While there have been many successful and promising interventions to promote mental, emotional, and behavioral (MEB) health across the country over the past several years, they are often a collection of smaller scale efforts implemented in an ad hoc fashion. Scaling them to achieve population-level impact, while still including important family and community perspectives to ensure health equity, remains a challenge. This chapter provides various perspectives on strategies to promote positive MEB health outcomes, the challenges of scaling them, and other considerations to keep in mind moving forward.
In describing his transition into the MEB field, Thomas Boat, dean emeritus of the College of Medicine at the University of Cincinnati and a professor of pediatrics in the Division of Pulmonary Medicine at the Cincinnati Children’s Hospital Medical Center, explained how he used to be much more focused on physical health, particularly for children with cystic fibrosis or asthma. He came to realize that addressing social and emotional issues and family wellness can have a big impact on health outcomes. While there are an impressive number of effective interventions for families, children, and youth in this area, he said that they have not translated nationally to broadly improving MEB outcomes. Taking these programs and efforts to scale is the next challenge, and he outlined five strategies for achieving population-level impact: identifying and implementing scalable interventions, leveraging existing system infrastructure, mobilizing cross-
sector community participation, utilizing informed policy, and focusing efforts through a national agenda.
Strategies for Scaling Programs
Just because an MEB program is successful in one population or community does not mean it will produce intended effects on a larger scale or translate well to another population or community, Boat said. Scaling programs requires investment in expertise and infrastructure. Even deciding which program to select can be difficult and requires thoughtful consideration. After identifying the population at risk, the number of people who might actually benefit from the program must be considered, he explained. Beyond effect size, this involves assessing enrollment rates, retention rates, and effect sizes, including the reduction of effect size with dissemination (see Figure 2-1).
For example, Boat noted that the metropolitan areawide Every Child Succeeds home visitation program in Cincinnati found that approximately 50 percent of families approached by the program declined enrollment in the program.1 The families most at risk were more likely to say no, whereas the families at lower risk would say yes. Other considerations that are important when trying to successfully scale programs include factors like sustainability of funding and the availability of a well-trained workforce. Researchers are paying increased attention to the identification of program
core components that must be adopted with fidelity, and elements that can be adapted to meet the needs of specific communities or populations. Data systems that support process and outcomes monitoring are critical for assessing and continually improving program outcomes.
Leveraging Existing Systems
A second strategy that Boat highlighted was leveraging systems that are already being routinely used by families and youth such as education, child care, and health care. While Boat recognized several challenges, he said concentrating promotion and prevention activities within these systems that universally serve children and families can have important advantages. All of these systems work with children at a population level, making recruitment and retention easier. The concentration of services can also reduce costs. For example, schools and health care already have personnel and data systems that can be engaged in fostering healthy MEB development. However, Boat noted, these settings are only recently recognizing their unique position to foster MEB development. Many such settings do not yet prioritize this.
Boat explained health care is a system that must be better leveraged to integrate MEB promotion efforts for children—especially through well-child care. By using primary care practices, there are opportunities to link parenting programs to practice, embed parenting specialists that can engage families while they are already at an appointment, and fully integrate the emotional and behavioral dimensions of health into the anticipatory guidance that is a pillar of well-child care. He pointed to two other important areas in health care that can promote healthier MEB development: chronic disease care and preconception/prenatal care. In both settings, patients are already coming in to see their provider team on a regular basis. Boat expressed the belief in the great potential for care models to prospectively support family and patient emotional and behavioral well-being while also addressing a child’s physical health needs.
The Economic Imperative
Boat concluded with the idea that there is an economic imperative for the next generation of young people to thrive. They should be providing a meaningful contribution to the workforce and add to U.S. social and economic well-being. Currently, the trajectory is not positive, but Boat hopes that can change with the right focus and investment in MEB health efforts. A recently published study makes a strong case for this investment. Researchers found strong links between a person’s social and emotional well-being in kindergarten and their income 30 years later (Vergunst et al.,
2019). For males especially, inattention and aggression at ages 3 and 6 were associated with lower annual earnings, and prosociality was associated with higher annual earnings. Being able to identify these characteristics at an early age, and knowing their future impacts, represents an opportunity to work with schools and teachers to intervene—ideally resulting in higher earnings for a larger number of individuals and overall improved social and economic status for the country.
The family perspective in considering a child’s MEB development is important. Lynda Gargan, executive director of the National Federation of Families for Children’s Mental Health, provided remarks from her experience acting as a voice for families in response to the worsening state of mental health for youth today. Gargan commented that it is difficult to speak on behalf of families because each family’s experience is unique.
Families often experience frustration when considering a child’s mental health concerns. For example, while statistics show boys between the ages of 2 and 8 are more likely than girls of the same age to have an MEB disorder, families question the validity of these statistics and are concerned that boys are more at risk of being diagnosed than girls. Families urge that statistics be interpreted contextually and that underlying bias be considered.
