The Forum on Promoting Children’s Cognitive, Affective, and Behavioral Health1 of the National Academies of Sciences, Engineering, and Medicine has addressed a number of issues since its launch in 2014—from individual programs that promote the health and well-being of children and families to national policy efforts implemented at scale. As the forum entered its 5th year, members recognized the need to highlight the urgency around health equity across research, policy, and practice, drawing on the framework of health disparities described by Tolan and colleagues (2016, p. 2):
Health disparities refer to systematic health differences related to group membership (e.g., socioeconomic status, gender, ethnic identity) and access to resources (knowledge, care, practices) that are avoidable or malleable, and are primarily socially determined. Thus, it is not just a matter of documenting health risk, status, use, or effect differences between groups . . . but it is reserved for systemic differences between groups that are related to social and associated political power and affect access to health opportunities, resources, and outcomes. A critical implication of this definition is that it proposes that systematic differences between groups can be affected or eliminated because they are representative of social and politically based inequities. Moreover, this perspective assumes, though not readily acknowledges, that these differences are essentially malleable.
1 The name of the forum was changed in August 2018 to Forum for Children’s Well-Being: Promoting Cognitive, Affective, and Behavioral Health for Children and Youth.
In November 2017, the forum, in collaboration with the Roundtable on the Promotion of Health Equity,2 convened a workshop on promoting children’s behavioral health equity. (See Appendix A for the workshop planning committee’s statement of task.) The workshop began with personal accounts of chronic and historical trauma, followed by a keynote presentation on addressing structural and systemic racism and its impact on the social determinants of health (including economic stability, neighborhood and community, education, food, health care, and housing). Participants were asked to keep these frames in mind throughout the day and reflect on them during the subsequent sessions on state and local policy opportunities; conditions and experiences in rural communities; experiences of historical, intergenerational, and chronic trauma; creating partnerships and engaging communities; and levers for addressing health equity through research, policy, and practice.
The workshop used a socioecological developmental model to explore health equity of children and families, including those with complex needs and chronic conditions. Particular attention was paid to challenges experienced by children and families in both rural and urban contexts, to include but not limited to poverty, individual and institutional racism, low-resourced communities, and hindered access to educational and health care services. Workshop participants also engaged in solution-oriented discussions of initiatives, policies, and programs that aim to improve social determinants of health, opportunities for behavioral health promotion, and access to quality services that address the behavioral health of all children and families. It should be noted that workshop participants presented different operational definitions of health equity. Some participants were focused on access and resources, some on health outcomes, and some on both.
Over the past several years, the National Academies has highlighted issues around health equity and the social determinants of health in its work (see Box 1-1). By focusing on behavioral health equity for children, families, and communities, forum members aimed to build on this work as well as to establish partnerships with and learn from stakeholders across sectors who have made progress in addressing health equity.
ORGANIZATION OF THE WORKSHOP AND PROCEEDINGS
The workshop proceedings is organized into 10 chapters. This first chapter gives the background of the workshop and summarizes the introductory remarks by the chair of the Board on Children, Youth, and Families
2 For more information on the roundtable, see http://nationalacademies.org/hmd/Activities/SelectPops/HealthDisparities.aspx.
(BCYF) and by the forum cochairs on the connection between health equity and social justice. Chapter 2 presents the social determinants of health and the social determinants of equity through three personal narratives of those who have experienced chronic and intergenerational trauma, as well as the keynote address. Chapter 3 describes the roundtable discussion on opportunities for advancing behavioral health equity through state and local policies. The following two chapters highlight the needs of specific populations to create health equity—Chapter 4 focuses on addressing access and quality of care for those in rural communities, while Chapter 5 addresses those who have experienced historical, intergenerational, or chronic trauma. Chapters 6 through 9 detail levers for advancing health equity—including research, community engagement, family-focused interventions, and restorative justice. Chapter 10 summarizes the final session, in which moderators presented key points from their panel sessions.
