|Proceedings of a Workshop—in Brief|
Responding to the Current Youth Mental Health Crisis and Preventing the Next One
Proceedings of a Workshop—in Brief
RESPONDING TO THE CURRENT YOUTH MENTAL HEALTH CRISIS
The workshop began with opening remarks from Sandra Fritsch, MD, a pediatrician at Children’s Hospital Colorado, where there was a 67 percent increase in youth presenting to emergency rooms for crisis evaluations between 2019 and 2021. Fritsch commented that while the COVID-19 pandemic continues to affect youth and their normal development, the youth mental health crisis predates the COVID-19 pandemic. From 2009 through 2019, reported suicide attempts for teenagers in the United States rose significantly. Youth reporting persistent sadness rose from just over 25 percent in 2009 to more than 35 percent in 2019, and reached 45 percent in 2021.
The lack of an adequate workforce to address the youth mental health crisis is a notable challenge, Fritsch said. For example, in Colorado, two-thirds of counties do not have any child or adolescent psychologists. Fritsch added that most of the country faces severe shortages of
child and adolescent psychiatrists, as well as other child mental health providers.
However, Fritsch commented, the response to the COVID-19 pandemic has introduced new opportunities. The Coronavirus Aid, Relief, and Economic Security (CARES) Act led to funding of more Pediatric Mental Health Care Access Programs under the Health Resources and Services Administration. Additionally, the American Rescue Plan delegated funds specifically for behavioral health. The expansion of telehealth has also increased access to mental health services for youth. Fritsch concluded by noting that the increased awareness of the problem introduces an opportunity for greater support for children and youth.
Following Fritsch’s remarks, four panelists provided comments on the national response to the current youth mental health crisis.2 First, Amy Knight, MHA, president of the Children’s Hospital Association, noted that responding to and addressing mental health concerns in youth prevents greater mental health challenges as those youth grow into adulthood. She echoed Fritsch’s comment that the youth mental health crisis predates the COVID-19 pandemic, and added that the pandemic, social unrest, and the current political environment have contributed to something bigger over the past couple of years.
To contextualize the crisis, Knight said about 1 in 285 children will be diagnosed with cancer, and 1 in 13 have food allergies. However, 1 in 5 children experience a mental health condition annually. She added that 50 percent of mental health conditions start before age 14, but that it takes an average of 11 years from when children first experience symptoms to when they start to receive treatment.
While promotion and prevention are essential for preventing a future crisis, Knight said, they will not solve the needs of children and youth who are struggling now. Thus, Knight called for investments across the behavioral health continuum, from the promotion of positive mental health all of the way through to the treatment of mental health disorders. Starting at promotion, she argued for adequate training for community members, family navigators, behavioral health social workers, therapists, and school counselors so they are able to intervene when appropriate. She added that there is also a need for greater investment in infrastructure to support child and youth mental health. Lastly, she commented that underpinning all of this is payment and the need for long-term sustainable funding streams to support the behavioral health continuum.
To conclude her remarks and highlight potential paths forward, Knight mentioned three pieces of proposed legislation to support children and youth mental health. The first, the Strengthen Kids’ Mental Health Now Act, includes reforms that will bolster the pediatric mental health workforce and expand the full continuum of care for children. The second, the Children’s Mental Health Infrastructure Act, provides funding to children’s hospitals and other providers to enhance care capacity and support mental health infrastructure. The third, the Helping Kids Cope Act, provides grants to pediatric providers to support community-based behavioral health coordination and integration, as well as grants to support pediatric behavioral health workforce training for physician and nonphysician professionals.
The second panelist was Moira Szilagyi, MD, PhD, president of the American Academy of Pediatrics (AAP), who focused her remarks on the primary care response to childhood trauma. Szilagyi noted that more than 243,000 children lost a primary or secondary caregiver during the pandemic, with the largest impact on traditionally marginalized and under-resourced families. She commented that the pandemic had disproportionate impacts on marginalized communities, noting “the historical embedding of racism into systems and structures ensure that Black, Native American, Alaska Native, Hispanic, and some immigrant populations have less opportunity.”
