intensive home and community interventions

Child Adolesc Psychiatric Clin N Am

13 (2004) 857–884

Intensive home and community interventions

Elizabeth M.Z. Farmer, PhD*, Shannon Dorsey, PhD,Sarah A. Mustillo, PhD

Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Box 3454,

Durham, NC 27710-3454, USA

In the mid-1980s, Stroul and Friedman [1] articulated a set of guiding

principles for a system of care for children’s mental health. These principles

built on ongoing work that incorporated an ecologic framework [2–4] to

emphasize the need for a continuum and a system of care. These principles were

disseminated throughout the United States via the Child and Adolescent Service

System Program [5,6], so that by the mid-1990s, system of care demonstration

projects and infrastructure development were spread throughout the nation [7].

As these principles were disseminated, the field of children’s mental health

services and treatment came increasingly to recognize that the traditionally

offered services—inpatient hospitalization and clinic-based outpatient therapy—

did not provide an adequate match or range of interventions to meet the often

complex needs of children with mental health problems, particularly youth being

served via the public mental health care system [7–11]. In this context, a range

of innovative, comprehensive, community-based interventions were developed,

implemented, and (sometimes) evaluated [12–17].

These community-based and intensive in-home approaches to intervention

differ on many dimensions. However, they share a common set of principles and

practices that unify them and distinguish them from other forms of treatment for

youth. These principles include an explicit recognition of the importance of

ecology and context, recognition of the multiple needs of youth and their families

and multifaceted approaches to addressing these needs, a concerted focus on

strengths and resources, individualized treatment planning and intervention based

on these needs and strengths, and active involvement of the community and focus

on building or maintaining community connections for the child and family. In

1056-4993/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved.

doi:10.1016/j.chc.2004.04.004

This work was supported in part by grants MH57448 and MH53419 from the National Insti-

tutes of Health.

* Corresponding author.

E-mail address: [email protected] (E.M.Z. Farmer).

E.M.Z. Farmer et al / Child Adolesc Psychiatric Clin N Am 13 (2004) 857–884858

line with these core components, these intensive in-home and community-based

treatment approaches viewed outcomes as multidimensional and multiply influ-

enced [18]. They also recognized that treatment rests within the broader rubric

and constellation of the child and family’s life and community [5,19,20].

Such an individualized, multifaceted, community-based approach was well

matched with children’s and families’ needs, particularly for the most seriously

affected subset of youth: children with serious emotional disturbance (ie, children

with psychiatric disorders and substantial functional impairments). Previous work

showed that such youth were likely to be either unserved or served in overly

restrictive environments [8,11].

The design and delivery of these multifaceted, individualized, community-

based interventions were poorly suited for systematic evaluation or research,

however, particularly when using the long-standing model for conducting such

research within the medical and mental health field [21,22]. This standard

approach to evaluation requires a systematic progression of steps, from small

efficacy trials through larger ‘‘real world’’ effectiveness studies [23]. Such a

linear progression is difficult, and perhaps impossible, for these types of treat-

ment approaches [5,24]. This results from many factors, including the inability to

conduct these interventions in a laboratory setting, the impossibility of recruiting

simple or non-comorbid cases, the necessity of examining real world fit from the

outset, and the difficulty of disentangling dose of treatment for individualized

interventions [5].

Research from the past 15 years on these types of services has provided

reasons for optimism and causes for concern. Findings from various demonstra-

tion projects (eg, the Robert Wood Johnson Foundation’s mental health services

program for youth and center for mental health services system of care sites)

suggested that systems of care could be created. Child-serving agencies could

cooperate and coordinate around treatment and care for youth, and an enhanced

continuum of services could be developed [6]. Data from these projects also

suggested that access to services could be improved [25,26]. Early findings from

several types of intervention, including multisystemic therapy (MST) [16] and

treatment foster care (TFC) [14], also showed positive gains for difficult-to-treat

youth within these community-based interventions. Simultaneously, however,

findings from other interventions seemed to suggest that enhanced community-

based services may or may not affect child and family outcomes [12,27]. These

various findings led to extended discussions within the field of children’s mental

health services and research about explanations for the disparate findings [28,29].

They also fueled discussions about deficiencies in contemporary research and

evaluation and provided a foundation for a subsequent period of conceptualiza-

tion and research to assess more adequately the effects of community-based

treatment for youth [24,29]. Such discussions have led to a renewed focus on

theories of treatment and change, specification of active ingredients, improved

attention to manualization and assessment of fidelity, and a recognition that

system change, although perhaps necessary, is likely to be insufficient to affect

individual-level outcomes [5,30].

E.M.Z. Farmer et al / Child Adolesc Psychiatric Clin N Am 13 (2004) 857–884 859

Currently, the research base on community-based services has advanced

considerably, and a great deal of work is currently underway to continue this

expansion of knowledge. The evidence base is still limited, however. The current

review and discussion draw from several sources and approaches. Our aim is to

identify the best available community-based treatments for youth with psychiatric

disorders, particularly for youth with a combination of psychiatric diagnosis and

significant functional impairment (ie, serious emotional disturbance) [31]. In

recent years, many reviews have focused on the evidence base for various child-

oriented treatments [32–35]. These reviews have used criteria from several sources

[36–38] to determine the level or quality of the evidence base. These approaches

share common elements and provide frameworks for determining the quantity and

quality of the scientific evidence for an intervention. For an intervention to be

classified as the highest level of evidence (ie, well established), criteria require at

least two well-designed studies with appropriate comparison groups (or more than

nine well-conducted, single-case studies), replication (results from more than one

team of investigators), and treatment manuals (so that the intervention can be

distributed for replication). A designation of the next level of evidence, probably

efficacious, generally requires at least two studies showing it to be more effective

than a no-treatment control group (or several single-case studies).

Given the relatively limited research base for most of the community-based

treatments for youth, reviews of such services often have used less stringent

criteria (eg, any comparison group, use of established outcome measures)

[33,39,40]. We follow this expanded approach in the current review. In line with

Drake et al [41], we have focused on the best available scientific evidence for

potential evidence-based interventions. We include a wide range of acceptable

research designs rather than a narrower focus on randomized trials. This broader

definition provides less detail about essential mechanisms but is sufficient for

establishing effectiveness [36]. Given the complexity of many of these inter-

ventions and the need to fit into the broader environment, we also attempt to

evaluate the intervention’s readiness for transportability or dissemination and

applicability to real world settings [24,42].

In this issue, Kazdin [30] suggests that an exclusive emphasis on evidence-

based versus not evidence-based provides a partial and potentially limiting view

of effective treatments. Instead, he suggests a broader continuum of evidence that

would include (1) not evaluated, (2) evaluated but unclear (no or possibly

negative effects at this time), (3) promising (some evidence), (4) well established

(parallel to well established in conventional schemes), and (5) better/best treat-

ments (treatments shown to be more effective than other evidence-based treat-

ments). We use this nomenclature to discuss the existing evidence base for

community-based treatments.

The current review is parameterized from a system of care perspective. We

include services that are traditionally viewed as elements of a system of care for

youth with mental health problems and are implemented in the home or com-

munity. These services include community-based residential treatment, multi-

modal treatments that provide individualized services to children and families,


services that are designed to coordinate and integrate multisector interventions,

and auxiliary and supportive types of services that are conventionally delivered in

the community. We have not included traditional outpatient therapy or school-

based services, although such services are frequently provided within a system of

care structure and are likely to occur in conjunction with the types of modalities

included herein [43] and are reviewed in other articles in this issue.

Recent reviews of the evidence base within the field were used to identify po-

tential treatment approaches or modalities that should be included herein [33–35,

44,45]. Given the broader focus on the full range of interventions with varying

levels of evidence, additional treatments that have been shown to be commonly

used in systems of care also were identified [43,45]. Once candidate approaches

and modalities were identified, we placed them within the four-category scheme

(ie, residential, multimodal, coordinating and facilitating, auxiliary). This schemata

was viewed as an ideal type because many identified approaches contained ele-

ments across categories. Approaches were clustered together based on their domi-

nant features or treatment approach to provide a heuristic for assessing evidence

within and among different types of treatment.

A review of the available evidence was then conducted to determine the level

and extent of current evidence for the focal treatment. For the current discussion,

we have limited eligibility to sources that have been published in peer-reviewed

outlets. To identify potential pieces of evidence, we used electronic database

searches, reference lists from identified articles, and a networking approach based

on key words, authors, and related topic areas.

Because there have been a series of reviews of the evidence base in the

relatively recent past, we approached this topic as an update. We read the

previous reviews, conducted new searches on the previously covered years (to

assess adequacy of the previous work), and performed a review of peer-refereed

publications on each topic that have been published since the previous reviews

were completed. We also used our knowledge of current work within the field to

provide brief updates on current research directions. This article, therefore,

provides a brief overview of the long-term evidence base, a focus on recent

work, and, where possible, glimpses of current foci and research efforts.

Community-based residential treatment

This category includes treatment approaches that combine a community-based

residential placement with a specific focus on treatment (rather than merely

providing childcare or room/board). Two potential treatment modalities were

identified in this category: TFC and therapeutic group homes.

Treatment foster care

TFC is considered to be the least restrictive treatment-based residential option

for youth with mental health or antisocial behavior [46]. It combines implemen-


tation of structured therapeutic interventions with opportunities for development

within a family setting [47]. As such, it provides a potentially valuable

component for a continuum of care within a system of care [33,48].

TFC is distinguished from other community-based residential placements (eg,

regular foster care) by its explicit focus on treatment and substantial training and

supervision of trained treatment foster parents. It is distinguished from other

treatment-based residential placements by its use of individual families’ homes,

placement of few (usually only one) child per home, and lower costs than other

treatment placements [49,50]. TFC’s role in a system of care is diverse: it can be

used as a step-down from more restrictive placements, as a short-term placement,

or as a long-term placement [51]. TFC is regarded favorably within the field of

community-based children’s mental health treatment, mainly because of its

applicability and flexibility within a system of care, its concordance with child

and adolescent service system program-type principles (eg, providing intensive

treatment within a community and family setting), its comparatively advanced

evidence base, and its relatively low cost [33,52].

