A Response to Proposed Budget Cuts Affecting Children’s Mental Health: Protecting Policies and Programs That Promote Collective Efficacy

In recent years, an antifederalism platform has gained ascendancy in the United States, driving efforts to overhaul health and social services and cut core safety-net funding. Of those who stand to lose the most as a result of these efforts, children are at the top of the list. Federal programs and policies on the chopping block include several for children and families, such as the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program, Supplemental Security Income (SSI) for families of children with severe disabilities, the Department of Education’s (DOE) Every Student Succeeds Act (ESSA), and Medicaid coverage for children’s mental health, to name only a few.

EPSDT provisions in Medicaid affect over 30 million children and youths, enabling them to access comprehensive preventive general health and behavioral health care. SSI provides income supports to more than 1.3 million families of children with severe disabilities, half of whom have mental disabilities; these supports lift a majority of these families out of poverty and enable them to access disability services for their children (1). Congress is considering various proposals to transform Medicaid into a block grant. Medicaid is the primary source of federal support for low-income children with mental health needs, and the proposed plans would cut it drastically and may even eliminate mental health coverage (2). Congress recently voted to roll back DOE’s regulation governing the ESSA; this act holds schools accountable for the performance of historically marginalized students, including students with disabilities, and provides “guardrails” to ensure that all schools help students with disabilities achieve proficiency. Congress has never before voted to overturn an education regulation, much less one that protects the most vulnerable students. This Congressional action, among others, suggests that perhaps Medicaid expansion, and other programs supporting low-income families, are indeed on the chopping block; as of this writing, funding for the Children’s Health Insurance Program, which expired September 31, 2017, has not been restored.

Anticipated federal budget changes will shift decision-making responsibility to states and significantly reduce federal support to families, particularly low-income families. An actionable strategy for states to offset these threats is to focus on supporting programs and policies that either explicitly or indirectly increase family and community capacities. States should also seek to increase these capacities by exploring the use of cross-system approaches, which use navigational, peer, and bridging models to provide services across health, mental health, education, and juvenile justice systems. Children are likely to benefit from these strategies because the policies, programs, and models that increase family and community capacities also shore up the contexts that affect children’s mental health.

In this article, we describe several strategies for addressing possible federal budgetary changes by investing in services that strengthen families and communities. This approach is based in the theory of collective efficacy, a sociological process that has been shown to have positive long-term effects on children’s ongoing development and adult outcomes. We provide examples of two federal programs that by virtue of their impact on families and communities are likely to promote collective efficacy and positively affect children’s mental health; both programs are facing severe cutbacks. We provide examples of cross-system programs that are likely to promote collective agency: peer-to-peer support models and Safe Passage, a program created to ensure the safety of children walking to school in some of Chicago’s crime-ridden neighborhoods.

What Is Collective Efficacy?

Family and community capacities are essential to building the foundations of lifelong health in early childhood. Until recently, however, policy makers lacked a useful framework for depicting the interconnections among policies, families, and communities. An exception is the framework developed by Mistry et al. (3), which explicitly acknowledges that building the capacities of both parents and communities is a key factor in optimizing health in early childhood. According to the model, child health and development is moderated by the social and economic contexts that affect families and communities and the settings in which services are delivered.

As described in the Mistry et al. (3) framework, the foundations of health include responsive care, safe and secure environments, adequate and appropriate nutrition, early education opportunities, and health promotion. Policies that support these issues, whether they target children directly or indirectly, affect children’s health. However, a valid argument can be made that policies that promote collective efficacy are likely to have longer lasting effects on children than most early childhood health programs and policies, which focus on specific individualistic outcomes, such as immunizations and avoiding injuries. Collective efficacy, on the other hand, improves the health of children by strengthening families and communities.

Sampson et al. (4) have defined collective efficacy as social cohesion among neighborhoods and the willingness of members of a community to intervene for common social good. The theory is derived from an extensive literature that applies theories of social learning and self-efficacy to neighborhood processes and mechanisms that affect individuals within their communities. The theory of collective efficacy contrasts with the view that neighborhoods are simply collections of the attributes of individuals (5). Studies by Sampson (6) and others have found that many health problems cluster at the neighborhood and community level. These include violence, low birth weight, infant mortality, child maltreatment, and risk of premature adult death. Community-level social problems and health are related: community-level predictors common to health-related outcomes include concentrated poverty or affluence, racial segregation, family disruption, residential instability, and poor-quality housing. Furthermore, experimental studies have found a direct association between social contexts and health (7,8).

