Intervening in the Lives of Youth with Complex Behavioral Health Challenges and Their Families: The Role of the Wraparound Process
介入具有复杂行为健康挑战的青年及其家庭的生活：包裹过程的作用

Wraparound; Care management; Community-based; Policy; Children and adolescents; Effectiveness; Systems of care
包裹式服务；护理管理；社区化；政策；儿童与青少年；有效性；照护系统

With the recent change in presidential administrations and ongoing scrutiny of the nature of our nation’s health care system, it is incumbent upon those of us who work in the arena of children’s mental health to take stock of recent research and promising frameworks, in the name of improving our policies and practices. It is true that it has become standard operating procedure to preface articles on children’s mental health with a recitation of bad news- that the children’s mental health system is “in shambles” and getting worse (Knitzer 1982; New Freedom Commission on Mental Health 2003; Tolan and Dodge 2005), that access to services for youth with mental health problems is limited (Huang et al. 2004; US Department of Health and Human Services 2005a), and that when it is provided, the services will be unlikely to be based on current evidence of what will be most effective (Hoagwood et al. 2001). Moreover, when a child’s needs are complex and overlapping, services are not likely to be coordinated across key providers and helpers and/or engaging of parents, teachers, family members, and the youth themselves (McKay and Bannon 2004; New Freedom Commission 2003; Stroul and Friedman 1994). And, for many youth, the result is all too often placement in restrictive out-of-community placements, use of which continues to increase nationally despite a lack of evidence for their long-term effectiveness (Burns et al. 1998; Farmer et al. 2004).
随着最近的总统行政变更和我们对国家医疗体系性质的持续审视，我们这些在儿童心理健康领域工作的人有责任评估近期的研究和有前景的框架，以改善我们的政策和实践。的确，在关于儿童心理健康的文章中，先列举坏消息已成为标准操作程序——即儿童心理健康系统“一团糟”且日益恶化（Knitzer 1982；新自由心理健康委员会 2003；Tolan 和 Dodge 2005），青少年心理健康问题的服务获取受限（Huang 等人 2004；美国卫生与公众服务部 2005a），并且当服务被提供时，它们不太可能基于当前最有效的证据（Hoagwood 等人 2001）。 此外，当孩子的需求复杂且重叠时，服务不太可能在关键提供者和帮助者之间协调，并且/或者可能不会让父母、老师、家庭成员以及青少年自己参与进来（McKay and Bannon 2004；New Freedom Commission 2003；Stroul and Friedman 1994）。并且，对于许多青少年来说，结果往往是安置在限制性的社区外机构中，尽管在全国范围内使用这种做法不断增加，但缺乏对其长期有效性的证据（Burns et al. 1998；Farmer et al. 2004）。

While all of this may be true, we are poised at a moment in history in which health care reforms are being proposed, access to care is being emphasized, and coordination of care for specialty mental health populations has become a focal point for change efforts. Recognizing the considerable work that has been done in children’s mental health over the past 25 years and with an eye toward the future, we present reason for optimism and a belief that research and practices exist that can inform new approaches and policies. In this paper, we take a fresh look at the wraparound philosophy and intervention model, to understand its role in children’s mental health systems. In the pages that follow, we will review the place of the wraparound process in behavioral health and discuss related systems changes that accompany successful wraparound implementation. We conclude with a discussion of the opportunities and challenges presented by the wraparound model, and recommendations for federal actions that have the potential to improve the likelihood of wraparound’s positive contribution to improving the well-being of youth with the most serious behavioral and emotional needs and their families.
尽管这些说法可能都有道理，但我们正处在一个历史时刻，医疗改革正在被提议，医疗服务可及性被强调，而针对特殊心理健康群体的医疗服务协调已成为变革努力的重点。鉴于过去 25 年儿童心理健康领域已取得的显著成就，并着眼于未来，我们呈现了乐观的理由，并相信存在研究和实践可以指导新的方法和政策。在本文中，我们重新审视了包裹式服务理念和干预模式，以了解其在儿童心理健康系统中的作用。在接下来的章节中，我们将回顾包裹式服务流程在行为健康中的位置，并讨论伴随成功包裹式服务实施的相關系统变革。最后，我们将讨论包裹式服务模式带来的机遇和挑战，并提出联邦行动建议，这些行动有可能提高包裹式服务对改善最严重行为和情感需求青少年的福祉及其家庭福祉的积极贡献的可能性。

