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Strengthening social support: Research implications for interventions in children's mental health

Winter 2006
arch, P
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Strengthening Social Support
FOCAL POiNT Vol. 20, No. 1
Winter 2006
Strengthening Social Support
Janet S. Walker &
Melanie Sage............................3
My Greatest Ally
Craig Delano.............................8
Building Family-to-Family Suppor t
Programs: Rationale, Goals, and
Henry T. Ireys & Diane
Dvoskin Sakwa........................10
Unmasking Lena
Lena Gladden..........................12
The “Keys for Networking”: Targeted
Parent A ssistance
Jane Adams, Elizabeth
Westmoreland, Corrie Edwards
& Sarah Adams........................15
Techniques for Assessing Social
Suppor t
Mary I. Armstrong...................19
Social Support from Adults and Peers in
Early Adolescence:
It’s a Balancing Act
Naida Silver thorn &
David L. DuB ois.......................23
Wraparound and Natural Supports:
Common Pr actice Challenges and
Promising Coaching Solutions
Greg S. Dalder.........................26
Natural Supports from a Parent
Greg S. Dalder & Lyn Gordon
(from an interview with Jeanette
FOCAL POiNT is a publication of the Re-
search and Training Center on Family
Support and Children’s Mental Health.
This publication was developed with
funding from the National Institute on
Disability and Rehabilitation Research,
United States Department of Educa-
tion, and the Center for Mental Health
Services, Substance Abuse and Mental
Health Services Administration (NIDRR
grant H133B040038). The content of
this publication does not necessarily re-
flect the views of the funding agencies.
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Winter 2006 FOCAL POiNT Staff:
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Nicole Aue,, Assistant Editor
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large body of research evidence Hogan, Linden, & Najarian, 2002). ment. Yet, as is the case with research
demonstrates that people who The lack of knowledge about on social support interventions more
are involved in supportive social rela- whether and how social support in- generally, evaluations of these models
tionships experience benefits in terms terventions work is an important issue of community-based care have not
of their health, morale, and coping. within children’s mental health. There so far demonstrated success from ef-
Conversely, low levels of social sup- is a growing consensus in the field that forts to increase social support (Cox,
port have been repeatedly linked to strengthening interpersonal and com- 2005).
poor physical and mental health out- munity ties is a promising resilience- When thinking about the implica-
comes. Recognition of the benefits of and development-promoting strategy tions of this research, it is obviously
social support has fueled the develop- for all children and families who are important to maintain a sense of re-
ment of a wide variety of interven- affected by mental health difficulties. alism and to acknowledge that the
tions designed to improve the quantity For children and youth with the high- field does not at this point have a wide
or quality of the support that people est levels of need, the field is increas- repertoire of proven and potent strat-
receive. Unfortunately, evaluation of ingly embracing the idea of commu- egies for strengthening social support
these interventions has so far not yield- nity-based care as an alternative to for children and youth with mental
ed clear information about what sorts out-of-home placements. A common health difficulties and their families.
of intervention are most likely to be element of models for community- What we do have are a few strategies
successful. Indeed, it is not even clear based care—including wraparound, that appear promising and a few that
that social support interventions—as multisystemic therapy, and intensive have been modestly successful. Most
they are currently implemented—are family preservation services, among of these strategies focus on providing
actually successful at increasing social others—is the emphasis on strength- support to caregivers. With the excep-
support for people who lack it (Co- ening family ties to supportive people tion of mentoring programs, strategies
hen, Underwood, & Gottlieb, 2000; within the family’s social environ- for increasing social support for ado-
FFOOCCAALL PPOOiiNNTTis produced bis produced by the Ry the Research and Tesearch and Trraining Center on Faining Center on Family Support amily Support
and Children’and Children’s Mental Health in Ps Mental Health in Portland, Oregon.ortland, Oregon.
Winter 2006, Vol. 20 No. 1
Regional Research Institute for Human Services, Portland State University.
This article and others can be found at For reprints or permission to
reproduce articles at no charge, please contact the publications coordinator at 503.725.4175; fax 503.725.4180 or email
FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health
lescents or children have not been well
studied. On the other hand, this does
not mean that other strategies that are
currently in use have been disproven,
nor does it mean that we cannot build
on what we are learning in order to
improve existing strategies and create
new ones.
This issue of Focal Point explores
some of what we do and don’t know
about strengthening social support.
This introduction outlines some of
the major concepts and themes in re-
search on social support, and some
implications of this research for inter-
ventions in children’s mental health.
This sets the stage for the rest of the
issue, which presents information and
examples that can be
helpful in future efforts
to design and imple-
ment social support
strategies and interven-
tions for children and
Types of Support
The literature offers
many definitions of so-
cial support; however,
most definitions refer
to the exchange of one
or more of three main
types of support—
emotional, informa-
tional, and instrumental—that people
provide to friends and family mem-
bers in times of need. Emotional sup-
port involves the expression of empa-
thy, reassurance, and positive regard,
and is believed to enhance well-being
by promoting self-esteem, reducing
distress, and providing an emotional
context for positive coping efforts. In-
formational support involves the provi-
sion of guidance, advice, or other in-
formation that can reduce confusion,
increase perceptions of self-efficacy,
and form the basis for positive coping
strategies. Instrumental support refers
to the provision of money, goods, and
services that can be used in coping
and problem solving efforts.
Additionally, some theories of so-
cial support also highlight the impor-
tance of social integration—a sense of
belonging—and the role of compan-
ionship—participation in social and
leisure activities. Many social support
interventions are aimed at fostering
peer support—emotional support from
people who share key experiences
with the recipient. In the case of chil-
dren’s mental health, peer support to
caregivers is seen as helping to reduce
feelings of social isolation and reduce
feelings of shame and self-blame.
Families can access social support
through both natural and more formal
support systems. Natural support, also
often called informal support, is most
typically provided in relationships
with friends and family, while formal
support is provided by professionals.
Many sources of support, however, do
not fall neatly within one or the other
category; support offered through
community or peer-run organizations,
for example, may mix the two. Within
children’s mental health, a key distinc-
tion is whether or not the support is
from sources that are likely to endure
in the family’s life. It is thought that
families who receive consistent sup-
port from these enduring sources will
not only achieve higher levels of com-
munity integration and well-being, but
will also become less entangled with
(and dependent upon) formal servic-
es. Efforts to intervene thus typically
focus on strengthening a family’s con-
nections to natural support systems
and to community organizations such
as clubs, religious organizations, and
peer-run support organizations.
Lessons from Research
The research on social support
interventions comes from many dif-
ferent fields and encompasses many
different intervention strategies. Con-
sequently, results may or may not be
relevant for interventions in the field
of children’s mental health. What is
more, methodological, analytical, and
conceptual difficulties make it diffi-
cult to draw firm conclusions from the
existing literature. In reviewing exist-
ing research, it is thus important to
avoid jumping to premature conclu-
sions: There is much
we don’t know at this
point about the specif-
ics of whether and how
social support interven-
tions “work.” Despite
these shortcomings, the
literature does point to
some particular chal-
lenges that should be
some promising strate-
gies that can be incor-
porated—in the design,
implementation, and
evaluation of future
social support inter-
ventions in children’s
mental health.
In the field of children’s mental
health, efforts to increase social sup-
port for caregivers typically use one of
two basic types of interventions: those
that aim to mobilize peer support and
those that strive to increase support
available from naturally occurring so-
cial networks.
Peer Support
As is true with the research on so-
cial support intervention more gen-
erally, conclusions from research on
peer support can only be tentatively
drawn; however, in general, it appears
that providing support through peers
is a promising approach. Peer-to-peer
support interventions generally fall
Winter 2006, Vol. 20 No. 1
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FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health
into two basic types: peer support
groups, and peer support at the indi-
vidual level.
In peer support groups, participants
can both offer and receive aid, usually
emotional support, but sometimes
also informational and instrumental
support. In addition, peer support
groups offer an opportunity for mem-
bers to add new relationships to their
social networks. Despite the popu-
larity of such groups, there are rela-
tively few studies that evaluate their
outcomes. While some of these stud-
ies show benefits from participation,
others do not (Hogan et al., 2002).
Research has typically documented
participants’ satisfaction with groups
(Helgeson & Gottlieb, 2000), but a
small number of studies have shown
other benefits, including improved
social support and general well-being.
There may be many reasons for these
inconsistent findings, but research-
ers caution that in loosely structured
support groups, the quality of support
may be quite variable. Group mem-
bers may interact in ways that actually
increase stress, undermine self-confi-
dence, and promote the use of ineffec-
tive problem solving strategies. Thus,
structured groups that are led by well-
trained facilitators, and that offer an
educational or informational compo-
nent may be most helpful (Helgeson
& Gottlieb, 2000).
Individual-level peer-support
interventions typically pair pro-
gram participants with support
providers who share salient ex-
periences or conditions. Such
interventions usually aim to
increase emotional support, but
also often include an explicit
focus on informational support;
they may also target instrumen-
tal support by teaching advo-
cacy skills and/or by having the peer
interveners help participants access
community resources. Hogan (2002)
finds the research on these types of
interventions “encouraging,” particu-
larly when peer supporters are trained
to interact with program participants
in ways that maximize emotional sup-
portiveness and offer problem solving
strategies and information. However,
since the number of research studies
is small, and since the interventions
differ substantially one from another,
existing research does not provide
firm guidance about which interven-
tion components or strategies might
be most effective, or under what cir-
The articles on Parent Connections
(pages 10-14 in this issue) and Keys
for Networking (pages 15-18) describe
peer support programs that are consis-
tent with main themes from existing
research. Both rely on well-trained
peers who provide a combination of
emotional and informational support.
Peer supporters in both programs
also model and teach advocacy skills,
which are a route to increasing the in-
strumental support available to fami-
lies. Importantly, both programs also
offer opportunities for participants
to give and receive support. Newer
commentaries on social support inter-
vention often highlight the idea that
support is most beneficial when the
support relationships are reciprocal.
Offering support increases feelings
of self-efficacy and competence, and
builds a sense of belonging to and be-
ing valued by a social group. It is pos-
sible that this is particularly important
for people at times when self-worth is
challenged by stressful events and stig-
ma. Finally, both programs also have
the backing of a larger peer-run orga-
nization, though this is more central
to the intervention in the Keys model.
Connecting caregivers with the larger
organization provides access to a va-
riety of different people, activities,
and groups, and a wide variety of po-
tentially supportive relationships. An
organization also has the potential
to provide a stable source of support
over time. This can help guard against
‘burning out’ individual support giv-
ers, or over-reliance on a particular
relationship, since support can come
from multiple sources. This may be
particularly important when support
is being provided by caregivers who
may experience periodic crises arising
from their own children’s difficulties.
Having access to a variety of support-
ive relationships and activities is also
in line with recent interpretations of
research that suggest that support will
be more effective when it is matched
with recipients’ needs (Gottlieb,
2000). A larger organization offers
choices so that people can access the
kinds of support that they find most
comfortable and helpful.
Intervening in Natural Networks
The most compelling rationale for
intervening to increase support in nat-
ural networks is that there is a long-
term commitment from friends and
family members that is not typically
available from paid relationships. The
support of friends and family is par-
ticularly predictive of positive health
and mental health outcomes (Cutrona
& Cole, 2000; Werner, 1995). What
is more, support offered through the
natural network is more likely to be
culturally appropriate, and may be
easier to accept than professional
help. Natural network interventions
vary along a number of dimensions,
and the number of research studies is
small; however, once again, research
indicates that this approach can be
beneficial (Cutrona & Cole, 2000; Ho-
It is thought that families who receive consistent
support from enduring sources will not only
achieve higher levels of community integration
and well-being, but will also become less entangled
with (and dependent upon) formal services.
Winter 2006, Vol. 20 No. 1
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FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health
gan et al., 2002).
The most-researched approach to
intervening in natural networks in-
volves the use of interventions that are
intended to improve the quality of re-
lationships within an existing network.
These interventions are motivated by
some studies showing that “negative
support” (behavior that is perceived
as harmful, critical, or hostile, or
that contributes to stress
or anxiety) has a stron-
ger link to outcomes than
positive support (Hogan
et al., 2002). Even among
well-intentioned friends
and family, interactions
intended to be supportive
may have the opposite ef-
fect. This can happen, for
example, when supporters
minimize a problem by
implying that it is not seri-
ous, or when sympathetic
supporters go too far in
the other direction by cat-
astrophizing the problem.
