Mitigating the Impact of Coronavirus Disease-2019 on Child and Family Behavioral Health: Suggested Policy Approaches

Abstract

The coronavirus disease-19 (COVID-19) pandemic has exacted a significant toll on children and families and deepened an existing national child and family behavioral health (“Behavioral health” is used throughout the commentary to encompass mental health and substance use. When “mental health” is used specifically, it is done so purposefully so as not to inadvertently alter the presentation of specific research findings or the intention of authors and their work.) crisis.1Russell B.S. Hutchison M. Tambling R. Tomkunas A.J. Horton A.L. Initial challenges of caregiving during COVID-19: caregiver burden, mental health, and the parent–child relationship.Child Psychiatry Hum Dev. 2020; 51: 671-682Crossref PubMed Scopus (239) Google Scholar Although we have not seen the full scope of the pandemic’s effects on behavioral health, we have already witnessed negative impacts from social isolation, child care and school closures, grief and loss, and family economic insecurity.1Russell B.S. Hutchison M. Tambling R. Tomkunas A.J. Horton A.L. Initial challenges of caregiving during COVID-19: caregiver burden, mental health, and the parent–child relationship.Child Psychiatry Hum Dev. 2020; 51: 671-682Crossref PubMed Scopus (239) Google Scholar,2Bartek N. Peck J.L. Garzon D. VanCleve S. Addressing the clinical impact of COVID-19 on pediatric mental health.J Pediatr Health Care. 2021; 35: 377-386Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar And although children across the globe have borne pandemic distress, in many communities, children of color have been disproportionately burdened.3Clawson A.H. Nwankwo C.N. Blair A.L. Pepper-Davis M. Ruppe N.M. Cole A.B. COVID-19 Impacts on families of color and families of children with asthma.J Pediatr Psychol. 2021; 46: 378-391Crossref PubMed Scopus (7) Google Scholar Unfortunately, existing behavioral health care systems were inadequate before the pandemic, and they are certainly insufficient to address these increased behavioral health needs. Our child and family behavioral health “safety net,” including pediatric primary care and the public school system, is underresourced to handle the surge in concerns, especially with staffing shortages caused or exacerbated by the pandemic.4American Hospital Association (AHA)Fact sheet: Strengthening the health care workforce.https://www.aha.org/fact-sheets/2021-05-26-fact-sheet-strengthening-health-care-workforceDate accessed: January 19, 2022Google Scholar,5Carver-Thomas D. Leung M. Burns D. California teachers and COVID-19: How the pandemic is impacting the teacher workforce.https://learningpolicyinstitute.org/product/california-covid-19-teacher-workforce-reportDate: March 4, 2021Date accessed: January 19, 2022Google Scholar The pandemic nevertheless presents an opportunity. We must harness the national attention generated by the current crisis to advance equitable solutions that are family-centered and include a continuum of support from prevention to treatment. Leading experts on child health, including the American Academy of Pediatrics, declared a national state of emergency in child and adolescent mental health in October 2021, followed in December by a Surgeon General’s Advisory to call for urgent attention to address the crisis.6Office of the US Surgeon GeneralProtecting youth mental health: The US Surgeon General’s Advisory.https://www.hhs.gov/sites/default/files/surgeon-general-youth-mental-health-advisory.pdfDate: 2021Date accessed: January 19, 2022Google Scholar,7AAP-AACAP-CHA Declaration of a national emergency in child and adolescent mental health.http://www.aap.org/en/advocacy/child-and-adolescent-healthy-mental-development/aap-aacap-cha-declaration-of-a-national-emergency-in-child-and-adolescent-mental-health/Date accessed: January 19, 2022Google Scholar We owe children and families a swift, comprehensive policy response that will lead to permanent strengthening of a behavioral health system that was already struggling before the pandemic, including promotion of policies to increase access to behavioral health services, expand and develop a culturally appropriate family-focused behavioral