Szilagyi cited the 1998 Adverse Childhood Experiences Study, which showed that a greater burden of
intrafamilial childhood adversities was associated with worse adult medical, mental health, and social outcomes. The pandemic, she noted, increased these adversities for many children. She commented that while a little stress may promote learning for children, significant stress that occurs in the absence of protective relationships can lead to toxic stress, which may negatively impact a child’s brain development. Trauma-informed care can promote healthy child development for children at risk, she said.
As defined by the National Child Traumatic Stress Network, trauma-informed care is medical care in which all parties involved recognize, assess, and respond to the effects of traumatic experiences. Szilagyi broadened this definition to include the promotion of resilience, to prevent trauma or its effects, and to promote health brain and emotional development. For further information, Szilagyi pointed participants to an AAP policy statement on toxic stress3 and a clinical report on trauma-informed care with guidance for providers.4
The third speaker for this panel, Warren Y.K. Ng, MD, MPH, president of the American Academy of Child and Adolescent Psychiatry, echoed previous comments related to the different mental health experiences of youth, noting that suicide rates are higher for children of color and LGBTQ youth. Ng also noted that youth with intellectual or developmental disabilities, youth from low-income families, youth living in rural areas, and immigrant youth are disproportionately impacted by mental health concerns.
The COVID-19 pandemic highlighted and exacerbated the health inequities in this country, Ng said. In particular, the impact of the COVID-19 pandemic on social determinants of health disproportionately affected families living in poverty and communities of color. Ng commented that in addressing mental health concerns, it is crucial to address these social determinants that serve as risk factors.
Quoting former Surgeon General David Satcher, Ng said “there is no health without mental health.” He said approaches to addressing youth mental health concerns should be relationship-centered, youth-based, culturally responsive, trauma-informed, and should utilize community partnerships. He noted that youth need not only the right care at the right place and time but also at the right intensity. As Knight previously pointed out, Ng commented increasing prevention and promotion efforts is not enough to address the needs of youth who need help in this current crisis. Now is the moment to leverage the available resources to provide the right care at the right place with the right team members at the right intensity for all youth, he concluded.
The fourth and final speaker for this panel was Nanfi Lubogo, CCHW, president of the Family Voices Board of Directors, who spoke about the impact of racism on child development. She said racism can lead to the toxic stress described by Szilagyi, and can eventually lead to weathering through chronic exposure to social and economic disadvantage.
Lubogo noted suicide rates for Black children in the United States are higher than the rates for their White peers. She added that while 9 percent of Black youth report major depression, only 40 percent of them seek treatment, compared to 46 percent of White youth with major depression. While the COVID-19 pandemic and the racial reckoning that occurred in the summer of 2020 brought to light many of the issues that families of color face, Lubogo pointed out that these issues were not new. “People have been suffering in silence for years,” she said.
Adding to Szilagyi’s comments about trauma, Lubogo highlighted the intergenerational trauma experienced by many families of color in the United States. She commented that histories of genocide, slavery, and systemic racism have contributed to cumulative emotional and psychological wounding across generations, which affects today’s youth. Lubogo noted that recognizing this intergenerational trauma is a key component to effective trauma-informed care. As a result of this intergenerational trauma, she said, many families of color lack trust in health care providers. In
adding to the earlier comments about building up the behavioral health workforce, she said part of those efforts need to include diversifying the workforce so that more families are able to find providers they can trust and who understand their needs. She suggested providers should “think outside the box” in connecting with families—community health workers and peer-to-peer mentors from organizations like Family Voices can help close the communications gap between patient and provider.
Following their presentations, the panelists responded to questions from the audience. One audience member asked them to consider how different members of the workforce might be better engaged to address the youth mental health crisis. Szilagyi responded that AAP is setting up interdisciplinary conversations across the country, and is providing some small grants to encourage this work. Ng agreed that it is crucial to remember everyone brings a different set of skills to the table. Lubogo added that training the future workforce to think collaboratively and to recognize their implicit bias is also important, as is teaching providers that resilience in patients will differ across cultures and backgrounds.
To conclude this portion of the workshop, the panelists were asked to comment on how those in the field can find support to better respond to the youth mental health crisis. Knight said network building at the local level helps to build community and increase support for providers. Each community has different needs, she said, and requires different responses. She added that diversifying the workforce and introducing mental healthcare as a career option earlier in school programs will create a more sustainable workforce. Ng noted that relationships are important. He also reminded providers to reach out for support when they are experiencing burnout. Caring for youth and families is difficult, Lubogo emphasized. She closed the session by reminding providers to build their own resilience just as they teach it to their patients.