The evidence base for TFC comes almost exclusively from work by Cham-

berlain and colleagues at the Oregon Social Learning Center [14,49,53,54]. This

model of TFC is based on a long tradition of social learning theory [55–59]. As

such, it is built on a well-developed model of the development of problematic

behavior, and it posits specific mechanisms that may be effective at reducing such

behaviors (eg, parental discipline, supervision, peer relationships). TFC, as it is

delivered in the Oregon model, includes significant treatment foster parent

training, supervision of treatment foster parents by experienced case managers,

careful monitoring of behavior and consequences, use of a points/levels sys-

tem, and significant additional services for youth and families (eg, in-house

therapists, skills builders, strong relationships with other child-serving agencies)

[49]. The model emphasizes the importance of a proactive approach to behavior

and discipline, consistency, and a team of adults working with the youth.

The published evidence base for TFC comes primarily from two randomized

trials conducted by Chamberlain and colleagues. One study involved youth

transferred from a state psychiatric hospital and the other focused on juvenile

offenders. In these studies, results favored TFC over the alternative treatment

(group home or hospital) [14,60,61]. Youth in TFC showed more rapid decreases

in problematic behavior, increased community residence, and lower rates of

recidivism, and these positive effects in favor of TFC were sustained after

discharge throughout the longitudinal follow-up (up to 2 years) [49,60,62].

In addition to these overall promising findings, the Oregon version of TFC’s

foundation in theory has provided substantial guidance on mechanisms that may

influence outcomes. Findings to date have emphasized the importance of four key

mediators of outcomes: (1) type and amount of supervision the youth receives,

(2) consistency and perceived fairness of discipline, (3) presence and quality of a

relationship with a mentoring adult, and (4) lack of association with deviant peers

[49]. A randomized trial that compared youth in TFC with youth in group homes

showed that these mechanisms differed between the two settings and that such


differences were associated with outcomes [63,64]. Findings also have pointed to

potential differences in mechanisms and effects for boys and girls [65–67].

Research on TFC beyond Oregon has been sparse and mixed. Evans et al

[68–70] used TFC as the comparison condition in a randomized trial of intensive

case management. Over an 18-month follow-up period, the intervention group

(ie, case management) showed more favorable gains in role performance, inter-

nalizing and externalizing behaviors, and functioning. These increased improve-

ments in case management were achieved for approximately one-third the cost of

TFC. Clark et al [71] used a randomized trial in Florida to compare TFC with

standard foster care. Youth in TFC showed fewer placement changes, lower

rates of delinquency, and improvements in externalizing behaviors compared

with youth in regular foster care. These results from beyond the Oregon model

suggest potential variability in results, based on the comparison condition. They

also provide relatively fewer details on the implementation of TFC, so it is

difficult to know how similar TFC was across these studies and whether the

non-Oregon programs included many of the elements that are bundled into the

Oregon model.

Current work in TFC focuses on several fronts. First, within the group of

researchers at the Oregon Social Learning Center, there are ongoing efforts to

develop a better understanding of the intervention with girls [72]. Considerable

work is also being devoted to disseminating TFC from Oregon to other sites

across the nation (Chamberlain P, Price J, unpublished data) [73] and modifying

the Oregon model to meet the needs of younger children [74,75]. Current work

by others [52] has shown that TFC, as widely practiced in other settings, differs

substantially from the model implemented in Oregon. Additional ongoing work is

evaluating a revised model of TFC to meet the needs of youth in long-term TFC

served in disparate agencies and communities (Farmer E, unpublished data).

Currently, the evidence base for TFC seems to be promising or probably

efficacious. Positive effects (compared with other usual care conditions) have

been shown in two randomized trials. Findings from researchers beyond the core

group have found inconsistent effects of TFC. Current efforts in dissemination

and additional research by other investigators may provide the additional

evidence required to move TFC into the ‘‘well-established’’ category in the

relatively near future. In addition to the ongoing research, the initial developers

and several of the ongoing projects are developing materials and manuals that

may be used for training, disseminating, and assessing implementation. Current

work on modifying the model (for use in other target populations and diverse

settings), however, suggests that the Oregon model of TFC may be subject to

substantial modifications in order to apply it to other target populations.

Group homes

Reviews of evidence-based interventions for youth with mental health prob-

lems frequently do not include group homes because the evidence base is so

sparse for this type of treatment. Data on service use within systems of care


suggest that group homes are the most common community-based residential

treatment placement for youth with such difficulties [51].

Probably the most fully articulated and most widely practiced model of group

home care is that developed and disseminated as the teaching family model

(which, coincidentally, also has been used in implementing TFC in settings across

the country) [76,77]. This model focuses on a family-style environment for six to

eight youths at a time, uses teaching parents as the front-line staff, and emphasizes

a milieu approach to therapeutic intervention. In many ways, this model of group

home care mimics many of the tenets of TFC (ie, trained ‘‘parents,’’ focus on

structure and supervision, explicit recognition of the ecologic nature of their

work). The two settings have an essential difference in their theory of change,

however. Teaching family group homes emphasize self-government and peer

interactions as key components of the therapeutic environment, whereas TFC

places its emphasis on adult-mediated intervention [63]. Group home care also

costs substantially more than TFC (usually two to three times more expensive).

The evidence base for TFC is promising but fairly limited. In comparison to

the evidence base for group home care, however, it is voluminous. The de-

scription of group homes focused on the teaching family model, because this is

the only type of group home care that has received any systematic research

attention. Much of the research was conducted more than 20 years ago [77–80].

Early work showed that the original teaching family site (Achievement Place,

University of Kansas) showed significantly more positive outcomes (on criminal

behavior) than dissemination sites or group homes that were not using the

teaching family model [80]. Subsequent work that compared youth in teaching

family group homes to usual treatment youth has shown more positive outcomes

on functioning and symptomatology, greater satisfaction, fewer feelings of

isolation, and a greater sense of control for the group home youth [76,81].

Since 1990, little research on teaching family group homes has appeared in the

literature. What has appeared has focused on issues of dissemination rather than

outcomes [82,83]. A search of the literature since 2000 shows little research on

group homes. What has appeared has focused primarily on processes within

homes and assessing satisfaction and well-being within group homes [43,84–86]

rather than on outcomes of group homes, per se. The focus of this research also

primarily occurred within the child welfare literature rather than the children’s

mental health literature.

Comparisons of the interventions in this category—TFC and group homes —

are few but have favored TFC. An early comparison that used a matched-group

design to compare youth in the two settings [87] showed equivalent gains in the

two settings, but indicated that these gains were achieved at half the cost in TFC.

A randomized trial of TFC versus group home care showed that TFC was

associated with more positive behavioral changes in a shorter period of time,

increased community tenure, and decreased arrests and incarcerations in the year

after discharge [64]. Recent work is beginning to appear that will make it possible

to conduct a direct comparison of processes and outcomes between these two

settings [43,51,88].


The evidence base for group home treatment is thin. Findings in published

work have suggested some potential for positive gains. Additional work has

raised questions about potential iatrogenic effects of grouping youth with similar

problems together, however [89]. No systematic research has examined the extent

to which such concerns are justified, although there is some evidence of

deterioration of behavior in at least some group homes [80]. In light of these

concerns, and without ample evidence to dispel them, it seems that the current

evidence base for group homes should be regarded as ‘‘evaluated but not clear.’’

Significant research is necessary on this commonly used treatment modality.

Multimodal treatment

This category includes interventions that are explicitly multimodal and

incorporate various treatment approaches, foci, or sectors to intervene directly

with youth. TFC, as currently implemented by the Oregon Social Learning

Center, has been relabeled as multidimensional TFC to emphasize its multimodal

focus. Despite this development, it remains classified as a community-based

residential treatment because of its primary focus on providing a family-alter-

native residential treatment, which is supplemented and supported via additional

services. One dominant approach was identified within this category: MST.

Multisystemic therapy

MST is regarded as among the strongest evidence-based interventions for

youth [35,90]. MST’s appeal and support come from a number of fronts. First, it

is built on a strong theoretical underpinning of ecologic theory and has carefully

hypothesized and examined potential change mechanisms [91,92]. Given MST’s

ecologic underpinnings, it focuses on the fit between youth and environment and

concentrates on interventions and modifications that improve this fit with the goal

of improving targeted behaviors. As with other community-based interventions,

MST is individualized to meet the needs and strengths of participating families.

Unlike many other community-based interventions, however, MST follows a

clearly defined iterative analytical process for assessing fit, identifying goals,

developing and implementing intervention, and assessing success and barriers

[93]. As in many other community-based interventions, MST services are

individualized, available 24/7 to families, and provided in the context of a

family’s values and culture. MST is delivered via MST therapists (usually

masters-level professionals) who work intensively with a few families at a time

for a time-limited duration. MST has taken a lead in community-based services

for youth with its careful attention to fidelity and manualization [94,95].

MST is a well-validated treatment model within community-based children’s

mental health treatment [33,34,96]. An ongoing program of systematic and

rigorous research has included eight randomized trials in various settings and

with various target groups of youth. Initial research focused primarily on use of


MST with youth in the juvenile justice system [97–101]. Findings from these

studies have shown consistently positive results compared with usual treatment,

including reduced recidivism, fewer out-of-home placements, and lower rates of

substance-related offenses.