health workforce, promote the integration of behavioral health in pediatric primary care, and improve schools’ ability to address behavioral health needs of students. Our commentary outlines suggested policy strategies, especially at the state and federal level, that could guide deliberations and action of policymakers. The suggested policy reforms also could provide a roadmap for pediatric providers who are in a position to engage in advocacy. For all child health practitioners caring for children and families during these challenging times, this commentary will provide a deeper understanding of the policy dynamics shaping the behavioral health care environment. For years, children and families in the US have been sounding the alarm bell: suicide is the second-leading cause of death among young people aged 10-24 years.8Centers for Disease Control and PreventionWISQARS™ (Web-based Injury Statistics Query and Reporting System). Injury data.https://www.cdc.gov/injury/wisqars/index.htmlDate accessed: October 6, 2021Google Scholar Concerning disparities among racial and ethnic subgroups exist, such as significantly higher incidence of suicide among Black children versus White children aged 5-12 years and disturbingly high rates of suicidal ideation and behaviors among special populations, such as LGBTQ youths.9Ivey-Stephenson A.Z. Demissie Z. Crosby A.E. Stone D.M. Gaylor E. Wilkins N. et al.Suicidal ideation and behaviors among high school students—Youth Risk Behavior Survey, United States, 2019.MMWR Morb Mortal Wkly Rep. 2020; 69: 47-55Google Scholar, 10Lindsey M.A. Sheftall A.H. Xiao Y. Joe S. Trends of suicidal behaviors among high school students in the United States: 1991-2017.Pediatrics. 2019; 144: e20191187Crossref PubMed Scopus (119) Google Scholar, 11Bridge J.A. Horowitz L.M. Fontanella C.A. Sheftall A.H. Greenhouse J. Kelleher K.J. et al.Age-related racial disparity in suicide rates among US youths from 2001 through 2015.JAMA Pediatr. 2018; 172: 697-699Crossref PubMed Scopus (105) Google Scholar, 12Congressional Black Caucus Emergency Taskforce on Black youth suicide and mental health. Ring the alarm: the crisis of Black youth suicide in America.https://watsoncoleman.house.gov/uploadedfiles/full_taskforce_report.pdfDate accessed: October 15, 2021Google Scholar Additionally, the incidence of behavioral health disorders has been increasing. A study found that one-half of US children with a treatable mental health disorder did not receive needed treatment from a mental health professional during the previous year.13Whitney D.G. Peterson M.D. US National and state-level prevalence of mental health disorders and disparities of mental health care use in children.JAMA Pediatr. 2019; 173: 389-391Crossref PubMed Scopus (185) Google Scholar Not surprisingly, emergency department (ED) visits for behavioral health concerns also have been rising, and without adequate inpatient resources to care for those youths with more severe and acute behavioral health concerns, patients may spend days in an ED before being admitted to an appropriate inpatient facility.14Kraft C.M. Morea P. Teresi B. Platts-Mills T.F. Blazer N.L. Brice J.H. et al.Characteristics, clinical care, and disposition barriers for mental health patients boarding in the emergency department.Am J Emerg Med. 2021; 46: 550-555Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar The shortage and maldistribution of licensed behavioral health care providers15American Academy of Child and Adolescent PsychiatryWorkforce map 2018.https://www.aacap.org/aacap/Advocacy/Federal_and_State_Initiatives/Workforce_Maps/Home.aspxDate accessed: October 6, 2021Google Scholar,16Beck A. Page C. Buche J. Rittman D. Gaiser M. Estimating the distribution of the U.S. psychiatric subspecialist workforce.https://www.behavioralhealthworkforce.org/wp-content/uploads/2019/02/Y3-FA2-P2-Psych-Sub_Full-Report-FINAL2.19.2019.pdfDate: 2018Date accessed: October 11, 2021Google Scholar and inadequate insurance networks for behavioral health17Melek S. Davenport S. Gray T.J. Addiction and mental health vs. physical health: widening disparities in network use and provider reimbursement.https://assets.milliman.com/ektron/Addiction_and_mental_health_vs_physical_health_Widening_disparities_in_network_use_and_provider_reimbursement.pdfDate: 