A National Agenda for Children’s Mental Health

While many challenges existed for children’s mental health prior to the pandemic, COVID-19 has exacerbated shortfalls and inequities while increasing the need for services. Thus, the challenges we describe here are relevant to specific conditions related to the pandemic but will remain broadly relevant to children’s mental health after the pandemic fades.

Current approaches to children’s mental health tend to focus on treatment, with less attention given to universal strategies that promote mental wellness and prevent mental illness.

While much of the nation’s mental health infrastructure is managed at the state level, few states use a population approach to promote, prevent, identify, and treat children’s mental health. Additionally, most states lack a standalone children’s mental health agency, resulting in competition with adult programs for scarce resources. Services are often delivered in siloes, with little coordination across the various service sectors that interact with children and families, including education, child care, health care, housing, child welfare, and law enforcement. This lack of coordination has impeded efforts to respond quickly, flexibly, and comprehensively to children’s mental health needs during the pandemic. Better multi-sector planning is necessary to achieve population-level mental health at the federal, state, and community levels.

Current funding is insufficient to address children’s mental health needs during and after the pandemic.

Children’s mental health was inadequately funded even prior to the pandemic, but the problem will grow worse as COVID-19 continues to impact the psychological well-being of children and their families. Increased investments in children’s mental health are urgently needed, particularly for promotion and prevention approaches, which are more effective in the long run and offer a better return on investment. Support for programs that address family well-being by meeting their basic needs for education, child care, health care, housing, and economic stability—particularly in communities with concentrated poverty—are an essential part of comprehensive efforts to promote mental wellness and prevent and treat mental illness. Federal pandemic relief for states, mental health providers, and schools have some potential to buffer the mental health effects of the pandemic in the short term.

There is a serious shortage of children’s mental health providers.

Prior to the pandemic, there were already too few mental health providers to meet the needs of children, youth, and parents—especially in rural communities. The rise in unmet mental health needs caused by the pandemic will likely worsen the workforce shortage. Further compounding the problem, many mental health providers are themselves experiencing heightened stress and secondary traumatic stress, which are strongly associated with high rates of provider turnover (estimated at 30% to 60% of the workforce annually prior to the pandemic).

Communities with concentrated poverty and those that are geographically isolated face significant barriers to accessing high-quality mental health supports.

Many of the challenges experienced by children and families living in poverty have been exacerbated by the pandemic. Children and youth living in poverty prior to the pandemic were already much less likely to access mental health services than their more economically advantaged peers, due in part to structural barriers such as clinic hours that do not accommodate caregivers who work low-wage jobs. Rural children and youth also faced significant barriers to accessing mental health care due to provider shortages and a general lack of mental health infrastructure in many rural communities, in addition to other barriers such as transportation issues and challenges related to high rates of poverty. In many rural communities, these preexisting challenges have been compounded by the pandemic, which has brought increased isolation due to social distancing and economic hardship.

Systemic discrimination and structural barriers make it difficult for Black, Indigenous, and People of Color (BIPOC) and for lesbian, gay, bisexual, transgender, and queer and/or questioning (LGBTQ) children and youth to have equal access to high-quality services.

Access to mental health supports have historically been linked to race and ethnicity. For example, schools serving primarily Black students are much more likely to have more security staff than mental health staff relative to schools serving primarily White students. Racial disparities also exist in the processes by which BIPOC are linked to mental health treatment, with Latinos much more likely to be referred by the criminal justice system than White children and youth, and Black children and youth more likely to be referred by social services or criminal justice systems. These differences are reflected in documented racial biases in juvenile justice and child welfare. Patterns of discrimination have led to widespread racial and ethnic inequities in mental health care, and have been exacerbated by the pandemic. Disparities in accessing care have also been documented among LGBTQ youth.

These inequities have been amplified by disproportionate impacts of the pandemic on BIPOC and LGBTQ children and youth. While a large and growing number of evidence-based practices are available for children’s mental health, intervention outcomes for BIPOC are often not as positive as those for White people, due in part to a dearth of interventions developed or adapted for BIPOC and LGBTQ families. Thus, a focus on equity must be integrated into all efforts to support children’s mental health.

