Introduction

For decades, the demand for pediatric mental health services has exceeded the supply of mental health providers, despite efforts to increase the number of child psychiatrists.1 This imbalance was exacerbated by the COVID-19 pandemic. Nearly 75% of states have fewer than 10 child psychiatrists for every 100,000 children, which translates to wait times of nearly a year for child psychiatric appointments in some localities.1–4 Trying to find ways to meet the mental health needs of children prompted 2 of the coauthors (one of whom was a medical student at the time) to write an article outlining the benefits of Pediatric Mental Health Care Access Programs (PMHCAPs, also known as Child Psychiatry Access Programs, or CPAPs) and provide suggestions for sustainable funding of these programs, which was published in January of 2021.5 PMHCAPs were established to increase primary care providers’ capacity to manage pediatric mental health problems by providing continuing education offerings, clinical consultation, and resource/referral support, with some programs also offering limited direct-to-patient consultation and/or treatment (e.g., telepsychiatry evaluation).6

Given that PMHCAPs are a viable strategy to address the provider shortages, we sought to advocate for federal financial support of PMHCAPs by meeting with members of US Congress. We highlighted the need for and benefits of PMHCAPs, and ultimately asked that they sign a letter that advocated for an allocation of $16 million toward the continuation and expansion of PMHCAPs. What began as an email exchange on January 25, 2021, about a timely journal article led to a collaboration among people of varied professional backgrounds in multiple cities and states (in just over 6 weeks) working alongside extant advocacy efforts. In this article, we will describe an advocacy effort that ultimately culminated in $80 million being allocated to support and expand mental health services through PMHCAPs for children in every state and territory in the US. This was an effort that we worked on in conjunction with several organizations (outlined below) and individuals who had been laying the groundwork prior to our involvement. Interdisciplinary teamwork, collaboration with the American Academy of Pediatrics (AAP), having a clear ask of Congresspeople, and fortuitous timing were all instrumental to our success in contributing to the ongoing efforts to increase funding for the provision of mental health services for children and adolescents.

Advocacy Strategy

Our advocacy team represented different types of providers who are critical to the success of PMHCAPs, including a child and adolescent psychiatrist, a licensed clinical social worker, a child psychologist, a medical student, and a general pediatrician. One of the advocacy team members resided in a Congressional District represented by a Maryland Congressperson who, because of the unfortunate and recent loss of a child to suicide, was thought to be particularly motivated to address the perennial shortage of mental healthcare providers. We expanded our team to include other key stakeholders who were particularly knowledgeable of the local mental health challenges relevant to the Congressperson. This included the Program Director and Medical Director of Maryland’s Behavioral Health Integration in Pediatric Primary Care Program (BHIPP), both of whom had in-depth experience in managing a federally funded PMHCAP. We also invited providers from the PMHCAP, who helped draft the original article to join us in our advocacy effort, including the Medical Director and Project Manager of the Pediatric Psychiatry Resource Network (PediPRN) of the PMHCAP team in Rhode Island.

Throughout our advocacy effort, we faced 2 major challenges that resulted in 2 of our greatest assets: timing and virtual meeting capabilities. At the time, the new Presidential administration was actively pressing for a monetarily large piece of legislation to address the COVID-19 pandemic. This meant that Congress was amid active negotiations on this bill and would be voting on it in a matter of weeks. As can be the case with such large spending bills, several related provisions can be added if there are Congressmembers that will support their inclusion in the final bill. This provided us with a fortuitous, albeit narrow, window to speak with Congressmembers who may be willing to advocate for federal financial support of PMHCAPs to be included in the bill. Fortunately, our advocacy goals aligned with ongoing advocacy efforts of the AAP. The AAP Federal Affairs office had been cultivating a list of Congressmembers (in addition to the Maryland Congressmember) who were identified as mental health “champions” (because of personal or professional experience) that would likely support the expansion of mental health services, and we focused our advocacy efforts on these individuals—a list broader than ours given the circumstances of the identified Congressmember. The AAP also had ready-made, one-page summaries that we shared with Congressional staffers (Figure 1).

The physical distance would normally have made it temporally and financially difficult for our group to hold strategy meetings and to meet with Congressional staff (the team worked in 3 different cities, in 2 different states, and were separated by 400 miles) in such a short time. However, one of the silver linings of the COVID-19 pandemic is that many meetings occurred virtually, including those with Congressional staff. We met with a Congressional staff member virtually within 8 days of the initial email sent to gauge interest in pursuing this advocacy effort. During this meeting, we made our case for the positive impact that PMHCAPs can have on child mental health, requested that federal financial support continue, and requested that these programs should be expanded to all US states and territories. We had a similar meeting with a Congressional staff member from a Senate office 2 weeks later.

Unexpected Outcomes

On March 11, 2021, President Biden signed the $1.9 trillion American Rescue Plan, of which $80 million went to funding PMHCAPs. That was 5 times larger than our original $16 million request made in conjunction with the organized effort of the coalition. This money was set to provide 5 years of funding to expand PMHCAPs to states (including Washington D.C. and US territories) that did not previously have them, in addition to providing financial support for the 21 states that already had federally funded PMHCAPs. The signing of this bill occurred just six and a half weeks after our team had our initial introductory email.

