American Journal of Orthopsychiatry
2016, Vol. 86, No. 2, 103–108
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
© 2016 American Orthopsychiatric Association
http://dx.doi.org/10.1037/ort0000154
New Frontiers in Building Mental, Emotional and
Behavioral Health in Children and Youth:
Introduction to the Special Section
Mary E. Evans
University of South Florida
Mary I. Armstrong, Sharon Hodges, and Mario Hernandez
University of South Florida
T
he passage of the Patient Protection and Affordable Care
Act (ACA; 2010) has had tremendous influence on behav-
ioral health in the United States (Alker & Chester, 2015).
Shortly after its passage, the editors of this special section became
interested in examining the provisions of the ACA related to care
for mental, emotional, and behavioral disorders in children and
youth and synthesizing their implications in the context of other
contemporary trends in children’s behavioral health promotion.
We first developed a white paper with the goal of increasing our
own understanding of these issues and their possible influence on
the status quo of designing, implementing, financing, and evalu-
ating behavioral health services for children and their families.
From our discussions came the idea of developing a special section
in the American Journal of Orthopsychiatry featuring input from
researchers who have been exploring these issues and who have
tangible and relevant examples of “new frontiers” in building
mental, emotional, and behavioral health for children and youth.
The result is the current special section, the purpose of which is
to highlight the importance of prevention in behavioral health and
to explore examples of efforts that have used a broad public health
approach to prevention and early intervention in mental, emo-
tional, and substance use disorders in children and youth. In
addition, we solicited articles in which authors address the ways in
which the ACA might provide additional impetus for the use of a
public health approach in designing, implementing, financing, and
evaluating approaches to the promotion of behavioral health of
children and youth, and for behavioral health entities to refine their
traditional goals and broaden their vision of partnerships to ac-
Mary E. Evans, Department of Child and Family Studies, University of
South Florida; Eric J. Bruns, Department of Psychiatry and Behavioral
Sciences, University of Washington School of Medicine; Mary I. Arm-
strong, Louis de la Parte Florida Mental Health Institute, Department of
Child and Family Studies, University of South Florida; Sharon Hodges,
Department of Child and Family Studies, University of South Florida;
Mario Hernandez, Department of Child and Family Studies, University of
South Florida.
Correspondence concerning this article should be addressed to Mary E.
Evans, Department of Child and Family Studies, University of South
Florida, 13301 Bruce B. Downs Boulevard, Tampa, FL 33612. E-mail:
mevans@health.usf.edu
103
Eric J. Bruns
University of Washington School of Medicine
complish these goals. The result of our call for abstracts was
acceptance of the seven manuscripts included in this special
section.
Through the publication of these seven manuscripts and our
introduction, we hope to accomplish several goals:
• Inform persons responsible for planning and providing ser-
vices to children and youth about opportunities and options
for integration of preventive services into the health care
environment under the ACA;
• Help individuals and systems in balancing treatment interven-
tion and behavioral health promotion and prevention initia-
tives;
• Build a network of persons interested in using a public health
approach to prevention, early identification, and treatment;
and
• Begin a dialogue about how to successfully implement pre-
vention and behavioral health promotion initiatives, including
in novel environments such as primary care, early learning
programs, schools, child welfare systems, and other settings.
Before introducing the seven articles in this special section, we
describe in detail our foundational thinking about building mental,
emotional, and behavioral health for children and youth, as ex-
pressed in our initial white paper on this topic.
Context: A New Policy Environment for
Improving Children’s Behavioral Health
As has already been well documented, the passage and imple-
mentation of the ACA has largely fulfilled its central promise of
increased access to comprehensive health care (Alker & Chester,
2015; Sanger-Katz, 2014). In addition, its provisions hold the
potential to profoundly affect the delivery of behavioral health
care, particularly by promoting changes in financing, organizing,
and promoting quality of care, such as through integration of
primary care and specialty behavioral health services through
patient-centered Medical Homes, Medicaid Health Homes, and
Accountable Care Organizations (ACOs; Barry & Huskamp,
2011).
