3
Promoting Mental, Emotional, and Behavioral Health for Children Across Sectors
The presentations highlighted in Chapter 2 provide an overview of the remaining challenges to implementing mental, emotional, and behavioral (MEB) health efforts widely. They also suggest a need for investment and cooperation across sectors in order to meet the goals of improving MEB health for children and families. This chapter provides an overview of the various strategies being employed by different sectors in the effort to improve MEB health for children, the barriers that remain, and breakthroughs that are still needed. Participants were organized into five groups: federal and state policy, local and community, business and private sector, education, and health and public health. In each discussion group, participants noted benefits and challenges from their perspectives and what the Forum for Children’s Well-Being can learn from each sector.
FEDERAL- AND STATE-LEVEL STRATEGIES
The federal and state governments play an important role in advancing MEB health for children. The federal level typically involves laws and guidance, one participant said, and the state level is focused more on the rollout and implementation of those laws. People often think the work is done once a law is passed, but that is rarely the case. For example, the Family First Prevention Services Act (Family First Act) has toolkits available for states to implement the law as best as possible. Other organizations have provided additional resources such as examples of programming that may
qualify and talking points to help support states.1 This type of advocacy is important at the state level, one participant pointed out, because if a state decides not to implement such programs, federal funding is potentially “left on the table.”
A few participants also gave examples of strategies at the state level, such as the award from the Health Resources and Services Administration (HRSA) to 21 states to look at pediatric mental health care access; funding for seven states to conduct screening and treatment for maternal depression-related behavioral disorders; and the Integrated Care for Kids state payment model through the Centers for Medicare & Medicaid Services (CMS).2 A challenge to the design of these policies at the state level is the lack of systematic implementation, making it difficult to share lessons across states or understand whether certain interventions have worked for other similar communities or regions, according to one participant.
Opportunities for Greater Federal- and State-Level Contributions to MEB Health
Several participants had ideas for possible ways the public sector could increase its contributions to the field. One potential solution would be for federal agencies supporting MEB health efforts to consistently write up best practices with strong evidence to support them and disseminate the write-ups to reach more states. Another participant highlighted the need for integration of data so agencies can ask for similar metrics that are more easily shared among grantees and stakeholders. Even standardized definitions of various youth age groups across agencies would be helpful. For example, when searching for “adolescents,” some sites use the age range of 0–18, while others use 12–24 or 18–34. It may take a few critical metrics to compel funding, a participant noted, so there is a need to be strategic. But there is precedent in other fields, she said, giving the example that $20 million was needed to get the cigarette tax implemented and shift the culture on smoking and tobacco.
The public sector can also play a role by enacting policies for their employees, whether at the federal, state, or local/county level, which can have huge implications for the field, a participant suggested. For example, enacting broad family leave policies can make a statement that will be noticed by others.
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1 The Children’s Defense Fund tool “Implementing the Family First Prevention Services Act” will be updated regularly and can be found at https://www.childrensdefense.org/policy/policy-priorities/child-welfare/family-first/implementing-the-family-first-prevention-services-act.
2 For more on the Integrated Care for Kids Model, see https://innovation.cms.gov/initiatives/integrated-care-for-kids-model.
Barriers to Success
While the Family First Act has been a great example of success in the MEB area across many states, participants highlighted several barriers that continue to present challenges. These include lack of data, funding, and an adequate workforce. One person noted that one of the problems that led to the HRSA behavioral health access grants was the trouble pediatricians often had in finding psychiatrists to whom to refer patients. There often were long wait times for referrals, and families had a hard time accessing care. There is often also a lack of knowledge among doctors and the medical system about the mental health services available to their patients, the participant added.
Another person shared that HRSA does projections of the mental and behavioral health workforce. In 2019, a projection for child and adolescent psychiatry found an oversupply of psychiatrists in 2030 (Health Resources and Services Administration, 2018). However, the participant noted, digging into the data showed adult data were used to calculate the unmet need with no adjustment for the existing shortages. According to a recent analysis, only 27.7 percent of U.S. counties have at least one child and adolescent psychiatrist. The majority of counties do not have any (Beck et al., 2018).