The mechanisms of action for collective efficacy include attitudes and behaviors that facilitate social control without requiring strong ties or associations (4,9), especially given that social ties among neighbors are complex and that many families lack close ties with their neighbors (10,11). Thus the linkage of mutual trust and shared expectations for intervening on behalf of the common good define the collective efficacy in a neighborhood context. In the same way that self-efficacy is situation specific rather than global, in that an individual has self-efficacy relative to a particular task, a neighborhood’s efficacy exists relative to specific social tasks or goals, such as maintaining public order. In contradistinction to a focus on private ties, collective efficacy signifies an emphasis on shared beliefs in a neighborhood’s or a community’s capability for action oriented toward a common goal, thus leading to active engagement on the part of residents. As stated by Sampson (12), “Too often our policies and theories are reductionistic in nature, looking only at (or to change) individuals. . . . It is not that individuals or individual characteristics are unimportant, but rather that much can be learned, and possibly changed, by focusing on community and social organizational context.” Thus collective efficacy is, in essence, the “glue” that binds neighborhoods together. This theory explains why some neighborhoods or groups of individuals successfully fight crime and, therefore, create safer environments for families in their community.

Collective efficacy can also be conceptualized at a system level to explain the potential of cross-system approaches to effect sustained change in children’s mental health. The fragmentation of the mental health service system has long been decried as a major barrier to improving the quality of care for children and improving their mental health (13,14). Taken together, the Mistry et al. framework, which focuses on improving the capacity of families and communities across systems, and the theory of collective efficacy provide a critical lens through which to analyze proposed federal program cuts.

Programs Likely to Promote Collective Efficacy

The Medicaid program, Medicaid expansion, and housing programs that promote neighborhood transformation and housing security have the potential to promote collective efficacy. These policies support the provision of services targeting health (for example, preventive services and well visits) and housing, two of the foundations of children’s health identified by Mistry et al.

Medicaid and Medicaid Expansion

The chief goal of Medicaid is to improve access to health and behavioral health services. Viewed through the Mistry et al. framework, however, the goal of Medicaid can also be understood as a way to reduce poverty by providing the basic foundations of health, thus strengthening families and communities. With a safety net of health services and the building blocks in place for healthy child development, communities can thus focus on establishing the shared values and trust that define collective efficacy.

Medicaid currently provides health coverage to 74 million low-income adults, children, pregnant women, elderly adults, and people with disabilities; approximately one in five Americans receives Medicaid. Most important, children represent the largest group of Medicaid beneficiaries, constituting half of Medicaid enrollees. More than one in three children in the United States is covered by Medicaid or the Children’s Health Insurance Program (CHIP).

The Affordable Care Act (ACA) (P.L. 111–148 and P.L. 111–152), passed in 2010, expanded Medicaid coverage to millions of low-income Americans and made numerous improvements to both Medicaid and CHIP. ACA requires states to expand their Medicaid programs to cover those caught in the “Medicaid gap,” persons who make too much money to qualify for Medicaid but who are unable to afford marketplace insurance. Under the ACA, 90% to 100% of state expansion costs are funded by the federal government; a subsequent Supreme Court decision gave states the option to accept or decline this Medicaid expansion. To date, 32 states have opted for expansion (15).

A study to assess the effects of past Medicaid eligibility expansions found that states that expanded their Medicaid eligibility before ACA enactment (1997–2009) showed improvement in mental health status among low-income adults (including many parents), better coverage, improved access to care (including mental health care), and lower health care costs (16). Another study of states that expanded Medicaid under ACA found that these states were better able to treat adults with mental health conditions, leading to a decrease in hospitalizations related to mental disorders (17).

Proposed legislation repealing and replacing the ACA indicate a radical restructuring of the Medicaid program toward a block grant or per capita cap system (2). Under a repeal of the Medicaid expansion, many low-income adults (including many parents) will be at risk of losing eligibility for Medicaid, which is likely to increase the number of uninsured persons, depending on the coverage options available under a repeal (15). Of major concern to state mental health authorities is what will happen to behavioral health services if Medicaid expansion goes away or if Medicaid is capped and restructured as a block grant. The concern is that behavioral health services will have to compete for funding with services for every other health condition, and the gains that have been made in mental health coverage would be at risk (personal communication, Lutterman T, 2017). These gains have been exceptional, largely driven by expansions in Medicaid and CHIP; the children’s uninsured rate is at an all-time low of 5% (18).