2019Date accessed: October 11, 2021Google Scholar contribute to the difficulty children and families face in accessing timely treatment. Although not specific to pediatrics, a 2015 Department of Health and Human Services report projected that by 2025, there would be major behavioral health workforce shortages of 16 940 mental health and substance abuse social workers, 8220 clinical counseling and school psychologists, and 13 740 school counselors.18Health Resources and Services Administration, US Department of Health and Human ServicesNational projections of supply and demand for behavioral health practitioners: 2013-2025.https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/behavioral-health-2013-2025.pdfDate: 2016Date accessed: January 19, 2022Google Scholar Although it is clear our behavioral health system was under significant strain prior to the COVID-19 pandemic, the needs have only intensified over the past 2 years, and evidence is accumulating that children’s behavioral health has been negatively impacted by the pandemic.19Leeb R.T. Bitsko R.H. Radhakrishnan L. Martinez P. Njai R. Holland K.M. Mental health-related emergency department visits among children aged <18 years during the COVID-19 pandemic—United States, January 1-October 17, 2020.MMWR Morb Mortal Wkly Rep. 2020; 69: 1675-1680Crossref PubMed Google Scholar Data show increases in children’s mental health–related ED visits and rates of suicide ideation and attempts at various time periods during the pandemic.19Leeb R.T. Bitsko R.H. Radhakrishnan L. Martinez P. Njai R. Holland K.M. Mental health-related emergency department visits among children aged <18 years during the COVID-19 pandemic—United States, January 1-October 17, 2020.MMWR Morb Mortal Wkly Rep. 2020; 69: 1675-1680Crossref PubMed Google Scholar, 20Hill R.M. Rufino K. Kurian S. Saxena J. Saxena K. Williams L. Suicide ideation and attempts in a pediatric emergency department before and during COVID-19.Pediatrics. 2021; 147 (:e2020029280)Crossref PubMed Google Scholar, 21Yard E. Radhakrishnan L. Ballesteros M.F. Sheppard M. Gates A. Stein Z. et al.Emergency department visits for suspected suicide attempts among persons aged 12-25 years before and during the COVID-19 pandemic—United States, January 2019-May 2021.MMWR Morb Mortal Wkly Rep. 2021; 70: 888-894Crossref PubMed Scopus (95) Google Scholar Young children (birth to 5 years) also have been adversely impacted. Studies show that when caregivers experienced more financial and material hardship, they also reported more emotional difficulties in their young children.22Center for Translational NeuroscienceA hardship chain reaction: financial difficulties are stressing families’ and young children’s wellbeing during the pandemic, and it could get a lot worse. Medium.https://medium.com/rapid-ec-project/a-hardship-chain-reaction-3c3f3577b30Date: July 30, 2020Date accessed: October 14, 2021Google Scholar There is reason to be concerned that the negative behavioral health impacts from the COVID-19 pandemic might not be borne equally by all groups of children. Evidence shows that African American and Latinx adults have experienced more behavioral health symptoms during the pandemic than other groups, and studies report increased concerns about the impact of the pandemic on their children’s education, ability to care for their children, and relationships.23Panchal N. Kamal R. Cox C. Garfield R. 2021. The implications of COVID-19 for mental health and substance use.https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/Date: February 10, 2021Date accessed: October 6, 2021Google Scholar Additionally, an estimated 140 000 children lost a primary or secondary caregiver during the first 14 months of the pandemic, and 65% of those were children of racial and ethnic minority groups.24Hillis S.D. Blenkinsop A. Villaveces A. Annor F.B. Liburd L. Massetti G.M. et al.COVID-19-Associated orphanhood and caregiver death in the United States.Pediatrics. 