Interventions thus focus
on working to improve in-
teractions within the sup-
port network by teaching a variety of
relationship skills, including problem
solving, communication skills, and/or
assertiveness. One type of approach
focuses on teaching friends and fam-
ily how to improve the quality of the
support they provide to people who
experience chronic stress. This kind of
approach is one of the components of
family psychoeducation, a set of evi-
dence-based practices used with adult
mental health consumers and their
families (McFarlane, 2003). Other in-
terventions have focused on teaching
relationship skills to people in need of
support, and the results of these stud-
ies have been encouraging (Hogan et
al., 2002). The best-evaluated interven-
tions to improve relationship skills are
those that have been created and led
by professionals, and the distinction
between this kind of intervention and
various forms of psychotherapy is not
always clear. On the other hand, this
distinction may not be as important
as other dimensions of the interven-
tion, such as whether it is delivered in
a strengths-based or recovery-oriented
manner. What is more, the same types
of intervention can also be designed
and delivered by peers. For example,
family advocacy organizations have
offered peer-led programs that include
many of the same components as pro-
fessionally-led family psychoeduca-
tion programs.
The articles on wraparound (pages
26-30) describe other strategies for in-
tervening in natural networks: engag-
ing network members in providing
specific forms of support, coordinat-
ing support available from an existing
network, and recruiting new members
into the network. These strategies
have intuitive appeal, and they are a
core component of several varieties of
person-centered planning. A number
of studies of these kinds of interven-
tions have been published, and posi-
tive outcomes have been documented;
however, the evaluation strategies
used were often weak. Thus these
studies offer only limited insight into
whether or when these strategies are
helpful in producing long term in-
creases in social support or other de-
sired outcomes. Given the increasing
popularity of wraparound and allied
interventions within children’s mental
health, it is clearly important to build
knowledge in this area. Continued on pg. 8:
Strengthening Support
Interventions for Youth
For younger children, the family is
the most important source of support,
and many therapeutic interventions
have been developed to increase the
supportiveness of family relationships.
However, these are not usually consid-
ered social support interventions per
se. Throughout later childhood and
adolescence, young peo-
ple develop wider social
networks that include
peers and others from
the community. The re-
search described in the
article by Silverthorn
and DuBois (page 23-
25) supports the hypoth-
esis that good outcomes
for youth are promoted
when young people re-
ceive social support that
is balanced between peer
and adult sources. The
article also describes
GirlPOWER!, a mentor-
ing program designed to
increase available social
support. Mentoring is
perhaps the best studied social support
intervention for youth, and research
has provided guidelines for develop-
ing effective programs (Herrera, Sipe,
& McClanahan, 2000). In essence,
mentoring programs like GirlPOW-
ER! are designed to add new, compe-
tent adults to a young person’s social
network. Mentors are trained to offer
emotional support, and often, as is
the case with GirlPOWER!, programs
also include informational support
that focuses in part on how to build
with peers and to recruit additional
support from adult sources. This type
of intervention combines many of
the components of interventions for
adults described above, and often oc-
curs in the context of a community or
youth-serving organization that offers
youth multiple routes to access social
support through participation in a va-
riety of activities and relationships.
Winter 2006, Vol. 20 No. 1
Regional Research Institute for Human Services, Portland State University.
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FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health
After arriving home from a hard
day’s work, I slip off my jacket and
boots. I look out the kitchen window
to glance a peek at the snow-covered
ground on a beautiful December day.
The lawn is all dressed in white. As
I look across the street at a cozy yel-
low ranch home, I notice the evening
sun reflecting off the
icicles growing from
the roof ’s drip cap.
Suddenly, my eyes
begin to fill with glee
and my heart fills
with joy as I remi-
nisce fond winter
childhood memories
of a small city off
the shores of Lake
Michigan where my
family used to live.
In those days,
the snow was my
dreamland. My two
sisters and I would
eagerly come home
from school to hot
chocolate and a tasty
snack mom would prepare for us al-
most daily. A little snack was essen-
tial after walking five blocks in snowy
conditions, or at least that was what
we led mom to believe. After happily
consuming our treats, completing our
homework, and viewing some tele-
vision, we would venture outdoors.
Since we lived on a city block, the only
hill available to slide on was the snow
hill in the front yard that dad created
from the snow he shoveled from the
driveway. We would slide down our
snow hill until our boots were soaked
and our little fingers were numb. Then
we would return indoors where mom
kept warm as she prepared our deli-
cious hot meals. After our meals and
kitchen duties, it would be bedtime.
Bedtime was also an anticipated time,
as mom and dad together would snug-
ly cover my sisters and me in our beds.
Throughout the night I would dream
of how exciting the next day would
also be. But, like the night, the dream
did not last much longer.
When I was 9, my father left us.
Consequently, things were never the
same, My hero, the one I most ad-
mired, abandoned us for a new life.
What he did not realize was that the
lives of my mother, my sisters, and
me were taken away because we were
no longer good enough. For the first
time in my life I felt horrific pain, like
a stab to the heart. This is much more
difficult to heal than average pain.
The anguish would grow for years
to come. At this point, my behavior
started to change. It began at school.
I would leave my class briefly to visit
the restroom and then scurry to the
main office where I would claim to be
ill, adamantly requesting to go home.
This was routine for several months.
Later, my conduct developed into act-
ing out in class and skipping school.
These actions were unlike me. Teach-
ers were beginning to become con-
cerned with my transformed behavior.
My mother soon arranged therapy for
me at Catholic Social Services. None-
theless, I refused to comply with the
several therapists who had seen me.
Meanwhile, my negative actions con-
tinued as time progressed.
When I was 11, my mom, my sis-
ters and I moved 55 miles away to a
small town. Here
would be a fresh
start. My mother
even remarried.
Eventually, regard-
less of the changes,
my conduct re-
sumed. Then my
behavior escalated
at full throttle. This
led to my involve-
ment in the court
system. My mom
worked with the
school system and
community mental
health in search of
a solution to my be-
haviors. I was start-
ed on medications.
Then I was often hospitalized for med
changes as a result of having my diag-
nosis altered. The process was drain-
ing for my family and me, and it lasted
eight years. At home my mom made
many efforts to keep safety a priority.
She provided a safety plan at home
in case I lashed out or attempted to
inflict self-harm. She also arranged a
support system with wraparound, a
family strengthening process to keep
me from out-of-home placement and
to strengthen family values.
When a child with emotional
challenges is going through behavior
changes, a support system is vital. Not
only does the child benefit from the
support system, but their family does
as well. The support system I believe
in most is provided through the family
focused planning that is at the center
Winter 2006, Vol. 20 No. 1
Regional Research Institute for Human Services, Portland State University.
This article and others can be found at For reprints or permission to
reproduce articles at no charge, please contact the publications coordinator at 503.725.4175; fax 503.725.4180 or email
FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health
Thus while the mentor him- or herself lized for children and youth affected merely receiving support may not be
may not become an enduring part of by mental health difficulties and their as potent as mutual exchanges of sup-
the young person’s social support net- families. The research reviews cited in port. It is worth considering how op-
work, the organization may continue this article include studies of a wide portunities to give and receive support
to link the youth with support oppor- variety of support interventions that can be built into future interventions.
tunities over time. focus on providing support to diverse The same reviews also suggest that
Other types of interventions de- populations, from people with chron- interventions would likely be more ef-
signed to build or increase support ic medical conditions to impoverished fective if greater attention were paid
from youths’ natural networks are not single mothers to recovering addicts. to matching a person’s support needs
well researched. In principle, wrap- This relatively small yet heteroge- with potential sources of support.
around aims to increase the social neous body of research may label cer- Some people, particularly those who
support available to youth as well as tain types of interventions “encour- are highly introverted or independent,
caregivers, but, as noted previously, aging” or “promising,” but evidence may not desire additional support,
the success of these efforts has not of their effectiveness is by no means even if their networks are relatively
been well studied. At least one strat- definitive. These studies can inform small. In general, women are more
egy for adding friends to the social interventions developed for our own likely than men to use social support
networks of children with disabilities field, but more work will need to be as part of their efforts to cope with
has been described (Cook, 2001), but done to design, implement, and evalu- stress and adversity (Taylor, Dick-
not as yet formally evaluated. ate programs suited specifically to our erson, & Klein, 2002) and may thus
needs. benefit more from intervention to in-
Conclusions and Cautions Several reviews of social support crease support. This implies that in-
interventions conclude by suggesting terventions should include an assess-
It bears repeating that we know that reciprocity may be an important ment of support needs and potential
relatively little about whether or how element in successful interventions. support resources. Armstrong (pages
social support can be created or mobi- Some research supports the idea that 19-22) describes some methods that
CCoonntt.. ffrroomm ppgg.. 66:: SStrengthening Supporttrengthening Support
of wraparound. This was more bene- and give me friendly advice, not lec- blessed to have such wonderful sisters.
ficial than one-on-one therapy. In fact ture me. And I was fortunate enough They are very dear.
it was not therapy at all. My entire to have many who would offer this I now realize that throughout these
family would meet for discussion in type of positivity throughout the hard times in my life, I had a wonder-
the comfort of our own home. Friends wraparound process and thereafter. ful family who loved and cared for me.
and other family members would also The toughest part of this family-fo- They will always be my greatest sup-
join in for many of our meetings. We cused process for me personally was port system. And now at 23, I am no
discussed our family and personal is- realizing how badly my issues had longer involved with Mental Health,
sues in a strength-based way. This affected those whom I love the most. and I am no longer on medications.
allowed us to better understand one Up to that point, it was hard for me I am trying to lead a positive life with
another and the full spectrum of the to think of anyone other than myself. a positive future to inspire those who
issues surrounding us so we could However, this process opened my eyes feel as though hope is out of reach.
target them together. There were mo- in the greatest ways. I began to realize And so I glance another peek out
ments of tear shedding, and hugging that everybody’s heart aches just as my the kitchen window. These snow-cov-
was common. During this process own, and my behavior had to change, ered hills are once again my dream-
I grew closer to my family members not only for my own good, but also for land. Glorious and content, they’ve
and my relationships with friends also the good of my family, especially my withstood my pain and forever they
grew stronger. loving sisters. All they knew is that I will stand as a symbol of my priori-
In my time of need, it seemed as had problems, and because of that I ties, to stay sound and pure with my
though everybody who had worked had to be the main focus. So they felt soul.
with me tried to be a therapist. But as though they had to put their own
this was not what I needed. I needed a feelings aside so I could get the help Craig Delano
friend; someone who would sit down I needed, and that makes me feel sad.
with me, listen to what I had to say Their understanding was sincere. I am
Winter 2006, Vol. 20 No. 1
Regional Research Institute for Human Services, Portland State University.
This article and others can be found at For reprints or permission to
reproduce articles at no charge, please contact the publications coordinator at 503.725.4175; fax 503.725.4180 or email
FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health
are currently used for assessing avail-
able and/or potentially available so-
cial support.
While there is little enough re-
search on whether interventions can
increase social support over the short
run, there is even less informa-
tion about whether such in-
creases are sustained over time.
In fact, there is some evidence
that deterioration can follow
when support is withdrawn
(Rook & Underwood, 2000).
People planning social support
interventions should thus con-
sider carefully how to maintain
support once the intervention
has ended. Linking people to
supportive organizations is one
strategy for addressing this con-
Finally, it should be remem-
bered that most of the research
on social support focuses on
mitigating stress and manag-
ing threats and crises. Relatively
little attention is paid to the
role social support may play
in promoting thriving or posi-
tive development. Interpersonal
relationships are a source of
enjoyment as well as intellectual, ar-
tistic, and moral stimulation. Com-
panionship is a form of support that
may be particularly essential for pro-
moting experiences that enhance well
being. As we contemplate the design
of interventions, it is essential not to
overlook these important aspects of
social support.
Cohen, S., Underwood, L. G., & Got-
tlieb, B. H. (2000). Social relationships
and health. In Cohen, S., Underwood,
L.G., & Gottlieb, B. H. (Eds.), Social
support measurement and intervention: A
guide for health and social scientists (pp.
3-25). New York: Oxford University
Cook, J. ( 2001). Friendship facilita-
tion. Focal Point: A National Bulletin on
Family Support and Children’s Mental
Health, 15(2), 11-13.
Cox, K. F. (2005). Examining the role
of social network intervention as an
integral component of community-
based, family-focused care. Journal of
Child and Family Studies, 14, 443-454.
