4
Implementing a National Agenda
David Willis opened the final workshop session by introducing the various perspectives that are important in considering how the Forum for Children’s Well-Being can work to improve mental, emotional, and behavioral (MEB) health. The main opportunities and challenges were summarized from the points of view of the local and community levels, the education system, federal and state levels, business and private sector, and the public health and health care system. This chapter concludes with commonalities highlighted by participants across various sectors, and opportunities for the Forum for Children’s Well-Being to advance this work in the future.
OPPORTUNITIES AND CHALLENGES ACROSS SECTORS
In the final session of the workshop, speakers reported on the highlights of discussions among their group sectors. These included definitions of terms, opportunities and challenges for MEB health across various environments, and future work the Forum could focus on to move this effort forward.
Federal and State Levels
Fan Tait, chief medical officer at the American Academy of Pediatrics, discussed some barriers and solutions with respect to state and federal policies. One immediate barrier that is found at both levels is data sharing. “We cannot get the data needed from different agencies, across grants, and different implementation of laws,” she said. Having someone at the federal
level who can direct appropriate data measurement and sharing could help overcome this challenge. While there are several examples at the state level of laws that support MEB health, Tait explained that it is also necessary to consider the regulatory sections of those laws and how they frame accountability. She used maternal depression screening as an example, saying that until the Centers for Medicare & Medicaid Services (CMS) released a letter saying that providers could be reimbursed for screening, it was difficult to move forward on that intervention, despite known benefits of the practice.
While there are several opportunities to move MEB health prevention and promotion forward, there is a need to acknowledge how much of a pressing issue this is, a participant suggested. A federal interagency group with legislative authority to decide what data are collected and which elements need to be consistent as reported across various grants from different agencies on related topics would help, the participant added. With this direction and requirement in place, it would be easier to realize shared accountability and consistency at every level—whether federal, state, local, or community. To make an impact, Tait said, both “top-down” and “bottom-up” approaches are needed. She also identified the criminal justice system as a missing seat at the table. Examples of other groups that should be included in these conversations but currently are often missing include adult care, self-advocacy groups, and children and youth with special health care needs.
Local and Community Levels
Erin Hegarty, executive associate with the Afterschool Alliance, began by identifying a common opportunity for community interventions: When implemented at this level, intervention teams are already familiar with the culture, local government, and nuances of the target population. Community interventions allow for close observation to know both when things are working and going well and when practices need to be reexamined. However, this can be challenging when policies and practices may have come from the state or federal level. Additionally, using evidence-based practices can be difficult because they often are not tailored to individual communities. Hegarty suggested practices need to be adapted in ways that make sense for the community. Finally, effective communication is a necessary tool at the local level, because there are often multiple groups that might be working on similar issues. This includes communication across organizations, as well as with families and parents who are on the receiving end of these practices. Lynda Gargan noted that it is important to have authentic feedback and input from families, rather than having one person at the table to “check the box” for family or patient engagement. To ensure that agencies and organizations are not duplicating efforts and working toward the same goals, strong communication is paramount, she urged.
Business and Private Sector
In highlighting the effectiveness of advocacy by the business sector, Robert Dugger introduced ReadyNation, an organization he cofounded that has 2,500 members nationwide who are available to advocate for proven early childhood development programs. Generally, he said, the trigger for business leader involvement is the recognition of acute workforce challenges that require specific solutions. ReadyNation advocates for programs that have positive effects on youth in all aspects—health, education, socialization, workforce, and so forth. While the primary focus is early childhood, it works across the life course, he said, from “cradle to career.”