SHIFTING TO PROMOTION AND PREVENTION IN MENTAL HEALTH
The second day of the workshop agenda focused on incorporating promotion and prevention into the response to the current youth mental health crisis to help prevent future crises. This portion of the workshop started with a conversation between Surgeon General Vivek Murthy, MD, MBA, and Harolyn Belcher, MD, MHS, Forum member, and vice president and chief diversity officer at the Kennedy Krieger Institute. Murthy commented that adolescence is a time when people should be feeling joy and excitement about the future, rather than persistent sadness or anxiety. As a country, he said, there are steps we can take to address the problem.5 The first step is to recognize the extent of the crisis. The second is to involve youth in determining a solution. The third is to address the social determinants of health that contribute to the inequities in youth mental health outcomes.
In his discussions with youth around the country, Murthy said, he hears them talk about the stress they feel related to the pandemic, as well as concerns about bullying, loneliness, racism, climate change, and violence in their communities. Stigma surrounding mental health and lack of access to adequate care mean many youth are suffering in silence. Murthy commented that a greater investment in evidence-based prevention programs may reduce substance use disorders, reduce teen pregnancies, increase graduation rates, and reduce encounters with law enforcement, while also promoting positive mental health. Belcher added that youth who report feeling less isolated also report better mental health outcomes, so building community connectedness is critical.
In considering the need to reorient priorities to better emphasize prevention, Belcher noted the importance of communities, schools, researchers, and local, state, and federal government, and asked Murthy about his vision for youth in the United States. Murthy responded, “That we will have a society where it is as easy to talk about our mental health challenges as our physical health challenges.” He said this begins to change when more people are open about their mental health struggles and seeking help. He suggested parents can model the behavior for their children by having open conversations about mental health in the same way a parent may check
5 For additional information, see https://www.hhs.gov/sites/default/files/surgeon-general-youth-mental-health-advisory.pdf.
in on homework or how their child is doing in sports. This type of conversation, Murthy said, begins to teach youth the language to talk about their emotions.
Belcher noted that the pandemic has shifted the way in which people talk about mental health, as well as how communities provide mental health services. Murthy agreed, saying the pandemic exposed gaps in the mental healthcare system. For example, he noted, that it needs to be easier to get healthcare, which includes not only reliable insurance coverage, but also mental health parity so people have access to both physical and mental health care. He commented that expanding telehealth can provide mental health services to people who might otherwise not be able to find a provider. Another lesson learned from the pandemic, Murthy said, is that the failure to provide proactive mental health care results in problems worsening over time. Screening for mental health and integrating mental health into primary care, he said, are crucial in addressing mental health concerns before they become more serious.
Lastly, Murthy said the COVID-19 pandemic showed us how important relationships are when it comes to mental health and overall well-being. Loneliness and isolation put people at increased risk of anxiety and depression. Relationships, he said, are a key component in building a foundation for emotional well-being in youth.
Following the conversation between Murthy and Belcher, a series of panelists spoke about examples of prevention-focused interventions from communities across the country. The first presenters were Mary Ann Woodruff, MD, a pediatrician at Pediatrics Northwest, and Wendy Pringle, LMHC, director of pediatric healthcare integration at HopeSparks. They work together in northwest Washington state to integrate mental health into a pediatric primary care setting, where data from 2018 showed that it took an average of 26 phone calls by a parent to secure a mental health appointment for their child. The pediatric collaborative care model—called the Bridge of Hope—that Woodruff and Pringle support, is intended to provide the appropriate resources for families in need.
The pediatric collaborative care model supports a pediatric medical home that is child and family-centered, relationally focused, equity-based, community-connected, providing whole person care primary care medical home. The model emphasizes prevention and uses a team-based approach to address the needs of patients and families from birth through young adulthood. Noting that only 20 percent of what primary care addresses is strictly medical, Woodruff said it is crucial for primary care providers to understand and address the social determinants of health. Their model utilizes community health workers to coordinate care and address concrete needs of families. Using a public health lens, they are able to target concerns before they escalate to a full diagnosis.