Cutrona, C. E., & Cole, V. (2000).
Optimizing support in the natural
network. In Cohen, S., Underwood,
L.G., & Gottlieb, B. H. (Eds.), Social
support measurement and intervention: A
guide for health and social scientists (pp.
278-308). New York: Oxford Univer-
sity Press.
Gottlieb, B. H. (2000). Selecting and
planning support interventions. In
Cohen, S., Underwood, L.G., & Got-
tlieb, B. H. (Eds.), Social support mea-
surement and intervention: A guide for
health and social scientists (pp. 195-219).
New York: Oxford University Press.
Helgeson, V. S., & Gottlieb, B. H.
(2000). Support groups. In Cohen, S.,
Underwood, L.G., & Gottlieb, B. H.
(Eds.), Social support measurement and
intervention: A guide for health and social
scientists (pp. 221-245). New York: Ox-
ford University Press.
Herrera, C., Sipe, C. L., & McClana-
han, W. S. (2000). Mentoring school-
aged children: Relationship development
in community-based and school-based pro-
grams. Philadelphia: Public/Private
Hogan, B. E., Linden, W., &
Najarian, B. (2002). Social sup-
port interventions: Do they
work? Clinical Psychology Review,
22, 381-440.
McFarlane, W. R. (2003). Fam-
ily psychoeducation and schizo-
phrenia: A review of the litera-
ture. Journal of Marital and Fam-
ily Therapy, 29, 223-245.
Rook, K. S., & Underwood, L.
G. (2000). Social support mea-
surement and interventions:
Comments and future direc-
tions. In Cohen, S., Underwood,
L.G., & Gottlieb, B. H. (Eds.),
Social support measurement and
intervention: A guide for health
and social scientists (pp. 311-334).
New York: Oxford University
Taylor, S. E., Dickerson, S. S., &
Klein, L. C. (2002). Toward a biology
of social support. In C. R. Snyder &
S. J. Lopez (Eds.), Handbook of positive
psychology (pp. 556-569). New York:
Oxford University Press.
Werner, E. E. (1995). Resilience in
development. Current Directions in Psy-
chological Science, 3, 81-84.
Janet S. Walker is Director of Re-
search and Dissemination for the Re-
search and Training Center on Family
Support and Children’s Mental Health
in Portland, Oregon. She is also Edi-
tor of FOCAL POiNT.
Melanie Sage, MSW, is a PhD
student in the Social Work Program
at Portland State University. She is
a Research Assistant at Portland’s
Regional Research Institute for
Human Services.
Winter 2006, Vol. 20 No. 1
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FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health
Many states and communities
are working to strengthen
their child mental health systems by
supporting intensive home and com-
munity-based services for children
with serious emotional or behavioral
disabilities and their families. Fam-
ily-to-family support programs, often
operated by family-led organizations,
are an essential component of these
efforts. The President’s New Freedom
Commission on Mental Health sup-
ports this concept by recommending
that child-serving systems increase
the opportunities and capacities of
consumers to share their inspiration,
knowledge, and skills.
Family-to-family support has in-
tuitive appeal. In theory, families
who are facing similar challenges of
raising children with serious emo-
tional or behavioral disabilities can
find common ground and prevent
feelings of isolation or hopelessness
by sharing practical information, pro-
viding encouragement to each other,
and swapping stories of survival. But
the actual task of developing, imple-
menting, and sustaining meaningful
family-to-family support programs
presents major conceptual, logisti-
cal, and financial challenges. Few
scientific studies on effective family
support practices are available and
specific techniques for building fami-
ly-to-family support programs remain
Parent Connections was a joint
project of Families Involved To-
gether (FIT), a parent-to-parent sup-
port organization, and faculty from
the Johns Hopkins School of Public
Health. This team of parents and
researchers worked longer than five
years developing, implementing, and
evaluating the program. The develop-
ment and evaluation of the project
was supported in part by a major
grant from the National Institute of
Mental Health.
This article is intended to highlight
program theory and format, chal-
lenges encountered, and key scientif-
ic theories and findings. This material
may provide insight and direction for
family support organizations, mental
health programs, and others wishing
to craft a useful approach to provid-
ing peer support for families in their
own communities.
Types of Support
We define support as “informa-
tion leading people to believe they
are esteemed and valued and that
they belong to a network of mutual
obligations” (Cobb, 1976). We view
Parent Connections as a method for
generating family-to-family support
by offering intensive personal atten-
tion and information-sharing oppor-
Winter 2006, Vol. 20 No. 1
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FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health
tunities, thereby building a network
of mutual obligations among partici-
pating parents. As a practical matter,
this was achieved by linking “veteran”
parents with parents of school-aged
children with serious emotional or be-
havioral disabilities. Knowing that the
veteran parents had “walked in their
shoes” helped participating parents
feel a sense of trust and safety, which
in turn allowed them to expand their
ability to learn, make changes, and
manage the needs of their children
more successfully.
The staff of Parent Connections
dubbed the veteran parents Parent
Support Partners (PSPs). Our PSPs
had children over 18 years old who
had been identified as having emo-
tional or behavioral disabilities when
still in school. The PSPs worked with
seven or eight families and were paid
for up to 10 hours of work per week.
They made weekly telephone calls to
each assigned mother, and worked to
build a supportive relationship with
each family. The intervention also
included a series of 15 educational
workshops facilitated collaborative-
ly by parent advocates and mental
health professionals. The workshops
provided opportunities for PSPs and
families to meet each other, strength-
en support networks, and share exper-
tise. The goal of these activities was to
provide informational, affirmational,
and emotional support to participat-
ing parents.
Informational Support is shared in-
formation about childhood behaviors,
developmental transitions, parenting
skills, coping techniques, and com-
munity resources. This type of sup-
port can be offered over the phone or
by mail. However, a large part of this
support occurred during our educa-
tional workshops. These sessions pro-
vided a safe environment for parents
to admit what they didn’t know, the
first step toward building a stronger
foundation of knowledge. In addition,
the PSPs helped their assigned moth-
ers identify difficulties, issues, or un-
met needs, and then modeled various
ways to find alternative strategies for
resolving these issues or meeting these
needs. PSPs also encouraged mothers
to discuss their children’s care with
mental health and education profes-
sionals and to increase their access to
relevant and up-to-date information,
knowledgeable advice-givers, and
needed services.
Affirmational support is focused
on enhancing a mother’s confidence
in her own parenting. PSPs sought to
reassure mothers that their concerns
were appropriate and shared by others
in similar situations. To do this, PSPs
continuously sought out opportunities
to identify parenting competencies.
This feedback encouraged mothers’
positive self-evaluations and elevated
them to the roles of “expert” and po-
tential “advisor.”
The PSPs provided emotional sup-
port by establishing a relationship of
trust. They aimed to listen closely to
a mother’s concerns, demonstrate a
continued interest in her viewpoints
and experiences, and communicate
an understanding of her feelings.
PSPs also encouraged the growth of
mothers’ natural support networks
by discussing means for finding and
strengthening emotionally supportive
relationships with relatives, friends,
church members, and other key peo-
Program Theory
Parent Connections is a family-
to-family support program that en-
compasses five primary principles or
assumptions that are drawn from spe-
cific theories of social support and re-
lated concepts. (For further details see
Ireys, DeVet, & Sakwa, 2002.)
A strong support network linking
relevant information and resources
can improve parents’ responses to the
challenges of raising a child with a
serious emotional or behavioral dis-
order. Basic information about where
to get help, how to overcome adminis-
trative obstacles, and how to perform
effectively in crisis situations was pro-
vided through PSP contacts and the
educational workshops. Increasing a
parent’s knowledge level in this way
can contribute to more effective par-
enting, thereby improving a child’s
functioning and preventing further
deterioration of his or her mental
Support can help parents deal
more effectively with their own wor-
ries and doubts. Virtually all parents
of children with serious emotional
or behavioral disabilities have serious
doubts about whether they have the
knowledge and emotional resources
required to help their children grow
into capable, independent adults. En-
couragement by a trusted supporter
can help parents overcome their fears
and manage their potentially crippling
Support can diminish feelings of
stigma. Parents of children with seri-
ous emotional or behavioral disorders
often cannot find naturally occurring
sources of support in their communi-
ties because stigma prevents parents
from freely discussing their child’s
emotional or behavioral disorders with
relatives, neighbors, or church congre-
gants. Without personal knowledge
of the causes, signs, and treatment of
children’s emotional disorders, family
members, neighbors, and others are
not likely to understand the special
challenges parents face. Too often,
this lack of empathy leads to blaming
and judgmental thinking. As a result,
the parent and child become isolated
from those who should serve as their
Encouragement by a trusted supporter can
help parents overcome their fears and manage
their potentially crippling anxiety.
Winter 2006, Vol. 20 No. 1
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FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health
system of natural supports. The process
of family-to-family support essentially
“grafts” experienced parents into the
social network of families struggling
with their child’s behaviors and needs.
Family-to-family support may allow
professional treatment to work more
effectively. Parents who have sufficient
support may be more likely to stay in
treatment, develop collaborative re-
lationships with the child’s therapist,
make use of resources in the educa-
tional system, and implement effective
behavior management techniques at
home. Confident, knowledgeable par-
ents are more capable of partnering
with providers from various child-serv-
ing systems. Overall, family support
and education programs can increase
the value of mental health and educa-
tional services.
Building parents’ knowledge and
skills can produce a heightened sense
of efficacy, both at home and within
the mental health and education sys-
tems. Parent Connections designed
workshops to increase parents’ capacity
to identify and advocate for more ap-
propriate services to meet their child’s
needs, use behavior modification tech-
niques effectively with their child, and
be aware of their own strengths and
limitations. Better skills in these areas
can lead directly to behavior changes at
home and better access to appropriate
Implementation Challenges
In the process of developing, imple-
menting, and evaluating Parent Connec-
tions, we encountered several obstacles.
First, we had to find the right PSPs. Al-
though many parents of children with
serious emotional and behavioral dis-
abilities want to “give back” and help
other parents, an effective PSP requires
additional attributes. These include be-
ing able to listen carefully, to distinguish
between “help” and “support,and to
manage their own emotional reactions
to the struggles of other families. There-
fore, we required PSPs to be parents of
young adults who had received mental
health services as a child or adoles-
cent. This allowed them to communi-
For so many years, I wore an invis-
ible mask. Before I came to Fam-
ilies Involved Together, the acronym
F.I.T. meant Faking It ‘Till (I make
it). As a wounded child, one of my
disguises was laughter. Unfortunate-
ly, I made poor choices in men that
led me to becoming a single mother.
Though I love my son very much, his
special needs
presented great
challenges. The
of motherhood
brought on ad-
ditional stress
that caused me
to indulge in
unhealthy be-
havior. Years
later, I finally
sought help from
a wonderful community program and
I began to put my life’s puzzle back
together. While this process set my life
on a better path, I had not totally let
go of my mask.
One day, I ran into a friend who was
working as a Parent Support Partner
at Families Involved Together. She
said FIT was looking for new sup-
port partners and that I should call
for an interview. I was accepted and
invited to participate in FIT’s Par-
ent Connections project. I attended
many hours of training that prepared
me to offer constructive encourage-
ment toward growth and insight by
parents just like myself. The sessions
were quite intense at times. We were
learning information and skills that
I wished I had known while raising
my son. Despite that regret, I noticed
that something new was happening
to me.
Eventually, I was matched with sev-
eral parents who were going through
what I had struggled with years be-
fore. Many began the Parent Connec-
tions workshops looking very down-
trodden. They felt as if they had come
to the end of the line. They expressed
great fear for their children’s future—
and their own.
My assigned parents and I spoke by
phone during the week and met in-
person at the scheduled workshops.
These educational sessions presented
ideas and skill-
building that
these parents
had never ex-
perienced. In
time, the par-
ents seemed
to develop a
sense of trust
and affection
when we spoke
or met. When
they graduated,
the mothers were no longer sad and
apprehensive. They were bright and
hopeful. They shared with me how
much the program—and I—had
meant to them. I listened to them tell
me how much I had done for them
and the changes they were able to
make because of my friendship and
I was, of course, very proud and
happy for their success knowing I had
contributed to it. But more than that,
I also began to realize that, some-
how, my own life had also totally
changed—a metamorphosis of sorts.
I had dropped my wooly outer layer,
which was my defense mechanism.