Wraparound has been described variously as a philosophy, a process, an approach, and a service. As it is currently conceived, wraparound is an individualized, family-driven and youth-guided team planning process that is underpinned by a strong value base that dictates the manner in which services for youth with complex needs should be delivered (similar to system of care values; Stroul and Friedman 1994). Wraparound can also be described with respect to the types of system and program conditions that are necessary to facilitate model adherent implementation. These necessary system and programs conditions recognize that, though wraparound has historically been delivered on an individual basis, it is most likely to be faithfully implemented (and effective for youth and families) within a hospitable system that includes a care management model that can support the wraparound values and principles across all services delivered in the system. When implemented in this context, wraparound can help overcome common barriers to accessing effective services and supports for youth with multiple needs and/or multiple agency involvement. In the rest of this introductory section, we will summarize each of these components of the wraparound model in turn.
包裹式干预被描述为一种哲学、一种过程、一种方法以及一种服务。就目前的概念而言，包裹式干预是一种个性化的、以家庭为主导和以青少年为引导的团队规划过程，其基础是强大的价值观基础，这些价值观规定了为有复杂需求的青少年提供服务的具体方式（类似于照护系统价值观；Stroul 和 Friedman 1994）。包裹式干预也可以根据必要的系统和项目条件来描述，这些条件能够促进模型忠实地实施。这些必要的系统和项目条件认识到，尽管包裹式干预历史上一直是单独提供的，但它最有可能在一个友好的系统中忠实地实施（并且对青少年和家庭有效），该系统包括一个能够支持包裹式干预价值观和原则的照护管理模型，这些原则和价值观贯穿于系统提供的所有服务中。在这种背景下实施包裹式干预，可以帮助克服有多重需求的青少年和/或多机构参与的情况下获取有效服务和支持的常见障碍。 在本节余下的部分，我们将依次总结围绕式模式中的各个组成部分。

Wraparound represents a philosophy and value base which has been presented fairly consistently over the past 25 years and has recently been distilled into a set of ten principles (Bruns et al. 2008). This value base explicitly dissents from more traditional service delivery conceptualizations, in which a professional, viewed as the source of primary expertise, singlehandedly creates a treatment plan based on a diagnosis and/or enumeration of deficits. The value base also deviates from more traditional approaches by emphasizing an ecological model, including consideration of the multiple systems in which the youth and family are involved, and the multiple community and informal supports that might be mobilized to successfully support the youth and family in their community and home.
围绕式代表了一种在过去 25 年里一直相当一致地呈现的哲学和价值基础，最近被提炼为十条原则（Bruns 等人，2008 年）。这种价值基础明确反对更传统的服务提供概念，在这些概念中，被视为主要专业知识来源的专业人员单方面根据诊断和/或缺陷的列举来创建治疗方案。该价值基础也通过强调生态模型而偏离了更传统的做法，包括考虑青少年和家庭所参与的多重系统，以及可能动员起来以成功支持青少年和家庭的社区和非正式支持。