Echoing Murthy’s comments on the importance of relational health, Woodruff emphasized the importance of partnering with caretakers, noting “stable and nurturing relationships” serve as the “foundation of well-being.” Routinely, pediatricians screen parents for perinatal mood disorders and connect families to community resources. As part of Bridge of Hope, universal screening for mental health concerns occurs at all well-child visits.
Pringle added that because they do these screenings, they feel an obligation to provide solutions for families when concerns arise. Thus, they utilize a pediatric collaborative care model for children ages 4 to 21. This stepped care system includes brief support from the primary care provider, collaborative care, referral to specialty mental health care, and referral to crisis services when necessary. Their ultimate goal, Pringle said, is to treat mild to moderate mental health concerns in the pediatric primary care setting.
Pringle noted that while COVID-19 affected the startup of Bridge of Hope, the initial results show the program has been helpful for families. An initial review found 72 percent of families referred actually connected to services, compared to an average 15 percent connect rate for mental health referrals in the community at large. Woodruff added thus far, none of the participating
patients have been seen in an emergency department for mental health concerns.
The second presentation came from Kini-Ana Tinkham, executive director of the Maine Resilience Building Network (MRBN), a statewide nonprofit connecting organizations and individuals in support of health and well-being of families and communities. In 2019, Tinkham said, a Maine survey revealed 41 percent of middle school students and 44 percent of high school students reported they did not feel as if they mattered in their community. To address this problem, MRBN started its Cultivating Youth Mattering Initiative.
Tinkham defined mattering as “the sense of being significant and valued by others,” and said it can serve as a protective factor. Mattering, she said, is strongly connected to social connectedness, and youth who experience social connectedness are less likely to experience negative health outcomes related to substance use and mental health.
The Cultivating Youth Mattering Initiative strives to promote social connectedness for youth across Maine. The initiative started by bringing together thought leaders across sectors. Tinkham noted inclusion of business leaders was particularly important in rural communities, where those leaders are often also civic leaders. These initial conversations highlighted the need to rebuild community linkages, and the importance of supporting caregivers, teachers, and youth development professionals. Next, MRBN took the initiative into public health districts across the state, where they held community conversations about how to take small steps to help young people feel like they matter.
Now, the initiative is working to develop community-based solutions. In one example, MRBN collaborated with a county on an action program that addresses social determinants of health from both youth mattering and food security perspectives. Tinkham also shared the Maine Youth Thriving: A Guide for Community Action, which will help community coalitions develop a vision and bring youth to the table to be part of the solution.
The third presenter was Christina Dobson, director of data and performance at Ready for School, Ready for Life (Ready Ready) in Guilford County, North Carolina. Ready Ready is a community initiative that aims to reduce disparities and improve outcomes in early childhood across the population. It is a collaborative effort to build a connected and innovative system of care for Guilford County’s youngest children.
Similar to MRBN, Ready Ready also began by listening to families and learning from their experiences in their children’s early years. Based on these conversations, Ready Ready developed a set of priorities to guide its work. One of its priorities, Dobson said, is to develop a navigation system to connect families with effective services. To accomplish this, Ready Ready is building a system of navigation—called Routes to Ready—to connect families with effective services from prenatal to early childhood. With an emphasis on promotion and prevention, navigators are embedded in obstetric pediatric medical sites and conduct universal assessments once per year to proactively identify child and family strengths and address needs before they affect development. These assessments include mental health challenges that caregivers may experience, a broad range of social drivers of health, and other factors that can impact the social-emotional well-being for young children. Once the family’s needs are identified, Dobson said, navigators help make targeted connections to the appropriate services.
However, “navigation is only as effective as the landscape of resources and services that families need to thrive,” Dobson said. Thus, community alignment is a vital complement to navigation. She described community alignment as the process of working with community agencies, systems, and individuals to create change at the system level. The first step in creating community alignment is the development of an agency finder, a comprehensive resource directory with details on the array of available community services. The second step is ensuring that referrals can be made effectively. To accomplish this, Ready Ready is building connections among the navigation services, community partners, and
families. The third step is to identify gaps in services and build community capacity to address them.