I had emerged as something quite
beautiful. Now clothed with knowl-
edge and truth, I was able to fly above
past circumstances and soar into my
own fantasy. I had arrived! I finally
had discovered my true “FIT” and
become the person I was meant to
be—one without a mask, one without
Lena Gladden
Winter 2006, Vol. 20 No. 1
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FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health
cate their personal experiences while
maintaining some emotional distance
from the day-to-day issues of raising
a young child. We also established
a three-stage process for recruiting
PSPs. In the first stage, we developed
an interview that assessed a mother’s
ability to maintain boundaries and ob-
jectivity, avoid being judgmental, and
encourage trust and self-confidence in
others. In the second stage, all parents
who were accepted on the basis of the
interview participated in a short-term,
skill-building training. This served as a
way for us to get to know them and for
them to get to know the program. In
most cases, those who were not suited
for the position dropped out. Those
who stuck with the program partici-
pated in the third stage of the train-
ing: an intensive program designed to
further strengthen their listening and
communication skills.
Second, we had to find a way to
invite families to participate in Par-
ent Connections. We pursued several
routes, including a general invitation
to families associated with Families
Involved Together. In addition, we
worked with all of the major child
mental health clinics and schools in
the area to help identify parents who
might be interested in participating.
Third, we needed to provide con-
tinuing support to PSPs during the
months in which they were working
with families. To accomplish this,
PSPs met weekly with the program
directors to share their own concerns,
find their own affirmational support,
and develop effective ways of respond-
ing to difficult situations that arose
with their assigned families. The soli-
darity that developed within the team
of PSPs was critical in sustaining their
commitment to the project.
Fourth, it was important for ad-
ministrative purposes to ask PSPs to
document their work. The PSPs were
effective listeners, coaches, and advo-
cates but, for some, recording their
good works proved quite formidable.
The process for tracking their activities
had to be modified more than once to
accommodate the needs of both the
PSPs and supporting agencies. Even-
tually reporting forms were developed
that combined the right levels of sim-
plicity and comprehensiveness.
Our final hurdle was obtaining ad-
ditional funding to continue the pro-
gram after the research project was
complete. Despite positive results
from the evaluation, it was difficult to
identify a continued funding source
because this type of program is not
typically reimbursable under public
or private health insurance plans. We
were, however, able to combine the
dollars of two private foundations to
continue Parent Connections for one
year beyond the study.
Evaluation Results
We evaluated Parent Connec-
tions using a randomized controlled
clinical trial design with two groups:
a low-dose control group and an ex-
perimental group. The control group
received a packet of information on
services and resources for families of
children with serious emotional disor-
ders. The experimental group received
the identical information packet. Ad-
ditionally, they were offered the op-
portunity to participate in the full Par-
ent Connections program.
Although the evaluated program
lasted 15 months, data were collected
at enrollment and 12 months post-
enrollment. We used this approach
because our experience with similar
studies suggested that measuring out-
comes at the very end of a project can
lead to detecting temporary negative
effects brought about by a sense of
loss as the program is terminating.
This common response by partici-
pants can obscure an otherwise more
enduring positive effect. In addition,
we viewed one year as a more natural
intervention assessment period than
15 months.
The project utilized data collected
from 257 families enrolled at base-
line. We examined effects on child
functioning and the impact on ma-
ternal mental health and perceived
support. Perceived social support was
measured using items from the Mul-
tidimensional Social Support Inven-
tory (MSSI; Bauman & Weiss, 1994).
These items were used to assess per-
ceived availability of support across
five areas, including having someone
to confide in or having someone to
talk to about the child’s needs. For ex-
ample, one item asks: “Does anyone
show that they are interested in and
want to understand your concerns
about raising a child with a serious
emotional or behavioral disorder?”
Items from this scale have been used
in prior evaluations of similar parent
support programs (Ireys, et al., 1996;
Ireys, et al., 2001). To assess perceived
adequacy of support, interviewers
asked parents whether they got the
support they needed all, most, some,
or none of the time.
On the measure of perceived
Winter 2006, Vol. 20 No. 1
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FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health
breadth of support, the mean increase
for the experimental group was sig-
nificantly greater than for the control
group. At the second data collection
point, all participants were asked
“whether there was ever a time in the
last year when you wished you could
have talked to someone about your
child’s condition,” and, if they did
wish this, whether they actually talk-
ed to anyone. About three-quarters
of mothers in the experimental group
indicated that they wished they could
have talked to someone and of these
about three-quarters actually did so.
In contrast, about two-thirds of moth-
ers in the control group indicated that
they wished they could have talked to
someone and of these only about half
actually did so.
To assess changes in maternal
mental health status, we examined
whether the two groups differed with
respect to change in levels of anxi-
ety. Nine percent of the mothers in
the control group moved from high
anxiety at baseline to lower anxiety 12
months later. In contrast, 22 percent
of the mothers in the experimental
group moved from high to lower anxi-
This study is an example of a
methodologically strong evaluation of
a theory-driven, family-to-family sup-
port program for low-income families
with high-risk children and multiple
other stressors. Overall, the study pro-
vides evidence that Parent Connec-
tions produced modest positive effects.
It is not surprising that the program
demonstrated only a modest impact
in light of the many factors that influ-
ence the functioning of low-income,
urban families. Nevertheless, what we
have learned represents an important
step toward a better understanding of
how to support parents of children
with serious emotional or behavioral
disabilities. Our findings should en-
courage further study of Parent Con-
nections or other well-defined models
of family-to-family support.
Bauman, L. & Weiss, E. (1994, May).
Psychometric properties of the Multi-
dimensional Social Support Inventory.
Paper Presented at the Psychosocial
and Behavioral Factors in Women’s
Health Conference. Washington, DC.
Cobb, S. (1976). Social support as a
modifier of life stress. Psychosomatic
Medicine, 38, 300-314.
Ireys, H., DeVet, K. & Sakwa, D.
(2002). Family support and educa-
tion. In B. Burns & K. Hoagwood
(Eds.), Community Treatment for Youth.
New York: Oxford University Press.
Ireys, H., Chernoff, R., DeVet, K., &
Kim, Y. (2001). Maternal outcomes
of a randomized controlled trial of
a community-based support program
for families of children with chronic
illness. Archives of Pediatrics and Ado-
lescent Medicine, 155, 771-777.
Ireys, H., Sills, E., Kolodner, K., &
Walsh, B. (1996). A social support
intervention for parents of children
with Juvenile Rheumatoid Arthritis:
Results of a randomized trial. Journal
of Pediatric Psychology, 21, 633-641.
Diane Dvoskin Sakwa has ad-
dressed the need for change in child
and adolescent systems of care as both
parent and advocate by sharing her
encouragement, knowledge, and voice
with thousands of families and profes-
sionals for close to 20 years.
Henry T. Ireys is currently a Se-
nior Researcher at Mathematica
Policy Research, Inc., in Washington
DC and for many years has been ex-
amining the effectiveness of support
programs for families of children with
special needs.
Building parents’ knowledge and skills can
produce a heightened sense of efficacy, both
at home and within the mental health and
education systems.
Winter 2006, Vol. 20 No. 1
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FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health
Parents in Kansas
whose children have
or are at risk of emotional
and/or behavioral prob-
lems call Keys for Net-
working seeking help. Par-
ents call when they cannot
get the response they need
from agencies. Most report
feeling isolated, alienated,
disconnected, alone, or
abandoned, even by fam-
ily members. They often
doubt their ability to help
their own children. In the
process of learning how to
obtain effective plans and appropriate
programming, however, they become
connected with a statewide social sup-
port network that offers contact with
other parents who have had similar
experiences. Keys for Networking, or
“Keys,” is this statewide organization.
It is managed and staffed by parents.
Since 1987, Keys has offered peer-
to-peer support to parents so they can
advocate first for their own child, and
then for other children. Not only do
Keys’ parent staff meet callers’ imme-
diate needs for information, they strive
to connect parents to other parents so
they can support each other. Keys de-
velops and sustains the network by
supporting long-term relationships
between Keys and parents, among
parents in the network, and between
parents and their child’s providers.
With targets and benchmarks to
engage parents at their level of experi-
ence and interest and to affirm their
role as primary decision maker for
their child, the Keys Targeted Parent
Assistance (TPA) model includes pro-
cedures, interventions, and technolo-
gy-based tracking mechanisms. Devel-
oped with support from the American
Institutes for Research, TPA provides
the system infrastructure to create
and sustain parent connections. With
TPA, the parents who have received
help and become connected to the
network develop into help-givers and
sustainers of the network: They hold
the keys to networking.
TPA is based on a ten-level con-
tinuum that was developed from Dr.
Barry Kibel’s Outcome Engineer-
ing (Kibel, 1996) and Journey Map-
ping (Kibel, 2000). The continuum
describes the movement of parents
toward family and system advocacy.
Using the continuum, Keys staff de-
tails each parent’s progression from
seeking help to emerging as a problem
solver to becoming a systems change
agent. Figure 1 depicts the continu-
um’s ten levels of parent engagement
and groups them into three stages: Ini-
tiation, Solution-Focused, and Expand-
ing Interests.
In the Initiation stage, the three lev-
els are about “getting to know you.”
Parents at level 1 call Keys seeking
information about what Keys can
do for them. Keys staff provide im-
mediate answers to “What do I do
know?” questions and offer Keys and
local service contact information and
emotional support. Parents remain
at level 1 until they initiate a second
contact. At level 2, parents may say,
“I am interested in more
information. Tell me more
about exactly what I can
do.” Staff limit discussion
to the questions asked and
encourage parents to at-
tend Keys’ trainings related
to their interests. They of-
fer mileage, childcare, lodg-
ing, and travel connections
with other parents from
their geographical area.
Connecting families, with
their permission, builds
relationships and increases
the likelihood that new
parents will attend. It sustains the
commitment of experienced fami-
lies and involves them as mentors to
new families. Parents move to level 3
when their actions—such as complet-
ing training—indicate deepening in-
volvement. The support relationship
between Keys and parents at level 3
evolves into exploring larger system
and family issues.
At the Solution-Focused stage
(levels 4-6), parents work with staff
on strategies to improve and monitor
planning documents, secure neces-
sary services, and integrate program-
ming. At level 4, parents contact Keys
frequently and Keys staff call them
to revise Individualized Education
Plans, mental health treatment plans,
wraparound plans, and other formal
service planning efforts. Staff may
attend meetings to support the fami-
lies. At level 5, parents report that
some part of the original problem
that brought them to Keys is resolved:
“My child is back in school,” or “We
have attendant care.” At level 6, par-
ents have resolved their initial prob-
lem and decide to take on additional
areas of concern. Parents at this level
may say, “Help me think about how
to do this.” During this stage, staff en-
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FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health
gage parents to expand their skills and
self-confidence. Staff members invite
them to attend sophisticated trainings
on topics such as IDEA legislation
and wraparound facilitation.
The Expanding Interests stage (lev-
els 7 through 10) focuses on outreach
to others and system issues. This stage
begins at level 7 when parents offer to
help other families. They may say,
“I would like to get involved. How
can I help someone else?” or “I don’t
want what happened to me to happen
to anyone else.” These words denote
expanding interest outside one’s own
family. Responding quickly to these
statements with training and help-
ing opportunities is critical. At level
8, parents complete training to help
others. At level 9, parents assist other
parents. They call Keys often, not for
themselves, but for advice to further
their work with others. They are at-
tending meetings, revising plans, and
sharing advice with other families. At
level 10, parents ask for assignments
to work on local and state commit-
tees, join boards, testify to legislative
bodies, and participate in policy-mak-
ing efforts. They serve as vocal and
effective system advocates, offering
testimony in very public forums. They
support and organize other parents
and sustain the family organization
and state services. They have come
full circle, returning the help they got
from Keys to other families in a wide
variety of ways, facilitated by an orga-
nization whose mission is to build a
statewide network of informed fami-
Monitoring individual parents and
groups of parents along the TPA con-
tinuum, Keys staff members provide
information and support appropriate
to the parents’ readiness level, while
also promoting movement to higher
levels. TPA marks change increments
in parents’ engagement with Keys and
with service providers and systems. It
documents the interventions offered
and tracks the usefulness to parents
of Keys’ suggestions by check-in calls
to parents at least monthly that al-
low staff to ask, “What is working?”
When parents do not respond or do
not show up at a meeting, staff mem-
bers examine contact notes to iden-
tify problems with Keys’ intervention.