Breakthroughs Needed for Further Success
While there has been positive progress in the MEB health field in the public sector, a participant pointed out that 20 years have passed since the Institute of Medicine report From Neurons to Neighborhoods (National Research Council and Institute of Medicine, 2000). That report called attention to the long-term positive impact of investment in social determinants and prevention of adverse childhood experiences. There is a need to make a compelling case for this type of investment in MEB health so it can become a priority with a national agenda, the participant said.
Determining financial incentives for promoting MEB health is another strategy that demands involvement from the federal and state levels. For example, a participant mentioned that Mental Health America is requesting feedback on a proposed pediatric payment measures program that would provide funding for cost measure research and development to incentivize prevention and early intervention of mental health conditions in adulthood. Then, the participant continued, ideally this research would be translated into practice by mandating CMS and its office of innovation to implement the interventions and take a more comprehensive view of what “value” means. The savings or return on investment window would be closer to 15–20 years, recognizing that savings do not always happen in the first 5 years.
Another strategy needed for success is that of communication and alignment of messaging, one person suggested. If stakeholders could agree upon 5 key messages instead of the 100 used, there would be real potential in mobilizing for action. Part of a successful messaging strategy is articulating the urgency of the problem, the participant continued, which seems to get lost by those unfamiliar with the field. Another person noted the impact that youth engagement has had on moving LGBTQ issues along the spectrum of progress. Developing similar messages that are motivating but resonate with a wide range of stakeholders could be valuable, the person added, citing the efforts of the Child and Adolescent Mental Health Coalition, cochaired by the American Academy of Pediatrics and the National Alliance to Advance Adolescent Health, as an example. The coalition came together to develop broad mental health principles and action steps for each principle. It was difficult for everyone to get on the same page, and various groups have different focus areas depending on age range or cohort type. However, they were able to identify five big bucket areas to coalesce around to make their voices more powerful: workforce, insurance coverage and repayment, integration of MEB health into pediatric primary care, early identification and intervention, and mental health parity (Child and Adolescent Mental Health Coalition, 2019).
For this sector to be really successful, a few participants proposed creating an interagency group to look at the top five priorities for MEB health. Existing interagency infrastructures are not sufficient as they often lack the authority needed to move initiatives forward, one stated. But another participant said that agencies do not collaborate, people do. There is often a lot of activity and partnership at lower levels, but it may not elevate to the highest leadership, which results in the disconnect. With nearly every sector involved in MEB health touching the federal and state levels in some way, several people raised questions on how best to coordinate efforts with others. Suggestions included bringing together representatives from early childhood/infant centers, adult care, population advocacy groups, disability law centers, deaf and hard-of-hearing communities, corrections (prioritizing trauma-informed intervention instead of detention and correction), payers such as CMS or Kaiser Permanente, and civil rights organizations.
LOCAL- AND COMMUNITY-LEVEL STRATEGIES
As the session began, several participants noted that there is much to learn about community investment and trying to respect communities and their leaders. The discussion covered successes achieved and barriers encountered, breakthroughs still needed, and how the Forum for Children’s Well-Being can help advance the field.
Past Examples of Success
Four programs were described as examples of success. The first example highlighted came from Kelly Kelleher’s experience with Nationwide Children’s Hospital in Columbus, Ohio, investing in the south-side communities of the city to improve social factors affecting health. Instead of taking the sole lead, the hospital partnered with the community to drive the process and coordinated funding together. They created a public-private partnership that included United Way and the mayor’s office to increase programming effectiveness. Working with neighborhood leaders also helps replicate a project, Kelleher said, because they can help connect with leaders of the next neighborhood and trust is already built. The partnership also prevents the spending of money on things that are not needed.
Another highlighted success began 20 years ago in Montgomery County, Maryland, driven by the county’s Department of Health and Human Services. The department put a program in schools to work with teachers and identify struggling children and tried to engage the parents early. The program, called Linkages to Learning,3 began in three schools. Case workers were brought in who had access to food stamps, child welfare records, and other needed resources. The results were very successful, the participant added, and the program is ongoing in 28 schools, including middle school.