2021; ([E-pub ahead of print])https://doi.org/10.1542/peds.2021-053760Crossref Scopus (26) Google Scholar Positive and stable caregiver–child relationships are crucial for the behavioral health and well-being of children. Emerging evidence is revealing the extent of the strain that the pandemic has put on caregivers’ mental health.25Rudolph C.W. Zacher H. Family demands and satisfaction with family life during the COVID-19 pandemic.Couple Fam Psychol Res Pract. 2021; 10: 249-259Crossref Scopus (9) Google Scholar,26American Psychological AssociationStress in the time of COVID-19.https://www.apa.org/news/press/releases/stress/2020/reportDate: 2020Date accessed: September 23, 2021Google Scholar Compared with adults without children, caregivers—especially maternal figures—with minor children have experienced higher levels of stress, mental health diagnoses, and rates of mental health treatment.26American Psychological AssociationStress in the time of COVID-19.https://www.apa.org/news/press/releases/stress/2020/reportDate: 2020Date accessed: September 23, 2021Google Scholar Although general stress levels in caregivers decreased over time, stress specific to care-giving responsibilities continued to increase.27Adams E.L. Smith D. Caccavale L.J. Bean M.K. Parents are stressed! Patterns of parent stress across COVID-19.Front Psychiatry. 2021; 12: 626456Crossref PubMed Scopus (39) Google Scholar Research also shows that caregivers’ coping during the pandemic and the caregiver–child relationship is strongly related to children’s and adolescents’ emotional and behavioral functioning,28Cooper K. Hards E. Moltrecht B. Reynolds S. Shum A. McElroy E. et al.Loneliness, social relationships, and mental health in adolescents during the COVID-19 pandemic.J Affect Disord. 2021; 289: 98-104Crossref PubMed Scopus (23) Google Scholar,29Li X. Zhou S. Parental worry, family-based disaster education and children’s internalizing and externalizing problems during the COVID-19 pandemic.Psychol Trauma. 2021; 13: 486-495Crossref PubMed Scopus (8) Google Scholar an association consistent with reports from previous pandemics and disasters.30Fong V.C. Iarocci G. Child and family outcomes following pandemics: a systematic review and recommendations on COVID-19 policies.J Pediatr Psychol. 2020; 45: 1124-1143Crossref PubMed Google Scholar Although for many the pandemic has been conducive for strengthening family relationships,31Cornell S. Nickel B. Cvejic E. Bonner C. McCaffery K.J. Ayre J. et al.Positive outcomes associated with the COVID-19 pandemic in Australia.Health Promot J Austr. 2021; ([E-pub ahead of print])https://doi.org/10.1002/hpja.494Crossref Scopus (9) Google Scholar,32Egan S.M. Pope J. Moloney M. Hoyne C. Beatty C. Missing early education and care during the pandemic: the socio-emotional impact of the COVID-19 crisis on young children.Early Child Educ J. 2021; 49: 925-934Crossref PubMed Scopus (26) Google Scholar for others it has strained caregiver–child relationships and led to punitive, psychologically abusive, or high-conflict interactions owing to increased caregiver stress and depression experienced during the pandemic.1Russell B.S. Hutchison M. Tambling R. Tomkunas A.J. Horton A.L. Initial challenges of caregiving during COVID-19: caregiver burden, mental health, and the parent–child relationship.Child Psychiatry Hum Dev. 2020; 51: 671-682Crossref PubMed Scopus (239) Google Scholar,33Lawson M. Piel M.H. Simon M. Child maltreatment during the COVID-19 pandemic: consequences of parental job loss on psychological and physical abuse towards children.Child Abuse Negl. 2020; 110: 104709Crossref PubMed Scopus (171) Google Scholar,34Wolf J.P. Freisthler B. Chadwick C. Stress, alcohol use, and punitive parenting during the COVID-19 pandemic.Child Abuse Negl. 2021; 117: 105090Crossref PubMed Scopus (6) Google Scholar Conversely, a close caregiver–child relationship was found to be protective against mental health difficulties for adolescents.28Cooper K. Hards E. Moltrecht B. Reynolds S. Shum A. McElroy E. et al.Loneliness, social relationships, and mental health in adolescents during the COVID-19 pandemic.J Affect Disord. 