They may determine that the interven-
tion was sound but was offered at the
wrong level of the parents’ readiness
to use it.
The majority of parents move
quickly through the first three lev-
els (averaging 2.5 months per level),
slowing when they reach level 4. Lev-
els 4-6 average 4.6 months per level,
and levels 7-10 average 6.3 months per
level. Graph 1 (adapted from Cheon
& Chamberlain, 2003) shows the av-
erage duration of time at each level.
Time is an important consideration in
building relationships and establishing
reasonable expectations when asking
parents to deepen their involvement,
complete training, attend meetings,
advocate for their child, or commit to
system change efforts.
The Keys TPA model provides
the structure to document process
and outcomes. Staff members track
the interventions delivered and note
which ones move parents forward.
Data from a study conducted by the
University of Kansas School of Social
Welfare (Cheon and Chamberlain,
2003) show that parents move for-
ward over time along the continuum.
The data shows that parents who
reach higher levels of engagement on
the TPA continuum stay active with
Keys over longer periods of time than
parents scoring at lower levels. Only
26.3% of low-level (1-4) parents main-
tain contact with Keys for two years,
compared to 67.2% of high-level (5-
10) parents. Most parents who be-
come inactive do so at level 1 (50.4%).
The data shows that only 29% of mi-
nority parents remain active after two
years compared to 44.5% of Cauca-
1. Seeks information
2. Initiates additional contact
3. Commits to address problem
4. Works on Problem
5. Resolves initial problem
6. Takes on new problems
7. Offers to help others
8. Completes training to help others
9. Helps others
10. Impacts local, state, national policy
Winter 2006, Vol. 20 No. 1
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FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health
sian parents.
To improve retention and promote
depth of engagement, staff must re-
spond quickly at lower levels (1-3) to
parents needs with interventions that
parents find useful and that are appro-
priate to parents’ concerns and inter-
ests. Concerns vary by stage, as do
parents’ ability to use the information
provided. At the Initiation stage (lev-
els 1-3), 30.4% of parents ask about
Keys program information, 20.3%
have service system concerns (mental
health, child welfare, juvenile justice),
and 19.8% have specific school issues.
They really want to know most what
Keys can offer and what service pro-
viders should do. At this stage, the
most useful intervention is to answer
the specific questions asked. With very
different interests at the Solution-Fo-
cused stage (levels 4-6), the majority
of parents want help resolving specific
service concerns. At the Expanding
Interests stage, 30.3% of parents had
questions about Keys’ programs and
services, 28.9% had no concerns, and
19.7% had service system concerns.
In the Expanding Interests stage, par-
ents want Keys to support them to
assist other parents, to invite them to
serve as spokespersons at events, and
to bring parent voice to boards. Keys
staff link these parents to people and
programs where they can serve, train
them in sophisticated content areas,
and encourage them to call when they
need help with their own children.
Table 1 (also adapted from Cheon
and Chamberlain, 2003) identifies the
frequency of Keys’ interventions of-
fered by stage. In the Initiation Stage,
when most parents call to learn what
Keys can do for them, 46.6% of the
interventions involve description of
Keys’ services and an invitation to
Keys events. During the Solution-
Focused stage, Keys’ most frequent
interventions are discussing options
and following up to make sure issues
are resolved. At the Expanding In-
terests stage, the interventions focus
on linking these advanced parents to
Keys activities where they can serve
as spokespersons and following up
to provide them with what they have
asked of staff.
Bobbie’s story illustrates the jour-
ney of one parent who has benefited
from TPA and demonstrates her
growth from family crisis to fam-
ily and systems advocacy. Her testi-
mony shows her commitment to her
own children and her drive to learn,
to transfer what she knows to help
other families, and to build service
pathways across Kansas for families
whose children have serious emotion-
al and/or behavioral problems. Her
children still have many problems, but
her capacity to manage them and re-
late effectively to the service world has
changed dramatically. She is a parent
who Keys helped and who now helps
Keys and all Kansas families.
My interest in advocacy began six years
ago when I met the people at Keys for Net-
working. Before I knew the Keys staff, I
was too afraid to leave my house. I was
raising four children on my own. In May
1999, I attended a conference in Topeka.
Keys staff held parent information meet-
ings and provided childcare during these
meetings. It was at this meeting that I got
their phone number. I kept the number al-
most a year before I called to ask questions
about why it was taking so long to get my
son’s testing done. I talked to Angie, who
told me she was a parent of a child with
serious emotional problems. She suggested
I talk to the IEP team about my concerns.
She called me back four days later to ask
how I did. I could not believe it. She invit-
ed me to a training about my child’s school
rights. I said yes on the spot. She told me I
could attend by phone and would not have
to leave home. At that training I connected
with other parents whose children had the
same problems as mine. I learned that my
son was eligible for additional services. I
requested additional testing and the school
The Keys staff started calling me, to
check on me, they said. For almost a year,
I did not return their calls. They left mes-
sages to call if I needed help. In August of
2001, I attended the annual Keys Oscars
event. I nominated my son’s case manager
for an award, which she won. In October
2002, Keys hired me to bring parents to a
meeting with the Department of Educa-
tion about the connection between NCLB
[the federal No Child Left Behind Act] and
reauthorization of IDEA [the Individuals
with Disabilities Education Act]. About
this time, my younger son started getting
in trouble. I knew what to do. I asked for
a special education evaluation and started
him on an IEP. I started thinking maybe
other parents could use my help. I attended
Graph 1: Duration of Stay at Levels by Month
Winter 2006, Vol. 20 No. 1
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FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health
benefits them and allows them to give
back what they learn. TPA provides
opportunities for parents to affiliate
with a large body of Kansas parents
who represent the 70,000 children
(10% of Kansas’ youth population)
whom the Kansas State Department
of Social and Rehabilitation Services
estimates have serious emotional dis-
turbance. They see that they are not
alone. As parents grow in their self-
advocacy abilities, they also experi-
ence a renewed (and in some cases
new) sense of self-worth and capacity
to help others. When parents take the
step of offering to assist and advocate
for other families with Keys’ support,
their sense of belonging and feelings
of reciprocal services to Keys and to
the community of parents is strength-
ened. Parents who experience success
in helping other families recognize
the magnitude of need on a system-
wide level and are welcomed to the
network of parent advocates through
trainings and meetings, and they are
given other opportunities to speak for
children and families in policy-mak-
ing activities.
Cheon, J., & Chamberlain, R. (2003).
Targeted parent assistance: What Keys for
Networking, Inc. did for the families and
children with mental health problems in
Kansas. [Unpublished manuscript].
University of Kansas School of Social
Welfare, Lawrence, KS.
Kibel, B.M. (1996). Evaluation using
results mapping. New Designs for Youth
Development, 12, 9-15.
Kibel, B.M. (2000). Outcome engineer-
ing toolbox. Pacific Institute for Re-
search and Evaluation.
Jane Adams is Executive Director
of Keys for Networking, the statewide
organization of the Federation of
Families for Children’s Mental Health.
Dr. Adams represented the child fam-
ily consumer voice on the President’s
New Freedom Commission on Men-
tal Health, 2003.
Elizabeth Westmoreland ana-
lyzes Keys’ monthly TPA records and
reviews them for progress and suc-
cess/failure of interventions offered.
Her adult sister and brother and her
mother have chronic mental illnesses.
Corrie Edwards is Program Direc-
tor at Keys for Networking. Corrie has
a sister who has experienced chronic
mental and emotional problems.
Sarah Adams is Director of Infor-
mation Systems and programmer for
the Filemaker Pro data base, which in-
tegrates daily journaling by staff with
the Keys 1-10 targeted outcomes.
wraparound and parent support
trainings and then called Keys for
direction on how I could help
a family get mental health ser-
vices for their child. In March
2003, Keys called to give me
information about legislative
issues and encouraged me to
talk to senators and representa-
tives if I cared to discuss these
topics. They gave me my legis-
lators’ names and phone num-
bers. I was invited to attend
Mental Health Advocacy Day
at the Capitol. In July of 2003,
Keys invited me to serve on their
NCLB state advisory council.
In May 2004, Dr. Adams called
to ask if I would help a family prepare for
a wraparound meeting so their child could
come home from the hospital. I did. Also,
the Governor appointed me to the Mental
Health Services Planning Council. At that
point, I was feeling pretty connected.
Then in July my daughter tried to com-
mit suicide. I was so overwhelmed I did
not know where to turn. Keys staff came
to my aid and fast. They kept telling me I
was a good mother and that I knew what
was best for my child. They said they were
behind me all the way. They encouraged
me to ask for a 504 Plan to help my daugh-
ter succeed in school. In September 2004,
I testified at the Capitol, encouraging
the legislature to develop policies against
school seclusion and restraint. In May
2005, I facilitated a group at the Freedom
Commission Goal 4 Summit with over
200 people. I brought my daughter and
she participated. Recently, I called for help
with my son’s IEP and the wording for
his behavior plan. The problems with my
children don’t stop. Most of the time I am
able to handle them. I know where to get
help when I need it. I am not afraid any
more to ask for help. Other parents in my
community see me as a resource when they
need help. And, through me, they see Keys
as a resource when I cannot help them.
TPA is a reciprocity model. Parents
who seek help become help givers. By
design, they join a state network of
natural and professional supports that
Interventions Initiation Solution-
Interests Total
Information 6.8% 12.4% 14.3% 10.9%
Discuss options 13.2% 22.9% 15.6% 19.2%
Follow up issues 18.3% 35.0% 37.7% 30.2%
Refer to others 7.3% 7.7% 2.6% 7.0%
Provide advocacy
& action 7.0% 9.1% 6.5% 8.4%
Describe and/or
invite to Keys
46.6% 12.9% 23.4% 24.2%
Winter 2006, Vol. 20 No. 1
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FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health
This article reviews a number of
techniques for assessing a fami-
ly’s social support network. Some of
the techniques are typically used in
care planning or treatment to gather
information about support that can be
mobilized to help families meet needs
or reach goals. These assessments are
usually easy to use and can be adapt-
ed for use with adults, adolescents, or
children. Other techniques are more
formal and are used to measure social
support for research and evaluation
Techniques for assessing social
support are valuable in a wide range
of planning, intervention, and evalu-
ation contexts; however, this article
focuses on how they can be used
by wraparound teams or programs.
Wraparound is a collaborative, fam-
ily-driven process for creating indi-
vidualized plans of care for children
and youth with emotional or behav-
ioral difficulties. One of the principal
goals of the wraparound process is to
strengthen the family’s social support
and community connections.
Informal Assessment
Social support assessments are use-
ful in the wraparound process because
they help the team pay attention to
important information that may oth-
erwise be overlooked. Given the em-
pirical evidence for the importance of
social support for families caring for
a child with a disability (Beresford,
1994; McDonald, Gregoire, Poertner,
& Early, 1997; Snowdon, Cameron,
& Dunham, 1994), the identification
of actual and potential social support
resources is an essential part of the
team’s assessment process. Individuals
who offer informal supports to parents
or youth can be valuable resources in
the implementation of a plan of care.
What is more, these individuals will
probably be available for the youth/
child and family after wraparound and
other formal services have ended.
An ecological map or eco-map (fig-
ure 1) is one technique that teams can
use to show a family’s relationships
with helping resources. To create an
eco-map, the team begins with a piece
of paper that has a large circle (repre-
senting the family) in the middle, and
a number of smaller circles around
the larger circle. Family members
are asked to identify both people and
services that serve as resources for
them. Possible resources are extended
family, church, recreation activities,
friends, health care, and school.
The family then indicates the nature
of the connections between themselves
and the resources by drawing different
kinds of lines between the large circle
and the smaller circles, and/or using
a descriptive word that can be writ-
ten on the map. Typically, a strong
positive connection is indicated by a
solid line, a moderate connection by
a broken line, and a stressful connec-
tion by a line with slanted lines drawn
through it. Arrows can also be used
to illustrate whether the relationships
and flow of resources are reciprocal,
or in one direction only. The team can
use the information on the completed
map to identify supports that may be
useful in the development of the ser-
vice plan and to identify gaps where
additional supports may be needed.
Another tool for depicting the rela-
tionships between a caregiver and her
age 34
age 12
Eco-Map by
Jan M. Markiewicz
Winter 2006, Vol. 20 No. 1
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FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health
social systems is the Social Network
Map (Tracy & Whittaker, 1990). This
instrument attends to both the struc-
ture (the number and quality of social
relationships) and the function (the
various types of supportive exchanges)
of informal social supports. A circle
mapping technique is used to portray
network members and a grid is used to
identify the supportive and non-sup-
portive functions of relationships. For
example, who provides what types of
supports, which relationships are con-
flicted, and which are reciprocal? In-
formation is collected about network
size, reciprocity, perceived availability
of support, closeness, directionality,
stability, and frequency of contact.
