The Patient Protection and Affordable Care Act (ACA), which was signed into law in 2010, has several provisions that could greatly improve the behavioral health of children and adolescents in the United States. It requires that many insurance plans cover mental health and substance use disorder services, rehabilitative services to help support people with behavioral health challenges, and preventive services like behavioral assessments for children and depression screening for adults. It increased funding for community health centers to improve the delivery of care for millions of children and their families. It legislated the standards of pediatric well-child and preventive coverage recommended by the American Academy of Pediatrics. It established a grant program to provide voluntary, evidence-based home-visiting services to young at-risk children and their families. These and other provisions provide an opportunity to confront the many behavioral health challenges facing youth in America.
To explore how the ACA and other aspects of health care reform can support innovations to improve children’s behavioral health and sustain those innovations over time, the Forum on Promoting Children’s Cognitive, Affective, and Behavioral Health held a workshop in Washington, DC, on
1The planning committee’s role was limited to planning the workshop. The workshop summary has been prepared by the rapporteurs as a factual account of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants and are not necessarily endorsed or verified by the National Academies of Sciences, Engineering, and Medicine. They should not be construed as reflecting any group consensus.
The Forum on Promoting Children’s Cognitive, Affective, and Behavioral Health was established as an outgrowth of the 2009 National Research Council and Institute of Medicine report Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities, which called on the nation to make the prevention of such disorders and the promotion of mental health of young people a high priority. The forum engages in dialogue and discussion to connect the prevention, treatment, and implementation sciences with settings where children are seen and cared for, including health care settings, schools, social service and child welfare agencies, and the juvenile justice system, and to create systems that are effective and affordable in addressing children’s needs. Members of the forum include representatives from the sponsors and additional experts in the implementation and evaluation of mental and behavioral health interventions for youth.
The workshop on health care reform and children’s behavioral health was the fourth held by the forum. The first, on April 1–2, 2014, examined strategies for scaling tested and effective family-focused preventive interventions so they can have widespread economic and social benefits (IOM and NRC, 2014a). The second, on June 16–17, 2014, was on harvesting the scientific investment in prevention science to promote children’s cognitive, affective, and behavioral health (IOM and NRC, 2014b). The third, on November 5–6, 2014, explored innovations in the design and utilization of measurements systems to monitor the well-being of children and guide the implementation of services (IOM and NRC, 2015).
April 1–2, 2015, titled “Opportunities to Promote Children’s Behavioral Health: Health Care Reform and Beyond” (see Box 1-1 for details about the forum). The workshop grew out of a learning collaborative formed within the forum to look at how the ACA might provide new opportunities to promote children’s cognitive, affective, and behavioral health. Through a series of phone calls, the initiative was broadened to include health care reform more broadly, with a focus on children’s behavioral health. (The workshop Statement of Task is provided in Appendix A.)
The workshop format was designed to stimulate discussion among experts, forum members, and the workshop audience. (Appendix B provides the workshop agenda.) Moderators directed questions to panels of experts and then opened each session up for general discussion. Each panel included representatives of different sectors and areas of expertise to explore the areas where disciplines and fields intersect and to break down silos of thinking and discussion. (Appendix C provides the biographies of the workshop speakers.) The workshop explicitly addressed the behavioral health needs
of all children, including those with special health needs. It also took a two-generation approach, looking at the programs and services that support not only children but also parents and families, because many evidence-based prevention programs and interventions involve parents.