2021; 289: 98-104Crossref PubMed Scopus (23) Google Scholar These data underscore that adult and family behavioral health should be considered inextricable from children’s behavioral health. A multifaceted approach attending to the behavioral health needs of children, their primary caregivers, and the entire family unit will be paramount to a successful COVID-19 behavioral health mitigation strategy. Policy changes at federal, state, local, and institutional levels are needed to address the child and family behavioral health crisis in the immediate and long-term recovery phases from this pandemic. Our nation must bolster our health care, school, and community systems to be better positioned to deliver high-quality and developmentally and culturally appropriate behavioral health care through new or amended federal, state, and local policies. These solutions will need to address existing behavioral health conditions exacerbated by the pandemic, the onset of new behavioral health conditions resulting from the pandemic, and pandemic-induced behavioral health symptomatology that does not result in a disorder but should be supported with appropriate early intervention. Additionally, a racial and health equity framework should be applied when crafting and advancing behavioral health policies. Existing inequities have been exacerbated by COVID-19 and will not be rectified without intentional effort. Numerous frameworks exist35Tools and resources for achieving racial equity in policymaking. Independent Sector.https://independentsector.org/resource/tools-resources-for-achieving-racial-equity-in-policymaking/Date: February 10, 2021Date accessed: October 1, 2021Google Scholar,36Malawa Z. Gaarde J. Spellen S. Racism as a root cause approach: a new framework.Pediatrics. 2021; 147 (:e2020015602)Crossref PubMed Google Scholar; regardless of the exact framework, an intentional process that prioritizes the voice of those most impacted by the proposed policy in solution development is a critical step in advancing equitable behavioral health policies.37Charles A. Healthy and Equitable Communities Workshop Series: Action Planning. Child Health Advocacy Institute Racial Equity Training Series, Washington, DC2021 May 20Google Scholar Furthermore, as our society responds to this crisis, we should guard against a singular focus on the elements of our behavioral health care system most often utilized when individuals are in crisis: EDs, inpatient facilities, and outpatient treatment services. Ensuring an adequate supply of these types of services is paramount but must not be done to the exclusion of investing in and prioritizing upstream approaches, including revised financing and payment structures. Behavioral health conditions and concerns, including those exacerbated and/or brought on by the pandemic, need not be life-long or long-term. Prevention, early intervention, and timely treatment when indicated can propel children and families toward a lifetime of thriving. From a systems perspective, behavioral health, and especially children’s behavioral health, remains a “second class citizen” compared with physical health conditions. Nationally, a child’s mental health office visit is 10.1 times more likely to be out-of-network than a primary care office visit and twice as likely to be out-of-network than an adult mental health office visit.17Melek S. Davenport S. Gray T.J. Addiction and mental health vs. physical health: widening disparities in network use and provider reimbursement.https://assets.milliman.com/ektron/Addiction_and_mental_health_vs_physical_health_Widening_disparities_in_network_use_and_provider_reimbursement.pdfDate: 2019Date accessed: October 11, 2021Google Scholar As cited previously, more than one-half of children with a treatable mental health disorder are not receiving necessary treatment from a mental health professional.13Whitney D.G. Peterson M.D. US National and state-level prevalence of mental health disorders and disparities of mental health care use in children.JAMA Pediatr. 