More recent work has included a randomized trial for youth with psychiatric

problems rather than juvenile delinquency. The study included youth who had

been approved for an emergency psychiatric admission. Among youth who were

randomized to MST (rather than hospital care), short-term findings indicated

fewer hospitalizations, fewer days in the hospital, more days in mainstream school

settings, and more substantial improvements in severity of symptoms [102,103].

These positive short-term findings, however, were not maintained across time. By

approximately 12 months after enrollment, differences between MSTand the com-

parison group had diminished or evaporated on nearly all examined dimensions.

Current work in MST revolves around two primary foci: refinement and

reconceptualization of the MST model for youth with mental health problems

(rather than primarily juvenile delinquency issues) [104] and issues in dissemi-

nating MST [42,105].

Classification of the evidence base for MST illustrates some of the complexi-

ties of such categorization. On one hand, MST probably has the strongest

evidence base among community-based interventions. Its effectiveness (com-

pared with various other usual care conditions) has been demonstrated in multiple

randomized trials, and it has a well-developed treatment manual and means of

assessing fidelity. On the other hand, nearly all of the existing research has been

conducted by individuals who developed the approach, and recent results with

mental health populations have not shown the strong and lasting effects that were

found with juvenile delinquent populations. Despite widespread enthusiasm and

support for MST as the gold standard for evidence in community-based treatment,

it seems to qualify as promising (using Kazdin’s [30] scheme) or probably

efficacious [36,38]. Current work on dissemination, replication by other groups,

and continued refinement on approaches for mental health populations may

propel it quickly into the well-established or even better/best treatments desig-

nation within the near future.

Coordination and facilitation

This category includes approaches that focus more exclusively on facilitating

access and coordination of services than on actual provision of treatment. It

includes case management and wraparound. In some reviews, these two types of

intervention have been viewed as variations on a common theme [33]. As they

have evolved, however, they have developed distinct (although not entirely dis-

entangled) niches and literatures; they are reviewed separately herein. Case man-

agement and wraparound are internally heterogeneous in terms of the extent to

which they focus exclusively on coordination and facilitation rather than di-

rect services.

Case management

Case management is a commonly used strategy for increasing access to and

coordination of services within systems of care. Definitions and implementation

of case management vary widely [106–108], but all definitions recognize that

case management mobilizes, coordinates, and maintains an array of services and

resources to meet individuals’ needs [109]. Case management often is seen as the

lynchpin of a system of care, because it provides the central function of bringing

together the disparate interventions and practitioners into a coherent whole to

meet children’s and families’ needs.

Case management includes various functions to meet these needs, including

assessment, service planning and implementation, service coordination, monitor-

ing and evaluation, and advocacy [109]. Case management can be organized in

various ways and can be led by various players to fill these functions. Primary

models of case management include the generalist or service broker, primary

therapist, interdisciplinary team, comprehensive service center, family as case

manager, supportive care, and volunteer as case manager [110,111].

As of 2002 (when the last published review of the case management literature

was published), three studies with rigorous research designs (two randomized

trials, one quasi-experimental) had been conducted on case management for

youth with emotional and behavioral problems. One of these studies used a

randomized trial to compare treatment and outcomes for youth who received case

management from a full-time case manager (generalist/service broker model—

intervention condition) with youth whose primary therapist acted as case manager

(primary therapist model—control condition) [27]. Results showed considerable

impact on retention in services, array of services, use of less restrictive com-

munity-based services, and greater satisfaction with services for youth in the

intervention condition. There were few differences in individual- or family-level

outcomes between the groups, however. Evans et al [68–70] examined differ-

ences (using a randomized design) to compare youth in intensive case manage-

ment to youth in TFC. Results at 18 months showed significantly more positive

outcomes on a range of individual-level factors for youth in intensive case

management and at only one third the cost of TFC. Finally, Ruffolo (Ruffolo M,

unpublished data) used a quasi-experimental design to compare youth enrolled in

an expanded broker model of case management to an enhanced program that

included case management plus a therapeutic intervention based on McFarlane’s

[112] research on expressed emotions and multiple family groups. Youth in the

enhanced condition showed more improvement across time on symptoms and

problem behavior but no significant differences on other domains.

A literature search for the period since 2000 uncovered two additional studies

to evaluate the effects of case management. In one study [113], youth who were

being discharged from residential treatment for substance-related problems were

randomly assigned to usual care or assertive continuing care (assignment to a

case manager for 90 days after discharge). Results at 3 months after discharge

showed that youth in the case management group were more likely to access and



continue using services, were more likely to abstain from marijuana, and had re-

duced use of alcohol, compared with youth in the usual care condition. The sec-

ond recent study [114] continues Evans and colleagues’ work in New York. This

study examined effects of three interventions (with a randomized design): home-

based crisis intervention (based on homebuilder’s model of family preservation),

home-based crisis intervention plus (homebuilder’s plus a cultural competence

enhancement), and crisis case management (a scaled-down version of the inten-

sive case management tested by this group previously). All three interventions led

to improvements across time for youth and were successful at maintaining most

youth in their communities. Crisis case management was associated with more

significant improvements in internalizing symptoms but fewer positive changes

in family cohesion.

Recent and current research in case management is building on the existing

base and evaluating variations in service delivery. Substantial work also is being

conducted in adjacent fields (eg, with drug-dependent mothers, HIV-infected

youth) that may be relevant for understanding the processes and outcomes of case

management [115,116].

With the most recent work, effects of case management have been examined in

four randomized trials and an additional quasi-experimental study. Considerable

work has examined processes of case management and ways that it fits into the

broader system [117–119]. In general, case management has shown positive

findings against various comparison groups. In several studies, it has shown

findings that are comparable or superior to more intensive in-home or out-of-home

interventions [68–70,114]. Results of the most common form of case management

(the broker model) have suggested significant changes in service use, but the

results on individual-level outcomes have been either neutral [27] or evaluated for

short follow-up periods [113]. Given its current evidence base, case management

is classified as a promising or potentially efficacious intervention. Additional work

is needed to replicate the New York findings in other locales and more fully

specify the necessary dose, functions, and intensity of effective case management.

Additional work is also needed to assess fidelity, so that effects of case manage-

ment can be evaluated systematically net of other interventions that the youth and

family receive. If such work is successful, case management will be well po-

sitioned to move into the well-established or even better/best practices category.

Wraparound

Wraparound is an approach to treatment that developed as an attempt to

overcome the fragmented, uncoordinated way in which services traditionally

were provided to youth with multiple problems who received services from

multiple child-serving agencies. Wraparound is identified as a definable planning

process that involves the child and family and is designed to provide a unique set

of individualized community services and natural supports based on a set of core

principles and values [96,120,121]. There is a great deal of overlap between the

process and goals of wraparound and case management. Whereas case manage-


ment focuses more specifically on coordinating and facilitating service delivery,

however, wraparound provides more focused attention on the way in which

service delivery is planned. These are, however, ideal types. For case manage-

ment, the actual implementation of wraparound varies widely [121]. This

variation and flexibility have made wraparound simultaneously a widely used

approach (as of 2000, it was being used in 85% of the United States and

territories) [96] and a difficult intervention to operationalize and study [121].

Wraparound developed as a grass-roots intervention in response to frustration

over fragmented, restrictive, formal services for children with serious problems

[13]. Its unique appeal lay in its relatively simple philosophy to identify the

community services and supports (formal and informal) that a family needs and

provide them for as long as they are needed [121]. To achieve this, wraparound

focused on the process of planning services. According to wraparound principles

and values, this planning process needed to involve the family as full and active

partners, build on strengths, be individualized and flexible, be community based,

use a team approach, balance formal and informal services and supports, address

the full range of life domains, and include outcomes that are determined and

measured for each of the child and family goals and program- and system-level

goals [122].

As a philosophy, wraparound was appealing to professionals and families who

were frustrated with the usual way of providing services. Its flexible, individu-

alized, community-based, strength-based approach has made it difficult to

operationalize and evaluate, however. Early research was descriptive, with an

initial set of ten case studies based on the wraparound program in rural Alaska

[13]. Although the study was small and lacked a comparison group, description

of this approach and its apparent potential for difficult-to-treat youth in areas with

few formal services sparked tremendous enthusiasm in the field and a flurry of

additional implementation and research. To date, there have been 16 identified

studies of wraparound [96,121]. Among these studies have been two randomized

trials [69,71], three quasi-experimental designs [123–125], and nine pre-post

designs [126–132]. This list, however, is longer than typically would be included

in a review of the evidence base: six of the included studies have not been

published in peer-reviewed outlets (they appear only as conference proceedings,

book chapters, reports, or dissertations). Also, the peer-reviewed articles—with

two exceptions [125,129]—have appeared in a single journal (Journal of Child

and Family Studies).

Results from this set of studies have shown mostly positive effects of wrap-

around. Results from the most scientifically rigorous studies (randomized trials

and quasi-experimental designs) have shown improvements, relative to the com-

parison group, in living environment permanency and level of restrictiveness,

school attendance and adjustment, behavioral adjustment, family functioning,

and delinquency [69,71,124,125]. One study showed significant differences in

service use but fewer systematic differences on other individual-level outcomes

between youth who received wraparound and youth who received treatment as

usual [123].


Research on wraparound in the most recent years has continued the pattern of

early work and has begun to focus on the issue of operationalization and fidelity.

Much of the identified work continues to be program descriptions and other

discussions of the approach’s application and principles [133–136]. Work by

Epstein and colleagues [137,138] has focused on development and psychometric

validation of an instrument (the wraparound observation form) to assess the

degree to which the wraparound principles are adhered to in treatment team

planning meetings. To date, no published data examine whether better conformity

to this planning process is related to improved outcomes for youth or families.

A recent publication showed that treatment integrity (measured as percentage

of service hours prescribed versus received) was not related to outcomes, al-

though it is unclear whether this measure is an adequate and valid indicator of

wraparound [139].