There can be a number of advantag-
es of using the Social Network Map.
The map helps to identify and evalu-
ate not only resources but also sources
of stress and strain within the family’s
social environment. Responding to
the mapping and grid questions helps
caregivers review existing resources
and identify new sources of poten-
tial support. Using the tool may also
provide a vehicle for discussing other
issues, such as current stressors, that
the caregiver may be experiencing. Fi-
nally, caregivers sometimes find that
using the instrument is empowering,
because it helps identify specific steps
they can take to use their networks
more effectively.
The Community Connections and
Team Composition Questionnaire,
designed by the King County Blend-
ed Funding Evaluation Team (2001),
creates a list of the individuals, ser-
vices, and activities that a youth has
been connected to over the past three
months in five categories: family,
friends, school/work, community, and
formal services. After all the supports
are listed, the parent rates the strength
of the connection on a scale of 0 to
3, with 3 being the strongest connec-
tion. As a final step, the parent identi-
fies the members of the wraparound
team, if there is
one, and provides
information about
how often each
person attends the
team meetings and
the types of sup-
port that the team
member provides
for the parent and/
or the child.
Model (EMQ
Children & Fam-
ily Services, 2003)
is another tech-
nique that is used collaboratively with
a child and family to discover social
supports and connections. The tech-
nique is used to generate a Connected-
ness Diagram (Figure 2). The diagram
begins with a genogram, which shows
the child’s biological relationships
using horizontal tiers for the child’s
generation, parents’ generation, and
grandparents’ generations. This part
of the diagram is done in blue. The
next step is to identify the individuals
who the child loves, and by whom the
child feels loved. These connections
are done in red, to represent the heart,
and may extend beyond the biological
relatives and include friends, teachers,
coaches, siblings, foster grandparents,
etc. The color green, standing for the
fertile and creative mind, is used to
represent those from whom the child
learns and those the child teaches.
These may include teachers, siblings,
aunts and uncles, coaches, and others
with whom the child has a positive
connection. The spiritual dimension
is diagrammed in yellow, represent-
ing the light of the soul. As each of
these individuals and resources is
identified, the team can ask whether
they can be mobilized as a strength or
support, or whether they can provide
a specific activity that can be built into
the child’s service plan.
Teams should keep several things
in mind when assessing social sup-
port using any of these techniques.
First, information gathered through
such a process may be limited since
the data is self-reported. It can be af-
fected by factors such as the type of
social support, the individual’s recall
skills, and social desirability. Through
using the instrument, the team may
overestimate or underestimate the
social network’s strengths and capac-
ity for offering support, as well as the
family’s capacity for receiving sup-
port. Interpersonal relationships also
change over time, and change may be
particularly likely when the team at-
tempts to increase the support offered
by particular individuals in a family’s
interpersonal network. Thus, the team
should remember that the assessments
provide only a starting point for an
evolving understanding of the family’s
social network and its potential for of-
fering support.
Any structured instrument can
also miss population-specific or cul-
tural nuances related to social sup-
port. For example, in one study of so-
cial support, parents of a child with a
chronic disability reported the unique
challenge of resource maintenance
within their support network (Breg-
man, 1980). Given the long-term na-
ture of their child’s challenges, par-
ents’ supports can burn out unless
parents direct attention and resources
into maintaining and re-fueling the
members of their support network. In
addition, reciprocity with the social
support network is difficult because
the parents’ needs are often large
and ongoing. A structured technique
may miss these aspects and, thus, ig-
nore the risk of the family depleting
or losing a vibrant support network.
Cultural differences in the types of in-
teractions that are seen as supportive
have been documented. People from
Winter 2006, Vol. 20 No. 1
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FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health
different cultures also may have differ-
ent ideas about the kinds of support
or resources that can be appropriately
exchanged between friends and rela-
tives. Being aware of these differences
can help the team make adjustments
as new information about a family’s
social support network emerges over
Formal Assessment
The techniques that are described
above are useful for child and fam-
ily teams because they are directly
related to the team’s purpose--the
development and implementation of
an individualized service and support
plan. In research and formal program
evaluation, social support is often in-
cluded as an independent variable,
contributing to positive child and
family outcomes, or as a dependent
variable when the research question
is about how social support can be fa-
cilitated and maintained. There are a
number of standardized instruments
that are used to assess social support
in these studies.
The Inventory of Socially Sup-
portive Behaviors (ISSB; Barrera,
1981) is a 40-item self-report measure
of received support. Its purpose is to
gather information regarding the sup-
port recipient’s perceptions of avail-
able social support. Respondents are
asked to assess the informal supports
received from different individuals
during the past 30 days using a 5-point
scale from 1 (not at all) to 5 (about ev-
ery day). Concurrent validity of the
ISSB total score with measures of net-
work size has been demonstrated with
correlations of .24 and .42 (Barrera &
Sandler, 1984). Internal consistency
coefficients range from .90 to .94,
with a test-retest reliability over a one-
month interval of .80 (Barrera, 1981).
The Quality of Relationships In-
ventory (QRI) was developed to as-
sess perceived availability of support
in specific relationships and is based
on the interactional-cognitive model
that distinguishes between general
and relationship-specific perceptions
of social support. The QRI is com-
posed of three separate dimensions
labeled support, depth, and conflict.
The QRI is a self-report questionnaire
with 25 items that participants rate us-
ing a four-point scale regarding their
perceptions of a specific relationship.
It takes approximately four minutes to
complete for each relationship. Stud-
ies testing the psychometric properties
and validity of the QRI scales reflect a
broad range of methodologies, includ-
ing cross-sectional, longitudinal, ex-
perimental, observational, and retro-
spective designs. Internal consistency
for each of the scales has been shown
to be high, with Cronbach’s Alpha in
the .80’s and .90’s. In addition, QRI
scores have high test-retest reliability,
with correlations between scores on
each scale across a four-month period
ranging from .66 to .82, with an aver-
age correlation of .75 (Pierce, 1994).
Winter 2006, Vol. 20 No. 1
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Some research studies also collect
data on social support through ob-
servations of child and family team
meetings. For example, observers will
record whether one or more natural
helpers are present at the meeting,
whether social support is mentioned
and/or assessed during the meeting,
and whether social support is includ-
ed in the family’s service plan.
Social support assessments are
obviously useful in both practice and
research. Informal assessments help
stimulate thinking about ways that
interpersonal relationships can be
mobilized to help children and fami-
lies meet needs and achieve goals.
More formal assessments help devel-
op knowledge about whether or not
strategies designed to increase social
support actually succeed in doing so,
and whether increasing social support
contributes to other positive outcomes
for children and families. It is impor-
tant to remember, however, that these
assessments are only approximations
of what a family’s “real” social sup-
port network may be. Social support
is a complex concept and a complex
phenomenon, and knowledge about
the best ways to measure social sup-
port continues to evolve.
Barrera, M. J., Sandler, I. N., & Ram-
say, T. B. (1981). Preliminary deve-
lopment of a scale of social support:
Studies on college students. American
Journal of Community Psychology, 9,
Beresford, B. A. (1994). Resources
and strategies: How parents cope with
the care of a disabled child. Journal of
Child Psychology & Psychiatry & Allied
Disciplines, 35, 171-209.
Bregman, A. M. (1980). Living with
progressive childhood illness: Paren-
tal management of neuromuscular
disease. Social Work in Health Care,
5(4), 387-408.
EMQ Children & Family Services
(2003). Using the EMQ Connected-
ness Model. Campbell, CA: Author.
King County Blended Funding Evalu-
ation Team (2001). Community Con-
nections. [Questionnaire]. Renton,
WA: Washington State Organization
of the Federation of Families for Chil-
dren’s Mental Health.
McDonald, T. P., Gregoire, T. K., Po-
ertner, J., & Early, T. J. (1997). Build-
ing a model of family caregiving for
children with emotional disorders.
Journal of Emotional and Behavioral
Disorders, 5, 138-148.
Pierce, G. R. (1994). The Quality of
Relationships Inventory: Assessing
the interpersonal context of social
support. In B. R. Burleson, L. A. Al-
brecht & I. G. Sarason (Eds.), Commu-
nication of Social Support (pp. 247-266).
Thousand Oaks, CA: Sage Publica-
Snowdon, A. W., Cameron, S., &
Dunham, K. (1994). Relationships
between stress, coping resources, and
satisfaction with family functioning in
families of children with disabilities.
The Canadian Journal of Nursing Re-
search, 26, 63-76.
Tebes, J. K., Kaufman, J. S., Adnopoz,
J., & Racusin, G. (2001). Resilience
and family psychosocial processes
among children of parents with seri-
ous mental disorders. Journal of Child
and Family Studies, 10(1), 115-136.
Tracy, E. M., & Whittaker, J. K.
(1990). The Social Network Map: As-
sessing social support in clinical prac-
tice. Families in Society, 72(8), 461-470.
Mary I. Armstrong is Assistant
Professor and Director of the Division
of State and Local Support at the de la
Parte Florida Mental Health Institute,
University of South Florida.
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FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health
The period of transition from child-
hood to adolescence is a challeng-
ing time for many young people. Even
in the best circumstances, it can be
daunting for adolescents to cope with
the biological, cognitive, emotional,
and social changes that are unfolding
in their lives. Supportive relationships
are vital for ensuring the continued
healthy development of young people
as they journey through adolescence.
To design interventions and policies
that enhance the availability of appro-
priate supports for young adolescents,
two key questions must be addressed:
First, who is best equipped to offer as-
sistance? Second, what are the ideal
amounts of assistance that should be
obtained from each type of support
Our recent research finds that sup-
port from both peers and adults is im-
portant to the healthy development of
young adolescents. Adjustment dur-
ing the transition to adolescence is af-
fected by whether or not youth receive
balanced amounts of support across
peer and adult sources. The finding
that adolescents need a mix of sup-
port from peers and adults is not sur-
prising. After all, this is an age group
known for its gravitation toward peer
companionship, as well as its com-
plicated and sometimes ambivalent
stance toward help from parents and
other adults. Our findings highlight
promising directions for innovation in
interventions for young adolescents,
and have noteworthy implications for
both practice and policy.
Research on Social Support
During Early Adolescence
In one of our recent studies, we in-
vestigated the levels of social support
that 350 young adolescents (grades 5-
8) received from both peers and adult
sources (e.g., parents, teachers) over a
two-year period (DuBois, et al., 2002).
Findings revealed that youth who re-
ported receiving higher overall levels
of combined support from peers and
adults exhibited significantly better
behavioral and emotional adjustment
throughout the course of the study.
We found that those youth for whom
there was a lack of balance in the di-
rection of greater peer- versus adult-
oriented support were at heightened
risk for behavioral problems such as
aggression and delinquency. When
youth receive support predominantly
from peers, this may be an indication
of estrangement or conflict in their
relationships with parents and other
adults. Under these circumstances,
young adolescents are less likely to
obtain the adult guidance and encour-
agement that they need to cope with
different challenges they encounter in
areas such as schoolwork or friend-
ships. We also found in a follow-up
study (DuBois & Silverthorn, 2004)
that youth who relied on peers as their
main source of support were more
likely to associate with other youth
who were exhibiting problem behav-
Winter 2006, Vol. 20 No. 1
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FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health
ior, thus amplifying their own risk for
engaging in such behavior.
At the same time, other research
we have conducted points toward an
equally troubling downside for those
young adolescents who have imbal-
anced relationships with adults ac-
counting for a disproportionately large
source of their social support. The ab-
sence of support from peers appears
to leave youth susceptible to emotion-
al difficulties, including symptoms of
anxiety and depression (DuBois, et
al., 1999). Such liabilities
likely stem at least in part
from the premium placed
on peer group acceptance
during early adolescence.
Peers may be especially
qualified to offer support
in many of the areas of
greatest concern to this age
group, such as their friend-
ships and appearance.
Application to
Interventions for
Young Adolescents
The research findings that we have
summarized have important implica-
tions for the design of effective inter-
ventions for young adolescents. To be
optimally beneficial, our results indi-
cate that programs, policies, and in-
terventions for this age group should
be devised with the goal of promoting
support from both peers and adults.