Dugger highlighted some successful examples of business leader advocacy. A recent ReadyNation report shows the financial costs of not having effective national child care delivery policies. The report shows an annual loss of $57 million in lost earnings, productivity, and revenue (Bishop-Josef et al., 2019). This type of economic argument could certainly get the attention of businesses in the community, he said. Additionally, he shared an example of how implementing a quality pre-K program can offset the special education costs in schools to pay for the program, known as “Pay for Success” (PFS) financing. Salt Lake City, Utah, established a PFS Pre-K program that is working well. Working through its United Way, Salt Lake City secured a $2.5 million loan from Goldman Sachs and an additional $2.5 million from the Pritzker Foundation to fund the program for 3- and 4-year-olds. After several years of tracking children, the special education costs in the district have decreased enough for them to pay back the loans year by year. He added that research shows it is possible to finance other early childhood programs in similar ways. Quality prenatal care for an at-risk mother-to-be reduces Medicaid expenses and results in improved outcomes for children (Dubno et al., 2014).
In terms of barriers to engaging this sector, Lauren Caldwell offered one example of “noise in the system” as there are so many competing interests when it comes to business investment in communities. Moving forward, though the Forum has not specifically engaged the business sector before, Caldwell suggested bringing more businesses to the table and ensuring the right stakeholders are present, as well as leveraging the existing tools already created. The new consensus report (National Academies of Sciences, Engineering, and Medicine [NASEM], 2019) is a resource that could be used, adapting its language to engage businesses in a new way. Another participant offered the 2018 NAM Perspectives Commentary, Business Engagement to Promote Healthy Communities Through Child and Family Well-Being (Watson et al., 2018), written by several Forum members, as a resource for strategies and examples.
Education System
Stephanie Jones, Gerald S. Lesser professor in early childhood development at the Harvard Graduate School of Education, said the discussion group on education first asked themselves if they shared a common definition of the education sector and wanted to ensure they could reflect on and take advantage of successes found beyond the traditional K–12 education system. Marisa Paipongna, a project associate with the Afterschool Alliance, added that they decided the education sector encompasses all education experiences throughout the life course—both formal and informal. In formal education settings, she said it is important for staff members to have social and emotional learning (SEL) competencies and ongoing staff training, as well as SEL programs available for parents.
Kristin Darling, a research scientist at Child Trends, provided examples of successes in education related to MEB health that could be opportunities for the future. One example is the broad set of SEL programs, she said, with many being rigorously tested. The expansion of the programs from students to include a focus on social, emotional, and mental well-being for all staff members in a school was also crucial. Additional successes in the education sector include the promotion of alternatives to exclusionary punitive school discipline, school-based mental health services, and offering a range of programs to parents.
Carlos Santos, assistant professor at the University of California, Los Angeles, offered insights into current innovations from his work using social network analysis in school-based settings. This analysis moves beyond the traditional randomized control trial framework to get a better understanding of relationships in schools, he said. It is a fairly low-cost method in which children nominate their peers, identify influencers, or map out entire friendship networks—all of which can be used in a variety of ways. Building on Darling’s point about well-being of a school extending beyond the student base, Santos suggested engaging with innovative strategies and marketing professionals to reframe efforts in schools as not limited to youth, but also including teachers, cafeteria workers, reading specialists, custodians, and others. Jones reiterated the theme of leveraging data to be as efficient as possible and to target interventions strategically. For example, data can be used to consider how a classroom-based intervention may be adapted for a broader setting. She noted that the education field has the opportunity to leverage its extensive work in “nudge-like”1 interventions.
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1 In the behavioral sciences, a “nudge” is an intervention that is focused on encouraging desirable behavior(s) without taking away choice (Benartzi et al., 2017).
Public Health and Health Care System
Tom Boat offered some suggestions for MEB health within the overarching health system in the United States. Many opportunities in integrated behavioral health for primary and specialty care have not been realized yet, he said. First, from birth until age 3, there are 12 well-child visits. This is the only system in the country that universally accesses infants and toddlers, and parents trust the system. Unfortunately, electronic health records (EHRs) are not currently designed to encompass MEB health needs. Second, he said, there is a wonderful payment method for preventive surveillance visits around physical health from a pediatrician, but not MEB health. This system could easily be mirrored around a similar schedule and have payment for those visits cover both physical and MEB health. “We know what works,” he said, but there is a need to figure out the best way to finance it and document it so demonstrated quality is evident.