The final presenter for this portion of the workshop was Mary Gordon, who founded Roots of Empathy to raise levels of empathy in children and adults. Empathy, Gordon noted, cannot be taught in the same way mathematics or reading can be “taught,” but it can be “caught” through loving relationships. Empathy develops out of attachment relationship in infancy, she said. Gordon explained that Roots of Empathy brings the attachment relationship to a classroom through an instructor using a curriculum to coach students to observe the loving relationship between baby and parent over the school year. Students are also coached to identify the baby’s emotions to understand their own emotions and the emotions of their classmates. As students become proficient in taking perspective and emotional literacy, their empathy increases and aggression decreases.
Independent research on the Roots of Empathy program, including several randomized longitudinal randomized studies, shows consistent, positive, immediate, and long-term outcomes. These include an increase in prosocial behaviors, such as caring, sharing, including, and helping; an increase in empathy; an increase in knowledge of infant development; and a decrease in aggression, including bullying. Several studies found evidence that the reduction in difficult behavior was sustained for three years beyond program participation.
Following their presentations, the panelists responded to several questions from the audience. One audience member asked the panelists to comment on how they work with families of different backgrounds, cultures, and experiences. Woodruff noted that families, regardless of background, want their children to thrive, and programs are more successful when they partner with families throughout implementation. Dobson added that they include cultural humility—the ability to be open and make space for discussion—as part of their core competencies for navigators. Tinkham commented on the importance of creating authentic partnerships, including with youth themselves.
In closing, the panelists were asked to reflect on what has surprised them most about resiliency building and recovery from the COVID-19 pandemic among families and communities. Gordon said she is most surprised by the hopefulness and the increase in empathy in people. Dobson added she is inspired by the joy and excitement of parents even when these external stressors are there. Woodruff said she is surprised that people keep coming to these types of programs for help, and that they give their trust to program coordinators to help their families. Tinkham commented said she is grateful for the power of voice, and is inspired by communities’ ability to step up and help families.
RESPONDING TO CHALLENGES TO SUPPORTING MENTAL HEALTH PROMOTION FOR CHILDREN AND FAMILIES
The third and final day of the workshop elevated examples of how three states have learned to respond to some of the common challenges associated with prevention and promotion in mental health. This session started with opening remarks from Rahil Briggs, PsyD, Forum member, and national director of HealthySteps, a program of ZERO TO THREE. Briggs noted that the human brain experiences the vast majority of growth and development in the first three years of life. During this time, neural circuits that are used frequently become secure, and those that are not may not develop at all, or be pruned away. Thus, she said, babies with safe, stable, and nurturing relationships show greater brain development in areas related to language, memory, and learning than babies who grow up in unsafe environments. Focusing on young children, she said, is building the foundation for their future, and may help to prevent future population-level mental health crises.
Briggs said that despite knowing the importance of these early childhood experiences, a behavioral health promotion and prevention system is mostly nonexistent. Furthermore, treatment for diagnoses can be a complicated web of referrals, disparate quality, and challenging stigma. Briggs compared this to her
experience as a cancer survivor. All of her cancer prevention activities were covered fully by insurance. Within one week and two phone calls, she had appointments with two different oncologists. It took a little more than a month from thinking there might be a problem for Briggs to receive appropriate treatment—much less time than the 11 years many children wait to receive mental health treatment as noted by Murthy.
Briggs said providers must meet children and families where they are. She noted there are seven well-child visits in the first year of life and at least five more before the third birthday, and 90 percent of children attend these visits. Utilizing this trusted healthcare system provides an opportunity to engage with families on early behavioral health promotion and prevention efforts. Moving beyond the first years of life, schools can play an important role in promoting mental health for children. However, for schools to be effective, Briggs said there is a need for increased behavioral health staff in educational settings. Lastly, Briggs called for more focus on prevention across systems to better promote positive mental health outcomes for youth.
Lessons from Massachusetts
Following Briggs’s remarks, Jim Perrin, MD, professor of pediatrics at Harvard Medical School and the Mass General Hospital for Children, discussed efforts in Massachusetts to support youth mental health. First, he spoke about how Mass General Brigham (MGB) hospital is responding to the challenges in recruiting and retaining a mental and behavioral health workforce. MGB has agreements with educational institutions and nonprofit organizations to increase the number of nurses, social workers, and mental health specialists educated and trained in Massachusetts over the next five years. The hospital provides funds that support loan repayment, scholarships, living expenses, mentoring and supervision expenses, and stipends to work in community-based settings in under-resourced communities and psychiatric patient settings. Perrin said MGB also invests in community partners, and contracted with five behavioral health centers in under-resourced communities to establish pediatric behavioral health urgent care access.