A third example, Baltimore’s Charm City Care Connection, was founded in 2009 to help low-income residents navigate the system and access the services they need. Through a health resource center, they receive help that includes securing health insurance, accessing substance abuse programs; and accessing community services such as food stamps, energy assistance, and housing.4
The fourth example came from the maternal and child health sector in Indianola, Mississippi, where infant and maternal mortality rates were abnormally high. Five years ago, the Delta Health System went to communities to identify leaders and gave them a stipend to reach out to pregnant mothers and connect them with the health system. It ended up being so successful that Delta began paying more of a salary and developing other community health workers in the maternal and child health space, leading to what is now the Parent Engagement Program,5 which focuses on connecting people to the system. In just 5 years, the participant explained,
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3 For more information on the Linkages to Learning Program, see https://www.montgomeryschoolsmd.org/community-engagement/linkages-to-learning.
4 For more information on Baltimore’s Charm City Care Connection, see https://www.charmcitycareconnection.org.
5 For more information on the Delta Parent Engagement Program, see https://deltahealthalliance.org/parent-engagement-program.
the infant mortality rate decreased and the school readiness of the group increased by 40 percent.
Barriers to Success
While there has been clearly demonstrated success at the local and community levels in this area, participants identified barriers as well. Four big barriers to engagement mentioned by participants were transportation, language, child care, and food. Lack of trust among immigrant communities is an important challenge as well, said another participant. Many immigrant families are afraid to participate and often do not trust the programs. It can be expensive and time-consuming to truly engage communities, but it is crucial if programs are to be successful, a participant said.
Another challenge identified is integration of services and programs. Many groups working in related areas may want to offer things that seem needed, but no one wants to duplicate services. There is also a concern of misalignment of resources and community needs. Making sure all the leads involved are talking to each other and ensuring that those in the community understand what resources are available and how to access them is critically important, a participant stressed. Another said that honoring the family voice and lived experience can be both a barrier and an opportunity for consideration.
Breakthroughs Needed to Advance the Field
One of the breakthroughs needed, someone suggested, is figuring out a way to build relationships with youth at risk and teach the needed skills through interactions with them instead of trying to force a structured program. It is difficult to get teens to attend a program outside of school where they review a list of skills in session one and then another list of skills in session two, when they would rather be playing basketball with friends, a participant commented. Learning how to do this in a setting where there is a lot of turnover is difficult but would be really valuable, the participant added. Another commenter explained that many institutions often start programs, but nothing changes until the relationships change. For example, this participant’s organization has 200 nurses as mentors in schools and 50 secretaries who operate Play Streets, where the streets close to traffic once a week to let children play. People clean up the neighborhood in partnership, and the neighborhood and hospital have adopted each other. This way, the group is hearing feedback all the time and does not need to worry about securing that one voice at the table to try to “represent” the whole community.
In addition to creating more authentic relationships, a participant identified the need to find strong leaders—people who can engage the public,
private, and volunteer sectors. This is a challenge, but important, a participant said, because each community has its own specific needs, so typical “best practices” might not be easily implemented. Strong leadership can help bring the work to the core of the community and the heart of the people.
A final breakthrough suggested by a pediatrician is the importance of measures of well-being. Current measures of MEB health or well-being are quite thin, he said, but the identification of metrics and measures that honor the variation of human development will make it easier to reassure parents that they are on the right track. Early intervention when problems arise is also key, he added.
By nature, commented several members of the group, the local and community levels represent a variety of sectors, including business, faith, and local government. Aside from sufficient funding, what is critical in coordinating sectors is a strong anchor institution to convene people. In Oregon, a participant shared, the policy landscape created early childhood hubs for collective impact. Recommendations from the Oregon Health Policy Board, through its Care Coordination Organizations (CCOs), require a percentage of money to be invested in health activities within place-based community activities. Since CCOs need to report on the kindergarten readiness of their Medicaid population, working closely with the community can be incentivized, which can drive further coordination across all sectors involved in MEB health.