These changes have tremendous implications for the well-being
of children and youth who experience or are at risk for mental,
 104 EVANS, BRUNS, ARMSTRONG, HODGES, AND HERNANDEZ
emotional, and behavioral challenges. Approximately 1 in 5 young
people in the United States has a mental, emotional, or behavioral
disorder (National Research Council & Institute of Medicine,
2009). Beyond the human costs to youth and their families, these
disorders, which include both mental health and substance use,
impose an estimated $247 billion dollar annual cost to society (in
2007 dollars), without consideration of the emotional cost to youth
and their families (Eisenberg & Neighbors, 2007). Several influ-
ential documents have proposed that mental, emotional, and be-
havioral disorders in youth are among our nation’s top public
health concerns for reasons that include the suffering associated
with them, the limitations they may impose on life goals and
functioning, and the economic burden on society (National Re-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
search Council & Institute of Medicine, 2009).
This document is copyrighted by the American Psychological Association or one of its allied publishers.
ACA implementation, particularly the anticipated shifts to the
structure and process of service delivery, presents two important
opportunities for the field of children’s behavioral health. First, it
provides the opportunity to apply nearly three decades of experi-
ence in systems reform and service integration for children and
youth with serious emotional disturbance (SED) to the formidable
task of ACA implementation. Second, it allows the opportunity to
broaden the mission of the children’s mental health policy reform
agenda known as systems of care (SOC) from a primary focus on
treating children and youth with SEDs to a more population-based
public health approach that includes health promotion and preven-
tion of mental, emotional, and behavioral disorders and as treat-
ment and habilitation.
For more than 25 years, SOC reforms have focused on imple-
menting integrated, community-based, culturally competent, and
consumer-engaged services for children and youth with SED and
their families. SOC has been defined as an adaptive network of
structures, processes, and relationships— grounded in a value for
community-based, culturally competent, and family driven care—
that provides children and youth with SED and their families with
access to and availability of necessary services and supports across
administrative and funding jurisdictions (Hodges, Ferreira, Israel,
& Mazza, 2010). The concept of integrated access to community-
based services for this target population emerged from the work of
Knitzer (1982) who, more than 30 years ago, estimated that 3
million children with SED were not getting needed services, and
many others were receiving inappropriate hospital or institutional
care. Knitzer suggested specific strategies for organizing services
across child-serving agencies to reduce restrictiveness of place-
ment and to support smooth transition from one service to another
(Hernandez & Hodges, 2003).
Based on Knitzer’s work and the subsequent work of Stroul and
Friedman (1986), which articulated the interagency collaborations
necessary to ensure coordinated community-based care, federal
policy for children’s mental health has increasingly emphasized
improved service planning and delivery through increased collab-
oration among community partners (e.g., National Institute of
Mental Health, 1983; President’s New Freedom Commission on
Mental Health, 2003; Public Law 102–321, 1992; U.S. Public
Health Service, 2000). Specifically, the Substance Abuse and
Mental Health Services Administration (SAMHSA) has provided
several billion dollars through the Comprehensive Community
Mental Health Services for Children and Their Families program.
These dollars have gone toward supporting the development of
collaborative, community-based services for children and youth
with SED and their families, known as SOC since its inception in
1992 (U.S. Department of Health & Human Services, 2009).
SAMHSA continues to fund such efforts through SOC expansion
planning grants.
Investment in better coordinated and community-based chil-
dren’s behavioral health systems align well with the ACA’s focus
on broader health systems reform, service integration, health pro-
motion, disease prevention, and patient-centered care. Highly rel-
evant to the implementation of the ACA in community settings are
lessons learned from SOC regarding changes in the structure and
processes of service systems (Evans, 2012; Hodges, Ferreira, &
Israel, 2012), financing of integrated services (Armstrong, Milch,
Curtis & Endress, 2012), cultural and linguistic competence (Her-
nandez, Nesman, Mowery, Acevedo-Polakovich, & Callejas,
2009), and promotion of family- and youth-driven care (Bruns et
al., 2010).