Currently, the evidence base for wraparound seems to fall on the weak side of

‘‘promising.’’ What research exists shows positive gains. Other work, however,

shows equal gains with usual care at an increased cost for wraparound [123]. The

evidence to date is concentrated in weak study designs, however. Although

various researchers and authors have been involved, the publication outlets for

this work have been narrow (and frequently not peer reviewed). Current work on

assessing conformity should be helpful in operationalizing this intervention

approach and rigorously examining whether successful implementation is linked

to positive outcomes for youth. A great deal of work remains to be completed on

this widely used and popular approach for serving youth.

Auxiliary and supportive services

This category includes particular, identifiable services that may be provided

individually or in conjunction with any of the previously mentioned interven-

tions. Within a system of care, they usually would not be seen as a primary or

sole service. Instead, they are viewed as important supplemental services that

support and facilitate the broader range of interventions that youth receive. They

fit within the ecologic perspective of a system of care and provide coverage for

potential gaps in a continuum of care. In this area, we identified three community-

based candidates: family education and support, mentoring, and respite services.

Family education and support

Family support and education programs fill a niche in a system of care by

providing systematic efforts to enhance, strengthen, and empower families to

promote healthy outcomes for children in the face of stresses and risks [140,141].

Family education and support programs share much common ground with other

family-based interventions [142,143], but they occupy a unique niche in their

focus on providing a range of supportive, educational opportunities to parents that,

in turn, are hypothesized to improve outcomes for children. In short, the inter-


vention seeks to bolster parents’ resources (in terms of knowledge, support, and a

sense of empowerment) to face more adequately the challenges they encounter in

parenting. As such, family support and education is often viewed more as a pre-

ventive service than a treatment service [140]. It also has been used within systems

of care for youth with mental health and behavioral problems, however [144].

Most of the research on family support and education programs has involved

at-risk families (primarily those from impoverished, minority backgrounds).

Because this is a population that is overrepresented among systems of care,

findings from such studies may be directly relevant to this focal population.

Several reviews have been conducted on this type of intervention. Comer and

Fraser [140] reviewed six programs that had been rigorously evaluated. Although

each of the programs was unique and designed to meet the needs of particular

locations and populations, the programs shared common intervention compo-

nents, including home visiting, child development screening, parent training,

and broad-reaching support for the parents. All programs were staffed by

multidisciplinary teams [140]. Overall results were positive across the programs.

Findings at 12 months showed gains in parent-child interaction, parental

knowledge, and child health and development. Programs that collected longer-

term data (up to 10 years after admission) generally showed sustained benefits of

the programs, including cognitive development, school achievement, and various

measures of family functioning. An additional review of three randomized studies

of family education and support for parents of children with chronic health

conditions showed that the interventions decreased maternal anxiety but did not

affect other maternal mental health issues [145]. In contrast to these generally

positive results, a recent long-term evaluation of the comprehensive child

development program, a two-generation family support and education program,

failed to show any significant differences across a wide range of outcomes for

intervention and comparison youth [146].

The Vanderbilt Caregiver Empowerment Project was the only identified study

that focused specifically on youth with mental health problems [144]. Results

from this randomized study (which was conducted as a substudy within the

Ft. Bragg evaluation) showed significant improvements in parents’ knowledge

(eg, information about available services) and mental health self-efficacy (eg,

encouraging active participation in decision making). Changes in these domains

were maintained across the 12-month follow-up period; however, these improve-

ments did not affect distal outcomes, such as actual involvement in treatment,

service use, or child outcomes [144].

Currently, the evidence base for parent education and support is best

characterized as ‘‘not examined.’’ Although there have been systematic studies

of this type of intervention, they have focused on various at-risk populations

rather than on families of children with serious mental health problems. The one

case that focused on youth with such problems [144] provided a limited 11-week

intervention without the types of ongoing supports that are common among such

interventions. The focus on parents and families as active partners and collabo-

rators and the emphasis on building and supporting parent/family strengths


suggest the need for interventions that increase knowledge, empowerment, and

support for parents who are facing the challenges of raising youth with serious

mental health problems. To date, however, the evidence on how to do this

successfully is not available.

Mentoring

Volunteer mentoring programs have become increasingly widespread over the

past decade [147]. Currently, Big Brothers/Big Sisters of America, the most well-

known program, has more than 500 agencies throughout the United States, and the

National Mentoring Database includes more than 1700 organizations that include

mentoring programs [148]. The appeal of mentoring programs is based in part on

findings from the social support and resiliency literatures that positive relation-

ships with extrafamilial adults are related to positive outcomes for children and

adolescents, particularly for youth categorized as at-risk [149,150]. Mentoring

programs also are attractive to agencies because of their use of community

volunteers as resources in promoting positive youth development [151]. Mentor-

ing can be provided as a stand-alone program for at-risk youth, but it is often

provided as an additional support within systems of care [43].

Despite the popularity and proliferation of mentoring programs, the evidence

base for mentoring programs is relatively limited and somewhat inconsistent.

Whereas some studies support mentoring as a viable option for improving

outcomes for adolescents, others report no relationship or a negative relationship

between mentoring and outcomes [152]. Potentially, these varied findings result

from the heterogeneity within mentoring programs with regard to population

served, program characteristics, and program goals. For instance, mentoring

programs vary in the nature and extent of training provided to mentors, and

although most mentoring programs target the general goal of positive develop-

ment for adolescents, some address specific, instrumental goals, such as improv-

ing academic functioning or reducing delinquent behavior.

DuBois et al’s [153] recent meta-analysis of 55 mentoring programs provides

the best synthesis of the literature to date. Overall, their findings suggest that

participation in a mentoring program was associated with a modest benefit for

youth (ie, average effect sizes of 0.14 and 0.18 were obtained under fixed- and

random-effects analysis, respectively). Several factors were found to moderate

mentoring programs’ effects, however. Moderators fell into four broad categories:

program features, characteristics of youth, characteristics of relationships, and

outcomes assessed. For individual program features, using mentors with back-

grounds in helping professions, providing ongoing training for mentors (but not

prerelationship training), ensuring availability of structured activities for mentors

and youth, and including parent support or involvement were associated with

larger effect sizes for adolescents. Programs with explicit expectations for

frequency of mentor-mentee contact also had larger effect sizes; although only

12 of the 55 studies reported this information. DuBois et al [153] also examined

the collective contribution of programs’ use of best practices by computing an


index of 11 program features that included characteristics, such as monitoring

of implementation, screening of mentors, and training requirements. (For all

11 features, see DuBois et al [153]). Programs that included a larger number of

best practices were associated with larger effects, with no one feature predom-

inantly responsible for the relationship.

Characteristics of the youth involved also were related to the strength of

outcomes. For youth characteristics that acted as moderators, the largest effect

sizes were associated with youth who experienced either environmental stress

alone or in conjunction with individual risk. For youth who experienced only

individual risk factors, programs that used a majority of the best practices were

related to positive effects of mentoring, whereas programs that did not engage in

a majority of best practices were associated with smaller effects.

Currently, the evidence base for mentoring places it in the ‘‘promising’’

category. It seems that mentoring that conforms to best practices can encourage

positive outcomes for youth. Findings on program and youth factors that

moderate outcomes suggest the importance of good program implementation

and raise questions about the expected effect for youth with serious mental health

problems (eg, youth typically served in systems of care). There is a need to

bolster the evidence base by expanding the number of studies focused on this

target population, carefully assessing implementation, and designing studies

that can assess the impact of mentoring in conjunction with or net of other con-

current interventions.

Respite services

Respite services are defined as ‘‘the provision of temporary care to persons

with disabilities, with the primary purpose of providing relief to caregivers’’

[154]. Respite has been common in the fields of developmental and physical

disabilities [155,156]. Systems of care bring together a philosophy and approach

to services (eg, focus on families’ expressed needs, increased efforts to serve

children in homes, recognition of the stresses and impact of caring for a child

with mental health problems) that have emphasized the need for such relief

services for families of youth with mental health problems.

Research on respite, for any type of disability, is severely limited. Only a few

studies with minimally adequate methodology have been identified. Rimmerman

[157] studied use of respite care by mothers of young children with mental

retardation and found that it was associated with reduced parental stress. Sherman

[158], in a study of children with chronic illness, found a trend toward lower rates

of hospitalization for children in families that had access to respite services.

There was only one identified study of respite for youth with emotional and

behavioral disorders [159]. This study used a quasi-experimental (wait-list

control) design to assess effectiveness of respite care. Respite care was provided

on a preplanned basis for an average of 22 hours/month (ie, less than 1 day).

Overall, use of respite services was associated with lower caregiver strain, fewer

out-of-home placements, increased caregiver optimism about the future, and


decreased children’s externalizing behaviors in the community. There seemed to

be a dose effect so that families that received more hours of respite showed

increased optimism, family functioning, and reduced perceived stress.

Currently, respite is viewed as an essential element of a system of care.

Findings from the limited available data suggest that it may produce desired

outcomes to meet the needs of families and, indirectly, positively impact chil-

dren’s outcomes. Currently, however, the literature for youth with mental health

problems is limited to one wait-list control study. Its evidence base must be

regarded as a weak entry in the ‘‘evaluated but unclear’’ category.

Summary and discussion

This article has provided an overview of the state of the evidence base for

community-based interventions for youth within systems of care. The article

focused on approaches to treatment that are commonly provided within systems

of care for youth with mental health problems. It built from recent reviews of the

evidence base to examine the current status of a range of interventions. The

following discussion provides a brief overview of the state-of-the-science and a

discussion of what is needed to move the field forward.

The review was organized around four heuristic approaches to intervention:

approaches that are primarily residential, multimodal, coordinating/facilitating,

and auxiliary/supportive. Table 1 provides an overview of the current evidence

base and status for each identified type.

