In closing the workshop, David Willis provided some final reflections and several takeaways for the Forum to consider moving forward. First, he acknowledged the enormity of the challenges of the opioid crisis, but also saw reason for encouragement from all of the great work being done on the ground by local and community leaders, such as those presenting at the workshop. While there is no magic bullet for this type of multifaceted challenge, there are drivers for change that can include policies, practices, resources, relationships, mental mindsets, and even power dynamics, with various suggestions highlighted in Chapter 3. Addressing these drivers may require more of a top-down, multistrand approach than has been discussed at the workshop, but there is much to be learned from experiences, especially in those communities represented at the workshop.
POTENTIAL STEPS FOR FORUM CONSIDERATION
Willis highlighted five areas the Forum for Children’s Well-Being could consider in future efforts to address children’s health in the wake of the opioid crisis:
- equity and stigma;
- relational programming and the power of community;
- alignment of rules and messages; and
- attending to economic self-sufficiency with new strategies for trying to reduce poverty.
Equity and Stigma
Multiple speakers highlighted the importance of an equity frame in this work and maintaining it as a central focus. Without that frame, the root causes of opioid misuse and the populations that are intimately and adversely affected may not be accurately understood. Willis called out the need for having the voice of families and parents to bring the lived experience to the table. In addition to giving a platform to actual experiences, there is also a deep need for destigmatization, which he said is often at the root of the equity issue.
In this vein, Kelly Kelleher had mentioned in his presentation that women are often dually stigmatized because they get blamed as bad parents in addition to being drug users. Getting away from this language of “good” and “bad” can help to understand the underlying causes of the issues and illuminate prevention strategies to treat the problem more effectively. Carlos Santos added a relevant example from his work at University of California at Los Angeles that sought to understand the interface of immigrant populations with public services. He described a colleague’s study of Mexican-origin adolescent mothers and their mother figures in Arizona prior to and following the passage of a 2010 law requiring law enforcement officials to attempt to determine immigration status:1 The study found these types of policies may contribute to decreases in the use of preventive health care and public assistance among high-risk populations (Toomey et al., 2014). When working with immigrant populations, he said, the stigma associated with obtaining certain services clearly has a detrimental effect on the overall health and well-being of families.
In addition to thinking about stigma, Willis noted, another equity issue arose in the Wise Works Program—wanting to ensure that alternative types of programs to jail time are offered equally to all offenders. Often, marginalized or disenfranchised populations do not receive these types of lighter alternatives or may not have the appropriate network or support system to understand that they are available as an option.
Relational Programming and the Power of Community
Felicia Bowen, director of undergraduate programs in the college of nursing at the Medical University of South Carolina, suggested that the Forum consider and expand on the concept of relational programming in
1 The Arizona law “Supporting Our Law Enforcement and Safe Neighborhoods Act” (also known as SB 1070) requires state and local law enforcement to reasonably attempt to determine immigration status of a person involved in a lawful stop where reasonable suspicion exists that the person is unlawfully present. See more at http://www.ncsl.org/research/immigration/analysis-of-arizonas-immigration-law.aspx.
communities. Mental health and substance use recovery requires relationships from within the community. Some research is calling for this type of relational approach as the way forward (Price-Robertson, Obradovic, and Morgan, 2017). Hendricks Brown pointed out the difficulty, from the provider side, of providing direct services and managing staff, while also collecting data and conducting a sound evaluation of the program’s impact. However, Bowen noted, it is likely that there are people in the community who would want to collaborate and support data collection and evaluation and are invested in the outcome. She also suggested the Forum could be an avenue for people to tap into and learn about the many resources shared at the workshop that already exist, while also sharing professional conferences, white papers, or related workshops on relevant topics that people with “boots on the ground” could use. In that vein, Willis commented that most of the existing efforts related to prevention are deeply relational, so harnessing that can be very important in furthering their influence.
In summing up, Willis also noted the importance of place-based efforts, where people come together across sectors to address a complex, pervasive problem. He said that the relationships needed to solve these complex problems require local leadership and trust building under a common theme where everyone is invested. This trust is not something that happens overnight, but rather takes discussion, engagement, and genuine interest with the community and civic stakeholders.
Taking this idea of community engagement and collective efforts a step further, paired with the notions of relational health and culture change, Willis said he has been encouraged by recent emerging evidence and practices about the importance of community. He mentioned the new work of David Brooks at the Aspen Institute, now leading a project called “Weave,” a movement to “repair the country’s social fabric, which is badly frayed by distrust, division, and exclusion” (The Aspen Institute, n.d.). He said the project is working to end loneliness and isolation and shift the culture from ultra-individualism to one where relationships are put at the center of people’s lives.
Alignment of Rules and Messages
Willis reviewed the discussions throughout the day that talked about the importance of aligning data, narrative, and messaging. For example, during the discussion, James Perrin, professor of pediatrics at Harvard Medical School, highlighted the discordant example presented by Kelleher in central Ohio. Although the Center for Medicare & Medicaid Innovation is working on updated payment methods, Medicaid policy still requires careful strategy at the state level. In Kelleher’s example, they are unable to bill for services to both a mother and child in the same space on the same
day. However, there are existing Substance Abuse and Mental Health Services Administration grants that can pay for paired mental health services together. Just in this small example, Perrin wondered what functional collaboration across all of these groups might look like and what outcomes it could lead to.
New Strategies for Trying to Reduce Poverty
Willis noted that while there was discussion about poverty, he was struck that there was no mention of universal basic income or other monetary approaches for reducing poverty. He described programs being implemented, such as cash transfers to new mothers and babies. Another approach is communities that are investing in the next generation, such as the Family Rewards Program in New York City started in 2007: it resulted in reduced material hardship for families as well as increased school attendance and student performance in high school (Miller et al., 2015). These types of efforts to support economic self-sufficiency can really have an impact on well-being and reduced stress and maternal depression rates, he noted.
Willis added that researchers examining these programs are even starting to look at their potential effects on reductions in child abuse and improved well-being. While more research and program evaluations are needed, there are promising advances that should continue to be monitored. David Hawkins echoed this point, calling attention to research at Washington University-St. Louis, providing child savings accounts. The researchers conducted a study beginning in 2007 with the state of Oklahoma, investing $1,000 in a college savings plan for more than 1,300 newborns. Results include positive effects on social-emotional development for the children in comparison with a control group that did not receive investment at 4 years old, with even more pronounced benefits in disadvantaged households (Huang et al., 2014). The researchers believed part of the benefit was due to the improved outlook by the parents for the children, irrespective of who put the money into the account.
Regardless of the exact mechanism, Willis, said, there are many avenues for exploration in terms of fostering the well-being of young children, and partnering with local, state, private, tribal, and federal partners to understand the fundamental pieces of the complex, ongoing challenge of the opioid crisis that is plaguing many communities across the country. In this workshop, the Forum was able to elevate several examples of intervention programs that incorporate multisector and multigenerational approaches for promoting child and family well-being.