As a result of ACA implementation, children and youth with
mental, emotional, and behavioral disorders should have im-
proved access to care that is both medically based and person
centered. In addition, because of the ACA and other reforms
associated with it, funding for substance use disorders should
increase. Furthermore, services should be better integrated into
general health care, with fewer residential programs and more
outpatient and integrated programs (Buck, 2011). It is essential
with the introduction of the ACA that the traditional SOC
approach be expanded to use a public health model. This
approach would not only focus on reducing mental, emotional,
and behavioral disorders among children with an identified
problem, but would also be community based and promote
mental, emotional, and behavioral wellness in all children
(Miles, Espiritu, Horen, Sebian, & Waetzig, 2010).
In addition to opportunities to apply the experience of sys-
tems reform in children’s behavioral health to ACA implemen-
tation, the ACA’s focus on health promotion and prevention
offers an opportunity to extend SOC reform efforts from a
primary focus on children and youth with SED to a more
population-based public health approach. Lessons learned from
SOC implementation—such as how best to promote culturally
competent interventions, family- and youth-driven care, and
greater integration of financing and service delivery across
systems can now be increasingly applied to health promotion,
prevention, and early intervention for mental, emotional, and
behavioral disorders in children and youth. Numerous case
studies of SOC implementation suggest that communities that
have successfully sustained reforms for a number of years have
also been successful in expanding their outreach and service
integration efforts to broader populations. (Grimes et al., 2011;
Hancock, 2010; Kamradt, Gilbertson, & Jefferson, 2008).
In summary, the ACA provides an opportunity for the behav-
ioral health community to expand beyond the partnerships that
have sustained its focus on the populations with serious mental
health and substance use disorders and to engage with other
partners focused on the health and well-being of communities. To
take advantage of this opportunity, the children’s behavioral health
field must broaden its vision of partnerships and shared goals to
embrace strategies that span the spectrum from health promotion
and prevention to intensive intervention.
 SPECIAL SECTION: INTRODUCTION
The Special Section: Building a
Comprehensive Spectrum of Mental,
Emotional, and Behavioral Health Supports
To examine options for providing a more comprehensive con-
tinuum of mental, emotional, and behavioral health supports—and
explore opportunities afforded by the ACA and the lessons learned
from SOC—we take as our model the Behavioral Health Interven-
tion Spectrum (Mrazek & Haggerty, 1994; National Research
Council & Institute of Medicine, 2009).
As shown in Figure 1, the Behavioral Health Intervention Spec-
trum presents specific types of promotion, prevention, treatment,
and maintenance strategies with behavioral health promotion
posed as a strategy that spans the continuum. Other authors have
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
recently focused attention on innovative methods for improving
This document is copyrighted by the American Psychological Association or one of its allied publishers.
some of the components of the spectrum: for example, how best to
improve usual care (e.g., Garland et al., 2013); provide psycho-
therapy that is efficient and tailored to real world systems yet
evidence-based (e.g., Chorpita & Daleiden, 2009; Kazdin & Blasé,
2011); and provide intensive, coordinated services and supports
that maintain youth in the community despite presence of multiple
and complex needs (e.g., Bruns et al., 2014). Our focus in this
special section is on the first four “wedges” in the spectrum:
promotion, universal, selective, and indicated prevention efforts.
Behavioral Health Promotion and
Prevention Strategies
According to the National Research Council and Institute of
Medicine (2009), behavioral health promotion initiatives are tar-
geted to the general public or an entire population to enhance
individuals’ competency and ability to deal with adversity. Uni-
versal preventive initiatives are targeted to populations that have
not been identified on the basis of individual risk, such as com-
munities or school classrooms. Selective preventive initiatives are
targeted to individuals or groups at higher-than-average risk of
developing mental, emotional, and behavioral disorders (e.g., chil-
Figure 1. The mental, emotional, and behavioral health intervention spectrum. From Reducing risks for mental
disorders: Frontiers for preventive intervention research (p. 23), by P. J. Mrazek & R. J. Haggerty, 1994,
Washington, DC: Institute of Medicine. Copyright 1994 by Institute of Medicine. Adapted with permission.