Another issue, raised by Rebecca Baum, a pediatrician with Nationwide Children’s Hospital and clinical assistant professor at The Ohio State University College of Medicine, is improving MEB core competencies in the health care and public health workforce, such as the work done through the Forum’s Collaborative on Creating an Integrated Health Care Workforce to Improve Cognitive, Affective, and Behavioral Health for Children and Families (Workforce Collaborative).2 The MEB workforce itself is very diverse, and there is a need to work across all organizations. Baum praised the Forum as a great convener for that work. As the importance of team-based care has emerged, an additional workforce consideration is training people in an integrated model, not only primary care physicians, but also subspecialists caring for children with chronic disease, mental health staff, front desk staff, nursing staff, and others. Engaging youth and families in this effort and maintaining a health equity approach will also be paramount, she said.
Commonalities Across Sectors
While each sector will need to work within itself to identify champion stakeholders and opportunities for making changes to improve MEB health outcomes, there are some strategies that can be applied in multiple areas. Throughout the discussions, certain interventions were mentioned by a number of participants from the different areas. One simple, yet critical aspect is acknowledgment of the urgency of the problem. For example, the country has been hearing about the opioid crisis and other MEB health
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2 For more on the collaborative, see https://sites.nationalacademies.org/DBASSE/ccab/DBASSE_180693.
issues throughout the population for years, but communication differs depending on the sector, Tait observed. She emphasized that the lack of alignment in messaging has made it difficult to demonstrate the urgency and pervasiveness of the problem. Working across sectors and developing key messages can help communicate the urgency for action and provide understanding for the collaborative actions needed across these sectors.
As another example, a few speakers said engaging families in a meaningful way could inform policies that apply to a diverse population and also ensure that recommendations are actionable. Whether at the local/community level, within the education system, or, as Baum noted, within health care and public health as they train their workforce to employ a health equity approach, inclusion of the family perspective is a necessary component.
Finally, integrating MEB health services and interventions into established systems was mentioned by multiple participants, supporting the initial statements made by Boat during his presentation on strategies for scaling efforts. Whether incorporating MEB strategies into the education system or adapting primary or chronic health care protocols to include MEB specialists, promotion of MEB health will be better served by partnering across interested and involved sectors.
NEXT STEPS FOR THE FORUM FOR CHILDREN’S WELL-BEING
Throughout the discussion, several participants identified opportunities for the Forum to continue advancing this important issue of MEB health promotion. Lynda Gargan suggested engaging families and various communities on the report recommendations before disseminating it widely. She said that would be an opportunity for the Forum to make the recommendations more actionable and understand how they might work better in the community. Kathleen Siedlecki stressed the need to make the information easily available. She added there should be mechanisms for the communication to be bidirectional, so the Forum members and stakeholders can receive feedback from the community level in order to tailor approaches as needed. Tracking data long term can also be a good investment, in order to better understand how these programs affect families intergenerationally, Siedlecki added.
Jones proposed using the Forum to investigate innovations that have been implemented in the education system around MEB health to learn how they can be best implemented or scaled in other platforms. During the federal- and state-level discussion, Tait suggested the Forum could work with existing laws and toolkits to develop talking points for various groups and to enhance implementation of laws such as the Family First Prevention Services Act at the state level. Another opportunity would be examining
various MEB health-related grants in states to learn from them, understanding the strengths and weaknesses of each and how best to replicate successes across other states.
Caldwell suggested the Forum increase its engagement with the business sector. Bringing more businesses to the table and encouraging them to help solve some of the persistent challenges and ensure more stakeholder representation could be a helpful way forward, she said. The Forum can leverage existing tools, including Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda (NASEM, 2019) to develop new resources that businesses are more likely to respond to.
Finally, Baum and others suggested that the Forum can be a neutral convener for the multiple disciplines involved in MEB health and can help improve MEB competencies that need to be developed in the public health and health care workforce. She noted that the Forum’s Workforce Collaborative has begun this important work and urged it to continue.
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