Wraparound Programs – An Alternative Approach to Address the Children’s Mental Health Crisis

The mental health crisis impacting America’s children requires states, parents, guardians, and behavioral health professionals to rethink how we provide treatment. For many young people, high fidelity wraparound programs are the answer.

Even before the pandemic, mental health issues were a leading cause of disability for children. The pandemic only worsened the situation. In the fall of 2020, Challenge Success conducted a national study that found that only one-third of high school students reported being able to cope with the stress they experienced and 83% reported having at least one related physical symptom. 

As the isolation, stress, and other factors associated with the pandemic continued, youth suicides also increased, leading the American Academy of Pediatrics to declare a national emergency in children’s mental health on October 19, 2021. It was followed by an advisory from U.S. Surgeon General Vivek Murphy on December 7, 2021, highlighting the urgent need to address the mental health crisis facing the nation’s youth.

Today, the mental health crisis impacting American youth remains dire. On October 11, 2022, the Preventive Services Task Force recommended that children eight years-old and up be screened for anxiety, and that children 12 years-old and up be screened for depression. The Adverse Childhood Experiences (ACE) Aware initiative also recommends that all children should be screened annually for trauma to help indicate risk for a variety of medical and psychiatric outcomes through adulthood. 

Clearly, action must be taken, but regrettably, in many parts of the country, efforts to address children’s mental health are encumbered by a lack of providers and services. According to the American Psychological Association, less than 5% of the nation’s more than 100,000 clinical psychologists are clinicians for children and adolescents, a reality that creates numerous behavioral healthcare deserts nationally.

Of course, the pandemic was not the sole cause of the increase in the incidence of children’s behavioral health issues. The anxiety, depression and mental illness impacting our youth is the result of a litany of factors, including everything from macro-economic trends to social determinants of health. 

An international study conducted last fall put this last point in stark focus. More than half of those surveyed, 10,000 young people aged 16-25 years, reported that they feel “sad, anxious, angry, powerless, helpless and guilty” and nearly half said their feelings on the issue negatively “affected their daily life and functioning.”

Other issues are also endemic. In one study published immediately prior to the pandemic, researchers found that increased social media use leads to an increase in “mental distress, self-injurious behavior and suicidality among youth…” The same research noted that in the U.S. 89% of young people between the ages of 13 and 17 years have a smartphone and that 70% use social media “multiple times” each day.

Substance use, a common psychiatric disorder, is another significant factor. According to the National Center for Drug Abuse Statistics, nearly half of teens, 46.6%, have tried illicit drugs by the time they reach 12^th grade. Just as alarming, longstanding research demonstrates the children of parents with a substance use problem are more likely to suffer from mental and behavioral health conditions, as seen in the data from The 2020 National Survey on Drug Use and Health which reported 40.3 million Americans had a substance use disorder in the previous year. 

Taking Action – The Treatment Landscape:

Individualized treatment approaches are necessary to meet the unique needs of each child. Traditional residential treatments in which children are temporarily removed from their homes and placed in institutional care under strict clinical supervision remain viable and appropriate treatment options for the small percentage of youth with several behavioral issues – particularly those who exhibit self-harm or pose a risk of injury to others. 

Today’s residential treatment programs are designed to help patients return to home as quickly and responsibly as possible – all with the end goal of providing them with the tools and time they need to effectively address underlying mental health conditions.

Great gains are being made, with one state recently seeing a 74% decrease in inpatient admissions following patients’ completion of its residential program. Notably, that same effort also reduced the monthly cost per patient by 40%.

Despite these gains and the proven benefits of residential treatment programs for the children that need them, they are more costly, resource intensive and less accessible in many communities. When it is appropriate, care that does not remove children from their homes and families is often more effective.

The Alternative – Wraparound Programs:

Increasingly, states and communities have implemented an alternative to traditional residential treatment programs. These innovative home and community based programs can be used not only to help ensure positive outcomes for youth with several mental and behavioral health conditions, but also those experiencing an episodic event. Wraparound programs are those that employ an evidence-based process – a “wraparound” – that includes all of the support and programs these children need and that in effect are “wrapped around” their family and home environments. 

These wraparound programs address a singular reality: youth with mental health issues often have needs that require treatment in multiple settings from disparate caregivers, providers, and programs. Beyond clinical care, this can include local and state agencies focused on juvenile justice, child welfare, the courts – such as for custody proceedings – counseling services, as well as developmental disorder resources, educational service and supports. 

Effective wraparound programs integrate all of these efforts into one comprehensive program that seeks to address not only the patient’s mental and behavioral health needs, but also to ensure that other issues such as social determinants of health are identified and addressed. Typically, such programs include several core components:

– Community partnerships: Liaisons work to ensure that representatives of each stakeholder, including the youth, their family, and all state and community agencies involved collaborate in the planning and implementation of the wraparound program. In this way, state, county and local departments of health, children and family services, juvenile justice, disability services, and other participants are involved from start to finish. 

– Collaborative action: Stakeholders work to create concrete policies and practices that govern the operation and execution of the wraparound program. In this way, the treatment program follows set, yet customizable practices and processes. This collaboration is team based and reflects the cultures and values of the family.

– Fiscal policies: The most successful wraparound programs include fiscal policies that reward participating stakeholders for successful patient outcomes – for example enabling agencies to apply savings generated by wraparound programs to proactive efforts to foster greater mental health for children. 

– Access to needed support: Proactive efforts ensure that patients have access to all of the services and support needed to provide assistance and treatment to a diverse array of young patients. Highly effective programs also increase the scope and scale of participants, ensuring that the wraparound program addresses a wide range of patient needs.

– Development and support of staff at partner agencies: All wraparound programs should include not only effective training, but also annual recertification programs conducted by certified coaches and trainers. 

– Accountability and tracking of outcomes: To ensure that the wraparound program includes the effective ability to benchmark success against national standards, as well as thresholds determined by independent assessors.

Two recent state-wide wraparound programs for children’s mental and behavioral health reflect the effectiveness of such wraparound programs. In one, 78% of 6,982 discharged patients over a four-year period showed improvement in at least one area of clinical functioning and 69% experienced improvement in five or more points, with a one-point change being a meaningful gain. Overall scores from the first to last assessment improved by a statistically significant 23% and improvement was observed across all Child and Adolescent Needs and Strengths, among them life functioning, youth behavioral and emotional needs, youth risk behaviors, and youth strengths.

Notably, such results often coincide with significant cost savings when compared with residential treatment programs. In one state, fidelity scores, measurements that an intervention follows a set program model, were above the national average – the caregiver score was 79.5%, compared to the national average of 72.0% and the youth patient score was 76.8%, compared to the national average of 69.3%. This state-wide wraparound program simultaneously cost less than half as much as its residential program alternative, with an average annual cost of $21,482 versus $47,045.

As the children’s mental and behavioral health crisis continues, wraparound programs clearly offer an alternative to residential treatment programs for many children. They are proven to benefit youth with behavioral health diagnoses, their families and communities while providing states with an effective and fiscally sustainable way to address substance use and juvenile developmental, educational and behavioral health challenges. Most importantly, wraparound programs allow youth to remain in the comfort of their homes and communities with access to a coordinated system of care. This builds youth and family strength while addressing needs and ensuring access to a diverse array of outpatient resources. 

About Dr. Jamie Hanna 

Dr. Jamie Hanna serves as the medical director for the Louisiana Coordinated System of Care. Prior to her current role, Dr. Hanna served as assistant professor and assistant training director at Louisiana State University School of Medicine while working with the acute behavioral health unit, consult liaison services and emergency psychiatric services at Children’s Hospital of New Orleans.

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