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Principles for a National Children’s Mental Health Agenda

A national children’s mental health agenda that successfully promotes children’ mental health must take a population health approach. At its core, a population approach assumes that an exclusive focus on individual well-being is not sufficient, and that a comprehensive approach that uses multiple levels of intervention—at the individual, family, community, and broader societal levels—is critical to building a mental health system that addresses social determinants of health (i.e., the social, economic, and physical conditions that affect individual health and well-being) and existing systemic shortfalls and inequities. A population health approach requires attention to four broad areas of mental health services: Promotion—an intervention approach to maximize mental health in a population prior to the emergence of mental illness; prevention—an intervention approach to minimize mental health problems in a population, including children at high risk for mental illness; early intervention—an intervention approach to address mental health concerns as early in life as possible, when children begin to show early signs or symptoms of mental illness and before serious mental health problems develop; and treatment—a targeted intervention approach to address an identified mental health disorder.

The following principles should guide the implementation of the agenda:

• Mental health systems should be equitable and should seek to eliminate barriers that have reduced access to high-quality services for all children, youth, and families—especially for groups that experience discrimination and marginalization, including BIPOC and LGBTQ communities.
• Children’s mental health is inextricably intertwined with their physical health and overall well-being.
• Children’s mental health is a product of interactions among individual, family, and broader environmental characteristics over time, so multi-sector, multigenerational approaches are essential.
• Mental health promotion and prevention efforts should be a high priority, as should early intervention to help children follow positive developmental trajectories. But high-quality interventions can be effective at any life stage.
• Mental health supports are most effective when the communities that are most affected are engaged in decision-making roles when planning, implementing, and evaluating mental health interventions for children, youth, and their parents.
• Mental health supports for children, youth, and their families should be comprehensive (i.e., address the wide range of influences on mental health, consistent with a social determinants of health approach) and coordinated (i.e., community service providers work collaboratively and across fields of practice).

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Five strategies to promote children’s mental health during and after the COVID-19 pandemic

The following five strategies provide federal, tribal, state, and local mental health policymakers and leaders with the blueprint needed to establish and maintain a national children’s mental health system that promotes children’s mental health broadly. The strategies also facilitate supporting the social, emotional, and behavioral needs of children, youth, and families affected by COVID-19.

State, tribal, and local governments can play unique and pivotal roles in ensuring that mental health supports for children, youth, and their families are comprehensive, coordinated, inclusive, and non-duplicative. Tribal governments face unique challenges related to coordination with neighboring states given complicated relationships between state and tribal governments and barriers to sharing health data across jurisdictions. However, some tribal communities have been innovators in addressing mental health during the pandemic by focusing on cultural values and coordinating with multiple partners, including the Indian Health Service, the Federal Emergency Management Agency, and the Centers for Disease Control and Prevention.

Efforts to promote children’s mental health are often spread across multiple agencies that operate independently of one another, leading to fractured efforts that have resulted in the education, child welfare, and juvenile justice sectors serving as a de facto mental health system for children and youth. Public agencies that serve children and families can also act as important hubs for coordinating efforts across multiple sectors (e.g., mental health, physical health, child welfare, education, child care; home visiting, housing) and service modalities (e.g., infant and early childhood mental health consultation; screening and referral; universal, selective, and indicated preventive interventions; evidence-based treatment). Communities and states must work together to develop effective systems for coordinating mental health promotion, identification (mental health and trauma screening and assessment), early intervention, treatment, and follow-up. For example, the Georgia Health Policy Center recently developed a framework for aligning three critical sectors—health care, public health, and social services—with potential for application to current efforts to address the pandemic. Programs have also demonstrated their ability to effectively integrate a focus on mental health into ongoing services; for example, HealthySteps, a partnership between pediatricians and child development specialists, has shown positive mental health and parenting outcomes.