Future Directions for the Forum
Overall, multiple participants saw a role for the Forum in taking the recommendations from Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda (National Academies of Sciences, Engineering, and Medicine [NASEM], 2019) further. Beyond just sharing the information, these participants suggested, there is a need to engage families and communities across the country to understand what the report got right, as well as what was missing. They stated elevating the stories from families and positive activities that are going on, even if they have not been properly documented or stamped as “evidence based,” could bring energy to others working on similar issues. Also, several added, having cross-sector conversations in communities—similar to those at the workshop—as a targeted outreach effort with similar questions could generate a lot of knowledge to support the work of the Forum.
One participant highlighted a lack of investment options for local communities that focus on children and youth. Similar to other fields such as clean energy, impact investing, and social impact bonds for recidivism, there could be creative investment options to increase available financing. As an
example from another sector, there is a competition between solar funds at Goldman Sachs and Chase Bank to see who can retain the most clients, she observed. She asked whether hospitals could invest their residual funds in a child development pool.
Another valuable effort the Forum could take on is a communication strategy, suggested another participant. Fostering Healthy Mental, Emotional, and Behavioral Development is full of resources and important findings and recommendations. Those messages could be translated into shorter and more digestible pieces, another participant added, making it easier to reach interested policy makers and researchers. Each sector may need the message to be slightly tweaked, but doing so can have great influence.
Lastly, a participant suggested the Forum could capitalize on its role as a convener and bring together national federal leaders from the United States, Canada, and elsewhere, to find exemplars of programs that promote MEB health in children and youth. Past work of the National Academies’ Forum on Investing in Young Children Globally has included hosting international workshops to gain insight into how similar problems are dealt with by varying governments and cultures (NASEM, 2017).
BUSINESS AND PRIVATE-SECTOR INVESTMENT
While the Forum has not historically engaged businesses in its efforts around children’s health and well-being, several participants suggested this could be a positive way forward to consider. The advocacy of businesses in state and local needs is a different perspective but can offer lessons for other stakeholders in advancing this field. Businesses and the private sector can be better engaged by leveraging existing resources, such as the consensus report (NASEM, 2019), but tweaking the communication tools and messaging to resonate with their goals and values.
Learning from the Business Sector’s Contributions to Healthy Development
Having businesspeople involved in advocating for an issue can be tremendously helpful in advancing discussions, several participants argued. Many business leaders see child health and well-being as essential to workforce development, as morally right, and as an essential determinant of a city’s, region’s, or nation’s workforce. It is also an essential determinant of the current productivity of parent employees. Employee productivity is greater where quality child care and early education resources are readily available, one person pointed out.
“As advocates, business leaders are very effective,” said Robert Dugger, founder of ReadyNation. He shared examples from his experience in
organizing business leaders to talk to legislators about increasing funding for young families to increase workforce competitiveness. He noted that this can be equated to supporting mission readiness in the military. However, he expressed the opinion that there is a lack of concerned scientists who want to talk about child well-being in the same organized fashion. Another participant disagreed, noting there are professional organizations who go to legislatures and make those arguments. However, the concerns of today’s young people often do not resonate with policy makers, the participant opined. Another person commented on the lack of credibility that scientists can have sometimes when arguing for policy changes and they do not have the same ability to secure attention as local businesses or members of the police or military.
One participant noted that the research community could do a better job of branding. There is value in learning how much coaching researchers need in delivering a message so it is heard. The participant suggested that organizations such as the National Academies could invest in learning how to distinctly brand and bring authenticity to researchers so they can deliver important messages to legislators and business leaders without getting caught up in technical details and statistics.
Lauren Caldwell, director of the Children, Youth and Families Office of the American Psychological Association, said her office helps businesses see the return on investment by bringing in researchers to conduct studies. The benefits can also be described as twofold, she said, as businesses get a more engaged workforce and develop loyalty if they provide child support. Such investments can also prepare the next generation to be productive in the workforce. Some see this value right away, she said, but asked how to marshal arguments to better engage more businesses.
