For over 20 years, communities throughout the country have mobilized to create “systems of care” (SOCs), which are coordinated efforts to improve the level and quality of services and supports for children with mental health problems and their families (e.g., Cook and Kilmer 2004; Holden and Brannan 2002; Huang et al. 2005; Pumariega and Winters 2003; Stroul and Blau 2008; Stroul and Friedman 1986b). These efforts provide opportunities for community psychologists to conduct applied research and engage in community change efforts. Furthermore, with a growing emphasis on interventions with younger children, and the advancement of a public health approach in the development of SOCs (Miles et al. 2010), there is an even greater alignment between the values and principles of community psychology (CP) and those of SOCs.

Although the federal efforts to create SOCs have, as a major focus, the treatment of children with severe emotional disturbances (SED), and much effort within SOCs is oriented toward the delivery of services designed to ameliorate problems associated with emotional problems, a key aspect of the creation of SOCs is change in the community systems that provide support for families, without which SOCs have little chance of being sustainable. This Special Issue of the American Journal of Community Psychology focuses on system change within SOCs, and opportunities available for community psychologists (CPs) and others to contribute to those efforts. As an introduction to this Special Issue, this paper will describe briefly the history of the SOC initiatives; detail the values, principles, and practices of SOCs; highlight the consistencies between the SOC philosophy and the core values and practices of community psychology (CP); and identify opportunities and roles for CPs in SOCs in applied research and evaluation, community practice, and training.

A Brief History of Systems of Care

Historically, many children and youth with SED have not received needed mental health services, with many receiving inappropriate, inadequate, or overly restrictive services (Burns et al. 1995; Joint Commission on the Mental Health of Children 1969; Knitzer 1982; President’s Commission on Mental Health 1978; U.S. Department of Health and Human Services 1999). These children typically experience difficulties across several different settings (e.g., school, home) and types of functioning (e.g., peer relationships, interactions with authorities), and are likely to require involvement from multiple systems, such as mental health, education, special education, child welfare, health, substance abuse, and juvenile justice (Stroul and Friedman 1986b).

Recent estimates suggest that 12 % of youth have a SED (Costello et al. 2006), yet it is estimated that only 20–25 % receive the services and supports they need (Kataoka et al. 2002). Furthermore, ineffective, inadequate, or inappropriate services for youth with mental health issues are associated with a range of negative consequences, such as school drop out and involvement with child welfare and juvenile justice systems (Institute of Medicine 2005). Consequently, communities need to develop appropriate systems to address the mental health needs of children, youth, and families.

To increase the levels of support provided to these children, the Child and Adolescent Service System Program (CASSP) was created (see Stroul and Friedman 1986b), followed by the Child Mental Health Initiative (CMHI) of the Substance Abuse and Mental Health Services Administration (SAMHSA), to help create systems of care for children and youth with SED and their families (see, e.g., Center for Mental Health Services [CMHS] 1997, 1998, 1999, 2003). Systems of care have been based on Stroul and Friedman’s seminal monograph, A system of care for children and youth with SED, in which they defined a “system of care” (SOC) as: “a comprehensive spectrum of mental health and other necessary services which are organized into a coordinated network to meet the multiple and changing needs of children and adolescents with SED and their families” (1986a, p. 3). Since this original definition was proposed, however, some minor changes have been proposed (e.g., Hodges et al. 2006, 2010; Pires 2002; Stroul 2002; Stroul and Friedman 1986b).

Since the CMHI began in 1993, SAMHSA has awarded 173 grants in 50 states, the District of Columbia, and 21 Tribal communities totaling over $1.63 billion to support creation of SOCs, making it the largest single mental health initiative in the country. Largely as a result of this initiative, the values and practices of SOCs have been adopted in an estimated 800+ sites, serving over 100,000 children and families (Bruns et al. 2011). These principles and practices (i.e., the wraparound practice model) are increasingly being used to address a wide range of problems experienced by children and families, and a growing number of states have adopted them statewide (Bruns and Walker 2011a).