Coordination is also critical in addressing the role of public systems in eliminating inequities in mental health access based on race and ethnicity—such as the disproportionate use of preschool expulsion with young Black boys compared to their White counterparts. A wide range of community entities must work together to address underlying mental health issues that lead to behavior problems. These entities may include child care, education, and mental health agencies; infant and early childhood mental health consultants; substance abuse recovery programs; child welfare; schools; domestic violence shelters; and public support programs that help families meet their basic needs. Several states have recently taken steps to address racism as a broad public health concern through public-private partnerships (e.g., education and business) to promote racial equity and advance awareness of racism as a public health crisis. Integrating children’s mental health into such efforts could be an important strategy in addressing racial inequities in children’s mental health.

Looming state budget cuts pose a significant threat to mental health supports. States, tribes and mental health providers have received short-term assistance through federal recovery funds such at the CARES Act and the COVID-19 Response and Relief Supplemental Appropriations Act, but more must be done to ensure that equitable investments are made in mental health promotion and prevention—and not just a focus treatment after mental health challenges become serious disorders. For example, the federal government should fully fund the Indian Health Service (IHS) to meet its trust obligation and honor treaty agreements. IHS has been underfunded for decades, resulting in longstanding health care crises that have been further exacerbated by the COVID-19 pandemic. In some instances, IHS is the sole service provider for tribal communities; therefore, full funding is necessary to sustain services and mitigate issues compounded by the coronavirus. Additional federal, state, and local investments are needed to address pandemic-related mental health issues, both during and after COVID-19. In July 2020, Sacramento County in California announced a $9.69 million investment in funding 35 prevention and early intervention programs, offering an example of the type of investments that will be needed to promote and sustain children’s mental health over time.

States can also leverage Medicaid as a sustainable source of funding for prevention, screening, early intervention, and treatment services. For example, since 2014, nearly a dozen states have amended their state Medicaid plans to allow for expanded reimbursement of school-based health services. Federal and state governments can request and implement Medicaid waivers and states can amend plans to expand access to mental health care. States should also address insurance payment rates for mental health services, which tend to be much lower than rates for primary care. For example, New Mexico addressed this issue in 2019 with a Medicaid provider rate increase for behavioral health. Lower reimbursement rates can result in a lack of mental health providers willing to accept insurance—including Medicaid. When providers don’t accept insurance, families must pay out-of-pocket, which is often not possible for families insured through Medicaid. This situation contributes to disparities in access to mental health for Black and Latino families, who are twice as likely as White families to be enrolled in Medicaid.

Federal, tribal, and state policymakers should support the development and maintenance of a cadre of well-trained professionals who can engage in evidence-based promotion, prevention, early intervention, and treatment of mental health problems in children, and who themselves reflect the diversity of the families they serve. The focus of training efforts should move beyond mental health professionals to also equip child care workers, educators, law enforcement, and other professionals who come in contact with children and youth with the knowledge and skills they need to support positive emotional and relationship skills among children and youth, and to help identify and refer children and youth who may need treatment.

The National Tribal Behavioral Health Agenda highlighted a number of challenges related to maintaining a well-trained workforce, including the critical need for culturally competent providers. States and communities can develop incentive programs for education and training (e.g., offering providers paid time to attend professional development opportunities; training multiple service sectors on working effectively with children, youth, and families—and each other—to promote the mental health of those whose mental health has been negatively impacted by the pandemic). They also can fund education and training for service providers across sectors on effective methods of service coordination to help children and families cope with the negative mental health impacts of the pandemic (e.g., mental health consultants, who can support early care and education programs; schools; Early Intervention [Individuals with Disabilities Act-Part C]; primary care).

Focal areas of education and professional development should be tailored to each professional’s role, but should always include mental health literacy trauma and mental health equity. For example, in Massachusetts, the Child Trauma Training Center trains a wide range of child-serving professionals—including educators and law enforcement—on identifying and screening for trauma-related symptoms. Nebraska has begun to address a workforce shortage by establishing a comprehensive initiative focused on recruitment, training, placement, and retention of mental health professionals. As part of its recruitment efforts, the Behavioral Health Education Center of Nebraska partnered with the Nebraska Department of Education to create a high school course on mental health.