Gargan commented on some of the buzzwords that dominate the field, such as “poverty” and “social determinants of health” (SDOH), which she said contribute to a misunderstanding of causation. As an example, she shared that historically in West Virginia mining communities, even though families were poor and suffered from industry-related health issues, such as black lung, the community overall was resilient, lived well-rounded lives, and looked out for one another. But when industries shifted and livelihoods such as mining and farming began to disappear, there was nothing to take their place. It is not singularly the state of poverty that is the issue, she argued, but the social construct of destroying a community’s infrastructure with no regard for the consequences. Related to this, Gargan added that the term “SDOH” can be considered classist by some and can act as a deterrent to families who may be offended by it. Finding another way to talk about some of these challenges could be a helpful step forward, she suggested.
Gargan described additional challenges and roadblocks for families in seeking better MEB health outcomes for themselves and their children. The education system can be scary for families due to past negative experiences. As a proactive step for school systems, she offered the example of the Good Behavior Game, created by Dennis Embry.2 It is an evidence-based
2 For more information, see https://www.paxis.org/products/view/pax-good-behavior-game.
behavioral health strategy used to improve classroom behavior while also teaching self-regulation skills to children that can be applied in other settings. Gargan reported that the outcomes are impressive and that the next step is to train families to utilize the same strategies to ensure consistency for children throughout their day and ideally improve health outcomes. Other ongoing and emerging challenges for families include an increase in suicide rates for certain populations, such as Hispanic and Alaskan/Native American youth. Families are not educated on the signs of suicide, she noted, and unless the child frequently visits a pediatrician, warning signals may be missed.
Gargan said the epidemic of substance abuse is having a devastating effect on family units and creates worsening problems for MEB health outcomes. One example is the skyrocketing number of children in pockets of the country who are being resettled in the foster care system. Foster care was created initially as an emergency system—to be used as a stopgap until children could be returned to their homes. With the onset of the opioid crisis, she pointed out, children are now being placed in foster care at alarming rates, without a clear roadmap for returning to their families.
She also noted that a lack of access to services is resulting in parents being pressured to relinquish their children who experience MEB challenges to state custody so they can get needed services from child therapists and psychiatrists. But this process often takes children out of state, severing their ties with their families and communities of origin.
In conclusion, Gargan offered the utilization of trained family peer specialists as a promising practice to support families as they navigate these challenges and systems. Acknowledging that there will never be enough specialists and professionals to meet the need, she urged capitalizing on the opportunity to leverage people who have been through similar experiences. By training and certifying parents and family peers, the capacity of this workforce can be increased, ensuring that the families of children and youth who experience MEB disorders receive the support needed to increase their likelihood of positive outcomes. She noted her organization provides national certification for this parent/family workforce through its Certified Parent Support Providers Program.3
Bonita Williams, national program leader for vulnerable populations within the Division of Youth and 4-H at the U.S. Department of Agriculture, shared information about the Children, Youth, and Families At Risk
(CYFAR) Program. The program is a competitive grant that currently funds 43 grantees in 40 states, serving 12,000 youth and parents. She also explained that CYFAR is based on the Bronfenbrenner ecological model, which places the child at the center (see Figure 2-2). A selection of these programs uses the Positive Youth Development (PYD) approach, which emphasizes building on youths’ strengths and providing opportunities that can help them across their life course and have a productive transition to adulthood.
To provide a better understanding of what these programs look like in practice, Williams gave several examples of programs in different states. The University of Nevada, Reno uses the opportunity to fund the Nevada Heart and Shield rural domestic violence program,4 which focuses on
4 For more on this program, see https://nifa.usda.gov/announcement/heart-shield-programend-family-violence-nevada.
ending family violence through teaching skills and providing resources to child and adult survivors of intimate partner violence to break the cycle. All age groups work on topics ranging from communication to identifying emotions and problem solving. In another area promoting MEB health, Michigan State University’s Building Early Emotional Skills (BEES) Program5 focuses on providing parent education for those with children ages 0–3. Data from this program so far are very positive and suggest trends in the right direction, most especially an improved acceptance from parents of their children’s negative emotional behaviors. Under this program, knowledge about early social-emotional development increased, and parenting distress decreased following completion of the program. Results from the BEES Program suggest positive effects on parental functioning and overall quality of parenting. As a final example, Williams shared the University of Kentucky’s Youth Engagement and Support Program,6 which provides life-skills development for homeless or at-risk youth. The program helped 66 youth find employment, 13 find housing, 8 connect with mental health assistance, and 3 get out of human trafficking. This program uses the PYD approach with youth at the center of the family context and conducts evidence-based programming based on the needs of housing-unstable youth.
In conclusion, Williams added that 4-H groups around the country and at the national level have programs focused on mental illness. One example is “Talk, Text, Act,” a program designed to bring teens together to talk about mental health with peers and in their community. The 4-H program also partners with the Substance Abuse and Mental Health Services Administration to train volunteers on Mental Health First Aid,7 with positive results so far at Utah State University and University of Idaho.