Next, Perrin moved on to a broader statewide initiative to improve Medicaid coverage for children, youth, and families. In 2017, the state shifted to an accountable care organization (ACO) financing model, which provided direct payment resources for mental and behavioral health integration in primary care and payments to address social determinants of health, including housing and nutrition. However, none of these initial changes in 2017 affected the Medicaid enrollees under the age of 21.
Perrin said that in 2019 Massachusetts stakeholders began conversations about how the 2022 renewal of their Medicaid 1115 waiver could strengthen care for children. These conversations included people with knowledge of the current Massachusetts Mass Health ACOs, pediatricians, mental health clinicians, family care providers, child health and education experts, healthcare advocates, and family and parent engagement advocates. This coalition, the Massachusetts Child and Adolescent Health Initiative, called for a new approach to pediatric care to address family, social, and economic needs; integrate behavioral health; and integrate services across sectors. Because most pediatric care investments generate longer-term or cross-sector savings, and thus do not lend themselves to traditional healthcare payment models, this coalition hoped to adopt a specific pediatric approach to financing.
Ultimately, the group published a report in September 2020 titled Moving to the Vanguard on Pediatric Care, which included recommendations for the state. One of the major recommendations was to support and maintain a model of advanced pediatric primary care with enhanced per member per month funding to providers that offer integrated mental and behavioral health care, emphasizing upstream prevention and promotion.
A second major recommendation of the report was to address social drivers of health, and a third was to ensure investment in children and youth as a base for better outcomes in the future. The report also included several mental and behavioral health recommendations, including providing preventive and short-term behavioral health interventions for children without requiring a formal diagnosis and expanding the use of family therapy
and dyadic treatment without the requirement of a formal diagnosis, including expanding which provider types were eligible for reimbursements. Many of the recommendations in the report were included in the published 1115 waiver.
Perrin concluded by sharing that Massachusetts is now working to move primary care payment from the enhanced fee-for-service model to a partial capitation model. He said this model will provide enhancements for practices that engage mental and behavioral health practitioners in a three-tier model. In this model, tier one is practice as usual, including behavioral health screenings and referrals to care. Tier two practices have the capability to provide brief interventions for some behavioral health conditions, and have a telehealth capable behavioral health provider. Third tier practices have at least one behavioral health clinician and a community health worker on staff.
Lessons from California
Alex Briscoe, California Children’s Trust, and Kate Margolis, PhD, University of California, San Francisco, School of Medicine, shared some lessons learned from efforts in their state. Briscoe said that California ranks 43rd in the country for providing behavioral, social, and development screenings for youth. At Rady Children’s Hospital in San Diego, emergency department visits for behavioral health concerns increased 1,746 percent from 2011 to 2019—compared to an increase of just 23 percent for total emergency department visits. As in other states, these challenges were exacerbated by the COVID-19 pandemic.
Briscoe noted 75 percent of mental illness manifests between the ages of 10 and 24, but adolescents have the lowest rate of primary care utilization for any age group, which makes it difficult to detect early warning signs. Furthermore, the current diagnosis-driven model is only appropriate for some children. In his experience, a minority of children to whom he provides mental health services are appropriately diagnosable under Medicaid. The majority are in need of care, but do not meet diagnostic criteria. Additionally, he said, half of all children who commit suicide had no diagnostic history. He argued for a shift toward better understanding the impact of social determinants of health on mental health.
The California Children’s Trust is driving a package of reforms in California, including removing diagnosis as a requirement for treatment by expanding medical necessity criteria, expanding eligible provider classes to address workforce shortages, and focusing on benefit design in Medicaid managed care organizations (MCOs) to develop scalable reimbursement for dyadic models in pediatric primary care.
Margolis continued the discussion on California by highlighting a suite of Medicaid behavioral health benefits that align with prevention and the promotion of positive early childhood behavioral health. She noted the decision to integrate behavioral health in early pediatric visits will not only help prevent the next mental health crisis but also will help dismantle a “historically and currently racist system of healthcare that requires people to develop a pathological illness in order to receive behavioral health services.”