CHIP was established with bipartisan Congressional support in 1997 to provide coverage for uninsured children whose families have low incomes but earn too much money to qualify for health care coverage under Medicaid. The legislation was aimed at reducing the especially high rate of unmet health and mental health needs of uninsured children (19). States can use CHIP funds to expand their Medicaid programs, establish separate CHIP programs, or offer a mix of both types; states also have flexibility to determine benefit packages. Although separate CHIP programs (those not under Medicaid umbrella) are not required to cover behavioral health services, the majority cover outpatient and inpatient mental health services with few limitations (20); of the 14 states that have separate CHIP programs, one-third provide benefits that are either the same as or very similar to the comprehensive package provided to children in Medicaid. In addition, CHIP programs that are Medicaid expansions cover the EPSDT program for children, a comprehensive benefit package that covers not only health services but also developmental screening and behavioral health services (20). CHIP served 8.9 million children in 2016; the proposed fiscal year 2018 budget reduces the CHIP program budget by 20% and abolishes it thereafter. These cuts would result in fewer children receiving necessary preventive well-child visits and immunizations; research also suggests that eliminating children’s coverage could have broader long-term negative effects on their health, education, and financial success as adults (20).

Department of Housing and Urban Development (HUD) Programs

HUD sponsors a number of programs that both increase community capacity to provide improved housing conditions and strengthen family housing security through reduced-cost housing (such as rent vouchers and public housing), as well as programs to revitalize and strengthen neighborhoods. One example of a program that strengthens the capacity of both families and communities is the five-city Moving to Opportunity for Fair Housing (MTO) research program. MTO was a series of housing experiments in five cities that randomly assigned housing project residents to an experimental group receiving housing subsidies to move into lower-poverty neighborhoods, a group receiving conventional (Section 8) housing assistance, and a control group receiving no special assistance (21). Results from the Boston MTO site of short-term effects showed that children of mothers in the experimental group had a significantly lower prevalence of injuries, asthma attacks, and personal victimization during follow-up. The move to low-poverty neighborhoods was also linked to lower violent offending among juveniles and to significant improvements in the general health status and mental health of heads of households (22,23).

A subsequent study of long-term effects of the MTO program indicated that the children who moved before age 13 (at an average age of eight) were more likely to see a substantial increase in their earnings later in life, during their mid-twenties (24), compared with those who moved after age 13. Findings are mixed and require replication and further analysis. For example, a separate study of MTO reported some negative effects by gender; relocation to a more stable environment had negative effects on some boys’ mental health outcomes, perhaps owing to differences in social adaptability. Girls, however, showed reduced rates of depression and conduct disorder (25). This research reinforces the importance of neighborhood context on children’s development. Challenges remain to creatively implement policies that will mitigate unintended negative effects (by, for example, gender when accounting for boys’ social adaptability).

Similar to the MTO research program, the Choice Neighborhoods program funds locally driven, place-based strategies to reform distressed, high-poverty, high-crime neighborhoods into safer ones with lower poverty concentrations by linking housing improvements with appropriate services, schools, public assets, transportation, and access to jobs (26). Local leaders, residents, and other stakeholders (such as public housing authorities, city agencies, schools, police, business owners, nonprofit organizations, and private developers) create a transformation plan, which guides the revitalization of the distressed housing and the surrounding neighborhood and focuses on housing, people (for example, job opportunities) and neighborhoods (for example, good schools).

One example of a Choice Neighborhoods grantee is Seattle, where the housing authority, Seattle University, the school district, and their partners enrolled more than 280 children through a “cradle-to-career” pipeline, which includes home visits for toddlers and college preparation for high school students. The first phase of evaluation was completed in 2015, but full implementation is not expected until 2018; at that time, the effects of the program on the neighborhoods and the individuals who lived there will be evaluated. Early implementation lessons learned include the importance of strong local leadership committed to the neighborhood revitalization effort, the challenges of addressing serious public safety issues, and the relevance of local housing markets to neighborhood transformation plans (27). However, the proposed federal budget reduces HUD spending by $6 billion (28), which includes abolishing the Choice Neighborhoods program and reducing public housing funding (including funds to repair broken appliances or damaged property, which are many, that affect low-income families’ quality of life) as well as federal grants for community development programs, which include meal assistance (such as Meals on Wheels). This reduction is short-sighted in many ways, not the least of which is that the evaluation will be completed within a year and will provide actual data on program effectiveness and areas in need of new emphasis.