Barriers to Success and Future Breakthroughs Needed
Investing in pre-kindergarten (pre-K) and other child and family support is important for business leaders, Dugger said. They notice a lack of people trained in high-level skills and are looking outside the country for talent. They increasingly feel it is morally wrong to not adequately feed and educate kids across the nation, but there is a need to create a greater moral and economic argument around why this investment is necessary. Dugger offered suggestions of limitations, including resources and organization competence. There are also internal industry conflicts in things like quality child care, he said. While people might see the positive benefits, they do not want to pay for it. Businesses are worried about cost they will have to bear alone.
In terms of resources, one person added, more is spent on the elderly than on children. There is a lot of noise in the system, and children and
families have very little voice. He urged the need to constantly humanize people’s conditions. The breakthrough would be finding ways that advocates can talk about the well-being of children in personal ways. Nothing is communicated with a graph, Dugger said. Policy makers are people, and like all people, they respond to personal stories and advocacy.
Arun Karpur, director for data science and evaluation research at Autism Speaks, described the bucking of stigma as a positive change in his work with youth. Adolescents and young adults today are very open about their experiences and feelings, he said. Talking about going to therapy is something they are more open about, which can help reduce the stigma around MEB health issues. Karpur added that the accepting perspective of youth ready to work with people with autism and disabilities is important and increasing, because they often went to school together or they have friends with siblings who have developmental disabilities.
EDUCATION STRATEGIES
Formal school settings have much to offer in terms of improving MEB health, as children spend a large portion of their day in school. Some participants suggested the importance of informal settings, too, including out-of-school time, adult learning programs, and early child care environments to ensure this effort is comprehensive and takes advantage of all opportunities.
Role of Education in MEB Health
One overarching principle, a participant offered, was that MEB health is unavoidably impacted by the education sector. There are opportunities for developmentally relevant promotion efforts like universal social and emotional learning (SEL) and adult development. Schools present a great platform to teach core competency skills around SEL and allow children to develop their own skill sets to navigate relationships, work, and life in general. But, the participant warned, there is danger of marginalization and exclusion in these environments. Schools and educational settings can be places of trauma for both children and adults, so this consideration should be kept at the forefront of any intervention design. For example, for those children and teachers who make up a sexual or gender minority, structural processes of marginalization can exacerbate their stressors. The difficulty, another participant added, is that children have increasing awareness and understanding of inequality. He questioned how educators can effectively work with marginalized children without addressing their unequal conditions. Teachers may not be well trained, and schools often historically prefer a “colorblind” ideology, making it difficult to design SEL
interventions systematically. A participant added that doing this well will require the consideration of the MEB needs of staff, who may need to build resilience in themselves before helping to create an environment conducive to resilience building for children.
Opportunities and Barriers
Several workshop attendees discussed a variety of opportunities and barriers in the sector related to promoting MEB health. A few participants suggested SEL as a key strategy for pre-K through adulthood because there are formal and informal opportunities at every level. One person suggested making empathy a skill that is a graduation requirement for high school. If children and youth can learn to demonstrate empathy, conflict resolution skills, interpersonal skills, and communication, they are likely to have better MEB health potential going into adulthood. Similarly, the learning should not stop when formal education ends, the participant urged. Another participant highlighted the research demonstrating how mishandled marital conflict can negatively influence child development (Davies et al., 2016) and suggested the positive impacts of parenting groups. Helping couples in their transition from partners to parents can help alleviate conflict and the downstream consequences.
A second opportunity suggested is leveraging school climate initiatives. There are conflict resolution systems that avoid punishment and promote alternatives to exclusionary discipline. Programs such as “Engaging Schools”6 are also helpful in making the environment more welcoming to all children and revamping codes of conduct to be more developmentally focused and less punitive. Other participants suggested viewing students as agents of their own outcomes instead of things to be controlled. Teachers and educational providers can focus on promoting student success, tying “wins” into self-esteem and self-efficacy, and empowering students to prevent dropout and promote their success across physical, cognitive, and emotional dimensions.