In addition, training and education on equity and implicit bias across all sectors is vital to the development of a workforce equipped to deliver culturally relevant mental health supports to children and families. For example, an experimental study investigating the roles of race, class, and gender on behavioral health access found evidence of bias based on perceived class and race, with working class and Black individuals less likely to be given appointments than White and middle class individuals. Given the disproportionate health and economic impact of COVID-19 on Black, LatinX, and working class families, it is critical to address biases that restrict access to mental health supports. These efforts to address equity and bias should be informed directly by stakeholders from the specific racial and ethnic populations served.

Telehealth can improve access to high-quality mental health treatment services while allowing for social distancing, particularly in underserved and hard-to-reach communities. The federal Health Resources and Services Administration, or HRSA, distributed $15 million to support telehealth early in the pandemic, and the Centers for Medicaid and Medicare Services issued guidance for states looking to reduce barriers to telehealth billing. Many states increased flexibility for telehealth in response to the pandemic, although most changes will sunset when the public health emergency ends. Several states—such as Idaho and Colorado—have made their temporary changes permanent, including an expansion of allowable platforms and the removal of requirements for initial in-person sessions. Given that all 50 states introduced some degree of added flexibility in response to the pandemic, more states should determine whether any of their temporary changes should be made permanent.

Federal, tribal, state, and local governments and health care providers should invest in technology-based interventions that promote mental health and help connect children, youth, and their families with treatment. In addition to telehealth services, states, tribes, and localities should consider a wider array of technology-based approaches to increasing access to information and mental health services for children and youth. For example, a social marketing campaign to reduce stigma around mental health in California showed promise in increasing mental health service usage. A rigorous evaluation of My Teen, which texts mental health information to parents of adolescents, found increases in parents’ perceptions of their ability to address issues related to adolescent mental health. The Alaska Native Tribal Health Consortium serves as an example of successful adoption of telehealth services, meeting the needs of rural communities since 2001. A few states also offer digital platforms to link children and youth to evidence-based treatment, such as LINK-KID, a hotline in Massachusetts. To successfully leverage these strategies, policymakers and health care providers must address equity issues related to access to appropriate technology (e.g., telephones, tablets, computers, high speed internet).

Policymakers at all levels of government must recognize that poverty is one of the most salient risk factors for a host of negative outcomes, including mental health disorders. Economic research has shown that reducing poverty early in children’s lives can prevent a cascade of negative child outcomes through the promotion of healthy development in safe and stable family environments; this can ultimately reduce costs related to mental health treatment, dropout prevention, unemployment, and incarceration. BIPOC communities are disproportionately affected by financial insecurity and high COVID-19 infection rates. For example, American Indian/Alaska Native families are more likely to live in poverty than their White counterparts and bear a disproportionate burden of COVID-19 infections, likely due to historical trauma and racial inequities that adversely affect socioeconomic status and health.

States can use federal waivers and state plan amendments, loosen eligibility requirements, and implement administrative practices that expand public benefit programs that can promote children’s mental health and prevent future mental health problems. For example, providing essential supports for families—including school meals, Supplemental Nutrition Assistance Program (SNAP), housing assistance, the Earned Income Tax Credit, and Temporary Assistance for Needy Families (TANF)—can reduce economic hardship and related family stress. In addition, the federal government should fully fund universal two-generation programs that promote the social and emotional well-being of children and families with low incomes, such as Head Start and Early Head Start, which are currently able to serve less than 40 percent of eligible 3- and 4-year-olds and less than 5 percent of eligible infants and toddlers (under age 3), respectively. Recent efforts to temporarily expand access to public benefits during the pandemic—such as federal funding to states to increase low-income families’ access to SNAP and offering child nutrition waivers—should be examined by policymakers for their efficacy in supporting families and should be considered for extension beyond the current crisis.

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Conclusion

The pandemic offers child and youth stakeholders an unparalleled opportunity to reimagine and rebuild our country’s mental health system for children, youth, and their families. Raising awareness about this often invisible but powerful predictor of children’s well-being—their mental health—is an important first step. However, a profound shift toward universal mental health promotion, prevention, early intervention, and treatment will be needed to support the mental health of our youngest citizens. In doing so, our country will reap the benefits of productive, happy, and healthy citizens during and after COVID-19, and for generations to come.