It is not uncommon for current inter-
ventions to focus predominantly on
promoting support from only peers
or adults (e.g., social skills training to
improve peer relationships, family in-
terventions to strengthen parent-child
In our own research, we are ex-
ploring the value of introducing in-
novations focusing on social support
in mentoring programs for youth.
Mentoring programs currently en-
joy widespread popularity, with ap-
proximately 4,500 youth mentoring
programs operating in this country
(Rhodes, 2002). Mentoring programs
have focused most directly on increas-
ing the access of youth to social sup-
port through a relationship with a car-
ing adult volunteer. It is noteworthy
that youth participating in mentoring
programs have also demonstrated
improvements in their relationships
with peers (Rhodes, Haight, & Briggs,
1999). Evaluations of mentoring pro-
grams reveal that they can provide
benefits to youth in several areas, in-
cluding emotional, behavioral, social,
and academic adjustment (DuBois, et
al., 2002). However, the magnitude of
these benefits has typically been mod-
est. It thus appears that there is poten-
tial to strengthen mentoring programs
through promoting both adult and
peer support.
A Model for Integrating Adult
and Youth Support
Our current research is focused on
the development and evaluation of a
community-based mentoring program
for girls, GirlPOWER!, in partnership
with Big Brothers Big Sisters of Metro-
politan Chicago. The program is con-
sistent with the findings of our earlier
research in that it aims to foster sup-
port from both adults and peers. The
GirlPOWER! program is designed to
promote socially supportive relation-
ships between youth and their men-
tors as well as to promote supportive
relationships between other sources of
adult support and participating youth
(e.g., parents). An adult volunteer is
matched with a child with a commit-
ment to meet one-on-one two to four
times per month for at least one year.
Youth-mentor pairs structure their
own time together and may choose to
participate in agency-wide activities.
Each pair is also supported by ongo-
ing monthly contact with agency staff.
These innovations are complemented
by several strategies directed toward
enhancing access to peer support.
The GirlPOWER! program fea-
tures a series of 12 psychoeducational
workshops that are attended by a
group of 10-15 participat-
ing girls (ages 10-13) and
their mentors. During each
workshop, active learn-
ing strategies are used to
help the group explore
topic areas that have im-
portant implications for
healthy development (e.g.,
self-esteem, nutrition and
exercise, romantic relation-
ships, substance use). Each
session has a MatchBuild-
er segment, in which a
volunteer Match role-plays
a challenging interaction
between a hypothetical girl and her
mentor, and the group then discusses
ways to resolve the situation that is
depicted in the role-play. Other activi-
ties for youth-mentor pairs are linked
thematically with workshop content.
Youth and mentors are asked to con-
tinue these activities for a 3-month
period after the workshop series con-
cludes, leading up to a group reunion
at the end of the year. “POWER” is
used as an acronym for five core con-
cepts (Pride, Opportunity, Women-in-
the-Making, Energy and Effort, and
Relationships) that are interwoven
through all program components.
The “Relationships” concept reflects
the program’s focus on the cultivation
of supportive relationships between
girls, their mentors, other adults, and
peers. The joint participation of men-
tors and girls in the sessions gives
girls and mentors an “opening” and
common language to talk about top-
ics that are difficult due to their sen-
sitive or challenging nature. Through
Winter 2006, Vol. 20 No. 1
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FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health
this process, the program seeks to
enable mentors to move beyond com-
panionship to providing girls with
guidance and emotional support in
dealing with a wide range of issues.
The activities provide structured op-
portunities for mentors and youth to
talk about workshop topics and begin
to incorporate relevant activities into
their relationships (e.g., regular exer-
cise, healthy eating). There also is a
session early in the program that is
devoted specifically to developing the
Match relationship by having youth
and mentors set goals together and
then plan for how they can support
each other in reaching these goals.
Parents attend a program orienta-
tion and the final workshop in which
girls and their mentors perform a tal-
ent show and graduate from the pro-
gram. Parental involvement is encour-
aged throughout the program by hav-
ing girls bring home an informational
handout after each workshop. The
handouts summarize session activi-
ties and provide parents with tips and
suggestions for how they can support
their daughters’ healthy development
in areas related to the workshop topic.
Throughout the program, both girls
and mentors also are encouraged to
identify other adults in the girls’ so-
cial networks and to invite them to
join in activities where appropriate. In
this way, the youth’s mentor may be
able to work cooperatively with other
important adults in the youth’s life.
Likewise, through connections to the
mentor’s social network, the youth
may be exposed to new positive adult
role models and sources of support.
Several features of the GirlPOW-
ER! program are designed to help
girls establish supportive relationships
with peers. These include the group
setting for sessions in which girls are
able to meet and spend time with
other girls their age. The sessions are
structured to foster positive interac-
tions among girls through activities
such as games in which they compete
as a team against their mentors. The
sessions also allow girls to practice in-
terpersonal skills helpful to healthy re-
lationships with peers. These include,
for example, skills for support-seeking,
dealing with peer pressure, and asser-
tiveness in dating relationships. The
active involvement of mentors in ses-
sions ensures that youth have access
to adult support as they learn these
skills. This involvement provides the
mentor, too, with a valuable opportu-
nity to deepen her understanding of
the issues that influence the quality
of the youth’s peer relationships, en-
hancing her capacity to offer effective
guidance regarding peer-related issues
both in and out of program sessions.
Research indicates that young ado-
lescents who receive social support
from peers and adults are significantly
better equipped to cope with challeng-
es. An imbalance in the direction of
over-reliance on either peers or adult
sources of support places youth at risk
for problems in their emotional and
behavioral adjustment as they transi-
tion into adolescence. There is a need
for interventions and policies that are
designed to ensure that young ado-
lescents benefit from supportive ties
with both peers and adults in equal
measure. The GirlPOWER! program
described in this paper illustrates the
types of innovation to existing models
of practice that may prove successful
for achieving this important goal.
DuBois, D. L., Burk-Braxton, C., Sw-
enson, L. P., Tevendale, H. D., Lock-
erd, E. M., & Moran, B. L. (2002).
Getting by with a little help from self
and others: Self-esteem and social
support as resources during early ado-
lescence. Developmental Psychology, 38,
DuBois, D. L., Felner, R. D., Brand,
S., & George, G. R. (1999). Profiles
of self-esteem in early adolescence:
Identification and investigation of
adaptive correlates. American Journal
of Community Psychology, 27, 899-932.
DuBois, D. L., Holloway, B. E., Val-
entine, J. C., & Cooper, H. (2002). Ef-
fectiveness of mentoring programs for
youth: A meta-analytic review. Ameri-
can Journal of Community Psychology,
30, 157-197.
DuBois, D. L., & Silverthorn, N.
(2004). Do deviant peer associations
mediate the contributions of self-es-
teem to problem behavior during ear-
ly adolescence? A 2-year longitudinal
study. Journal of Clinical Child and Ado-
lescent Psychology, 33, 382-388.
Rhodes, J. E., Haight, W., & Briggs,
E. (1999). The influence of mentor-
ing on the peer relationships of foster
youth in relative and nonrelative care.
Journal of Research on Adolescence, 9,
Rhodes, J. M. (2002). Stand by me:
The risks and rewards of mentoringto-
day’s youth. Cambridge, MA: Harvard
University Press.
Naida Silverthorn is a post-doc-
toral fellow at the Institute for Health
Research and Policy at the University
of Illinois at Chicago.
David DuBois is Associate Profes-
sor in the Division of Community
Health Sciences in the School of Pub-
lic Health at the University of Illinois
at Chicago.
Youth participating in mentoring
programs have demonstrated improvements
in their relationships with peers.
Winter 2006, Vol. 20 No. 1
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reproduce articles at no charge, please contact the publications coordinator at 503.725.4175; fax 503.725.4180 or email
FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health
Wraparound is a support
planning process that is fa-
cilitated and team-based. The youth
(or child) and family, natural supports,
and service professionals partner to
develop and implement a strength-
based, culturally competent, and
highly individualized support plan
with the goal of maximizing youth
and family functioning and happi-
ness. Natural supports are individu-
als identified by the youth and family
who participate in the wraparound
process. These are people who know
the youth and family well, who care
about them, and who provide support
without being paid. Natural supports
are the individuals who provide long-
term support to the youth and family,
and who thus permit the wraparound
facilitator and other professionals to
transition out of their intensive service
and support roles over time. The role
of natural supports in wraparound
plan development and implementa-
tion is crucial and central to the pro-
cess, and is perhaps the aspect of the
wraparound that most distinguishes it
from other helping models.
As a wraparound trainer and
coach, I support facilitators as they
learn the craft of wraparound. Wrap-
around facilitators frequently report
that they have significant challenges
building natural supports. Since this
is an essential element of wraparound
practice, facilitators learning the
model need effective coaching sup-
port from supervisors and others who
guide their development targeted to
this area if natural supports are to be
successfully involved on wraparound
In this article, I will discuss three
specific challenges frequently re-
ported by wraparound facilitators in
building natural supports: identifica-
tion of natural supports, engagement
of natural supports, and recruitment
of surrogate natural supports.
Identification of
Natural Supports
I have lost count of the number
of times enthusiastic facilitators who
are learning wraparound have said to
me, “I know natural supports are an
essential element of wraparound, but
there just aren’t any for this family.”
I typically respond by saying, “Let’s
slow down and back up a few steps.”
It is necessary to determine if the fa-
cilitator has established enough trust
with the youth and family for them to
disclose information about the indi-
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FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health
viduals in their life from whom they
derive support.
It is important for facilitators to
establish a foundation of trust with
a youth and family before beginning
to identify natural supports. Prema-
ture initiation of the process of iden-
tifying natural supports can result in
superficial responses from the family.
This can lead the facilitator to falsely
conclude that the family does not have
any natural supports. Beginning facil-
itators may need support to strength-
en their youth and family engagement
skills so initial trust is reliably estab-
lished before the natural supports dis-
covery process is begun.
Wraparound facilitators must also
learn to conduct a discovery with the
youth and family that is of sufficient
breadth and depth to reliably iden-
tify current and potential natural sup-
ports. Many skillful facilitators use life
domains as a structure to guide their
natural support discovery efforts. It
helps them ensure that the natural
support discovery process covers all
areas of the youth and family’s lives
where current or potential natural
supports might exist.
Life Domains (see sidebar) are a
tool used to guide the discovery pro-
cess that helps ensure that the discov-
ery is broad enough to identify natural
supports across all areas of life of the
family and youth.
Skillful facilitators must learn strat-
egies to conduct deep discovery in
particular life domain areas. Domains
that need deep discovery include fam-
ily and extended family, spiritual and
faith community, and friends.
For example, to support deep dis-
covery in the family and extended
family life domain, I teach novice
facilitators skills so they can draw
three-generation family trees for each
wraparound family. To teach this skill
to a new facilitator, we draw a fam-
ily tree together using a wraparound
family selected by the facilitator. We
start the tree with the child or youth
that was referred to wraparound. We
next add the immediate family mem-
bers and any other individuals who
live in the household to the tree. Then
we add family members not in the
immediate household. Last we add
maternal and paternal grandparents
as well as aunts, uncles, and cousins
and step-family members not already
identified. I ask the facilitator to label
people on the tree by first name and to
note their whereabouts.
The beginning facilitator often rec-
ognizes that he or she has significant
information gaps about emotionally
significant relationships in the fam-
ily and extended family life domain
as a result of drawing the family tree.
Common information gaps include:
not knowing the names of one or sev-
eral of the individuals who live in the
household, not knowing the name or
whereabouts of the youth’s biological
mother or father, and/or little to no
information about the youth’s grand-
parents and other extended family. I
help the facilitator to understand that
deep discovery of natural supports in
the family and extended family life
domain is not complete until all infor-
mation gaps are filled. Only then can
the facilitator make accurate conclu-
sions with the youth and family about
the presence or absence of natural
supports in this life domain.
Engaging Natural Supports
Novice facilitators frequently tell
me, “The youth and family have
natural supports, but they don’t want
them on the team.” Facilitators learn-
ing wraparound practice sometimes
push prematurely for the involvement
of identified natural supports on the
wraparound team. Experienced fa-
cilitators recognize that taking time
to build a rationale for involving
natural supports on the wraparound
team maximizes the potential for the
successful involvement of these cru-
cial supports. A family is much more
likely to agree with the involvement of
natural supports on their wraparound
team when natural supports are invit-
ed to participate on the team to meet
a specific need that has been identified
by the facilitator and the family.