Two weeks later, on May 25, 2021, 2 of our advocacy team members participated in a virtual panel discussion between AAP chapters on the implications of federal Health Resources and Services Administration funding for the emotional, mental, and behavioral healthcare services of patients. This was an opportunity for chapters and states to compare approaches for soliciting and using federal funding to expand mental healthcare access for children. Information on developing advocacy efforts for utilizing federal funding to support PMHCAPs was also shared as part of continuing efforts to increase access to behavioral health care.

Key Lessons Learned

Timing is one of the main reasons that this advocacy effort was successful. There was a new federal administration voted into office, in part, on the promise to meaningfully address the mental health impacts of COVID-19 pandemic. This new administration had a finite window of time to enact significant change before the next federal election. Additionally, there was near-universal professional consensus (as represented by AACAP’s and AAP’s declaration of a pediatric mental health emergency) that this historic pandemic had significant mental health repercussions for everybody, particularly children. To that end, AAP’s Committee on Federal Governmental Affairs and Committee on State Governmental Affairs staff had been working on this issue and laying the groundwork prior to our advocacy team getting formally involved. This was fortuitous for our team and our cause. While the allocation of those funds was a welcomed step, the persistence of unmet mental health care needs over 2 years after the law was signed reminds us that much more work needs to be done.

Next Steps

An obvious next step is advocating for PMHCAPs to be funded in perpetuity, as the current legislation only provides funding for 5 years. We hope readers will be inspired to work with others in subsequent advocacy efforts to help realize this important goal.

One of the hopes of the authors is that we will empower readers to take meaningful steps to address issues encountered in a clinic, neighborhood, or in a journal article of interest. Once a topic of interest is identified, it would be ideal to reach out to the local chapter of an advocacy organization like the AACAP or AAP to determine if there is any work already being done in this area. In our example, other organizations (26 in total—see full list at end of article) all cosigned a letter asking key members of Congress to support increased funding for PMHCAPs.

If one’s advocacy efforts target members of the US Congress, it is helpful for you to speak with your own representatives (Congressmembers and Senators) and remind them that you vote, work, and/or live in their district, and that the issue of interests affects you, their constituent. The adage, “all politics is local” has a lot of truth in it and is applicable to many advocacy efforts.

Take Home Summary

Successful policy advocacy efforts often begin with identifying an issue of personal and/or professional interest, partnering with likeminded individuals and/or professional organizations who have similar interests and/or have a history of advocating for similar causes, finding political “champions” willing to join and or lift the issue, and doing all this while being mindful of and working with the timeline of the political process.

About the Authors

David E. Myles, MD, MS, Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
Kathryn Lamere, MD, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
Kelly Coble, LCSW-C, Department of Psychiatry, University of Maryland School of Medicine, Maryland, USA.
Karyn Horowitz, MD, Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.

Funding

The authors have reported no funding for this work.

Data and Materials Availability

All data are available in the main text.

Acknowledgments

Wendy Chill
Sarah Edwards, DO
Sarah Hagin, PhD
Tamar Magarik
Christina Ramsay
Lucy Shaw
Ian Van Dinther

Disclosure

The authors have reported no biomedical financial interests or potential conflicts of interest.

Correspondence to:

David E. Myles; email: david.e.myles3.civ@health.mil.

Author Contributions

Conceptualization: DEM, KL, KC, KH
Methodology: DEM, KL
Writing – original draft: DEM
Writing – review & editing: DEM, KL, KC, KH

List of Organization Members Involved in Advocacy Effort

  • American Academy of Pediatrics
  • American Association of Child and Adolescent Psychiatry
  • American College of Obstetricians and Gynecologists
  • American Foundation for Suicide Prevention
  • American Muslim Health Professionals
  • American Psychiatric Association
  • American Psychoanalytic Association (APsA)
  • Association of Children’s Residential Centers (ACRC)
  • Association of Maternal & Child Health Programs
  • Children’s Hospital Association
  • Children’s Wisconsin
  • Clinical Social Work Association
  • Eating Disorders Coalition for Research, Policy & Action
  • Family Voices
  • First Focus Campaign for Children
  • National Alliance on Mental Illness
  • National Association for Children’s Behavioral Health
  • National Association of Pediatric Nurse Practitioners
  • National League for Nursing
  • National Network of Child Psychiatry Access Programs
  • New Jersey Association of Mental Health and Addiction Agencies, Inc.
  • Society for Adolescent Health and Medicine
  • The National Alliance to Advance Adolescent Health
  • Virginia Chapter, American Academy of Pediatrics
  • Virginia Mental Health Access Program (VMAP)
  • ZERO TO THREE
Figure 1
Figure 1.Mental Health Champion Congressional Summary

Note: Republished with permission from American Academy of Pediatrics.