Currently, there is a great deal of promise for community-based interventions,

but a tremendous amount of work is needed to reach a well-established or better/

best practices for the included intervention approaches. Despite this need for

much additional research to establish the evidence base fully, the existing

evidence is encouraging. For all of the examined interventions, there is at least

some evidence that they produce positive changes in relevant domains. Such

differences are not always superior to those found in control conditions and may

not have been examined for the focal population of youth with serious emotional

disturbance. The overall picture of results suggests that these interventions work,

however. The challenge is in identifying key mechanisms and essential elements,

operationalizing and describing interventions in sufficient detail that they can be

replicated and studied, and examining which interventions—and under which

conditions—work more effectively for which youth.

MST and TFC are often viewed as the two evidence-based interventions

within this realm. Clearly, these two types of intervention have been evaluated

via systematic, rigorous, and carefully controlled studies. Each type needs

additional work to replicate findings, modify the intervention to meet the

treatment needs of particular populations, and move the intervention into the

disparate, heterogeneous, and resource-strapped communities and agencies. Each

one seems poised to make the transition into this highest level of evidence within

the foreseeable future.

Table 1

Overview of the current evidence base and status for each identified type of intervention

Category Intervention Comments

Community-based Treatment foster care Relatively strong evidence base

residential Need for research beyond Oregon

Current efforts focused on refinement and

dissemination

Group homes Little work in past 15 years

Concerns about iatrogenic effects have not

been evaluated systematically

Most promising findings for the teaching

family model

Multimodal

treatment

Multisystemic therapy Most extensive research base in community-

based treatment

Need for replication by additional researchers

Current focus on dissemination

Need for refinement and testing of model for

youth with psychiatric problems

Coordination/

facilitation

Case management Has amassed a respectable evidence base for

such an amorphous approach

Needs work on assessing fidelity

Wraparound Relatively weak research designs

Needs work on assessing fidelity

Requires substantial research

Auxiliary/supportive

services

Family education

and support

Positive findings come from nonmental health

populations

Need for research in target population

Mentoring Positive effects in related populations, but lack

of adequate data on mental health populations

Need to operationalize and assess fidelity

Need to examine net of other factors

Respite Little research


Case management is not often viewed in the same realm as TFC and MST, in

terms of its evidence. This article, however, suggests that the evidence base for

case management is convincing. Recently there have been publications from four

randomized trials and one quasi-experimental study. All of these studies have

shown positive improvements across time. Studies that have not shown signifi-

cant improvements (above comparison groups) for individual-level outcomes

have shown intended shifts in service use (which are, arguably, the relevant

outcomes for certain forms of case management).

The evidence base for the other types of interventions included here is much

less advanced. There has been virtually no research on group homes in recent

years and limited research on the effectiveness of this intervention. Current

efforts seem to focus on dissemination and small-scale processes rather than on

research that is likely to increase the evidence base. Wraparound has received a

good deal of attention but little systematic or strong research. Recent efforts to

more adequately assess conformity to wraparound principles and processes may

spur an increase in high-quality research in this area. The evidence base for the


auxiliary and supportive services requires considerable work, particularly to

examine effectiveness of these approaches within systems of care and for youth

with serious mental health problems. Among these interventions, mentoring has

the most promising research literature, but there is little evidence of its

effectiveness for youth with the types of complex difficulties and risks that are

served in systems of care.

In terms of envisioning next steps for these interventions, we use the

framework provided by the clinic/community intervention development model

[23,24]. This model modifies the traditional efficacy-effectiveness paradigm for

developing the evidence base to take into account more fully the complexities of

community-based interventions. The model conceptualizes eight steps in the

development, testing, and dissemination of interventions:

� Step 1: Theoretically and clinically informed construction, refinement, and

manualization� Step 2: Initial efficacy trial to establish potential for benefit� Step 3: Single-case applications in practice setting, with progressive

adaptations� Step 4: Initial effectiveness test, modest in scope and cost� Step 5: Full test of effectiveness under everyday practice conditions� Step 6: Effectiveness of treatment variations, effective ingredients, mod-

erators, mediators, and costs� Step 7: Assessment of goodness-of-fit within the host organization� Step 8: Dissemination, quality, and long-term sustainability within new

organizations

Current status of the community-based interventions discussed herein has not

necessarily followed this set of steps. It is possible to array them to determine the

next steps that would most systematically advance the current knowledge base

and provide the greatest potential for moving forward.

MST and TFC have come closest to following these ideal-type steps. MST has

completed steps 1 to 4. Currently, it is working on elements of steps 5 to 8.

Findings for youth with mental health problems also suggest the potential need to

retrace the steps and conduct smaller-scale evaluations (akin to steps 3 and 4)

that focus on protocol modifications for this population. TFC also has completed

the steps in a systematic fashion. Like MST, TFC has completed steps 1 to

4 and is currently engaged in a range of activities covered under steps 5 to 8. For

each of these interventions, there seems to be a somewhat premature leap toward

step 8, without adequate attention to issues of fit and effectiveness under

everyday conditions that may be crucial for long-term effectiveness and use of

these interventions.

Case management is a bit harder to characterize on this process. In many

ways, the research base leaped from a theoretical handling of step 1 to ran-

domized trials that would fall within step 4. Current efforts seem to be continuing

within steps 4 and 5 (tests of effectiveness under everyday practice conditions).


The widespread use of case management, in the absence of a controlled

development and dissemination plan, makes it difficult to retrospectively conduct

the steps sequentially. Currently, it seems that case management is ready for

research in step 6—effectiveness of treatment variations, effective ingredients,

core potencies, moderators, mediators, and costs.

Wraparound also is somewhat complex. Its evaluation seems to have begun

at step 3 (single-case applications), with iterative efforts at developing the theo-

retical underpinnings and manualization (step 1). Subsequent efforts have

spanned the remaining steps, but without apparent coherent strategy. It seems

that wraparound would benefit by using recent work in manualization and opera-

tionalization to conduct studies at step 5 (full test of effectiveness under everyday

practice conditions).

The auxiliary and supportive services would benefit by starting fairly early in

the process. Family education and support and mentoring have relatively strong

theoretical foundations and evidence in adjacent population groups. Each would

benefit from targeted work (probably at step 3 or 4—single-case application or

initial effectiveness tests) within systems of care. Respite care has the least

developed evidence base. It would benefit from initiation of a rigorous program

of research, beginning with step 1.

Overall, the evidence base for community-based settings is promising and

growing. Some interventions (ie, MST, TFC, case management) have relatively

well-developed evidence. Some of the most widely used services (eg, group

homes, wraparound) have underdeveloped evidence bases, however. The danger

for all of these interventions seems to be a leap toward dissemination without

adequate research on factors that will make such widespread application feasible

and successful. The challenge for the field is to develop the evidence systemati-

cally while simultaneously responding to the challenges of service delivery,

research, and the rapidly shifting landscape of policies and practices that impact

provision of children’s mental health services.

References

[1] Stroul B, Friedman R. A system of care for children and youth with severe emotional dis-

turbances (revised edition). Washington, DC: Georgetown University Child Development

Center, CASSP Technical Assistance Center; 1986.

[2] Bronfenbrenner U. The ecology of human development: experiments by nature and design.

Cambridge: Harvard University Press; 1979.

[3] Hobbs N. The troubled and troubling child. San Francisco: Jossey-Bass; 1982.

[4] Munger R. The ecology of troubled children. Cambridge: Brookline Books; 1998.

[5] Farmer E. Issues confronting effective services in systems of care. Child Youth Serv Rev 2000;

22:627–50.

[6] Stroul B. Systems of care in children with severe emotional disturbance: what are the results.

Washington, DC: Georgetown University Child Development Center, CASSP Technical Cen-

ter; 1993.

[7] England M, Cole R. Building systems of care for youth with serious mental illness. Hosp

Community Psychiatry 1992;43(6):630–3.


[8] Knitzer J. Unclaimed children. Washington, DC: Children’s Defense Fund; 1982.

[9] Stroul B, Friedman R. The system of care concept and philosophy. In: Stroul B, Friedman R,

editors. Children’s mental health: creating systems of care in a changing society. Baltimore (MD):

Paul H. Brookes; 1996. p. 3–21.

[10] VanDenBerg J. History of the wraparound process. In: Burns B, Goldman S, editors. Promis-

ing practices in wraparound for children with severe emotional disorders and their families.

Rockville: Center for Mental Health Services— Child, Adolescent, and Family Branch; 1999.

p. 93–118.

[11] Burns B, Friedman R. Examining the research base for child mental health services and policy.

J Ment Health Adm 1990;17:87–98.

[12] Bickman L, Guthrie P, Foster E, Lambert EW, Summerfelt WT, Breda CS, et al. Evaluating

managed mental health services: the Fort Bragg experiment. New York: Plenum Press; 1995.

[13] Burchard J, Burchard S, Sewell R, VanDenBerg J. One kid at a time: evaluative case studies

and description of the Alaska Youth Initiative Demonstration Project. Juneau (AK): State of

Alaska, Division of Mental Health and Mental Retardation; 1993.

[14] Chamberlain P. Family connections: a treatment foster care model for adolescents with delin-

quency. Eugene (OR): Castalia Publishing Company; 1994.

[15] Evans ME, Huz S, McNulty T, Banks SM. Child, family, and system outcomes of intensive

case management in New York State. Psychiatr Q 1996;67(4):273–86.

[16] Henggeler S, Rodick J, Borduin C, Hanson C, Watson S, Urey J. Multisystemic treatment of

juvenile offenders: effects on adolescent behavior and family interaction. Dev Psychol 1986;22:

132–41.

[17] Pecora P, Fraser M, Nelson K, McCroskey J, Meezan W. Evaluating family-based services.

New York: Aldine de Gruyter; 1995.

