases in the frequency of behaviors that place them at risk of being removed from their homes and communities and placed in highly restrictive settings.
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Yoe, Santarcangelo, Atkins, and Burchard
METHODS Subjects Participants in this study were 40 children and adolescents enrolled in community-based Wraparound Care for at least 12 months. This cohort consisted of predominantly boys (62%), and ranged in age between 7 and 20 years, with a mean age of 16 years. Upon entering Wraparound Care over three quarters (78%) were residing in substitute care situations and in the custody of the State of Vermont, 7% were in the custody of one or both parents, and 15% were 18 years and over and had gained self custody. At referral, 41% of the children resided in residential settings, such as inpatient hospitals or residential treatment centers.
Therapeutic Case Management The vehicle developed to deliver Wraparound Care in Vermont is the Therapeutic Case Management program (Santarcangelo, 1992). Therapeutic case managers are primarily responsible for conducting comprehensive strength-based assessments; establishing and facilitating interagency treatment teams; organizing and writing individual plans of care; developing, coordinating and monitoring individualized services; advocating on behalf of the child and family; and ensuring that the treatment teams are providing unconditional care to the child and family. Membership on a treatment team is unique to each child and family. These teams may include representatives from each agency with whom the child is involved (e.g., Mental Health, Social Services, Corrections, Vocational Rehabilitation, Education), past and present care givers, the parent and child, relatives, neighbors, and other members of the community (e.g., clergy, police officers, judges, doctors). The therapeutic case manager provides ongoing unconditional support to the individual child, family, and their team. The development of these trusting relationships combined with the flexible nature of the supports provided are essential in engaging the child and family in the planning process and in developing a strong spirit of cooperation among team members (McDonald, Boyd, Clark, & Stewart, in press; Santarcangelo et al., in press).
Target Population and Caseload Considerations While there is a commitment among policy makers and service providers that Wraparound Care should be available to all children and adolescents with multiple service needs, limited resources necessitated the
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targeting of priority groups. The initial implementation plan prioritized children and adolescents who were in or at high risk of being placed in residential or inpatient treatment settings. As resources become more available, this group will be expanded to include youth who are at risk of being placed outside of their natural or foster home and/or outside of their school district (Santarcangelo, Birkett, & MeGrath, in press). Vermont has made a commitment to maintain small caseloads. "lhnnen (1991) suggests that effective case management for multi-challenged children and families requires a minimum of 7 to 10 hours per week per child. Caseloads for Wraparound Care case managers typically range from four to seven children depending on the intensity of the services required to meet the individual needs of the child and family, the availability of other community and family support, and the strengths and limitations of other team members.
Assessment A comprehensive contextual assessment guides the development of child and family centered goals that serve as the foundation for the Individualized Plan of Care. Child and family assessments are typically conducted through informal discussions with the child, family, and other members of the community in their homes or in other community settings. These discussions focus on who the children are, where they have been, and their hopes and dreams for the future (O'Brien & Forest, 1989). A second level of assessment involves a thorough examination of the community context. This includes an assessment of cultural norms and expectations within the school and community, child and family social support networks, and the availability of community services and resources.
Development of an Individualized Plan of Care The case manager facilitates a team discussion to identify child and family treatment goals and to brain storm specific interventions, supports, and creative strategies to meet the unique needs of each child and family. Individual Plans of Care are reviewed on an ongoing basis, through regularly scheduled team meetings. This process allows for continual updating of a plan based on the changing needs of each child and family. In developing a plan of care, the case manager and treatment team draw upon a combination of community resources (e.g., local food shelves, libraries, YMCAs), natural supports (e.g., relatives, peers, other community members), and other existing social services. Available services include case
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Yoe, Santarcangelo, Atkins, and Burchard
management, individual, group, and family counseling, intensive homebased services, family education programs, parent and peer support groups, respite care, and specialized treatment such as substance abuse and sex offender programs (Santarcangelo et al., in press). In the event that a specific service or intervention does not exist, the ease manager and team will work to develop or recreate the elements of the service necessary to maintain the integrity of treatment in the community. Developing new interventions is accomplished either by expanding existing programs or by creating new child specific approaches. Examples of such non-traditional interventions may include training a family member or friend to provide respite, training peers to provide crisis support, and using martial arts training to enhance self-esteem and feelings of self control. As part of the development of an Individualized Plan of Care the treatment team needs to plan for, and where possible, prevent and/or diffuse potential crises. Specific preventive and crisis response strategies and interventions are an integral part of each Individualized Plan of Care. Developing a successful crisis strategy involves an understanding of what the child's triggers are and the resulting behaviors that have led to and precipitated subsequent crises (Santarcangelo et al., in press).