2019; 173: 389-391Crossref PubMed Scopus (185) Google Scholar Yet, a high proportion of children are covered by insurance. Medicaid and the Children’s Health Insurance Program (CHIP) insure more than 38 million children (more than one-half of US children),38Medicaid.gov. Centers for Medicare and Medicaid ServicesMedicaid and CHIP enrollment trend snapshot.https://www.medicaid.gov/medicaid/program-information/medicaid-chip-enrollment-data/medicaid-and-chip-enrollment-trend-snapshot/index.htmlDate accessed: October 15, 2021Google Scholar and >95% of children are enrolled in some type of health insurance program.39Children’s Hospital AssociationHealth care coverage sources for America’s children.https://www.childrenshospitals.org/issues-and-advocacy/general/fact-sheets/health-care-coverage-sources-for-americas-childrenDate accessed: September 19, 2021Google Scholar Given these numbers, there is potential to improve access by ensuring implementation and enforcement of current federal laws, particularly the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) federal Medicaid benefit for children and adolescents and the Mental Health Parity and Addiction Equity Act (MHPAEA). EPSDT is the legally required benefit for Medicaid eligible children that provides a comprehensive set of health benefits, including payment for pediatric screening services and for all Medicaid-coverable health and behavioral health care services that are medically necessary to correct and ameliorate health and behavioral health conditions (including those detected by screening).40Medicaid.gov. Centers for Medicare and Medicaid ServicesEarly and periodic screening, diagnostic, and treatment.https://www.medicaid.gov/medicaid/benefits/early-and-periodic-screening-diagnostic-and-treatment/index.htmlDate accessed: October 22, 2021Google Scholar It can be an important source of public financing of children’s behavioral health care. The unique focus of EPSDT on prevention, early intervention, and treatment coverage makes it an ideal current law to focus on robust and consistent enforcement (including across all settings, such as schools), clarification, and/or enhancement. Studies show that state-level enforcement of EPSDT mental health benefits can demonstrate measurable, positive changes in patterns of use of mental health services, with intensity of outpatient treatment increasing over time and rates of emergency care declining, at least initially, and increases in overall behavioral health screening and treatment.41Snowden L.R. Masland M.C. Wallace N.T. Evans-Cuellar A. Effects on outpatient and emergency mental health care of strict Medicaid early periodic screening, diagnosis, and treatment enforcement.Am J Public Health. 2007; 97: 1951-1956Crossref PubMed Scopus (16) Google Scholar,42Romano-Clarke G. Tang M.H. Xerras D.C. Egan H.S. Pasinski R.C. Kamin H.S. et al.Have rates of behavioral health assessment and treatment increased for Massachusetts children since the Rosie D. decision? A report from two primary care practices.Clin Pediatr (Phila). 2014; 53: 243-249Crossref PubMed Scopus (12) Google Scholar There have been calls to update EPSDT regulations,43Rosenbaum S. When old is new: Medicaid’s EPSDT benefit at fifty, and the future of child health policy.Milbank Q. 2016; 94: 716-719Crossref PubMed Scopus (11) Google Scholar and some states have initiated processes to clarify their public insurance policies.44Kraft A.C. MassHealth Managed Care Entity Bulletin 65: Preventive behavioral health services for members younger than 21.https://www.mass.gov/doc/managed-care-entity-bulletin-65-preventive-behavioral-health-services-for-members-younger-than-21-0/downloadDate: August 2021Date accessed: October 11, 2021Google Scholar Massachusetts, directly citing the adverse impact of COVID-19 on children and family behavioral health, including racial inequities, released Medicaid guidance in August 2021 stating that Medicaid managed care plans “must cover medically necessary preventive behavioral health services for members from birth until age 21…[E]ligibility requirements for preventive behavioral health services...include members...if they have a positive behavioral health screen (or, in the case of an infant, a positive post-partum depression screening), even if they do not meet criteria for behavioral health diagnosis and therefore do not meet medical necessity criteria for behavioral health treatment.”44Kraft A.C. MassHealth Managed Care Entity Bulletin 65: Preventive behavioral health services for members younger than 21.https://www.mass.gov/doc/managed-care-entity-bulletin-65-preventive-behavioral-health-services-for-members-younger-than-21-0/downloadDate: August 2021Date accessed: October 11, 2021Google Scholar Now is the time to undertake revisions to such policies, with an emphasis