Short-term behavioral health interventions were also suggested as a promising practice in the education sector. One participant shared an example in which community-based private providers agree to hold a certain number of spots for children in the school system in case those students do not have access to a provider or are met with a long waitlist. The providers agree to start them right away with six sessions so there is no lag time where the need is unmet. This is a collaboration between the county and the providers, so there is very little cost to the family, if any. Finally,
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6 For more information on Engaging Schools, see https://engagingschools.org/why-engagingschools.
preservice training of adults and teachers in the school system, and general expansion of school-based mental health providers in elementary and secondary school levels are an opportunity for improved MEB health, it was pointed out.
While the opportunities are promising, several barriers preventing the education sector from meeting goals related to MEB health were also discussed. First, while there are great examples of SEL as a strategy, the term itself is ill-defined. There is no strong consensus on what it means or how best to measure it. With this type of uncertainty, SEL programs can be hard to evaluate and replicate. Similarly, the available evidence makes it difficult to show that implementation beyond where a program was first studied would be effective and appropriate.
Structural issues are also a challenge, a few people pointed out. For example, the way schools are set up in terms of K–5, middle school, and high school may not track the optimal developmental stages of children. One person suggested grouping K–3rd grade and 3rd–7th grade as more appropriate. Additionally, school ends at 2:30 or 3:00 pm, well before many parents are able to leave work, which results in an often piecemeal approach to after-school child care. Out-of-school time should be framed as an issue around women and racial inequalities, a participant said. Even for those places with after-school programs, there is huge variability in evaluation (unless they are federally funded). The providers differ in their intentionality and programs are often understaffed. Because of these factors and the difficulty in measuring success, it is hard to develop metrics to help understand the efficacy of interventions.
Innovation and Ways Forward
Moving forward, several participants described innovations in the education sector that could be leveraged for MEB health. For example, one participant shared the prospect of “contagion” efforts and social network mapping, which provides insight into who child or youth leaders are and where problems may arise. Partnering with marketing and communications groups is another new idea that can positively frame these interventions to show they are about broadly influencing workforce development, the well-being of adults, and more, not only about children. Thinking carefully about how to strategically target interventions can have cascading effects, a participant observed. General lessons can be adapted to the education sector—both formal and informal—to shift the field in subtle ways. The Forum can play a role in this by bringing together the education sector and those committed to MEB health, advancing this discussion even further, a participant suggested.
HEALTH CARE AND PUBLIC HEALTH STRATEGIES
While the challenge of MEB health sits within the health care and public health fields, several participants acknowledged that it is not a “health only” problem to be solved. Tina Cheng, a pediatrician and director of the Department of Pediatrics at Johns Hopkins, said she can think about adverse childhood experiences and talk to her patients about them, but the solution lies in thinking about primary prevention. This discussion centered on the need to partner with schools, daycares, summer programs, and other specialists to achieve the goal of improved MEB health for children.
MEB Health Challenges for Children and Families
Describing the current situation in health care, Thomas Boat estimated around 5 percent of the total childhood population in the United States has a disabling, complex, chronic disorder that needs ongoing medical attention. This is a large number of children who also are likely to have a higher incidence of behavioral health problems. Boat continued that some disorders may have interventions that are not solely behavioral in nature but can make a difference for outcomes, such as prevention through better preconception and prenatal health. One of the biggest contributors to cognitive and behavioral problems for children in this country, he said, is the neurodevelopmental consequences of prematurity. Ten percent of children are born underweight and the more premature a baby is, the more likely that child will have neurobehavioral problems. Many of these problems can be mitigated, he added. The promotion of true value-based care for children, he said, includes preventing unintended pregnancies, improving preconception and prenatal care, preventing onset or serious consequences of chronic disorders such as asthma, and improving primary care provider coordination of surveillance and intervention for risks that may impede healthy MEB development. These investments in prevention can truly achieve value as children grow into adults, he said.