Interagency Funding Wraparound Care services are jointly funded by the agencies involved in the care of the child and family. Interagency policies and procedures related to blended funding have been established. Specifically, the Departments of Education (DOE), Social and Rehabilitation Services (SRS), and Mental Health and Mental Retardation (DMH/MR) share in the funding of wraparound plans through a combination of federal, state, and local dollars. T h e process of f u n d i n g a W r a p a r o u n d Plan starts with the Individualized Plan of Care. Once the services are identified in the Individualized Plan of Care, the ease manager prepares and negotiates an Individualized Services Budget which specifies the type, duration, cost, and funding source(s) for each of the identified services. After local approval, the budget and the Individual Plan of Care are submitted to the Therapeutic Case Management Coordinator at DMH/MR. The coordinator reviews the plan and proposed Individualized Services Budget to ensure that Federal and State funds are maximized, and that the proposed rates are reasonable. Depending on the types of funding requested, the budget may also be reviewed with representatives from the DOE, SRS, Vocational Rehabilitation, or Corrections. Once the budget process is complete, funds
Vermont WraparoundCare
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are approved and/or disbursed by the respective State Departments involved in funding the package and the plan is activated. EVALUATION As part of an ongoing evaluation of Wraparound Care, therapeutic case mangers serve as key informants. Descriptive and outcome information were gathered at referral (i.e., fight before entry into Wraparound Care) and updated every three months that the youth remained enrolled in services. Living Arrangement and Placement Restrictiveness
The type and restrictiveness of the living arrangements in which youth resided over the study period was assessed. This information was obtained from the youth's case manager at referral into Wraparound Care and updated quarterly thereafter, as long as the youth continued to receive services. The placement restrictiveness was measured on the Restrictiveness of Living Environment Scale (ROLES); Hawkins, Almeida, Fabry, & Reitz (1991). This instrument is used to rate residential settings on a scale ranging from .5 to 10, where .5 equals the least restrictive placement (i.e., independent living) and 10 equals the most restrictive placement (i.e., adult corrections). School Placements
School placement information was also obtained from case managers at referral and updated quarterly. This information was summarized into six categories: mainstreamed, mainstreamed with special education support (i.e., classroom aide, use of resource room, etc.), separate special education classroom, alternative/residential school, dropped out, and completed school. Behavioral Adjustment
The Quarterly Adjustment Indicator Checklist (QAIC) was adapted from the Daily Adjustment Indicator Checklist (DAIC) (Burchard & Schaefer, 1992) and is composed of 22 behavioral indicators which have been shown to place a child at risk of being placed in a more restrictive setting. These indicators include behaviors such as physical aggression, property
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Yoe, Santarcangelo, Atldns, and Burchard
damage, sexual acting out, and verbal abuse. The QAIC is completed on a quarterly basis by the youth's case manager, and the frequency of each behavior is rated on a three-point scale (0 = never, 1 = sometimes, 2 = often). The OAIC was recently adapted to a 6-point scale to reflect the actual number of days each behavior occurred over a three-month period (0 = never, I = 1 day, 2 = 2 days, 3 = 3 to 9 days, 4 = 10 to 30 days, 5 = 31 to 90 days). In order to compare response options across both versions of the QAIC, the revised options were recoded into a "never, sometimes, often" format (i.e., 0 = never, 1-4 = sometimes, 5 = often). The validity and reliability of the QAIC has been examined in several ways. A principal components analysis was performed on a sample of 138 children and adolescents experiencing severe emotional or behavioral disturbances, and revealed four distinct factors. The first factor consisted of six items that reflected externalizing types of behaviors (e.g., noncompliance, verbal abuse, property damage, poor peer relations, physical aggression, and theft). This