This paper is designed to provide a broad-view perspective on at least some of the implications of the Affordable Care Act for children’s behavioral health. Historical trends in behavioral health have tended to isolate both consumers of services (including children, youth and families) and practitioners from the larger world of healthcare, with decidedly mixed results. This paper uses the concept of path dependence to highlight the multiple challenges facing child behavioral health as it moves forward. The paper builds its recommendations on the 4 pillars of sustainable change: politics, practice, economics, and science. In a changing health care environment, behavioral health has to transform. The paper concludes with some observations on the kinds of transformative change required to move in new directions.