[18] Hoagwood K, Jensen P, Petti T, Burns B. Outcomes of mental health care for children and

adolescents. I. A comprehensive conceptual model. J Am Acad Child Adolesc Psychiatry 1996;

35:1055–63.

[19] Farmer T, Farmer E. Developmental science, systems of care, and prevention of emotional and

behavioral problems in youth. Am J Orthopsychiatry 2001;71(2):171–81.

[20] Isaacs-Shockley M, Cross T, Bazron B, Dennis K, Benjamin M. Framework for a culturally

competent system of care. In: Children’s mental health: creating systems of care in a changing

society. Baltimore (MD): Paul H. Brookes; 1996. p. 23–40.

[21] Friedman LM, Furberg CD, DeMets DL. Fundamentals of clinical trials. 3rd edition. St. Louis:

Mosby Publishing; 1996.

[22] Pockock S. Clinical trials: a practical approach. New York: John Wiley & Sons; 1983.

[23] Weisz JR. Lab-clinic differences and what we can do about them. I. The clinic-based treatment

development model. Clinical Child Psychology Newsletter 2000;15(1):1–11.

[24] Hoagwood K, Burns B, Weisz J. A profitable conjunction: from science to service in children’s

mental health. In: Burns BJ, Hoagwood K, editors. Community treatment for youth: evidence-

based interventions for severe emotional and behavioral disorders. New York: Oxford Univer-

sity Press; 2002. p. 327–38.

[25] Lourie I. A history of community child mental health. In: Pumariega A, Winters N, editors. The

handbook of child and adolescent system of care: the new community psychiatry. San Fran-

cisco: Jossey-Bass; 2003. p. 1–16.

[26] Stroul B. Systems of care: a framework for children’s mental health care. In: Pumariega A,

Winters N, editors. The handbook of child and adolescent systems of care: the new community

psychiatry. San Francisco: Jossey-Bass; 2003. p. 17–34.

[27] Burns B, Farmer E, Angold A, Costello E, Behar L. A randomized trial of case management

for youths with serious emotional disturbance. J Clin Child Psychol 1996;25(4):476–86.

[28] Bickman L, Noser K, Summerfelt W. Long-term effects of a system of care on children and

adolescents. J Behav Health Serv Res 1999;26:185–202.

[29] Friedman R, Burns B. The evaluation of the Fort Bragg demonstration project: an alternative

interpretation of the findings. J Ment Health Adm 1996;23:128–36.


[30] Kazdin A. Evidence-based treatments: challenges and priorities for practice and research. Child

Adolesc Psychiatric Clin North Am 2004;13.

[31] Costello EJ, Messer SC, Reinherz HZ, Cohen P, Bird HR. The prevalence of serious emotional

disturbance: a re-analysis of community studies. Journal of Child and Family Studies 1998;7:

411–32.

[32] Brestan E, Eyberg S. Effective psychosocial treatments of conduct-disordered children and

adolescents: 29 years, 82 studies, and 5,272 kids. J Clin Child Psychol 1998;27:180–9.

[33] Burns B, Hoagwood K, Mrazek P. Effective treatment for mental disorders in children and

adolescents. Clin Child Fam Psychol Rev 1999;2(4):199–254.

[34] Kazdin A, Weisz J. Identifying and developing empirically supported child and adolescent

treatments. J Consult Clin Psychol 1998;66:19–36.

[35] US Department of Health and Human Services. Mental health: a report of the surgeon gen-

eral. Rockville: US Department of Health and Human Services, Substance Abuse and Mental

Health Services Administration, Center for Mental Health Services, National Institutes of

Health, National Institute of Mental Health; 1999.

[36] Chambless D, Hollon S. Defining empirically supported therapies. J Consult Clin Psychol 1998;

66:7–18.

[37] Kazdin A. The meanings and measurement of clinical significance. J Consult Clin Psychol

1999;67(3):332–9.

[38] Lonigan C, Elbert J, Johnson S. Empirically supported psychosocial interventions for children:

an overview. J Clin Child Psychol 1998;27:138–45.

[39] Henegan A, Horwitz S, Leventhal J. Evaluation of intensive family preservation programs:

a methodological review. Pediatrics 1997;97:535–42.

[40] Rones M, Hoagwood K. School-based mental health services: a research review. Clin Child

Fam Psychol Rev 2000;3:223–41.

[41] Drake R, Rosenberg S, Teague G, Bartels S, Torrey W. Fundamental principles of evidence-

based medicine applied to mental health care. Psychiatr Clin North Am 2003;26(4):811–20.

[42] Schoenwald S, Sheidow A, Letourneau E, Liao J. Transportability of multisystemic therapy:

evidence for multilevel influences. Ment Health Serv Res 2003;5(4):223–39.

[43] Breland-Noble A, Farmer E, Dubs M, Potter E, Burns B. Mental health and other service

use by youth in therapeutic foster care and group homes. Journal of Child and Family Studies,

in press.

[44] Burns BJ, Hoagwood K. Community treatment for youth: evidence-based interventions for

severe emotional and behavioral disorders. New York: Oxford University Press; 2002.

[45] Farmer E, Compton S, Burns B, Robertson E. Review of the evidence base for treatment of child-

hood psychopathology: externalizing disorders. J Consult Clin Psychol 2002;70:1267–302.

[46] Hawkins R, Almeida M, Fabry B, Reitz A. A scale to measure restrictiveness of living environ-

ments for troubled children and youth. Hosp Community Psychiatry 1992;43(1):54–8.

[47] Meadowcroft P, Thomlison B, Chamberlain P. Treatment foster care services: a research agenda

for child welfare. Child Welfare 1994;73(5):565–81.

[48] Rivera V, Kutash K. Family support services and family support groups. In: Rivera V, Kutash

K, editors. Components of a system of care: what does the research say? Tampa: Research and

Training Center for Children’s Mental Health, Florida Mental Health Institute, University of

South Florida; 1994. p. 141–63.

[49] Chamberlain P. Treatment foster care. In: Burns B, Hoagwood K, editors. Community treatment

for youth: evidence-based interventions for severe emotional and behavioral disorders. New

York: Oxford University Press; 2002. p. 117–38.

[50] Stroul B, Goldman S. Community-based service approaches: home-based services and thera-

peutic foster care. In: Children’s mental health: creating systems of care in a changing society.

Baltimore (MD): Paul H. Brookes; 1996. p. 453–73.

[51] Farmer E, Wagner H, Burns B, Richards J. Treatment foster care in a system of care: se-

quences and correlates of residential placements. Journal of Child and Family Studies 2003;

12(1):11–25.


[52] Farmer E, Burns B, Dubs M, Thompson S. Assessing conformity to standards for treatment

foster care. Journal of Emotional and Behavioral Disorders 2002;10(4):213–22.

[53] Chamberlain P, Smith D. Antisocial behavior in children and adolescents: the Oregon Multi-

dimensional Treatment Foster Care model. In: Evidence-based psychotherapies for children and

adolescents. New York: Guilford Press; 2003. p. 282–300.

[54] Chamberlain P, Fisher P, Moore K. Multidimensional treatment foster care: applications of

the OSLC intervention model to high-risk youth and their families. In: Reid J, Patterson G,

editors. Antisocial behavior in children and adolescents: a developmental analysis and model

for intervention. Washington, DC: American Psychological Association; 2002. p. 203–18.

[55] Chamberlain P. Multidimensional Treatment Foster Care program components and principles

of practice. In: Treating chronic juvenile offenders: advances made through the Oregon Multi-

dimensional Treatment Foster Care model, law and public policy. Washington, DC: American

Psychological Association; 2003. p. 69–93.

[56] Dishion T, Patterson G. The timing and severity of antisocial behavior: three hypotheses within

an ecological framework. In: Stoff D, Breiling J, Maser J, editors. Handbook of antisocial

behavior. New York: John Wiley & Sons; 1997. p. 205–17.

[57] Patterson G, Gullion M. Living with children: new methods for parents and teachers. Cham-

paign (IL): Research Press; 1968.

[58] Patterson G, Forgatch M. Parents and adolescents living together: Part 1. Eugene (OR): Castalia

Publishing Company; 1987.

[59] Reid J, Eddy J. The prevention of antisocial behavior: some considerations in the search for

effective interventions. In: Stoff D, Breiling J, Maser J, editors. Handbook of antisocial behav-

ior. New York: John Wiley & Sons; 1997. p. 343–56.

[60] Chamberlain P, Reid J. Using a specialized foster care community treatment model for children

and adolescents leaving the state mental hospital. J Community Psychol 1991;19:266–76.

[61] Chamberlain P, Weinrott M. Specialized foster care: treating seriously emotionally disturbed

children. Child Today 1990;1:24–7.

[62] Moore K, Sprengelmeyer P, Chamberlain P. Community-based treatment for adjudicated delin-

quents: the Oregon Social Learning Center’s ‘‘Monitor’’ Multidimensional Treatment Foster

Care program. Residential Treatment for Children and Youth 2001;18(3):87–97.

[63] Chamberlain P, Ray J, Moore K. Characteristics of residential care for adolescent offenders:

a comparison of assumptions and practices in two models. Journal of Child and Family Studies

1996;5(3):285–97.

[64] Chamberlain P, Reid J. Comparison of two community alternatives to incarceration for chronic

juvenile offenders. J Consult Clin Psychol 1998;4:624–33.

[65] Chamberlain P. Antisocial behavior and delinquency in girls. In: Treating chronic juvenile

offenders: advances made through the Oregon Multidimensional Treatment Foster Care model.

Washington, DC: American Psychological Association; 2003. p. 109–27.

[66] Smith D, Stormshak E, Chamberlain P, Bridges-Whaley R. Placement disruption in treatment

foster care. Journal of Emotional and Behavioral Disorders 2001;9(3):200–5.