factor accounted 21% of the variance in the reported behaviors. The second factor consisted of seven items reflecting abuse related behaviors (e.g., sexual acting out, self injury, life threat, strange behavior, sexual abuse, cruelty to animals, and runaway) and accounted for 9% of the variance in these behaviors. The third factor, public externalizing, consisted of four items associated with acting out in the community (e.g., truancy, police contact, suicide attempt, alcohol & substance abuse) and accounted for 8% of the reported variance in behaviors. The fourth factor consisted of three items associated with internalizing types of behaviors (e.g., sad/depressed, lack of self confidence, anxious) and accounted for 8% of the variance in observed behaviors. This four factor solution accounted for a total of 46% of the variance in these behaviors. Based on the factors derived from the principal components analysis, four behavioral scales were developed for use in subsequent analyses by summing the items associated with each factor. A reliability analysis performed on all 22 behaviors yielded a Cronbach alpha coefficient of .82, indicating a high level of internal consistency among items. In addition, analyses performed on the four scales yield alpha coefficients ranging from .61 for the internalizing scale to .77 for the externalizing scale. RESULTS Living Arrangements and Restrictiveness Ratings The living arrangements of the 40 youth were assessed at referral to Wraparound Care and again at 12 months post enrollment~ While data were
Vermont Wraparound Care
31
collected at three month intervals, for our analysis, a 12-month assessment period was adopted to maximize the n u m b e r of children and adolescents in the sample and to allow for enough time in which change might be reasonably assessed. As shown in Table 1, over the 12-month study period, the percentage of children and adolescents residing in community-based living arrangements (including living with family members or relatives, independent living arrangements, treatment-oriented foster care and regular foster care) increased from 58% (n = 23) to 88% (n = 35). This shift was largely driven by the movement of children and adolescents from residential treatment facilities to community-based alternatives. While the number of children residing with family members, in independent living arrangements, and in treatment-oriented foster care arrangements all increased, the number of children living in regular foster care decreased over the 12-month study period. These placement changes contributed to a decline in the average level of residential restrictiveness from a mean of 4.67 at referral to a m e a n of 3.83, at 12-months, t(38) -- 2.24, p < .05.
Table 1. Living Arrangements at Referral to Wraparound Care and 12-Months Post-Referral for 40 Children and Adolescents At Referral 12 Months Living Arrangements n p n p Independent Living (LOR* = .5-3.5) 1 2% 7 17% Family Member or Relative (LOR ffi 2.0-2.5) 7 17% 9 23% Non-Treatment-Oriented Foster Care (LOR -- 3.6) 9 23% 3 8% Treatment-Oriented Foster Care (LOR = 4.6) 6 16% 16 40% Residential Treatment Facility (LOR = 5.6-6,5) 16 40% 4 10% Other (e.g., Community-Care Home) 1 2% 1 2% *LOR refers to the level of restrictiveness of the placement on the Restrictiveness of Living Environment Scale (ROLES).
Table 2. School Placements at Referral to Wraparound Care and 12-Months Post-Referral
for 40 Children and Adolescents At Referral School Placements n p Mainstreamed in regular classroom Malnstreamed with specialized educational support Self-contained special education classroom Alternative specialized school Not in school (e.g., dropped out or completed)
4 17 6 12 1
10% 43% 15% 30% 2%
12 Months n p 2 20 6 5 '7
5% 50% 15% 12% 18%
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Yoe, Santarcangelo, Atldns, and Burchard
School Placements As shown in "fable 2, a descriptive assessment of educational support services indicated that after 12 months in Wraparound Care the number of youth enrolled in alternative residential schools and the number completely mainstreamed in the regular school environment decreased while the number of youth mainstreamed with some form of Special education support (i.e., classroom aide, resource room) increased and the number in separate/segregated classrooms stayed the same over the 12 month study period. In addition, four youth dropped out of school and three successfully completed high school.