On the basis of the size and scope of the initiative alone, it is important that community psychologists are aware of the SOC approach and the ways that they might contribute to and utilize it to strengthen their communities. In addition, many community stakeholders, collaborative decision-making bodies, and administrators struggle to conceptualize systems-level issues in their mental health planning and programming. However, system change is an area in which CPs have clear strengths, and recent works by CPs have highlighted the need to attend to the boundaries and function of SOCs, engage communities in systems-oriented thinking, and extend the emphases in planning, practice, and policy beyond formal service delivery (Cook and Kilmer 2010a, b; Foster-Fishman and Droege 2010). In addition, CPs might help communities in translating SOC concepts into concrete actions or, put another way, “moving from principles to practice” (Kilmer et al. 2010).

System of Care Values, Principles, and Practices

The SOC approach does not prescribe specific steps and practices, but instead provides “a philosophy about the way in which services should be delivered to children and their families” (Stroul and Friedman 1986b, p. xxii), with the actual components and configuration varying across communities. As Stroul and Friedman (1986b) note, this philosophy is guided by three core values and several central principles. First, the SOC must be child centered and family focused, with the needs of the child and the family, as defined by the family, dictating the nature of the services provided; families are recognized as equal partners in efforts to plan and implement services and supports for children. Second, the SOC should be community based, so that children and their families receive assistance through a network of services and supports provided in normative environments within, or close to, the child’s home community. Finally, the SOC should be culturally competent, with its services and supports sensitive and responsive to the cultural, racial, and ethnic differences as well as the special needs of the populations they serve.

In addition to these core values, which have been modified slightly over the years (i.e., from family-focused to family-centered and, more recently, to family driven; see Hodges et al. 2010), Stroul and Friedman (1986b) delineated a number of guiding principles, which emphasize the importance of:

  1. 1.

    individualized services and supports that address the child’s specific needs and build upon his/her strengths;

  2. 2.

    ready access to a range of services in the least restrictive environments, which maximize freedom of choice and allow the child to maintain contact with his/her family, school and peers;

  3. 3.

    integrated and coordinated services, with professionals from multiple agencies collaborating with one another and with family members to ensure that services are provided in an effective and efficient manner; and

  4. 4.

    early identification and intervention, to enhance the likelihood of positive outcomes and prevent problems from becoming full-blown.

These key principles have been espoused as principles of sound practice for many years, yet remain broad principles, rather than specific blueprints for practice.

The most commonly articulated aspect of practice within SOCs, even becoming a required component of federally funded CMHI projects, is the ‘wraparound’ approach, as described by VanDenBerg and Grealish (1996; see also Bruns et al. 2008). In wraparound, services are to be customized to meet the needs of the children and families through the work of “child and family teams”, in which families, together with professionals and informal community supports chosen by the family, develop a plan to address the needs of the child and family (Bruns et al. 2008; Burns and Goldman 1999; Kendziora et al. 2001; see Bruns and Walker 2011b, for multiple papers focusing on wraparound service delivery). The team collaborates to identify the strengths of the child and the family, develop specific, measurable goals, and formulate individualized action plans that build upon those strengths (Handron et al. 1998). Moreover, as designed, the team helps mobilize community resources, including both formal services and informal community supports (e.g., neighbors, extended family, community organizations), to meet the needs of the family, and the team also follows up to determine if the plan is successful, revising it as necessary.

In sum, the SOC framework is based on the idea that an array of services from multiple agencies and disciplines must work in concert with informal supports within the community to address the needs of children with SED and their families (Stroul and Friedman 1986b). Thus, for SOCs to be successful, community systems must change to (a) facilitate collaboration among agencies, connections among families, service providers, and community supports, and (b) ensure that families become empowered to drive a wraparound process that will meet their needs. SOCs, then, have the potential to help families in need reconnect with their communities, and strengthen communities to better meet the needs of families.

Links Between SOC and CP Values and Practices

The values and practices inherent in a SOC approach are quite consistent with the core values of CP (see Dalton et al. 2007; Kloos et al. 2012; Moritsugu et al. 2010 for descriptions of CP’s core values). Table 1 briefly summarizes several notable parallels.