[67] Chamberlain P, Reid JB. Differences in risk factors and adjustment for male and female

delinquents in treatment foster care. Journal of Child and Family Studies 1994;3(1):23–39.

[68] Evans M, Armstrong M, Dollard N, Kuppinger A, Huz S, Wood V. Development and evalua-

tion of treatment foster care and family-centered intensive case management in New York.

Journal of Emotional and Behavioral Disorders 1994;2(4):228–39.

[69] Evans M, Armstrong M, Kuppinger A, Huz S, Johnson S. A randomized trial of family-

centered intensive case management and family-based treatment: final report. Tampa: Univer-

sity of South Florida; 1998.

[70] Evans M, Armstrong M, Kuppinger A, Huz S, McNulty T. Preliminary outcomes of an ex-

perimental study comparing treatment foster care and family-centered intensive case manage-

ment. In: Epstein M, Kutash K, Duchnowski A, editors. Outcomes for children and youth with

behavioral and emotional problems and their families: programs and evaluation best practices.

Austin (TX): Pro-Ed; 1998. p. 543–80.


[71] Clark H, Prange M, Lee B, Steinhardt-Stewart E, Barrett-McDonald B, Boyd L. An individu-

alized wraparound process for children in foster care with emotional/behavioral disturbances:

follow-up findings and implications from a controlled study. In: Epstein M, Kutash K, Duch-

nowski A, editors. Outcomes for children and youth with emotional and behavioral disorders and

their families: programs and evaluation best practices. Austin (TX): Pro-Ed; 1998. p. 513–42.

[72] Chamberlain P, Moore K. Chaos and trauma in the lives of adolescent females with antisocial

behavior and delinquency. In: Trauma and juvenile delinquency: theory, research, and inter-

ventions. Binghamton (NY): Haworth Press; 2002. p. 79–108.

[73] Chamberlain P. Some challenges of implementing science-based interventions in the real world.

In: Treating chronic juvenile offenders: advances made through the Oregon Multidimensional

Treatment Foster Care model, law and public policy. Washington, DC: American Psychological

Association; 2003. p. 141–9.

[74] Chamberlain P. An application of multidimensional treatment foster care for early intervention.

In: Treating chronic juvenile offenders: advances made through the Oregon Multidimensional

Treatment Foster Care model, law and public policy. Washington, DC: American Psychological

Association; 2003. p. 129–40.

[75] Fisher P, Gunnar M, Chamberlain P, Reid J. Preventive intervention for maltreated preschool

children: impact on children’s behavior, neuroendocrine activity, and foster parent functioning.

J Am Acad Child Adolesc Psychiatry 2000;39(11):1356–64.

[76] Friman P, Osgood D, Smith G, Shanahan D, Thompson RW, Larzelere R, et al. A longitudinal

evaluation of prevalent negative beliefs about residential placement for troubled adolescents.

J Abnorm Child Psychol 1996;24(3):299–324.

[77] Wolf M, Phillips E, Fixsen D, Braukmann CJ, Kirigin KA, Willner AG, et al. The achievement

place: the teaching-family model. Child Care Q 1976;5:92–105.

[78] Phillips E, Phillips E, Fixsen D, Wolf M. The teaching family handbook. Lawrence (KS):

University of Kansas Printing Service; 1974.

[79] Solnick J, Braukmann C, Bedlington M, Kirigin K, Wolf M. The relationship between parent-

youth interaction and delinquency in group homes. J Abnorm Child Psychol 1981;9:107–19.

[80] Kirigin K, Braukmann C, Atwater J, Wolf M. An evaluation of the teaching-family (achieve-

ment place) group homes for juvenile offenders. J Appl Behav Anal 1982;15:1–16.

[81] Roose A. Treatment outcomes in an adolescent residential treatment center. Dallas: University

of Texas, Health Sciences Center; 1987.

[82] Fixsen D, Blase K. Creating new realities: program development and dissemination. J Appl

Behav Anal 1993;26(4):597–615.

[83] Furst D, Boever W, Cohen J, Dowd T, Daly D, Criste T. Implementation of the boys town

psychoeducational treatment model in a children’s psychiatric hospital. Hosp Community Psy-

chiatry 1993;44(9):863–8.

[84] Baez A. Approach to fostering self-cohesion and developmental progression in female ado-

lescent group home residents. Child Adolesc Social Work J 2003;20(5):351–73.

[85] Altshuler S, Poertner J. The child health and illness profile, adolescent edition: assessing well-

being in group homes or institutions. Child Welfare 2002;81(3):495–513.

[86] LeSure-Lester G. Relation between empathy and aggression and behavior compliance among

abused group home youth. Child Psychiatry Hum Dev 2000;31(2):153–61.

[87] Rubenstein J, Armentrout J, Levin S, Herald D. The parent therapist program: alternative

care for emotionally disturbed children. Am J Orthopsychiatry 1978;48:654–62.

[88] Breland-Noble A, Elbogen E, Farmer E, Dubs M, Wagner H, Burns B. The use of psychotropic

medications by youth in therapeutic foster care and group homes. Psychiatr Serv 2004;55:706–8.

[89] Dishion T, McCord J, Poulin J. When interventions harm: peer groups and problem behavior.

Am Psychol 1999;54:755–64.

[90] Hoagwood K, Burns B, Kiser L, Ringeisen H, Schoenwald S. Evidence-based practice in

child and adolescent mental health services. Psychiatr Serv 2001;52:1179–89.

[91] Henggeler S, Schoenwald S, Pickrel S. Multisystemic therapy: bridging the gap between

university- and community-based treatment. J Consult Clin Psychol 1995;63(5):709–17.

[92] Huey S, Henggeler S, Brondino M, Pickrel S. Mechanisms of change in multisystemic therapy:


reducing delinquent behavior through therapist adherence and improved family and peer func-

tioning. J Consult Clin Psychol 2000;68(3):451–67.

[93] Schoenwald S, Rowland M. Multisystemic therapy. In: Burns B, Hoagwood K, editors. Com-

munity treatment for youth: evidence-based interventions for severe emotional and behavioral

disorders. New York: Oxford University Press; 2002. p. 91–116.

[94] Henggeler S, Melton G, Brondino M, Scherer D, Hanley J. Multisystemic therapy with violent

and chronic juvenile offenders and their families: the role of treatment fidelity in successful

dissemination. J Consult Clin Psychol 1997;65:821–33.

[95] Henggeler S, Schoenwald S, Borduin C, Rowland M, Cunningham P. Multisystemic treatment

of antisocial behavior in children and adolescents. New York: Guilford Press; 1998.

[96] Burns B, Schoenwald S, Burchard J, Faw L, Santos A. Comprehensive community-based

interventions for youth with severe emotional disorders: multisystemic therapy and the wrap-

around process. Journal of Child and Family Studies 2000;9(3):283–314.

[97] Bourduin C, Henggeler S, Blaske D, Stein T. Multisystemic treatment of adolescent sexual

offenders. Int J Offender Ther Comp Criminol 1990;35:105–14.

[98] Bourduin C, Mann B, Cone L, Henggeler SW, Fucci BR, Blaske DM, et al. Multisystemic

treatment of serious juvenile offenders: long-term prevention of criminology and violence.

J Consult Clin Psychol 1995;63:569–78.

[99] Henggeler S, Melton G, Smith L. Family preservation using multisystemic therapy: an effective

alternative to incarcerating serious juvenile offenders. J Consult Clin Psychol 1992;60:953–61.

[100] Henggeler S, Melton G, Smith L, Schoenwald S, Handley J. Family preservation using multi-

systemic treatment: long-term follow-up to a clinical trial with serious juvenile offenders.

Journal of Child and Family Studies 1993;2:283–93.

[101] Henggeler S, Pickrel S, Brondino M. Multisystemic treatment of substance-abusing and

-dependent delinquents: outcomes, treatment fidelity, and transportability. Ment Health Serv

Res 2000;1:171–84.

[102] Henggeler S, Rowland M, Halliday-Boykins C, Sheidow AJ, Ward DM, Randall J, et al. One-

year follow-up of multisystemic therapy as an alternative to the hospitalization of youths in

psychiatric crisis. J Am Acad Child Adolesc Psychiatry 2003;42(5):543–51.

[103] Schoenwald S, Ward D, Henggeler S, Rowland M. Multisystemic therapy versus hospitaliza-

tion for crisis stabilization of youth: placement outcomes 4 months postreferral. Ment Health

Serv Res 2000;2:3–12.

[104] Henggeler S. Commentary on Ellis et al: Adapting multisystemic therapy for challenging

clinical problems of children and adolescents. J Pediatr Psychol 2003;28(4):295–7.

[105] Henggeler S, Schoenwald S, Liao J, Letourneau E, Edwards D. Transporting efficacious treat-

ments to field settings: the link between supervisory practices and therapist fidelity in MST

programs. J Clin Child Adolesc Psychol 2002;31:155–67.

[106] Austin C. Case management in long-term care: options and opportunities. Health Soc Work

1983;8(1):16–30.

[107] Intagliata J. Improving the quality of community care for the chronically mentally disabled:

the role of case management. In: Case management and social work practice. New York: Long-

man Publishing; 1992. p. 25–55.

[108] Solomon P. The efficacy of case management services for severely mentally disabled adults.

Community Ment Health J 1992;28:163–80.

[109] Stroul B. Case management in a system of care. In: Friesen B, Poertner J, editors. From case

management to service coordination for children with emotional, behavioral, or mental dis-

orders: building on family strengths. Baltimore (MD): Paul H. Brooks; 1995. p. 3–25.

[110] Weil M. Key components in providing efficient and effective services. In: Weil M, Karls J,

editors. Case management in human service practice: a systematic approach to mobilizing

resources for clients. San Francisco: Jossey-Bass; 1985. p. 29–71.