Behavioral Adjustment Changes on the QAIC 12 months in cant decline
in behavioral adjustment were assessed using paired t-tests behavior ratings obtained at referral and those obtained after Wraparound Care. As shown in Table 3, there was a signifiin total problem behavior scores (i.e., sum of 22 QAIC
Table 3. Mean Behavioral Adjustment at Referral and 12-Months Post-Referral At Referral
12 Months
t
Total Problem Behaviors
Behavior Scale
13.27 (6.27)
9.90 (5.05)
3.02**
Externalizing Behaviors
5.7V (2.76)
4.30 (2.17)
3.21"*
Internalizing Behaviors
3.40 (1.46)
2.82 (1.28)
2.37*
Abuse Related Behaviors
2.82 (2.37)
1.60 (1.68)
2.94**
Public Externalizing Behaviors
.92 (1.57)
1.05 (1.68)
.47 n.s.
Note. Standard deviations are contained in parentheses. All behavioral items are scored along a 0 (never) to 2 (often) scale. Total problem behavior scores are based on the sum of 22 items with scores ranging from 0 to 44. The externalizing behavior scale contains six behaviors with scores ranging between 0 and 12. The internalizing behavior scale contains 3 items with scores ranging between 0 and 6. The abuse related scale contains 7 items and yields scores between 0 and 14. The public externalizing scale contains 4 items and yields scores between 0 and 8. * < .05 ** < .01
Vermont Wraparound Care
33
behaviors with maximum possible score of 44), t(38) = 3.02, p < .01. A comparison of QAIC subscale scores revealed significant reductions in externalizing behaviors, t(38) - 3.21, p < .01, abuse related behaviors, t(38) = 2.94, p < .01, and internalizing behaviors, t(38) = 2.37, p < .05. However, there was no significant change in public externalizing behaviors (i.e., police contact, truancy, suicide attempt, alcohol and substance abuse), t(38) = .47, ns.
DISCUSSION
The current findings support the hypothesis that youth involved in Vermont's Wraparound Care Initiative would move into, and remain in, less restrictive living environments over the 12 month study period. Our results indicated that after 12 months, 90% of the youth remained in the community, with 40% living either with a family member or independently. These results are encouraging when one considers that all of the cohort youth were at imminent risk of, or placed in residential treatment at the time of referral into Wraparound Care. These youth were also identified as among the most challenging and costly to serve in the state. Moreover, the level of challenge of these youth is indirectly substantiated by the fact that 78% of these youngsters had been removed from their families and were in substitute care situations (i.e., foster care, therapeutic foster care, or residential treatment) at the time of referral. In addition, a recent study that examined the behavioral adjustment of a similar cohort of Vermont Wraparound youth (Bruns, Burchard & Yoe, in press) reported that 94% of the youth in the sample scored above the clinical range on total problem behaviors on the Child Behavior Checklist (CBCL; Achenbach & Edelbrock, 1991) and 70% had been previously treated in a residential treatment facility. In comparison, the results of the National Adolescent and Child Treatment Study (NACTS) indicated that 82% of the children and adolescents in their residential cohort scored above the clinical range for total problem behaviors on the CBCL and 47% were previously treated in an inpatient or residential setting (Greenbaum, Prange, Newcomb, Lardieri, & Brown, 1994). These data suggest that youth in Vermont Wraparound Care are at least as challenging as children in the NACTS residential cohort. NACTS was a six-year follow-up study of 374 youth in six states, who resided in 27 residential treatment programs when the study was initiated. Using survival analysis, Brown and Greenbaum (1994) found that of the 184 youth who were successfully treated and discharged from residential treatment 32% were reinstitutionalized in either a residential treatment or in a correctional facility within 12 months of discharge. In contrast, after 12 months in Wrap-
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Yoe, Santarcangelo, Atldns, and Burchard