Table 1 Consistencies between community psychology and system of care: summary and comparison of key values
Full size table

In particular, empowerment is a key value of CP, with a strong emphasis on helping disadvantaged and disenfranchised groups gain control over their life circumstances (e.g., Maton 2008; Peterson and Zimmerman 2004; Rappaport 1981, 1987; Zimmerman and Perkins 1995). Similarly, SOCs stress the important contributions to be made by family members, many of whom occupy the lowest rungs on the socioeconomic ladder; in this approach, they are to have control over the types of services and supports they receive and serve as equal partners with professionals in planning and evaluating services in the system. Parents/caregivers are recognized in SOCs as having unique expertise and knowledge regarding the needs and abilities of their children (Friedman 1994; Osher et al. 1999) and, critically, they are to have a “voice and choice”. In addition to its consistency with empowerment, this notion also aligns with CP’s emphasis on the importance of citizen participation in decision-making; SOCs likewise stress family participation and involvement in decision making at the individual and system levels.

Similarly, collaboration with other disciplines and community members is a key value for CP (Dalton et al. 2007; Kloos et al. 2012; Moritsugu et al. 2010). Multiple perspectives are needed to address complex problems, and CPs increasingly emphasize collaboration in research, with community members and psychologists jointly determining the goals and methods of community research (Dalton et al. 2007; Jason et al. 2004). Successful SOCs also rely upon collaboration occurring at multiple levels—families, agencies, and professionals across multiple disciplines must communicate effectively, work together, and respect the contributions each offers to the process of meeting child and family needs (e.g., Cook et al. 1999). For instance, the CMHS has emphasized the key roles that parents and families should play in every step of the evaluation of the SOC, i.e., in the definition of questions, planning of methodology, collection of data, and interpretation of findings. Those working within the SOC framework (e.g., Koroloff and Friesen 1997; Osher et al. 2001; Turnbull et al. 1998; Vander Stoep et al. 1999) have described a participatory action research framework that empowers families as research partners, and is clearly in accord with the approach and methods of CP (e.g., Balcazar et al. 1998; Fetterman et al. 1996; Jason et al. 2004; Tolan et al. 1990).

Another clear parallel between CP and SOC values is the emphasis on strengths inherent to both approaches. CPs have long argued for the need to focus on strengths rather than pathology (Elias and Cohen 1999), and the SOC approach, particularly in the implementation of wraparound, focuses on child and family strengths as the basis for any successful intervention (VanDenBerg and Grealish 1996). Respect for and appreciation of diversity has also been a key concept in CP, and the provision of culturally competent services comprises a core value in SOCs. The social change emphasis so common to CP is inherent in the focus on creating new systems of care in communities. Indeed, at its core, the movement towards establishing SOCs is a system change effort. Finally, the ecological focus in CP can be seen in SOC principles related to the degree to which the child is viewed as part of a family and community, and interventions must take place in and include that context (e.g., informal community supports, community-based services). SOC principles related to placement in the least restrictive environment and in community-based services that respect and protect individual rights are also certainly consistent with values commonly espoused by CPs.

Community psychologists have long been concerned with intervening at the system and community level to help individuals and families function more effectively in society. Given the growing numbers of communities in which SOCs are found, the numbers of children and families affected by them, and overlapping values between SOC and CP, SOCs could be important venues for research and practice in CP. Furthermore, SAMHSA has recently espoused adoption of a public health approach to children’s mental health (Miles et al. 2010), which emphasizes a population focus and changing environments to promote “positive” mental health across multiple community systems. Although funding and policy barriers continue to limit the ability of SOCs to adopt a true public health approach (Cook and Kilmer 2010a; Kilmer et al. 2010), CPs certainly understand the contextual and policy issues and can provide assistance to mental health systems, and SOCs in particular, in their efforts to achieve a stronger public health focus.

The Disconnect Between CP and the SOC Effort

Despite the clear overlap in goals and values between SOC and CP, community psychology and community psychologists have historically had relatively little involvement and influence in SOC policy, practice, or research. Perhaps this is because the strong emphasis on mental health treatment in SOCs is viewed as inconsistent with the preventive and systemic focus within CP. For example, the guidelines for the CMHI specify the target population as children with SED and their families, who are involved with multiple agencies and at risk of out-of-home placement. Furthermore, CMHI grantees have typically been mental health agencies or local mental health management entities. In addition, even when the local site targets preschool children as the population of interest, the primary emphasis tends to be on early diagnosis and intervention, rather than prevention. Furthermore, managed care guidelines often dictate that services are limited to those who have a DSM-IV diagnosis, making it difficult for communities that desire more preventive and/or health-promoting interventions to secure funding that will sustain them (Cook and Kilmer 2010a).