In the wraparound process, a dedicated care coordinator works together with the family and youth (if developmentally appropriate) to identify the strengths, needs, and potentially effective strategies, culminating in a single, coordinated, individualized plan of care. It is in the facilitation of this planning process that the wraparound guiding principles are operationalized. Thus, two guiding principles of wraparound include family and youth voice and choice and team based. These two principles are actualized through the planning process in which families and youth are given intentional priority in decision making and are equal partners within the team structure ${}^1$${}^1$^(1){ }^{1}. The wraparound plan of care typically includes formal services that are balanced with natural supports such as interpersonal support and assistance provided by friends, kin, and other people drawn from the family’s social networks. The additional principles of collaboration, cultural competence, strengths based, and outcome based are all achieved and actualized through the team process with team members working cooperatively and sharing responsibility for a single plan of care, even when multiple providers are involved. The principle of unconditional support is achieved through wraparound teams not giving up on, blaming, or rejecting the youth or family, even in the face of significant needs and challenges.
在包裹式干预过程中，专门的治疗协调员与家庭和青少年（如果发育适宜）共同合作，识别优势、需求和可能有效的策略，最终形成一个协调一致、个性化的治疗计划。正是在这一规划过程中，包裹式干预的指导原则得以实现。因此，包裹式干预的两个指导原则包括家庭和青少年的声音与选择，以及基于团队的合作。这两个原则通过规划过程得以实现，在这个过程中，家庭和青少年在决策中受到有意优先考虑，并在团队结构中作为平等的合作伙伴。包裹式治疗计划通常包括正式服务，这些服务与自然支持（如朋友、亲属和其他来自家庭社会网络的人提供的人际支持）相平衡。 协作、文化胜任力、优势导向和结果导向的额外原则，都是通过团队成员合作共事、共同承担单一护理计划的责任而实现和具体化的，即使涉及多个提供者也是如此。无条件支持的原则是通过包裹式团队在面对显著需求和挑战时，不放弃、不责备或不拒绝青少年或家庭而实现的。

After family and youth voice and choice, perhaps the most important and enduring principles of wraparound are those of individualized and community-based. When implemented fully, the wraparound process results in a set of strategies and services provided in the most inclusive and least restrictive settings possible. These strategies are tailored to meet the unique and holistic needs of the youth and family, including supports to family members to reduce stress and to ensure that services are accessed and treatments completed by the identified youth. As described by VanDenBerg (2008), “the more complex the needs of the child and/or family, the more intensive the individualization and degree of integration of the supports and services around the family” (p.5). Thus, in the wraparound model, child, youth, and family needs drive access to services and the intensity of service integration, not the restrictiveness of services.
在家庭和青少年的声音与选择之后，围绕过程最关键且持久的原则或许是个性化和基于社区的原则。当完全实施时，围绕过程会形成一套策略和服务，这些策略和服务在尽可能包容和限制最少的环境中提供。这些策略是为满足青少年和家庭的独特和整体需求而量身定制的，包括为家庭成员提供支持以减轻压力，并确保被指定的青少年能够获得服务并完成治疗。正如 VanDenBerg（2008 年）所描述的，“儿童和家庭的需求越复杂，个性化和支持与服务整合的程度就越强烈”（第 5 页）。因此，在围绕模型中，儿童、青少年和家庭的需求驱动着服务获取和服务整合的强度，而不是服务的限制性。

For a number of years, wraparound was described primarily in terms of the above principles, and thus it was probably appropriate to conceive of it as an approach (i.e., an overall orienting view based on global concepts; Kazdin 1999). However, as initial program descriptions (e.g., Burchard et al. 1993; VanDen Berg and Grealish 1996) and evaluations of wraparound’s potential for positive impact (e.g., Burchard and Clarke 1990) emerged, and implementation efforts accelerated, researchers and implementers alike recognized the need to better define the practice model (Clark and Clarke 1996; Walker et al. 2008). As a result, several model-specification efforts were undertaken between 1998 and 2004. The latest of
多年来，围绕式干预主要以上述原则来描述，因此将其视为一种方法（即基于整体概念的整体指导观点；Kazdin 1999）可能是适当的。然而，随着初步项目描述（例如，Burchard 等人 1993 年；VanDen Berg 和 Grealish 1996 年）以及围绕式干预潜在积极影响的评估（例如，Burchard 和 Clarke 1990 年）的出现，以及实施工作的加速，研究人员和实施者都认识到有必要更好地定义实践模型（Clark 和 Clarke 1996 年；Walker 等人 2008 年）。因此，在 1998 年至 2004 年期间，开展了几项模型规范工作。最新的是