At the end of each day of the workshop Mary Ann McCabe, associate clinical professor of pediatrics at George Washington University and affiliate faculty in psychology at George Mason University, synthesized the major concepts that arose over the course of the day’s discussions. The highlights that she identified are presented here as an introduction to the broad range of issues discussed by workshop participants and should not be seen as the conclusions of the workshop as whole. The chapter numbers in parentheses provide the locations in this summary report where workshop presenters discuss these issues in greater detail:
- The ACA has brought such issues as prevention, health promotion, and accountability to the forefront of the policy agenda. This has provided an opportunity to make changes in primary care, but such changes also call for integration across other systems that affect health care. (Chapter 6)
- Many opportunities for alignment and collaboration exist, such as between education and health. Nevertheless, gaps still exits. Though capital expansion of school-based health centers was funded in the ACA, their operations were not, representing a gap in the legislation. “I find it so ironic that we used to have a federal Department of Health, Education, and Welfare,” said McCabe. “Here we are again saying, ‘Why do we have these silos of health, education, and welfare?’” (Chapter 7)
- The ACA offers the opportunity to pay attention to parents and to parenting. However, in many cases, children are insured while their parents are not, which is “a huge problem,” said McCabe. “We still have a lot of work to do on the public policy side.” (Chapter 5)
- The adult health community could partner with the pediatric system, especially if practitioners were engaged and learn to adopt a life course health development perspective. (Chapter 2)
- The policy emphasis in the ACA has been on access to care, but the workforce does not necessarily exist to deliver that care. (Chapter 5)
- Terminology differences continue to pose a barrier to collaboration. The terms integration, behavioral health, and evidence still have different definitions among stakeholders. (Chapter 2)
- Many good screening measures are not yet well translated or validated for certain populations. (Chapter 3)
- One prominent item on the research agenda is to track both investments and outcomes across social services, education, and health. Social services, for example, may have outcomes on health, but they are not being measured, and vice versa. (Chapter 8)
- Policy makers get part of their information about science from the news, and scientists need to pay attention to this dissemination of information and how priorities are established in communities and other stakeholder groups, McCabe said. Communications science and behavioral economics tools can help tell a compelling story. (Chapter 9)
- A tipping point may be at hand. What many people are recommending is consistent, which is exciting but also a great challenge. (Chapter 9)
Finally, McCabe drew attention to what she identified as a fundamental issue with prevention. “Public policy tends to pay attention to problems—and to crisis, even more so. This is not a good match for children’s development. It is much more effective to pay attention to healthy development early on and . . . preventing problems for kids who are at risk. That is really what [the forum] is all about.”
After this introductory chapter, Chapter 2 summarizes the two keynote addresses at the workshop, which introduced the wide range of behavioral health problems seen in children and adolescents and ways of overcoming those problems. Providing a framework for panel discussions, the keynotes introduced key concepts including adaptive systems, social determinates of health, life course health development, and community health works. Chapter 3 looks at the opportunities, threats, and potential for innovation created by funding provisions under the ACA and health care reform more broadly.
Chapter 4 is one of three chapters that look at experiences in implementing innovations that affect behavioral health—in this chapter, at the state and local levels. Chapter 5 considers intermediary groups that can advance a two-generation approach, such as community health centers, school-based health centers, and home visiting programs.
Chapters 6 and 7 return to the implementation of innovations, in primary care (Chapter 6) and in other settings, including child welfare, early childhood education, and schools (Chapter 7). Chapter 8 reviews meta-analyses of research on children’s behavioral health in two particular
areas—the integration of behavioral health services into primary care, and parental involvement in their children’s health.
Finally, Chapter 9 summarizes the reflections of a panel of policy makers and of other workshop participants, revisiting the major topics of the workshop and exploring possible future directions for the Forum on Promoting Children’s Cognitive, Affective, and Behavioral Health.
IOM (Institute of Medicine) and NRC (National Research Council). 2014a. Strategies for scaling effective family-focused preventive interventions to promote children’s cognitive, affective, and behavioral health: Workshop summary. Washington, DC: The National Academies Press.
IOM and NRC. 2014b. Harvesting the scientific investment in prevention science to promote children’s cognitive, affective, and behavioral health: Workshop summary. Washington, DC: The National Academies Press.
IOM and NRC. 2015. Innovations in design and utilization of measurement systems to promote children’s cognitive, affective, and behavioral health: Workshop summary. Washington, DC: The National Academies Press.
NRC and IOM. 2009. Preventing mental, emotional, and behavioral disorders among young people: Progress and possibilities. Washington, DC: The National Academies Press.
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