Before the final plenary session of the workshop, participants broke into three groups to discuss three central issues associated with implement-
ing evidence-based prevention by communities to promote cognitive, affective, and behavioral health in children:
Group 1: Responsiveness to Community Needs and Building Capacity
Group 2: Sustainability and Funding
Group 3: Programs versus Principles and Innovative Methodologies
This final chapter of the workshop proceedings summarizes the reports from representatives of the breakout groups in the final plenary session and the concluding remarks of the workshop cochairs.
EMPOWERED AND INCLUSIVE COMMUNITIES
The first breakout group, co-moderated by Deborah Klein Walker, Abt Associates, and José Szapocznik, University of Miami, discussed responsiveness to community needs and building capacity. In its report back to the plenary session, the group emphasized the need to take a systems approach to public health that focuses on populations and equity. Public health should be seen as “the practice of social justice using the best evidence possible,” said Klein Walker, who reported back for the group.
Participants in the breakout group also discussed the need to engage all levels of communities, including individuals who are not affiliated with any organizations, in collaborative decision making and shared accountability for actions and change. “The community is the organization that is responsible for ongoing change,” said Klein Walker. “They are the ones making the decisions.”
To achieve this goal, the workforce of researchers, practitioners, and others needs to have competencies in community engagement and systems change, Klein Walker continued. “Everyone needs to be involved, with a special outreach to people who are usually disenfranchised,” even though researchers and practitioners are not currently trained in many of the skills needed to partner with those who do have these competencies to ensure outreach to disenfranchised communities.
In the discussion following Klein Walker’s summary of the group’s discussions, Albert Terrillion, CADCA, pointed out that the lack of “diversity and inclusion means that certain people are not at the table now. They need to be at the table from the beginning on all decision-making level processes.” Klein Walker added that people with disabilities should also be included in addressing issues around diversity and inclusion.
Workshop participants also discussed how to integrate systems within a broader public health approach. As David Hawkins, University of Washington, pointed out, considerations of public health do not reside only in public health departments. “All the organizations, all the institutions, all
the agencies—the juvenile justice system, the child welfare system, health and human services—all these groups need to be involved,” he said. By labeling a set of issues as public health, other agencies may think that they do not need to be involved; yet these agencies need to know that they are integral to the public’s health.
Klein Walker agreed, pointing out that previous Institute of Medicine reports on public health encompass all the sectors that need to work together in a broader system, not just public health departments. However, “the assurance function to make sure that [a systems approach] happens has to be rooted in a shared place in a community,” she added. This approach is currently being operationalized in health care under the Affordable Care Act, but “from a public health perspective, you’d want to look at a population to be the entire community,” not just the people in a particular health care system.
The second breakout group, which was co-moderated by Kelly Kelleher, Nationwide Children’s Hospital, and Belinda Sims, National Institutes of Health, focused on sustainability in funding. The group discussed the need to support the development of prevention and wellness funds for needs-based community implementation of efforts that support functioning within the community, with a goal of promoting healthy development through the integration of systems and elimination of carve-outs (i.e., a program that excludes certain services). One result of this approach could be metrics on children and adolescents included in all ongoing community and agency needs assessments. “That would be our overarching statement,” said Sims.
By emphasizing the idea of “functioning,” from the individual to the community and governmental levels, group participants said they sought to convey the need to address issues at multiple levels, beginning with immediate and urgent needs and expanding from there. They also discussed how to generate funding for these efforts. One promising approach would be to extend “health in all policies” to “healthy development in all policies,” which would place the focus on both health and healthy development and facilitate sustainable funding for services, Kelleher reported. Health in all policies, he explained, means that all public policies—whether tax policy, transportation, housing, or policies on any other subject—should include an assessment of their impact on health. Healthy development in all policies would promote consideration of child cognitive, affective, and behavioral health in all policies. “If we were to do that at the local, state, and federal levels, we would provide a roadmap on different funding opportunities for communities, researchers, policy makers, and others,” Kelleher said. Essentially, considering healthy development in all policies
would establish social justice and equity as core principles of policy development, he added.
Other possibilities suggested by group members would be to use a collective impact model to pursue funding and policies, to broaden networking, to reduce duplicative efforts through better communication, and to prioritize children’s health in the Affordable Care Act. As Marc Atkins, University of Illinois at Chicago, observed on this final point, the Affordable Care Act prioritizes chronic diseases, not children’s health, but an emphasis on healthy development would affect not only short-term conditions, but also long-term and chronic conditions.
PROGRAMS, PRINCIPLES, AND INNOVATIVE METHODOLOGIES
The third breakout group, co-moderated by Wilma Peterman Cross, National Institutes of Health, and David Hawkins, looked at programs versus principles and at innovative methodologies. Group members noted first the need to better define such terms as programs, practices, principles, and kernels. As Hawkins, who reported back for the group, noted, presentations at the workshop made considerable progress on this issue, but the field as a whole could gain from consistent definitions of these terms.
In addition, Hawkins noted, that asking what works is not the end of the question. Instead, we need to go further in asking “what works for whom, when delivered by whom.” For example, some practices could be disseminated through psychologists who have learned cognitive behavioral health skills, whereas others may need other forms of dissemination. “There may be different criteria for dissemination depending on who is supposed to implement this intervention,” he said.
The group also talked about leveraging the opportunities for evaluation of preventive approaches being presented by implementation of the Affordable Care Act. For example, the Center for Medicare & Medicaid Innovation could capitalize on the investments and innovations currently being made in health care to learn what works for whom, and other research funders could be included in this effort.
Improved community monitoring and program evaluation could reveal areas of progress and lack of progress, breakout group members noted. Monitoring and evaluation data could have many audiences, from communities that want to make changes to funding agencies to researchers interested in innovative research designs. “If we have these kinds of monitoring systems in place, then it’s possible to use improvement designs consistently in communities to see if we are making progress,” said Hawkins.
Finally, the group talked about the potential value of a future workshop under the forum where people at the forefront of technology development and use could discuss the integration of technologically based approaches
into interventions. Such integration could encourage more collaboration not just among health care and human service providers but among the people who are developing and using technology to improve children’s cognitive, affective, and behavioral health.
In their final remarks at the workshop, Szapocznik and Walker-Harding called attention to the gradual broadening of the workshop’s scope over the day and a half of discussions. As Szapocznik said, to move the needle in a major way, it may be necessary to move from a strict focus on programs toward a broader focus on the social context and the social determinants of health. Social context may be changed at an individual level, a family level, a community level, or a population level. Interesting experiments are under way, such as using Medicaid funds to address housing issues. “Is there a way we could start thinking about addressing social determinants in a broader context?” he asked.
In broadening the agenda, the workshop could be “a fork in the road for the direction of our forum,” Szapocznik continued. It opened up “new avenues that we might want to consider in terms of the role of the environment, our focus on social equity, and social determinants. This group has achieved something important in helping to clarify—and maybe broaden or redirect—the thinking of the forum.”
Walker-Harding agreed, saying “We’re at the edge of a change here. We’re bringing up things in very different disciplines and different language. We need to begin to think differently.” As she put it, everyone is on the same journey, but they are not necessarily aware of the others traveling in the same direction. “Whether we’re talking about communities, or government, or the private sector, or the different systems of substance abuse or mental health. We’re all trying to find a common language,” she said.
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