1 The Problem
A maturing scientific knowledge base clearly demonstrates the critical influence of early neural development and maternal health on long-term (i.e., two- and even three-generation) health and mental health outcomes. At the same time, communities are demanding higher-quality child and family supportive services in light of the disturbing rise in mental, emotional, and behavioral health disorders, including increases in children’s depression, anxiety, self-harm, and suicide, and disparities in access to care, made even more concerning by the COVID-19 pandemic. The convergence of this critical mass of scientific evidence and community demand for better care is leading some state mental health policy makers to consider new ways of investing in the early childhood period to prevent later mental health problems (1, 2). “Prevention” refers to programs that address risks (e.g., interventions that address caregiver needs to mitigate potential risk factors or those that target externalizing or internalizing behaviors in early childhood settings); “promotion” refers to programs that strengthen skills and support resilience to facilitate healthy development (e.g., universal parenting support programs or social and emotional learning in early childhood settings) (3–5).
2 Components of the Solution
Numerous barriers to State Mental Health Authorities’ (SMHAs) implementation of evidence-based prevention and promotion programming exist, including organizational and practitioner-, payment-, and community-related barriers. However, we focus on the two issues that have been inadequately addressed. These are coalition building and issues related to contractual considerations. Contractual considerations include establishing agreed-upon measures and metrics to monitor outcomes, assigning accountability for those outcomes, and delineating realistic time frames for these investments before expecting improved outcomes.
3 Policy Recommendations
#1 Recommendation: Coalition Building
Coalition building includes establishing the structural conditions for implementing a prevention or promotion initiative, resolving workforce issues (i.e., who will carry the program out), and engaging communities and families in the effort. The coalition needs representation from across a range of sectors.
Clear delineation of roles for at least four coalition functions is important: a clearly defined leader or a catalyst for the effort (who may or may not be the primary funder of the initiative), an “integrator” (i.e., an anchor or facilitator), a funder or funders, and representation from both family organizations and community partners. Family and community engagement brings the perspective of service recipients (i.e., families) into the implementation process and helps ensure that interventions reflect the real needs of the community, rather than administrative conveniences. In addition to building coalitions and engaging families and communities, SMHAs have a unique opportunity to strengthen their behavioral health workforce, not only through licensing and credentialing but also through training. Two specific areas in which states can prepare their workforce for delivering prevention and promotion initiatives are in expanding parenting skills programs and peer support programs.
#2 Recommendation: Contractual Considerations
There are two primary contractual issues that arise when implementing prevention and promotion programming: establishing agreed-upon measures and metrics to assess outcomes and accountability to them; and delineating realistic time frames for any expected outcomes and Return on Investment (ROI) from the prevention and promotion initiatives. Measurement drives the implementation. The selection of the measures to track is a critical process for the coalition; the measures ultimately selected will change behaviors. ROI refers inclusively to long-term expected outcomes (e.g., reduced incarceration rates, less use of special education services, fewer child abuse or neglect reports, and decreased emergency room visits) that have value to the families, the different sectors engaged, or the larger society—whether ROI can be captured in explicit financial terms or not.
Promoting children’s well-being and preventing problems before children enter the state mental health system might be viewed as idealistic solutions to the inadequacies of the current mental health system. In some ways, they are. The United Nations has offered guidelines for rebuilding systems that have been weakened or destroyed by natural disasters, called “building back better.” These guidelines suggest adhering to the principles of fairness, equity, and stakeholder engagement in rebuilding system infrastructures in order to sustain permanent, positive change (6). We suggest that especially in the post-COVID-19 period, when the mental health system and other public “safety net” systems are facing daunting challenges, “building back better” is not just a recommendation but ethically necessary.