105
dren in economically poor neighborhoods, children who have
experienced death of a parent). Indicated preventive interventions
are targeted to high-risk individuals who have been identified as
having minimal, but detectable, signs or symptoms or biological
markers foreshadowing the development of mental health and
substance use disorders (e.g., children demonstrating early aggres-
sive behavior or mood disruptions).
The “National Prevention Strategy” (National Prevention Coun-
cil, 2011) states that early childhood experiences have lasting and
measurable consequences later in life, and therefore, it is important
to foster emotional well-being from early life to build a foundation
for future overall health and well-being. The first article in this
special section, by Shern, Blanch, and Silverman, describes this
relationship between early childhood experiences and behavioral
health outcomes in greater detail. Shern and colleagues postulate
that the interaction of genetic vulnerability and toxic stress are
antecedents to a developmental cascade that undermines healthy
development. This situation is seen as a public health crisis that
calls for a public health system with a strong behavioral health
component.
Meanwhile, the article by Oppenheim and colleagues describes
SAMHSA’s national grant program in early childhood, Project
LAUNCH (Linking Actions for Unmet Needs in Children’s
Health). The purpose of the program is to improve child outcomes
through prevention and wellness promotion practices. The article
describes six programs that are integrating behavioral health into
primary care settings. Such efforts to foster early well-being re-
quire behavioral health organizations to step out of their narrow
confines and engage with other entities focused on the health and
well-being of communities to foster the maximum welfare of the
population. The National Prevention Strategy report, for example,
recommends actions for the federal government, state, tribal, local,
and territorial governments; businesses and employers; health care
systems, insurers and clinicians; early learning centers, schools,
colleges, and universities; community nonprofit and faith-based
organizations; and individuals and families.
 106 EVANS, BRUNS, ARMSTRONG, HODGES, AND HERNANDEZ
Common examples of universal prevention initiatives that pre-
date the ACA include school-based behavioral programs such as
the Good Behavior Game (Kellam, Rebok, Ialongo, & Mayer,
1994), a classroom-based behavior management strategy for ele-
mentary school designed to prevent disruptive activity, and sub-
stance abuse prevention programs such as Life Skills Training
(Botvin & Griffin, 2004). Meanwhile, selective prevention strate-
gies target subgroups of the general population at risk for problems
such as mental, emotional, and behavioral disorders or substance
abuse. Examples of selective prevention programs may target
children of substance-abusing parents or families, children who are
experiencing family disruptions such as divorce or death of a
parent, youth who live in high-crime or impoverished neighbor-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
hoods, or mentoring programs aimed at children with school
This document is copyrighted by the American Psychological Association or one of its allied publishers.
performance or behavioral problems. Certain types of selective
prevention interventions, such as those developed to mitigate the
negative outcomes associated with family disruption, have been
proposed to be integrated into health homes under the ACA
(Sandler, Tein, Mehta, Wolchik, & Ayers, 2000; Sandler et al.,
2003). More recently, Pires (2013) has made suggestions for
customizing health homes for children with serious emotional
challenges.
The current special section includes two articles focused on
community-based prevention strategies. The first, by Kingston,
Mihalic, and Sigel, presents a case study of the development and
implementation of a comprehensive approach in a high-risk neigh-
borhood that is intended to reduce youth violence and other prob-
lem behaviors. This project, called Steps to Success, is funded by
the Centers for Disease Control and Prevention and uses the
Communities That Care model, an evidence-based community
mobilization strategy (Hawkins & Catalano, 1992). The second
article, by Salazar and colleagues, discusses the process of adapt-
ing Communities That Care to prevent the development of mental,
emotional, and behavioral disorders through preventing child
abuse and neglect and bolstering child well-being in children birth
to 10 years. The article presents preliminary findings from a pilot
study of the resulting strategy, called Keeping Families Together,
which indicate the potential promise of this adaptation of a
science-based approach to prevention through community mobili-
zation and implementation of evidence-based strategies.