[111] Burns B, Gwaltney E, Bishop G. Case management research: issues and directions. In: Friesen

B, Poertner J, editors. From case management to service coordination for children with emo-

tional, behavioral, or mental disorders: building on family strengths. Baltimore (MD): Paul H.

Brookes; 1995. p. 353–72.


[112] McFarlane W. Multiple family groups and the treatment of schizophrenia. In: Handbook of

schizophrenia. Amsterdam: Elsevier; 1990. p. 167–89.

[113] Godley M, Godley S, Dennis M, Funk R, Passetti L. Preliminary outcomes from the assertive

continuing care experiment for adolescents discharged from residential treatment. J Subst

Abuse Treat 2002;23(1):21–32.

[114] Evans M, Boothroyd R, Armstrong M, Greenbaum P, Brown E, Kuppinger A. An experimental

study of the effectiveness of intensive in-home crisis services for children and their families:

program outcomes. Journal of Emotional and Behavioral Disorders 2003;11(2):93–104.

[115] Jansson L, Svikis D, Beilenson P. Effectiveness of child case management services for offspring

of drug-dependent women. Subst Use Misuse 2003;38(14):1933–52.

[116] Johnson R, Botwinick G, Sell R, Martinez J, Siciliano C, Friedman LP, et al. The utilization of

treatment and case management services by HIV-infected youth. J Adolesc Health 2003;33S:

31–8.

[117] Jensen C, Turner W, Amero S, Johnson A, Werrbach G. Predicting resource utilization by

children with serious emotional disturbance and their families. Journal of Child and Family

Studies 2002;11(3):361–71.

[118] Werrbach G. Providing intensive child case management services: how do case managers spend

their time. Child Adolesc Social Work J 2002;19(5):473–86.

[119] Saunders R, Heflinger C. Access to and patterns of use of behavioral health services among

children and adolescents in TennCare. Psychiatr Serv 2003;54:1364–71.

[120] Burns B, Goldman S. Promising practices in wraparound for children with serious emotional

disturbance and their families. Rockville: Center for Mental Health Services—Child, Adoles-

cent, and Family Branch; 1999.

[121] Burchard J, Bruns E, Burchard S. The wraparound approach. In: Burns B, Hoagwood K,

editors. Community treatment for youth: evidence-based interventions for severe emotional

and behavioral disorders. New York: Oxford University Press; 2002. p. 69–90.

[122] Goldman S. The conceptual framework for wraparound. In: Burns B, Goldman S, editors.

Promising practices in wraparound for children with severe emotional disorders and their fam-

ilies. Rockville: Center for Mental Health Services—Child, Adolescent, and Family Branch;

1999. p. 9–14.

[123] Bickman L, Smith C, Lambert E, Andrade A. Evaluation of a congressionally mandated wrap-

around demonstration. Journal of Child and Family Studies 2003;12(2):135–56.

[124] Hyde KL, Burchard JD, Woodworth K. Wrapping services in an urban setting. Journal of Child

and Family Studies 1996;5(1):67–82.

[125] Myaard M, Crawford C, Jackson M, Alessi G. Applying behavior analysis within the wrap-

around process: a multiple baseline study. Journal of Emotional and Behavioral Disorders 2000;

8:216–29.

[126] Clarke R, Schaefer M, Burchard J, Welkowitz J. Wrapping community-based mental health

services around children with a severe behavioral disorder: an evaluation of project wrap-

around. Journal of Child and Family Studies 1992;1:241–61.

[127] Yoe J, Santarcangelo S, Atkins M, Burchard J. Wraparound care in Vermont: program devel-

opment, implementation, and evaluation of a statewide system of individualized services. Jour-

nal of Child and Family Studies 1996;5(1):23–37.

[128] Bruns E, Burchard J, Yoe J. Evaluating the Vermont system of care: outcomes associated with

community-based wraparound services. Journal of Child and Family Studies 1995;4(3):321–39.

[129] Illback R, Neill T, Call J, Andis P. Description and formative evaluation of the Kentucky

IMPACT program for children with serious emotional disturbance. Special Services in the

Schools 1993;7:87–109.

[130] Eber L, Osuch R. Bringing the wraparound approach to school: a model for inclusion. Pre-

sented at: the 7th annual research conference proceedings. Tampa, February 28–March 2, 1995.

[131] Hyde K, Woodworth K, Jordan K, Burchard J. Wrapping services in an urban setting: outcomes

of service reform in Baltimore. Presented at the 7th annual research conference proceedings.

Tampa, February 28–March 2, 1995.


[132] Kamradt B. The 25 Kid Project: how Milwaukee utilized a pilot project to achieve buy-in

among stakeholders in changing the system of care for children with severe emotional prob-

lems. Presented to the Washington Business Group on Health. 1996.

[133] Eber L, Sugai G, Smith C, Scott T. Wraparound and positive behavioral interventions and

supports in the schools. Journal of Emotional and Behavioral Disorders 2002;10:171–80.

[134] Cook-Morales V. The home-school-agency triangle. In: Marsh D, Fristad M, editors. Handbook

of serious emotional disturbance in children and adolescents. New York: John Wiley & Sons;

2002. p. 392–411.

[135] McGinty K, McCammon S, Koeppen V. The complexities of implementing a wraparound

approach to service provision: a view from the field. In: Dosser D, Handron D, editors. Child

mental health: exploring systems of care in the new millennium. New York: Haworth Press;

2001. p. 95–110.

[136] Morrison-Velasco S. The role of empathy in the wraparound model. In: Breggin P, Breggin G,

editors. Dimensions of empathic therapy. New York: Springer Publishing; 2002. p. 79–88.

[137] Epstein M, Jayanthi M, McKelvey J, Frankenberry E, Hardy R, Dennis K, et al. Reliability of

the wraparound observation form: an instrument to measure the wraparound process. Journal of

Child and Family Studies 1998;7(2):161–70.

[138] Nordness P, Epstein M. Reliability of the wraparound observation form (second version): an

instrument designed to assess the fidelity of the wraparound approach. Ment Health Serv Res

2003;5(2):89–96.

[139] Toffalo D. An investigation of treatment integrity and outcomes in wraparound services. J Child

Fam Stud 2001;9:341–61.

[140] Comer E, Fraser M. Evaluation of six family-support programs: are they effective? Fam Soc

1998;79(2):134–48.

[141] Ireys H, DeVet K, Sakwa D. Family support and education. In: Burns B, Hoagwood K, editors.

Community treatment for youth: evidence-based interventions for severe emotional and behav-

ioral disorders. New York: Oxford University Press; 2002. p. 154–76.

[142] Friesen B, Koroloff N. Family-centered services: implications for mental health administration

and research. J Ment Health Adm 1990;17:13–25.

[143] Patterson G, Reid J, Dishion T. Antisocial boys. A social interactional approach, volume 4.

Eugene (OR): Castalia; 1992.

[144] Bickman L, Heflinger C, Northrup D, Sonnichsen S, Schilling S. Long term outcomes to family

caregiver empowerment. Journal of Child and Family Studies 1998;7:269–82.

[145] Ireys H, Chernoff R, Stein R, DeVet K, Silver E. Outcomes of community-based family-to-

support: lessons learned from a decade of randomized trials. Children’s Services: Social Policy,

Research, and Practice 2001;4(4):203–16.

[146] Goodson B, Layzer J, St. Pierre R, Bernstein L, Lopez M. Effectiveness of a comprehensive,

five-year family support program for low-income children and their families: findings from the

comprehensive child development program. Early Child Res Q 2000;15:5–39.

[147] Vance J. Mentoring to facilitate resiliency in high-risk youth. In: Burns B, Hoagwood K,

editors. Community treatment for youth: evidence-based interventions for severe emotional

and behavioral disorders. New York: Oxford University Press; 2002. p. 139–53.

[148] Save the Children. Overview of the Save the Children’s national mentoring database. Available

at: www.savethechildren.org/mentors2d.html. Accessed October 2, 1999.

[149] Kashani J, Reid J, Rosenberg T. Levels of hopelessness in children and adolescents: a devel-

opmental perspective. J Consult Clin Psychol 1989;57:469–99.

[150] Rhodes A, Goering P. Gender differences in the use of outpatient mental health services. J Ment

Health Adm 1994;21(4):338–46.

[151] Tierney J, Grossman J, Resch N. Making a difference: an impact study of Big Brothers/ Big

Sisters. Philadelphia: Public/Private Ventures; 1995.

[152] Keating L, Tomishima M, Foster S, Alessandri M. The effects of a mentoring program on

at-risk youth. Adolescence 2002;37(148):717–34.

[153] DuBois D, Holloway B, Valentine J, Cooper H. Effectiveness of mentoring programs for

youth: a meta-analytic review. Am J Community Psychiatry 2002;30(2):157–97.

http:\\www.savethechildren.org\mentors2d.html

http:\\www.savethechildren.org\mentors2d.html


[154] Warren R, Cohen S. Respite care. Rehabil Lit 1985;46:66–71.

[155] Cohen S. Supporting families through respite care. Rehabil Lit 1982;43:7–11.

[156] Ferguson J, Lindsay S. The respite care co-op program: professionally guided parent self-help.

In: Salisbury C, Intagliata J, editors. Respite care: support for persons with developmental

disabilities and their families. Baltimore (MD): Paul H. Brookes; 1986. p. 143–66.

[157] Rimmerman A. Provision of respite care for children with developmental disabilities: changes

in maternal stress and coping over time. Ment Retard 1989;27(2):99–103.

[158] Sherman B. Impact of home-based respite care on families of children with chronic illnesses.

Children’s Health Care 1995;24:33–45.

[159] Bruns E, Burchard J. Impact of respite care services for families with children experiencing

emotional and behavioral problems. Children’s Services: Social Policy, Research, and Practice

2000;3(1):39–61.

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