Despite the focus on children with serious mental health problems, SOCs are intended to also focus on the broader family, including members who are not diagnosed. Many of these families are from very low socioeconomic backgrounds, with a wide array of needs. A focus on empowering families, connecting families with community resources, and effecting system change, together with program evaluation and applied research, are areas in which community psychologists can make particular contributions to SOCs.

The Disconnect Between SOC Theory and Practice

Although SOCs and the wraparound practice model have become fairly ubiquitous throughout the country, recent reviews of the research (Bruns and Suter 2010; Suter and Bruns 2009) found only 9 controlled studies of the effects of wraparound, and modest evidence for overall impact (mean effect size = .33), but large variation in effect sizes across individual studies (−.38 to 1.09). This is consistent with the growing body of work suggesting that service providers have difficulty implementing key aspects of wraparound (e.g., Bertram et al. 2011; Bruns and Walker 2011a; Cook et al. 2007; Epstein et al. 2003; Palamaro Munsell et al. 2011; Walker et al. 2003; Walker and Schutte 2005). These works demonstrate that practices both during and following federal funding often do not match the values and principles disseminated regarding the desirable components and foci of SOCs; many communities struggle to engage in practices that align well with the SOC philosophy and wraparound (see, e.g., CMHS 2003; Cook and Kilmer 2004; Holden et al. 2003; Kilmer et al. 2010; Kutash et al. 2011; Lunn et al. 2011; Pandiani et al. 1996). It is particularly noteworthy then that a national survey of state children’s mental health directors suggested that poor wraparound implementation was a cause of poor outcomes for children with mental health problems (Bruns et al. 2011). At the same time, an emerging literature suggests that, when wraparound is implemented well, better outcomes result (Bruns et al. 2005a, b, 2006, 2008; Haber et al. 2010; Hemphill et al. 2010; Rast et al. 2007). Notably, though, of the nine controlled wraparound outcome studies in the literature, only one assessed fidelity of implementation. Given the importance of effective implementation of interventions (Durlak and Dupre 2008), examination of the degree to which SOCs implement the principles is critical. Because implementation requires attention to broader system efforts (Fixsen et al. 2005), attention to the factors that contribute to system change are particularly salient to improving the outcomes for children and families (Cook and Kilmer 2010a).

The papers included in this Special Issue focus on system change in SOCs and how system changes can be implemented, either presenting empirical data applicable to system change or laying important conceptual groundwork for system change in this context. Given the growing emphasis on the use of SOCs with diverse populations, several papers focus on the ways that SOCs need to modify operations and practices to address the needs of those populations. For example, the systemic issues involved in addressing the needs of youth in the juvenile justice system (Erickson 2012), young children (Finello and Paulson 2012), youth with co-occurring traumatic stress and substance use (Suarez et al. 2012), and urban American Indian youth and families (West et al. 2012) and older youth (Haber et al. 2012) are described. Efforts growing out of the National Evaluation’s System of Care Assessment (SOCA), which focuses on system change, describe the variability across federally funded sites (Brannan et al. 2012) and the use of system change measures to predict individual-level change (Barksdale et al. 2012). Qualitative data reported by site visitors in the SOCA (Brashears et al. 2012) point out some of the implementation issues at local and national policy levels and highlight actionable recommendations, including several for macro-level system and social change.