Echoing earlier comments from Briggs, Margolis said that pediatrics is a prime setting to support family well-being in support of child health. Dyadic approaches can support caregivers’ mental health so they are better able to support their babies, and can include screening for and intervening in caregiver mental health concerns. Margolis pointed out that many of the presenting problems in early childhood—including family circumstances and caregiver mental health—are not diagnosable, but are related to later childhood mental health outcomes. She commented there is a need to reform Medicaid so that it also covers these earlier, nondiagnosable concerns.
Stakeholders in California attempted to address this need for reform through the dyadic billing demonstration pilot in San Francisco, which worked with MCOs to create a Medicaid reimbursement strategy that would scale and sustain dyadic billing. Ultimately, the result of the pilot was the approval of the dyadic care services package as a new Medi-Cal benefit for children ages birth to 20. Briscoe commented that a combination of factors allowed for California to be successful in this effort, including
state leadership, budget surpluses, and a recognition at the state level that the current system was failing.
Margolis commented that there are still several challenges that need to be addressed. First, Medicaid provider class limitations mean the new dyadic benefits are available to only licensed mental health providers. She called for this to be expanded to include peer specialists such as community health workers. She also noted the same day billing exclusion for federally qualified health centers in California is a disincentive for providing same day behavioral health and medical services. Finally, the workforce shortage is a challenge in California just as it is in the rest of the country. Briscoe concluded by saying that effective behavioral health systems cannot just be financed and administered differently; they must also be anchored in principles that acknowledge the impact of social determinants of health.
Lessons from South Carolina
Lastly, Kimberly Seals, South Carolina Title V director, and Georgia Mjartan, South Carolina First Steps, discussed their work on youth mental health in South Carolina. Seals explained the Title V program is the oldest formula block grant program in the country, and it helps provide funding and resources to women and children. Every five years, Title V requires states to conduct an assessment to determine the maternal and child health population needs in the state. In South Carolina, the 2015 and 2020 assessments highlighted a need to increase preventive health and developmental screenings.
To respond to this, the state created the Child Well-Being Coalition. One goal of the Coalition was to increase the percent of children, ages 10 to 71 months, receiving a developmental screening using a parent-completed screening tool. It also aimed to increase investments in preventive maternal and child health. Seals shared that the Coalition developed a strategic plan that focuses on developmental screening and emphasizes the need for investment in evidence-based interventions and building strategic partnerships in communities. In one example, the Coalition uses braided funding to partner with HealthySteps in some rural pockets in the state. Through the COVID-19 pandemic, the Coalition learned that it is not only a convenor of stakeholders in the state but also a lead partner, with the role of bringing awareness to child health issues, said Seals.
One of the partners in the Coalition is South Carolina First Steps, a state agency with a network of 46 county-level nonprofit affiliates. Its funding comes primarily from the state, leaning on preschool development grant funds and Elementary and Secondary School Emergency Relief III funds, with some private philanthropy funding. Mjartan said that at the start of the pandemic First Steps worked with its network to hear from families. It found 87 percent of caregivers reported the pandemic had disrupted their home and family life, 83 percent reported feeling more anxious and stressed than usual, and 75 percent reported feeling worried about the mental health of their young children. Emphasizing the importance of listening to families, Mjartan said these survey responses served as a call to action for First Steps.
Echoing previous comments about the importance of meeting families where they are, Mjartan said many children birth through age five in South Carolina are at home—40 percent of the state’s children live in a childcare desert. Thus, First Steps worked to implement evidence-based home visiting programs throughout the state, in addition to interventions in clinics and childcare settings. In its home visiting program, First Steps collaborates with the South Carolina Department of Mental Health and Department of Social Services, as well as local nonprofits, to implement an intervention proven to prevent and reduce cases of child abuse and neglect. In childcare settings, First Steps developed and invested in an early childhood and infant mental health consultancy, which allows caregivers in childcare centers to contact a centralized mental health hotline for support. It has also been able to expand HealthySteps across the state by blending and braiding federal resources, private funds, and support from three different state agencies. Mjartan concluded by commenting that coordination across different stakeholder groups is essential for meeting the needs of children and families, in South Carolina and across the country.
Question and Answer Session
Following the panel presentations, the panelists responded to a series of audience questions. The first question asked was about utilizing the full workforce in programs that integrate behavioral health into primary care. Mjartan commented that models that restrict which providers can participate limit scalability, whereas models that utilize different providers—including pediatricians, nurse practitioners, and community health workers—can expand access. Briscoe commented that behavioral health is headed toward team-based care, adding the workforce shortage provides an opportunity to reimagine who does the work and who gets paid for it, which may support a more culturally relevant workforce.