To start her presentation, Angelica Cardenas-Chaisson shared a personal example of the challenges her sister faced in accessing MEB health services for her son. Her sister often experienced difficulty accessing mental health services for her Latino son. His school often excluded her from decisions about his care and failed to follow his Individualized Education Plan. As her son grew and his MEB concerns worsened, she advocated constantly with professionals to access mental health services rather than direct him into the pipeline of the juvenile correction system. Her sister
5 For more information, see https://www.canr.msu.edu/building_early_emotional_skills_in_young_children.
6 For more information, see https://hes.ca.uky.edu/content/children-youth-and-families-riskcyfar.
recognized the need to advocate for her son and to challenge a system that disproportionately directs youth of color experiencing MEB issues into this pipeline. Cardenas-Chaisson shared that Iowa, like many states, has an overrepresentation of children of color in the juvenile justice system and an underrepresentation in mental health services. Cardenas-Chaisson said her sister faced negative, racist assumptions from White education and mental health professionals about her and her son. At one point in order to access appropriate services, she had to give up custody of her child to the state. Cardenas-Chaisson noted that while this seems like an unusual last resort, it is more common than it should be. She said she shared her personal story to highlight the need for services and systems that are culturally competent and to use an equity approach, especially when working with families of color.
Cardenas-Chaisson then described the work of the Health Equity and Young Children’s initiative funded by the Robert Wood Johnson Foundation. The initiative focused on working with programs and practices that support families with young children. Its purpose was to understand common strategies among exemplary programs and practices that best supported families. Four elements were highlighted (1) a health equity approach, (2) family engagement, (3) care coordination, and (4) community linkages. Cardenas-Chaisson emphasized that disparities in health are largely preventable, and, as such, change is possible. There is a need to focus on societal factors that address disparate outcomes for families of color and equalize health conditions for all groups. She also argued for the importance of a comprehensive approach that considers the different contexts and environments that children are living in. It is impossible to understand a child’s mental health diagnosis without understanding the family or particular circumstances. In that respect, a true health equity approach should take into account culture, race, socioeconomic status, and access to services, she said.
Cardenas-Chaisson called for moving away from a “cookie-cutter” approach, assuming that everyone has similar needs and will benefit from the same interventions. Instead, organizations should provide culturally responsive services. Strategies to do this include hiring staff from diverse backgrounds, providing ongoing cultural competency training, collecting data on the community being served, and soliciting feedback and input from families so their perspective can be built into policies and strategies. Cardenas-Chaisson cautioned not to get paralyzed, waiting for the “perfect” data to be collected or better data to be identified. Often the data available already show who is being left out. And while data and research are important components, she added, without connecting them to real stories of children in need, the urgency can be overlooked. Moving forward, she said, continued attention is needed on the potential threats of
the dismantling of federal civil rights mechanisms and pushback on equity approaches. Furthermore, advocates should continue to promote recognition that all policies are health policies, and they should equitably serve children and their families.
A discussion that followed the presentations between the panelists and attendees highlighted topics such as engaging youth, leveraging families for policy change, and considering the costs to implement and scale programs nationwide for MEB health.
Taking successful interventions to scale will be an ongoing challenge, many workshop participants commented. As one participant noted, there are few examples in the United States, and though there have been good programs, major policy changes have not followed. She shared a recent paper by the Society for Prevention Research titled Taking Evidence-Based Interventions to Scale in Public Health Systems that identified six key factors affecting scale-up: (1) public awareness, (2) skilled workforce, (3) data and evaluation capacity, (4) leadership, (5) community engagement, and (6) developer/funder capacity (Walker, 2019).
According to Gargan, children and youth play an important role in this work, highlighting an effort in her organization called Youth Move.8 Williams added young people are leading the way to change through 4-H programs and suggested that adults should listen to their new ideas. Cardenas-Chaisson referred to Achieving Maximum Potential as another example of youth-led action.9 Its 14 council sites around Iowa involve current and former foster youth, who are instrumental in going to state legislators and discussing what is needed to improve their own well-being.
Boat emphasized the importance of family input but lamented that often the people who are willing to give input and participate are in families that are fairly stable, while the families who need the most assistance do not engage. Gargan explained that when families are in crisis—especially if they have a child with chronic disease—they are in survival mode and it is difficult to participate in extra activities, even if they are beneficial. Cardenas-Chaisson and Williams stressed the importance for groups to be intentional about engaging families of color, which sometimes requires groups to leave their comfort zone and go to where families already are. Gargan also said that bringing in families early and often can be valuable in crafting policy and practices that address a diverse array of needs.
It is important to acknowledge the amount of money that these efforts cost, several participants said. Cardenas-Chaisson noted that Iowa recently passed a children’s mental health initiative but with no funding attached to it, making it difficult to fully implement. Boat argued that to enhance MEB health and development, the health system must invest in promotion and prevention services, and the business community must invest in social enterprise. This will take time but is needed before moving forward, he said.