Along the same lines as value-based care and early investment, another participant highlighted the issue of maternal stress during pregnancy. While it is not well understood, Boat acknowledged the links of both preconception and prenatal stress to prematurity and other adverse neurobehavioral risks in childhood. There is a need to understand triggers for the consequences and the pathways to adverse health outcomes, he said. This issue also relates to the lack of universal maternity leave policies in the United States, resulting in women typically having to work until the day they go into labor. Afterward, they often return to work several weeks after giving birth. Other countries understand the long-term implications of attachment theory and the importance of parent and child bonding, so have imple-
mented broader leave policies to encourage better health outcomes for all in the family.
When considering issues of MEB health for children with chronic health problems, it is also important to remember that entire families are often affected, Boat said. Hearing a positive result from health screening, whether genetic such as cystic fibrosis or neurobehavioral such as autism, can be a stressful experience for families, he said, and it is often difficult for them to recover. Almost one-half of parents experience depression, anxiety, and stress following a newborn diagnosis of cystic fibrosis or when their newborns leave the neonatal intensive care unit (Children’s National Health System, 2017). This may require other family members to step in and help. Regardless of the diagnosis, the family involved should be included in interventions.
Finally, another participant suggested the challenges in treatment programs for youth in terms of substance abuse. There are few youth-focused detox programs, special step-down programs, sober high schools, or other programs specifically targeted at adolescents taking into account their social, physical, and emotional needs. Encouragement of people in recovery can also lead to prevention of future recurrences and the prevention of others falling into similar patterns.
Implementing the Agenda from the Consensus Report
Several suggestions were offered when thinking about how to best implement the agenda and recommendations described in the consensus report (NASEM, 2019). Cheng emphasized the critical role of messaging and getting the right message out to mobilize political will. Right now, she said, health care is very focused on the value-based approach and how to best avoid high costs. Investing further upstream and earlier in life for children would be an example of improving value. This investment could include behavioral health integration in emergency department, inpatient, or outpatient settings; training primary care providers on mental health; or better care management to ensure that children do not fall through the cracks of the system. Overall, there is a need for more common language across disciplines, aligning messaging to disseminate the information in a way that can start changing societal attitudes.
Another suggestion offered by Rahil Briggs, national director of HealthySteps at ZERO TO THREE, is to increase the availability of HealthySteps. But, she added, if it is fully integrated into existing health care programs, HealthySteps no longer needs to exist as a standalone program. Integrated behavioral health for children from birth to age 3 is a two-generation intervention, she added. Many parents of children needing intervention are likely to have their own behavioral health needs or mental
health concerns. They may not go to well-health visits for themselves, but they do take their children to appointments, which presents an opportunity to address their needs.
A few suggestions were offered in terms of changes to infrastructure. One participant identified a need for preventive care that is paid for without a prior diagnosis. A behavioral health preventive code could be added onto a visit, just like physical health. If there were a diagnosis, then that patient could go to specialty care and may require additional payment, but having an “MEB code” that mirrored the payment structure that already exists in pediatrics would be key. Similarly, since the electronic health record (EHR) system often drives the care that people receive, the participant said, there is a need for a behavioral health template. A participant noted that capturing and harvesting data from outside the health care system should be improved so it is easier to understand whether children are meeting the functional outcomes that are being examined. Current EHRs do not do a good job of communicating with other systems and are also not conducive to behavioral health needs and reporting.
The MEB workforce was also highlighted as an area to focus on in terms of implementation. Instead of each discipline trying to make changes alone, several participants noted the need to think collectively and advocate for an increase in professionals across the board. A participant suggested developing shared competencies that would span different positions, which requires a different perspective. Everyone in an office, including front desk staff, could be trained at different levels depending on their interaction with the patient or families. While it is easy to visualize what a child with a conduct disorder might look or act like, it is much more difficult to understand what a 7-year-old with anxiety might look like. These providers on the front lines are depended on to do that initial identification, which should lead to a “warm handoff” to needed services.
Overall, a participant noted, there is a need for a systems perspective, instead of making small changes incrementally across various areas, at the state and local levels to think about the well-being of children, youth, and families. While this may exist in statute, support for this kind of infrastructure is needed in different states. Currently, the efforts are being made in a piecemeal manner. For example, for children with a physical health diagnosis, only certain states have turned on the cognitive-behavioral therapy or “procedure” codes for health and behavior intervention and assessment. Every state has a different set of criteria for who can bill under these codes. Even when billing is available, the reimbursement is not enough to sustain a workforce.