Examples of specific methods/processes for implementation of SOCs, each with different points of emphasis, are provided by Foster-Fishman and Watson (2012), Armstrong et al. (2012), and Hodges et al. (2012). As these authors illustrate, the implementation of these complex community initiatives requires simultaneous attention to multiple levels of analysis, and the sequence of actions can have important implications for successful implementation. Of particular note are the two papers (Slaton et al. 2012; Wenz-Gross et al. 2012) in which parents share their voice through first person accounts. While parents of children with SED are often viewed by professionals as the source of problems, these narratives provide examples of ways that systems have used parents as resources not only to address the needs of their children, but as important contributors to governance, evaluation, family support, and training. In addition, McCammon (2012) addresses conceptual issues surrounding the use of strengths, a core value within SOCs. The Special Issue ends with two commentary pieces that highlight lessons learned and strategies for expansion and sustainability (Miller et al. 2012) as well as needs, unanswered questions, and new directions for those working to implement SOCs (Kilmer and Cook 2012). Taken together, the Special Issue provides a compilation of research and experience that can guide future development and enhancement of SOCs.

In recent years, community psychologists have made increasing contributions to, and had an increased presence in, SOC work (see, e.g., Crusto et al. 2008; Foster-Fishman and Droege 2010; Tebes and Kaufman 2002; Tebes et al. 2005; Whitson et al. 2011, in press). Indeed, several of the papers in this Special Issue were written by the growing numbers of community psychologists involved with SOC efforts. We hope that this SI will lead to greater involvement by CPs in SOC efforts, and that this involvement can help SOCs better mobilize their communities and systems to meet the needs of children and families. There is strong potential for intersections between SOCs and community psychology in applied research, practice, and teaching/workforce development.

Applied Research and Evaluation

An important part of the CMHI has been the National Evaluation, with a major focus on examining change in functioning of the child and family over time, and a longstanding effort to examine system change through the SOCA (see Brannan et al. 2012; Barksdale et al. 2012). Because funding for communities through the CMHI has been significantly reduced and federally-funded SOCs have been the loci of much of the research on SOCs, opportunities for research in that context will almost certainly diminish. However, given the growing emphasis across the country on wraparound at the state level (as well as community-level initiatives; Bruns and Walker 2011a), additional opportunities may evolve.

Barksdale and colleagues demonstrate the use of multilevel analyses to assess the impact of system-level change on individuals. The potential for such analyses, using data from the national evaluation, has only begun to be tapped. Of particular need is research that examines changes in children and families as a function of the quality of implementation of wraparound and work that examines the utility of wraparound for older (Haber et al. 2012) and younger (Finello and Paulson 2012) youth, those involved in juvenile justice systems (Erickson 2012), and those experiencing traumatic stress and/or substance abuse (Suarez et al. 2012). SOC-based work has identified gaps in system functioning and provided a springboard for policy-oriented recommendations (e.g., Cook and Kilmer 2010a, b; Kilmer et al. 2010a; b); however, overall, scant research has examined the broader context of SOCs (Burns et al. 2006). Further applied research is needed to inform data-guided recommendations regarding responses to implementation issues and, critically, to examine the range of contextual and community-level factors that can influence fidelity of implementation and, more broadly, system function.

Engaging in partnerships with families and family organizations in the evaluation of SOCs and wraparound, from conception to interpretation and utilization, is clearly consistent with the values, training, and expertise of many CPs. Furthermore, given that CPs are often trained in diversity issues and participatory research methods (Fetterman et al. 1996; Seidman et al. 1993), they should be particularly sensitive to the needs of families from different cultural and ethnic backgrounds in the implementation of this inclusive evaluation approach. In partnership with families and other community stakeholders, SOC system change initiatives would be well-served by evaluation approaches that go beyond an individual-level focus in assessing change. That is, to elucidate the impact of SOCs and provide well-targeted feedback to improve services and supports for youth and families, evaluations must also account for salient family, agency, system, and community factors, including the degree to which the SOC initiative engages the broader community and its resources or whether families experience an increase in their access and use of informal and natural supports (e.g., Cook and Kilmer 2010b).

Community Practice

The values and competencies of community psychologists are clearly of relevance to SOCs, such that SOCs can benefit from the practice of community psychology. SOCS are designed to be collaborative, coordinated systems; for optimal functioning, agency administrators, providers, and line staff must change the way they ‘do business’. The involvement of CPs in these initiatives can help with coalition-building and work with organizations and stakeholders to support and improve their efforts to collaborate, engage and empower families, and utilize community resources. Foster-Fishman and Droege (2010) discuss the role of “policy entrepreneurs”, individuals who have the requisite skills and relationships to develop and disseminate innovations, as facilitators of change efforts in SOCs. Community psychologists are likely to have both the capacities and relationships in their communities to assume these roles and help promote systems change.