on behavioral health.45Hoagwood K.E. Kelleher K.J. Hogan M. Redesigning federal health insurance policies to promote children’s mental health. Think bigger do good.https://thinkbiggerdogood.org/redesigning-federal-health-insurance-policies-to-promote-childrens-mental-health/Date: October 17, 2018Date accessed: October 11, 2021Google Scholar Coupled with a focus on EPSDT, bolstering access to behavioral health services also could be aided by increasing the federal share of Medicaid costs for behavioral health during the COVID-19 pandemic.46Bailey A. Increasing FMAP Is essential to behavioral health care access amid COVID-19.https://www.cbpp.org/blog/increasing-fmap-is-essential-to-behavioral-health-care-access-amid-covid-19Date accessed: September 19, 2021Google Scholar,47Ogburn J. Gratale D. Counts N. Zakab T. Mental Health AmericaPediatric mental, emotional, and behavioral health: federal policy recommendations for Congress and the Executive Branch.https://mhanational.org/research-reports/pediatric-mental-emotional-and-behavioral-health-federal-policy-recommendationsDate accessed: October 18, 2021Google Scholar For example, the federal Medicaid Bump Act, if enacted by Congress, would increase the federal reimbursement rate for mental and behavioral health care services under Medicaid.48U.S. Senator Tina Smith introduces bill to increase mental health coverage.https://www.smith.senate.gov/us-senator-tina-smith-introduces-bill-increase-mental-health-coverageDate accessed: January 19, 2022Google Scholar Mental health parity has yet to be achieved, and network adequacy for behavioral health demands attention and action, especially as a critical response to the COVID-19 children’s behavioral health crisis. The MHPAEA, which mandates that health plans and insurers offer mental health and substance use disorder benefits that are comparable with their coverage for general medical and surgical care,49Emergency Economic Stabilization Act of 2008 [Internet]. Sect. Subtitle B: Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, 110–343 Oct 3, 2008.https://www.govinfo.gov/content/pkg/PLAW-110publ343/html/PLAW-110publ343.htmDate accessed: October 21, 2021Google Scholar has produced mixed results regarding efficacy for increasing access, yet most studies have focused largely on adults. A study of middle-income children and youth suggests that enactment of the MHPAEA improved access to care and mental health outcomes.50Li X. Ma J. Does mental health parity encourage mental health utilization among children and adolescents? Evidence from the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA).J Behav Health Serv Res. 2020; 47: 38-53Crossref PubMed Scopus (3) Google Scholar Federal actions to advance actualization of the MHPAEA could include extending the Act’s authority to include Medicaid fee for service and enhancing parity enforcement for both Medicaid managed care and private insurance;47Ogburn J. Gratale D. Counts N. Zakab T. Mental Health AmericaPediatric mental, emotional, and behavioral health: federal policy recommendations for Congress and the Executive Branch.https://mhanational.org/research-reports/pediatric-mental-emotional-and-behavioral-health-federal-policy-recommendationsDate accessed: October 18, 2021Google Scholar and utilizing US Department of Labor enforcement authority to penalize states and payors that do not comply with federal parity requirements.51McCray C.I. Rosenberg L. A path forward: mental health and the U.S. pandemic response.J Behav Health Serv Res. 2021; 48: 161-170Crossref PubMed Scopus (2) Google Scholar Although not sufficient to address the behavioral health crisis, an important component of a comprehensive solution will be to expand the pool of qualified behavioral health care professionals.52Kepley H.O. Streeter R.A. Closing behavioral health workforce gaps: a HRSA program expanding direct mental health service access in underserved areas.Am J Prev Med. 2018; 54: S190-S191Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Additionally, given the family stressors, shared trauma, and relational strain experienced by children and caregivers during the pandemic and the importance of addressing the behavioral health of caregivers within the pediatric behavioral health care