around Care, only 10% of the youth in the present cohort were in residential treatment settings. It should be noted that, unlike the NACTS sample, the Vermont cohort contained youth from both residential treatment and community-based settings. However, the youth who were not in residential treatment at the time of referral were identified as being at imminent risk of such a placement. In contrast to the residential findings, the school results provided only partial support for the hypothesis that youth would move to, and remain in less restrictive, more mainstreamed school environments. In fact, the findings suggest considerable consistency in the type of school placements and specialized educational supports used over the 12-month study period. However, the findings do indicate a decrease in the number of youth placed in alternative specialized schools from 30% to 12% over the study period. This decline may be explained by the movement of youth from residential treatment settings to community-based services because alternative schools are typically associated with residential treatment settings. On a positive note, these findings also indicate that the vast majority of youth in Wraparound Care were successfully integrated and maintained in the regular school arena throughout the 12-month study period. However, the results clearly suggest that this integration is accomplished only by providing a considerable degree of individualized educational support. The third hypothesis, that youth would exhibit decreases in the fiequency of negative behaviors that put them at risk of being placed in highly restrictive settings, was also supported in the current study. The results indicated a statistically significant decline in overall negative behaviors as measured on the QAIC as well as significant declines on three of four QAIC behavioral subscales (i.e., externalizing behaviors, internalizing behaviors, and abuse-related behaviors). However, this trend did not extend to public externalizing behaviors (i.e., police contact, truancy, alcohol and substance abuse, suicide attempt). In contrast, the results showed, small, although non-significant, increases in the frequency of police contacts, truancy, and alcohol and substance use over the 12-month study period. These findings might be explained, in part, by the older age of the youth and the increased opportunity to engage in such behaviors while living in the community rather than in a more restrictive environment. In addition, anecdotal data from treatment teams suggest that the use of natural consequences (i.e., police intervention) are a common part of treatment protocols for many youths. The observed reductions in negative behaviors in the current study is consistent with the findings of a previous study that examined a similar cohort of 27 youth enrolled in Wraparound Care in Vermont. In this study, Bruns et al. (in press) reported significant declines in severe negative behaviors, as measured by the DAIC, and corresponding declines
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Vermont Wraparound Care
in overall problem behaviors on the CBCL over a 12-month period. However, because no comparison group was available for either of these studies, we cannot be certain as to the elements responsible for the observed gains in behavioral adjustment. That is, we cannot say definitively whether the progress was due to the efficacy of the Wraparound Care intervention or to other factors influencing the child or adolescent's life. Another limitation of this study was the potential bias effects generated by using the child's case manager as primary informant of behavioral and service outcomes. In an attempt to limit this bias, all ease managers were trained on the appropriate use of the QAIC and evaluation staff met regularly with case managers to trouble shoot implementation problems and share aggregate results. In addition, several previous studies using similar cohorts of Vermont Wraparound youth suggest that bias associated specifically with case manager ratings may not be as problematic as one might expect (Bruns et al., in press; Yoe, Bruns, Tighe, Santarcangelo, & Burchard, 1993). Our results provide valuable information to guide system development and the delivery of services within an individualized community-based continuum of care. First, these findings suggest that youth who display the most challenging behaviors can be served in less restrictive community placements. Second, it may in fact be the presence of strong educational support versus alternative placement that promotes progress and continuation in community-based educational settings. Third, in comparison to Brown and Greenbaum's (1994) cohort of youth involved in residential treatment, youth involved in Wraparound Care may be less likely to be high users of more costly and restrictive treatment options. With the increasing importance of assessing the outcomes of children's services, the results of this evaluation reflect an encouraging trend in an area where positive outcomes have been difficult to achieve. ACKNOWLEDGMENTS This study and the behavior tracking system on which it was based was partially supported by a comprehensive services grant awarded to the Vermont D e p a r t m e n t of Mental Health and Mental R e t a r d a t i o n (DMH/MR) by the Robert Wood Johnson Foundation Mental Health Services Program for Youth. While many people contributed to the production of this paper, we are especially indebted to tireless efforts of "liraey and Kelly Leboeuf who maintained the child tracking system at the DMH/MR and spent countless hours entering and processing the data. We would also like to thank all of the case managers who participated in the collection