Future Considerations and New Ideas
Various suggestions and considerations emerged from participants as they thought about what this field could look like and how it could be optimized moving forward. Many participants called for bold actions but acknowledged the large resource requirements—with resources going to the public health system if the system were to be expected to facilitate local surveys in communities and manage the data required to direct interventions appropriately.
A suggestion in thinking about the future is incorporating the word “development” into MEB language, said one participant. There are developmental milestones met throughout childhood and adolescence—and even beyond as adults. Similarly, language and cognition are not quite included in the MEB lexicon but can present challenges for families who are dealing with developmental delays. As professionals, a participant added, we want to foster skills for these children with delays, but also recognize that not every child will be able to catch up to others, so we should think about how to encourage these children to flourish in their own way. Families with children who suffer from language, cognition, or development delays should not be left out. That would deepen the divides between fields based on arbitrary designations like type of diagnosis or type of health care institution, the participant said.
As an example, Boat described the Reach Out and Read program, which recognizes that only one-third of young children have the skills needed to do well when they enter kindergarten.7 Families are given books and a contact within the primary care office who introduces the concept of early reading and its benefits. Their data show that it makes a difference in kindergarten readiness, and multiple studies have found evidence that the program results in improved adherence to pediatric visits, increased literacy and engagement at home, and improved vocabulary scores (Reach Out and Read, n.d.). This is a scalable program, he said, and an example of how to be more creative in scaling behavioral health promotion.
Another consideration brought up by a participant is ensuring that information and emerging evidence are distributed, especially into the hands of teens and young people. Simply having doctors and academics discussing it will not get the job done, but engaging social influencers can have a great impact. The work that Lady Gaga has done in mental health through her Born This Way Foundation was cited as an example of a potential partner.
Several ideas were brought up during the discussion that could be implemented within the health care or broader public health system, together with payers, providers, and other roles. For example, one participant asked
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7 For more information on Reach Out and Read, see https://www.reachoutandread.org.
why discounts on insurance premiums exist for individuals who regularly go to the gym, but not for new parents who participate in parenting or nurturing programs. Similarly, others advocated for teaching about parenting well before pregnancy, even as early as high school. As another example, when people turn 50, they can expect to start receiving magazines from AARP. There could be a similar effort when a family learns they are expecting their first child. The field could be very intentional and mirror other health initiatives by conducting interventions in barbershops, hair salons, libraries, and other places where people already routinely visit.
A few participants brought up the role of nutrition and its importance in impacting mental health, but also identified the challenges in changing dietary habits of Americans. A nutrition checkup could be paired with a physical checkup and lead to outcomes measuring the impact of each one, a participant suggested. Someone shared an example of this concept, a U.S. Department of Agriculture-funded effort called Starting Early, which is primary-care based and family-centered, starting in the third trimester of pregnancy and focusing on child obesity and nutrition. A randomized control trial studying the program demonstrated increases in exclusive breastfeeding and reduction in complementary foods for 3-month-old infants (Gross et al., 2016).
Another participant shared a recent experience in Des Moines, Iowa, with the Burmese community, where families said they found it difficult to feed their children through government programs that forced them to buy food they were unused to. When thinking about nutrition interventions, the participant suggested the need to teach families how to cook certain foods, and also take into account the context of different cultures and the foods they eat. Nutrition policies can be creative, one person added. Some states are using proceeds from tobacco taxes and sugar-sweetened beverage taxes to fund early childhood development programs, which is a win in two ways.
Suggestions for the Forum’s Work
One participant suggested a role for the Forum, as a neutral convener, in working together with relevant stakeholders to see what it could look like to have MEB health fully integrated into the child health care system. Every state is doing this differently. Unless there is a list of the various policy interventions being tested, and which are working or not working, it is difficult for state and health system leaders to know where to begin. There are great examples, but unless stakeholders come together and define what this process should look like, it will be a slow and haphazard experience.
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