Multilevel interventions, ranging from individuals to complex systems, are the stock-in-trade for community psychologists, and critical for implementation of SOCs. As SOCs take on a greater “public health” approach to addressing the needs of families, community psychologists can help these efforts move from a “case finding” early treatment approach, to one that is focused more on prevention of problems. Even within the CMHI, in which the focus remains on children with SED, there is much potential for addressing the needs of younger siblings of these children in a preventive approach, fully consistent with efforts to address the needs of “children with SED and their families” (Kilmer et al. 2008, 2010).

Engagement of family members in multiple roles in SOCs has been a longstanding value (Friedman 1994; Graves and Shelton 2007; McCammon et al. 2001), helping families increase their self-determination, enhance dignity of children and families, and address their goals and wishes (Stroul and Friedman 1986b). The emphasis on empowerment within community psychology can certainly be used to help systems work more closely with families and increase their responsiveness to parental voices.

In sum, in the SOC initiative, CPs have the opportunity to help communities transform their service delivery system into one that is more consistent with many of the goals of CP and SOCs. Consistent with the urgings of the 1999 Surgeon General’s Report on Mental Health, CPs can help communities develop culturally competent services that transcend mental health’s traditional “focus on the ‘identified client’ to embrace the community, cultural, and family context of a client”, and become “connected with established, accepted, credible community supports” (U.S. Department of Health and Human Services, p. 186). Community psychologists can be assets in such endeavors, developing partnerships with neighborhoods, local agencies, and faith communities, building upon the community’s strengths. They can engage community residents in efforts to solve problems for all residents, including those with severe emotional problems, a strategy that is alien to many mental health professionals (McCammon et al. 2002). Essentially, to function effectively in a SOC, mental health professionals must learn how to build collaborative partnerships among diverse community groups and, as one important starting point, the concept of the “client” must expand to include the community and its various components (McCammon et al. 2002). CPs are clearly trained to do so.

Training/Workforce Development

The challenges in finding professionals who can readily implement the principles of SOCs have been identified (Brashears et al. 2012), leading to efforts to “retrain” professionals to allow them to successfully function within SOCs (McCammon et al. 2002). SOC ideas and practices can profitably be integrated into existing courses and programs without disruption of the extant curricula, and SOC principles are likely to be emphasized in most community psychology courses. In fact, “Community and Social Change” skills are viewed as a core set of competencies within community psychology training (Society for Community Research and Action 2012).

Conclusions

The SOC movement has grown significantly in recent years (e.g., De Carolis 2001; Dosser et al. 2001; Holden and Brannan 2002; Huang et al. 2005; Stroul and Blau 2008; Vinson et al. 2001), and the values of CP and SOC are quite similar, making existing or developing SOCs quite inviting to CPs. Indeed, across settings, fruitful roles abound for CPs, roles that can benefit the system and SOC effort, and prove professionally rewarding as well. As Miller et al. (2012) point out, community psychology’s ecological orientation and focus on “the community at large as the ‘identified client’” are highly consistent with the principles and values of SOCs.

Although much of the effort of SOCs involves work to address the needs of children who have already been diagnosed with SED, this effort is designed to change a system that affects thousands of children and families across the country. Community research addressing the contextual factors that affect system change and the impact of these changes on children and families can influence training, service delivery, and local and national policy. Research exploring the links between system and environmental factors and family functioning in this population, the factors predictive of positive service response, and the effectiveness of different types of programs, services, and approaches is clearly needed. SOCs yield the opportunity to conduct meaningful applied research and, if desired, utilize data for advocacy or activism. Community practitioners can help use research to develop better systems, assisting communities with the implementation of these principles and refining service coordination and delivery to best utilize community resources. Community psychologists can also become involved in training activities, both pre-service and in-service, that can help effect community and system-level change. A better integration of community psychology principles and skills into SOCs could help communities develop stronger systems to support children and families, while providing an expanded set of roles and opportunities for community psychologists to effect system change.