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of this information. Their support, input, and dedication to the evaluation of treatment outcomes was integral to the development and successful implementation of this evaluation effort. REFERENCES Achenhach, T. M., & Edelbrock, C. (1991).Manual for the child behavior checklist and revised child behavior profde. Burlington,VT.: Universityof Vermont, Department of Psychiatry. Brown, E. C., & Greenbaum, P, E. (March, 1994). Reinstitutionalization after discharge from residential mental health facilities: An example of competing-risks survival analysis. Paper presented at the 8th Annual Florida Mental Health Institute Research Conference: A System of Care for Children's Mental Health: Expanding the Research Base, Tampa, Florida. Bruns, E. J., Burchard, J. D., & Yoe, J. T. (In press). Evaluating the Vermont system of care: outcomes associated with community-based wraparound services. Journal of Child and Family Studies. Burehard, J. D., & Schaefer, M. S. (1992). Improving accountability in a service delivery system in children's mental health. Clinical Psychology Review, 12, 867-882. Clarke, R. T., Schaefer, M., Burchard, J. D., Welkowitz, J. (1992). Wrapping community-based mental health services around children with a severe behavioral disorder:. An evaluation of project wraparound. Journal of Child and Family Studies, l, 241-261. Greenbaum, P. E., Prange, M., Newcomb, D., Lardieri, S., & Brown, E. C. (March, 1994). Recent empirical findings from the national adolescent and child treatment study. Paper presented at the 7th Annual Florida Mental Health Institute Research Conference: A System of Care for Children's Mental Health: Expanding the Research Base. Tampa, Florida. Hawkins, R. P., Almeida, M. C., Fabry, B., & Reitz, A. C. (1992). Restrictiveness of living environments for troubled children and youths: A simple measure for program evaluation, policy planning, and placement decisions. Hospital and Communify Psychiatry, 43, 54-59. Knitzer, J. (1982). Unclaimed children: The failure of public responsibility to children and adolescents in need of mental health services. Washington, DC: The Children's Defense Fund. McDonald, B. A., Boyd, L. A., Clark, H, B., & Stewart, E. S. (In press). Recommended individualized wraparound strategies for serving foster children with emotional disturbances and their families. Community Alternatives: International Journal of Family Care. O'Brien, J., & Forest, M. (1989). Action for lnclusion~ Toronto, Canada: Frontier College Press. Santarcangelo, S. (1992). Case management for children and adolescents experiencing a severe emotional disturbance and their families: National and state perspectives. Waterbury, Vermont: Vermont Department of Mental Health and Mental Retardation. Santarcangelo, S., Birkett, N., & McGrath, N. (in press). Therapeutic case management: Vermont's system of individualized care. In B. Friesen & J. Poertner (Eds.), Building on family strengths: Case management for children with emotional, behavioral, or mental disorders. New York: Paul H, Brooks. Saxe, L., Cross, T., & Silverman, N. (1988). Children's mental health: the gap between what we know and what we do. American Psychologisg 43, 800-807. Stroul, B. A., and Friedman, R. M. (1986). A system of care for children and youth with severe emotional disturbances. Washington, DC: CASSP Technical Assistance Center, Georgetown University. Tannen, N. (1991). Guidelines for implementing an individualized plan of care for children and adolescents experiencing a severe emotional disturbance and their family. Waterbury, Vermont: Vermont Department of Mental Health and Mental Retardation.
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Yoe, J. T., Bruns, E. J., Tighe, T., Santarcangelo, S., & Burchard, J. D. (February, 1993). A comparison of two outcome measures for children's mental healtl~ Poster presented at the 6th Annual Florida Mental Health Institute Research and Training Conference for Children's Mental Health: A System of Care for Children's Mental Health: Expanding the Research Base, Tampa, Florida.