The presentations, including the powerful personal accounts of many of the speakers, have been summarized for this proceedings. Recordings of the full presentations can be viewed on the forum website at http://www.nas.edu/healthequity.
This proceedings has been prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. The planning committee’s role was limited to planning and convening the workshop. The views contained in the proceedings are those of individual workshop participants and do not necessarily represent the views of all workshop participants, the planning committee, or the National Academies.
Angela Diaz, chair of BCYF and member of the workshop’s planning committee, opened the workshop with remarks that highlighted the importance of health equity to BCYF as well as throughout the National Academies. She noted that health equity involves opportunities to achieve the highest level of health for all people, particularly those who have experienced socioeconomic disadvantage and historical injustice. Achieving optimal health includes the opportunity to access quality health care across the lifespan, she said, and additional steps have to be put into place for those who have been left behind.
Diaz highlighted a previous effort that focused on social justice and health equity. In May 2015, BCYF hosted Armchair Discussions on Social Justice and Equity across the Life Course,3 which aimed to establish an agenda to address social determinants of health inequities and social
injustices that disproportionately impact marginalized populations and perpetuate disparities. Objectives of that meeting were to (1) address the laws, policies, and leadership needed to ensure social justice and health equity for children, youth, and families; (2) highlight “institutions,” such as parenting, juvenile justice, foster care, and school systems and the ways that these institutions protect the development of children and youth in the context of social justice and health equity; (3) focus on health disparities resulting from discriminatory practices and policies, as well as missed opportunities for not investing in human capital; and (4) discuss topics and priority areas on equity for the National Academies.
In 2016, the Culture of Health Program4 was established within the National Academy of Medicine (NAM) to focus on cultural factors that give rise to health equity. This multiyear collaborative effort is identifying strategies to create and sustain conditions that support equitable good health for all Americans. As a member of the advisory committee, Diaz noted that this program aims to ensure that efforts across the National Academies are aligned and that partnerships and expertise are effectively leveraged to optimize outcomes.
Diaz closed by noting that the current workshop advances the important agenda and contributes to the acceleration of health equity—and equity in general. In thanking the steering committee, speakers, participants, and staff, she acknowledged that efforts around issues of health equity are extremely timely in changing the health of the population at large.
William Beardslee, cochair of the forum and child psychiatrist at Boston Children’s Hospital, underscored that health equity and strategies for achieving health equity are of central importance to the forum. He relayed his own experiences related to self-understanding, shared understanding, narratives, and the need for social action, and he said he has worked with families over many years trying to understand their challenging experiences and the impacts of those experiences. During his time in residency, he interviewed civil rights workers about what enabled them to survive in the face of enormous prejudice, racism, and threats to their lives, as well as the changes they were able to bring about. Through these interviews, these civil rights workers explained their motivations, visions, community connections, and self-understanding.
Beardslee said these principles have informed his work since, and that social justice and health equity are relevant to addressing the widening gap between high- and low-income families and the wealth and health disparities among communities. This lens is equally important, he explained, when addressing injustices in other areas of society and is central to the work of professionals and citizens.
More than 30 years ago, Beardslee served on a consensus committee (Institute of Medicine, 1986) that addressed the medical implications of nuclear war. With the charge of reviewing existing evidence and determining what would happen in the face of a major nuclear exchange, the committee concluded such an event would destroy the planet. The report had a large impact because the evidence was strong and it addressed a salient issue at this time. The committee, however, did this work with very little sense of whether it would have an impact or not. He acknowledged it is not clear what the impact of the current effort will be, but he urged the group to move forward the dialogue to promote children’s cognitive, affective, and behavioral health equity.
Hendricks Brown, Northwestern University and the other cochair of the forum, suggested that participants find common threads in the stories presented during the workshop and identify a shared vision for addressing health equity. He drew an analogy from music, in which individuals sing different melodies but harmonize their voices. He noted some speakers would focus on personal experiences, while others would speak from policy and research perspectives. “The whole aim is to come together by the end of the day,” said Brown. “The task is to work in harmony.”