Considering Seals’s discussion of the Title V program in South Carolina, the other speakers were asked about the utilization of that program in their states. Briscoe said California has a Title V program called the Comprehensive Perinatal Services Program. Initially, this program paid roughly $19 for a psychosocial visit and eligible practitioners included community health outreach workers. It was eventually discovered that the program was also eligible for state and federal WRAP funding, which would bring reimbursement up to $200 to $300 per visit. This enabled the coverage of community health outreach worker care using Title V triggers. Perrin said that efforts have been more limited in Massachusetts—they have had more difficulty in getting the Medicaid team to think broadly about cross-sector strategies. Briggs commented that this highlights how different states are going to need different strategies, and stakeholders should consider the resources and strengths of their specific state.
Next, the speakers responded to a question about the role of community-based organizations in youth mental health programs. Margolis provided an example of the Solid Start Initiative at San Francisco General Hospital, where physicians partner with a community-based organization called Homeless Prenatal Services to bring in community health workers to provide prenatal care for families. She said that community partners are essential to help coordinate care and provide case management when there is such a high volume of patients. Briggs commented that this care coordination is more than just updating phone numbers and addresses—it also involves holding conversations with families about their experiences around social determinants of health, and thinking about interventions that might be necessary to support early childhood development. Mjartan added the “flow of funds really matter.” In South Carolina, she explained, they could have sent funds directly from First Steps to clinics. However, she noted, doing so would have skipped over the network of community-based nonprofit providers, which would have removed those providers—and their local knowledge—from the coordinated care structure.
To conclude, the panelists were asked to reflect on the importance of bringing different stakeholders to the table to make progress in their states. Perrin shared that a broad coalition of people in the state who are invested in children and families—including family members themselves—was critical in Massachusetts. He added that a shared set of principles guided their progress, and the coalition’s ability to advocate successfully led to a change in Medicaid policy. Briscoe commented that society in general cares about the well-being of children, which can make it easier to build partnerships in this work. However, he added, the current financial incentives for MCOs are misaligned for children. Thus, stakeholders should work with MCOs to find a new financing strategy that better supports children.
DISCLAIMER This Proceedings of a Workshop—in Brief was prepared by ERIN FOX as a factual summary of what occurred at the workshop. The statements made are those of the rapporteur or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.
REVIEWERS To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by MARSHALL L. LAND, JR., University of Vermont. We also thank staff member LAURA BLASI for reading and providing helpful comments on this manuscript. KIRSTEN SAMPSON SNYDER, National Academies of Sciences, Engineering, and Medicine, served as the review coordinator.
Workshop planning committee members are RAHIL BRIGGS, ZERO TO THREE; LAURA KAVANAGH, Health Resources and Services Administration; CHERYL POLK, Safe & Sound; LARA ROBINSON, Centers for Disease Control and Prevention; DEBORAH WALKER, Global Alliance for Behavioral Health and Social Justice; and DAVID WILLIS, Center for the Study of Social Policy.
SPONSORS This workshop was supported by contracts between the National Academy of Sciences and the American Board of Pediatrics (unnumbered award); the Centers for Disease Control and Prevention (200-2011-38807, TO #69); and the Health Resources and Services Administration of the U.S. Department of Health and Human Services (HHSH2502015 00001I/5R60219F34017). Additional support came from the American Academy of Pediatrics, Chan Zuckerberg Initiative, Children’s Hospital Association, Family Voices, Global Alliance for Behavioral Health and Social Justice, Society for Child and Family Policy and Practice, Society of Clinical Child and Adolescent Psychology, Well Being Trust, and ZERO TO THREE. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2022. Responding to the Current Youth Mental Health Crisis and Preventing the Next One: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. https://doi.org/10.17226/26669.
For additional information regarding the workshop, visit: https://www.nationalacademies.org/our-work/responding-to-the-current-youth-mental-health-crisis-and-preventing-the-next-one-a-virtual-workshop.
Division of Behavioral and Social Sciences and Education
Copyright 2022 by the National Academy of Sciences. All rights reserved.