Indicated prevention interventions identify individuals who are
experiencing early signs of mental, emotional, and behavioral
problems, substance abuse, or related problem behaviors and target
them with special programs. An example of an indicated preven-
tive intervention predating the ACA is the Incredible Years Pro-
gram (Webster-Stratton, 1990). This program exposes parents to
videotaped vignettes of parent– child interactions that emphasize
the use of praise and reward and time-out and other mild negative
consequences. This program has been used successfully in pre-
venting further aggression in children who have shown early
aggressive behaviors. In the current special section, Bruns and
colleagues discuss opportunities presented by schools for prevent-
ing mental, emotional, and behavioral disorders and promoting
mental, emotional, and behavioral health in youth by describing a
community–academic partnership between the Seattle Public
Schools and the University of Washington School Mental Health
Assessment, Research, and Training Center. On the basis of their
experience with this collaboration, the authors present 10 recom-
mendations that may guide other communities who seek to lever-
age the array of opportunities presented by schools to apply
universal, selective, and indicated prevention strategies.
The final two articles in this special section discuss opportuni-
ties for leveraging the public health approach to the cause of
preventing mental, emotional, and behavioral problems in youth.
Using the state of Louisiana as a case study, Nagle and Usry
discuss application of a public health approach to early childhood
well-being. They focus their discussion on the three core functions
of public health: assessment, policy development, and assurance or
access to high-quality services. They conclude that a public health
approach can promote smarter investments and increasing finan-
cial commitments and is likely to be a more effective strategy than
addressing the needs of children in the multiple “siloes” of indi-
vidual child-serving agencies.
The final article, authored by Morris, a seasoned leader in
behavioral health, examines the question of whether behavioral
health can drive its own reformation. It first examines the path-
ways that have led the behavioral health system to be described
widely as “in shambles” (President’s New Freedom Commission
on Mental Health, 2003) and then describes a pathway forward.
The author believes that the way forward requires simultaneous
attention to politics, practice, economics, and science and de-
scribes each of these dimensions as they are related to positive
change in the health care environment.
Closing Thoughts
The time has come for the behavioral health community, includ-
ing those focused on both mental health and substance use disor-
ders, to step out of their narrow confines and engage with other
entities focused on the health and well-being of communities to
foster the maximum welfare of the population. Behavioral health
has developed and implemented hundreds of evidence-based treat-
ments and methods for organizing and financing service delivery
(such as SOC); however, these are primarily for individuals with
identified diagnoses and “deep-end” populations that incur the vast
majority of our behavioral health expenses (Bruns et al., 2014;
Pires et al., 2013). Behavioral health organizations now need to
broaden their vision, work with other child-serving and health care
delivery systems, and focus on the health of populations using a
public health approach that includes health promotion and preven-
tion as well as treatment and habilitation.
The ACA offers opportunities to follow this approach. Mean-
while, the experience gained in more than 25 years with SOC
provides communities with a model to use in planning, implement-
ing, financing, and evaluating services for children, youth, and
their families. Using what we have learned, we must now focus on
several agendas: (a) cultivating partnerships with multiple sectors
outside behavioral health; (b) improving environments in which
children live; (c) broadening our goals and using a public health
approach to promote behavioral health for all children and youth as
well as provide targeted services for those in need of care; (d)
basing our interventions on the needs and cultural and political
characteristics of communities; and (e) strengthening our ability to
continually analyze outcomes across levels of effort to continually
refine our strategies and provide the most effective services to the
population. It is our hope that the articles in this special section
contribute to the understanding of options for achieving these
goals and the mobilization of resources and political will to im-
 SPECIAL SECTION: INTRODUCTION
prove the mental, emotional, and behavioral wellness of our chil-
dren and youth.
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