Here are two typical examples:
1. A mother who agrees that she
is tired, alone, and needs more emo-
tional support enthusiastically agrees
to involve her best friend on the team
when the friend’s initial job on the
team is to provide her with emotional
support during the meetings.
2. A single father recognizes, with
facilitator support, that his adolescent
son would benefit from an adult fe-
male mentor. The father and youth
agree that the father’s sister might help
meet this need. The father is pleased
to have his sister invited to participate
at the next meeting.
Another factor influencing a fami-
ly’s willingness to involve natural sup-
ports on their team is feeling shame.
Novice facilitators sometimes fail to
anticipate feelings of shame and do
not adequately discuss and normalize
these feelings before suggesting natu-
ral support involvement on the fami-
ly’s team. Skillful facilitators actively
discuss feelings of shame as well as
other feelings and fears, address issues
of confidentiality, and define what
sensitive information needs to be
shared with team members in order to
develop a meaningful support plan for
the youth and family. Sensitive atten-
tion to these universal issues prepares
families for the inclusion of natural
supports on their teams.
In the process of discovery of natu-
ral supports, a youth and family may
identify friends, relatives, and other
natural supports who have provided
Family and extended family
Spiritual and Faith community
Work and financial
Residence and neighborhood
School and education
Winter 2006, Vol. 20 No. 1
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FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health
support to them in the past but who
do not currently have positive rela-
tionships with the family. The fam-
ily does not then see them as current
sources of support. Novice facilita-
tors often do not invest enough energy
to determine if these previously sup-
portive relationships can be restored.
Experienced facilitators might say to
a youth: “I understand you and Bill
were best friends before the argument,
and that since then, you aren’t talk-
ing anymore. What would it
take for you and him to make
things right?” With needed
support from the facilitator
and others who care, some
potential sources of natural
support can be restored and
then become available to par-
ticipate on the wraparound
Recruiting Surrogate
Natural Supports
Some families are truly
isolated—they have lost their
natural supports. In this cir-
cumstance, the facilitator
must assist the youth and
family to recruit surrogate
natural supports to partici-
pate on the team. Skillful
facilitators master various re-
cruitment strategies, includ-
ing the two that follow.
In the first strategy, the
facilitator, with support from
his or her colleagues and supervisor,
develops a plan targeting community
organizations often referred to as “bro-
kers of natural supports.” The plan
is designed to identify potential sur-
rogate supports and connect them to
youth and adult caregivers who need
them. Community churches, service
clubs, and many other community
organizations have members who are
interested in volunteering their time
in the service of youth and families
who have needs. The community
development plan begins by educat-
ing these broker organizations about
the wraparound process. As relation-
ships with broker organizations are
strengthened, a range of possible roles
for interested volunteers from these
organizations are defined, including
support of youth and families by par-
ticipation on wraparound teams and
one-to-one mentoring of youth and
adult caregivers. Willing volunteers
are then engaged on teams to broaden
the base of support of isolated youth
and families.
The second strategy is strength-
based recruitment of family-specific
surrogate natural supports. This strat-
egy is based on the use of the youth
and family’s strengths to guide highly
individualized recruitment efforts of
surrogate team members. For exam-
ple, a facilitator contacts a colleague’s
mechanic and asks him to meet with
a youth in wraparound based on the
youth’s interest in automotive repair.
The youth and mechanic hit it off.
The mechanic mentors the youth in
automotive repair and becomes a pe-
riodic participant on the wraparound
Strength-based recruitment maxi-
mizes “fit” of surrogates and the youth
and family by matching them on one
or more areas of shared strengths, in-
terests, preferences, and/or culture.
Mutual acceptance between surrogate
supports and youth and families max-
imizes benefits and the establishment
of self-sustaining relationships.
Wraparound is a complex process
whereby youth and families with mul-
tiple life challenges are supported by
a team composed of profes-
sionals and natural supports.
Natural support participa-
tion on the planning team
and assistance implementing
the service and support plan
are essential and unique el-
ements of the wraparound
practice model. Wraparound
facilitators often report prac-
tice challenges that can be-
come barriers to building
effective teams that include
natural supports. Some of
these common practice chal-
lenges were identified and
discussed, and promising
coaching strategies were re-
viewed. The preceding paper
was neither comprehensive
nor authoritative. Nonethe-
less, I hope it causes wrap-
around supervisors, trainers,
and others responsible for
wraparound practice qual-
ity to reflect on their current
coaching activities in this
area of wraparound practice. Further,
I hope such reflection leads to addi-
tional exploration of the role of natu-
ral supports in wraparound, as well as
improved coaching activities designed
to strengthen facilitator effectiveness
in building natural supports.
Greg S. Dalder is Executive Vice
President of Vroon VanDenBerg LLP.
Previous education in social work and
experience in family therapy inform
his current work, which is focused on
wraparound training and the provi-
sion of follow-on practice coaching.
Winter 2006, Vol. 20 No. 1
Regional Research Institute for Human Services, Portland State University.
This article and others can be found at For reprints or permission to
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FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health
am the mother of a grown son who
had significant behavioral health
and other challenges as a youth. I
am also a wraparound trainer, trainer
of youth and parent mentors, and
an active leader in our local parent
support organization. It is from these
perspectives that I will share my
thoughts about the importance of
natural supports in the wraparound
My adopted son, Jason, presented
many challenges. Some professionals
thought his biological mother’s heroin
and cocaine addiction during preg-
nancy were the cause of his difficult
and sometimes frightening behavior.
He was given numerous diagnoses:
Conduct Disorder, Bipolar Disorder,
PTSD, ADHD, and Oppositional De-
fiant Disorder.
In 1994, when Jason was 14 years
old, he was nearing discharge from
residential treatment. A psychiatrist
who had evaluated Jason told me he
would likely need institutionalization
for most of his life. I rejected this pre-
diction and believed there must be a
way for Jason to come home and stay
in our community.
In the early 1990s, wraparound
was in its initial implementation in
King County, Washington. I was re-
ceiving support from parents involved
in a parent organization in our area.
One of the local leaders and a profes-
sional partnering with the parent or-
ganization suggested that a new sup-
port- and strength-based approach,
wraparound, might be beneficial to
Jason and me, since typical profes-
sional services had not resulted in
sustained improvement in Jason and
our family life. I was given a copy of a
wraparound training manual, which I
read on my own.
I learned that the core of the wrap-
around process was a child and family
team and that the team should include
professional service providers as well
as natural supports—those individu-
als in the life of the youth and family
who knew them best. I learned that
the team’s job was to provide support
and to develop and implement an in-
dividualized and strength-based plan
that addressed priority needs.
As I considered the possibility of
the wraparound process for Jason and
me, I recognized that the prospect of
including natural supports on a team
was a good “fit” with our family cul-
ture. The tradition and culture of our
family emphasizes community, i.e.,
taking care of our own and each other
are prominent values of the tradition.
I was also raised in a Bible-believing
family. Biblical scripture emphasizes
supporting one another uncondition-
ally in the community of faith. Involv-
ing natural supports on our team was
consistent with our values, personal
beliefs, and family culture.
I recognized that the idea of orga-
nizing natural supports to help Jason
and me through the wraparound pro-
cess felt comfortable, safe, and natu-
ral. Who better to provide support
Winter 2006, Vol. 20 No. 1
Regional Research Institute for Human Services, Portland State University.
This article and others can be found at For reprints or permission to
reproduce articles at no charge, please contact the publications coordinator at 503.725.4175; fax 503.725.4180 or email
FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health
Thank you! This issue was made possible by the assistance of the following people: Stacey Sowders,
Melanie Sage, and Donna Fleming. We couldn’t have done it without you!
than those individuals whom we trust
the most and who know us the best?
Natural supports would be there with
us over the long haul—professionals
turnover and eventually go away—
and natural supports would be more
accessible. I could call a neighbor or
friend at 2 a.m. and know that they’d
be there; not so with Jason’s thera-
I decided to conduct our own
wraparound process. I convened and
facilitated our own child and family
wraparound team. Our initial team
was composed of Jason’s older brother
and sister, my best friend from work, a
boxing coach and his wife, my parents
over long distance, our case manager,
Jason’s therapist, and a teacher. Later
a neighbor couple joined the team
along with Jason’s friend Peter and his
mother. All of these people already
knew us, and knew our family’s sto-
ry; each person brought an ability, a
strength to match a specific need. The
boxing coach, for example, used his
skills to teach Jason how to regulate
his emotions, and a neighbor, who had
gotten to know Jason through shared
interests in REI (A Seattle-based out-
door equipment company), could de-
fuse his rages by simply coming to the
door when I called for help. Jason’s
older brother—his BIG older broth-
er, all of 6’3” and 240 pounds—also
helped interrupt disruptive behavior,
while Jason’s older sister and her hus-
band provided respite care.
Though there were many ups and
downs, our team showed us persistent
commitment, gave us much needed
emotional and tangible support, and
came up with many creative ideas we
would have never thought of alone.
One creative idea came from our
neighbors. After we’d agreed that
they would come over to my house
to help calm Jason, we needed a reli-
able, quiet way to signal that help was
needed. They found a solution: when
we needed help, I would flick on
Christmas lights in our kitchen win-
dows (a porch light wouldn’t serve the
same purpose, and our porch was not
visible from their home in any case).
Surprising emotional support came
from an extended family member who
organized an impromptu barbeque for
me to relieve the unrelenting tension
from one of Jason’s frequent ‘runs.’
This simple act of celebrating as fami-
ly and friends, rather than being
consumed by worry and caught
up in the ‘drama’ of my son’s
behavior, gave me a completely
new perspective.
In the years since as a wrap-
around trainer, trainer of youth
and parent mentors, parent
partner, and as an active leader
in our local parent support or-
ganization, I have been involved
with many other youth and
their families who were facing
daunting challenges. My expe-
riences with these families have
validated over and over again
the wisdom and importance of
helping families to identify, mo-
bilize and build sources of natu-
ral support. Natural support is
suitable for the culture of most
families as well as essential to
achieving and sustaining functional
Jason is 25 now. His life is not per-
fect. He lives on his own. He lives in
the community and we continue to
have an important relationship with
each other.
Jeanette Barnes is a Family
Treatment Court Specialist with King
County Superior Court, a Wraparound
Trainer, Parent and Youth Mentor
Trainer, and a Parent Organization
Leader for A Village Project.
This article was written by Greg S. Dalder
and Lyn Gordon, based on an interview
with Jeanette Barnes.
Winter 2006, Vol. 20 No. 1
Regional Research Institute for Human Services, Portland State University.
This article and others can be found at For reprints or permission to
reproduce articles at no charge, please contact the publications coordinator at 503.725.4175; fax 503.725.4180 or email
FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health
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Full-text available
In this article we describe the results of an ongoing effort to better understand the caregiving process in families of children with severe emotional problems. We make two assumptions. First, we assume that these families are essentially like other families but are faced with a special challenge in raising and caring for their special children while at the same time performing the multiple tasks and demands faced by all families. Second, we assume that public policy and programs must be supportive of the care of these children in their own homes and communities whenever possible. The purpose of this article is to present a model of family caregiving that draws broadly from available theory and empirical literature in multiple fields and to subject this model to empirical testing. We use structural equation modeling with latent variables to estimate an empirical model based on the theoretical model. Results of the model testing point to the importance of the child's external problem behaviors and the family's socioeconomic status and coping strategies as determinants of caregiver stress. Other findings highlight difficulties in measuring and modeling the complex mediating process, which includes formal and informal supports, perceptions, and coping behaviors. The use of structural equation modeling can benefit our efforts to support families by making explicit our theories about the important dimensions of this process and the relationship between these dimensions, which can then be subjected to measurement and validation.
Surgery and pharmaceuticals are not the only effective procedures we have to improve our health. The natural human tendency to care for fellow humans, to support them with social networks, has proven to be a powerful treatment as well. As a result, the areas of application for social support intervention have expanded dramatically during the past 20 years. The title is divided into four sections. The first provides some historical context as well as a conceptual overview of how social support might influence mental and physical health. The second discusses techniques for measuring social networks and support, and the third addresses the design of different types of support interventions. The final section presents some general comments on the volume and its implications for social support research and intervention. This resource is meant to aid researchers in understanding the conceptual criteria on which measurement and intervention decisions should be made when studying the relations between social support and health.