Cuts to housing programs weaken the capacity of families and communities to secure stable housing, a fundamental need affecting children’s mental health and well-being. For underresourced communities, in particular, the private sector has little incentive to take responsibility for community development, thus leaving families as well as entire neighborhoods without access to, or capacity for, safe and affordable housing. This promotes an individualistic response to meeting one’s needs (everyone for themselves) and diminishes the capacity for collective action to establish the basic building blocks of children’s health and development.

Cross-System Approaches to Promote Collective Efficacy

A cross-system approach can promote policies and programs in general medical health, mental health, housing, education, welfare and social services, and juvenile justice systems. Such an approach is a viable strategy to strengthen families and communities and promote collective efficacy. We provide examples of two cross-system programs that are likely to promote collective efficacy: a peer-to-peer support model and a program to improve the safety of children in some of Chicago’s crime-ridden neighborhoods.

Peer-to-Peer Support Models

Peer-to-peer support models for families of children with mental health needs (also called family support models) strengthen family and community capacity. These peer-to-peer models are expanding the workforce of paraprofessionals to provide case management, care coordination, engagement, and sometimes direct therapeutic services across the systems of general medical health, mental health, education, addiction, juvenile justice and child welfare, and even defense (for example, the U.S. Department of Veterans Affairs). In the mental health service system, this peer-to-peer model is used to combat stigma, distrust, disengagement, and the isolation faced by many parents of children with mental health challenges (29,30). The purpose is to educate, support, and activate parents and caregivers so they can clarify their own needs or concerns; reduce their sense of isolation, stress, or self-blame; become informed so they can advocate for their children and navigate complex service systems; and learn new parenting skills (31).

Family-to-family peer support models have developed commonly accepted principles (32), such as self-efficacy, sense of control, trust and credibility, and developing shared goals with service providers. This sense of trust and self-efficacy promoted through peer-to-peer support services is key to strengthening family capacity, improving the children’s mental health and, in turn, the family’s ability to participate in collective action to then help others in their community.

Safe Passage Program

A second example of a cross-system approach is a program for parents living in high-poverty communities in Chicago. Created by the nonprofit organization Leave No Veteran Behind, the Safe Passage program was created in 2009 after the fatal beating of a teenager outside his high school; the program is currently funded by the Chicago Public Schools. It was expanded in 2013—after 47 neighborhood schools were closed—in recognition of the dangers for children who needed to walk outside their neighborhood to attend school (33). The program enrolls more than 1,300 community members in over one-fifth of Chicago schools, armed with no more than a green identification vest, to literally stand guard on the most dangerous city streets in Chicago. To date, and despite a surge in gun violence in the past year, Chicago Public Schools report that no schoolchildren have been harmed by neighborhood violence while going to or leaving school since the inception of the program. As stated by one of the Safe Passage supervisors, “We are those kids’ parents from the time they’re leaving home to the time they’re getting to school, because those are our babies” (34).

Conclusions

Policy makers, researchers, and program officials concerned about the mental health of children should pay particular attention to policies and programs that address not simply the needs of individual children but also the needs of their families and communities. These include policies not typically involved in debates about children’s mental health issues, such as housing, income supports, and education, as well as health-related services. These policies are not incidental to children’s mental health; they are at its core.

As state policy makers consider action, many will remember that the past three decades of progress in mental health services can be characterized less as dramatic transformations and more as small, focused, and incremental steps toward a shared goal. An example of this type of incremental change occurred after the Reagan administration repealed the Mental Health Systems Act of 1980, which was developed under President Carter. Advocates, researchers, and policy makers created a series of recommendations for incremental changes to traditional federal programs, such as Medicaid, Medicare, and the disability programs overseen by the Social Security Administration. Over the next decade, Congress adopted most of those small progressive changes in a series of Omnibus Budget Reconciliation Acts, and eventually these evolved into the mental health parity legislation of 2008 (35). As a result, a small series of steps over three decades eventually culminated in the parity legislation we have today. Social progress is often invisible because it proceeds incrementally.

The primary lesson of this history is that advocacy on behalf of children is especially important in efforts to maintain longstanding family and community support policies, despite current political sentiment promoting fewer benefits for children and their families. As Rebecca Solnit (36) writes in Hope in the Dark, “We write history with our feet and with our presence and our collective voice and vision.” Policies and community-level programs that aim to change social environments, not just individuals, will have the strongest and longest impact on child development and children’s mental health.