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In the wake of the COVID-19 pandemic, the American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, and Children’s Hospital Association declared a national emergency in child and adolescent mental health. Additionally, the U.S. Surgeon General issued an advisory highlighting increased prevalence of mental health challenges in youth, impacts of the COVID-19 pandemic, and recommendations to address this crisis.
The pandemic required youth to isolate from peers and community supports, navigate remote learning environments, and cope with grief and loss; some 140,000 children in the United States experienced the death of a caregiver due to COVID-19.1 Virtually every system that supports children was affected. Whereas schools have historically been a main provider of child and adolescent mental health services, delivery of many school-based mental health programs was disrupted by school closures and staffing challenges. Subgroups of children (for example, those with intellectual and developmental disabilities) were particularly affected by these disruptions to daily life, and their use of emergency services increased.2 Surges in psychiatric emergency department visits among children led to increased boarding, reflecting unleveraged opportunities for early intervention. Families faced changes in child care, economic uncertainty, educational responsibilities, and increased rates of domestic violence.3 Communities of color were disproportionately affected in every way, from disease mortality to learning loss and increased school dropout rates.
To address gaps in the system, we must leverage school-based mental health programs, bolster access to and support of primary care providers, and embrace new, innovative models.
School-based mental health programs
Schools may be an ideal setting for universal mental health screening and opportunities for training, leadership, and whole school interventions. There is promising evidence that school-based interventions can decrease the incidence of suicide attempts and increase help-seeking behavior in students.4 There has long been interest in mental health screening in schools, though it has not been widely implemented given the significant resources required to both facilitate screening and effectively serve students who need additional support. Mobile apps may be one solution to scalability of both screening and interventions, but these initiatives should only be implemented within a stakeholder-engaged, family-centered multi-tiered model of behavioral support.
Other school-based initiatives include providing advice and training to teachers and school counselors and increasing access to specialized mental health professionals, including school psychologists, social workers, nurses, and behavior support workers, as well as community-based mental health providers. The 2021 American Rescue Plan Act included $170 billion for school funding, which many schools used to hire mental health workers. The Student Mental Health Helpline Act, if passed, will create helplines to support teachers as they help students address mental health issues.5 Educators can be trained to identify mental health needs, addressing mild symptoms themselves and referring students requiring more specialized services. Specific training programs for educators include Classroom Well-Being Information and Strategies for Educators (WISE), Youth Mental Health First Aid, and other resources funded by the U.S. Department of Health and Human Services. In addition to educators, other non–mental health professions interfacing with youth, including other youth, parents, clergy, coaches, and other community members, can be empowered with additional behavioral health knowledge and skills.
Increasing capacity in primary care
A number of programs are designed to improve knowledge and skills in children’s mental health among primary care providers, such as pediatricians. In Project ECHO, a “hub” of specialists, typically at an academic medical center, provides didactic lectures and case presentations for primary care “spokes” using teleconferencing.6 The REACH Institute uses interactive group learning followed by ongoing coaching and case-based training.
Collaborative care models known as Child Psychiatry Access Programs (CPAPs) engage child and adolescent psychiatrists to support primary care management of psychiatric disorders. Consultations may be direct or indirect, and involve technology or in-person care. Available in most states, these models increase access to mental health care, expand the capacity of the existing workforce, and decrease stigma and inconvenience for patients. Collaborative care models have been shown to lead to improved patient and family satisfaction, reduced utilization of emergency room and inpatient hospitalizations, and improved clinical outcomes. Off-site integrated care models may additionally serve larger and more geographically dispersed populations, minimize changes to existing infrastructure, reduce travel costs for clinicians, and decrease isolation of specialists. These programs are feasible, desirable, and sustainable. There is currently no cost to patients for their primary care providers’ participation in these models, as they are supported by the state, local, or insurance payer sources in addition to federal funding. Financially sustainable models are essential to ensure equitable access to these services in the future.
New service models
For adolescents and young adults, integrated youth service hubs such as those that have emerged in Australia, the United Kingdom, Canada, and more recently in the United States may be particularly appealing. These hubs emphasize rapid access to care and early intervention, youth and family engagement, youth-friendly settings and services, evidence-informed approaches, and partnerships and collaboration.7 In addition to mental health, these “one-stop shops” offer physical health, vocational supports, and case management to support basic needs. They address a particular system gap by providing services for transition-age youth rather than cutting off at age 18, as many children’s mental health services do.
Emerging solutions to the high utilization of emergency departments for pediatric mental health needs include utilization of pediatric Crisis Stabilization Units (CSUs). CSUs are community-based, short-term outpatient units that provide immediate care to children and families experiencing a mental health crisis. The goal of CSUs is to quickly stabilize the individual – often within 72 hours – and refer that individual to available community resources. This model may also reduce police involvement in mental health crises, which may be particularly important for racialized populations.
Conclusion
The thoughtful implementation and stable funding of evidence-based models can help schools, the health care system, and communities more effectively support children’s mental health in the post–COVID-19 pandemic era. Only with sufficient investments in the mental health system and other systems designed to support children and families, as well as careful consideration of unintended consequences on equity-deserving populations, will we see an end to this crisis.
Dr. Richards is assistant clinical professor in the department of psychiatry and biobehavioral sciences; program director of the child and adolescent psychiatry fellowship; and associate medical director of the perinatal program at the University of California, Los Angeles, Semel Institute for Neuroscience and Human Behavior.
References
1. Hillis SD et al. COVID-19–Associated orphanhood and caregiver death in the United States. Pediatrics. 2021;148:e2021053760.
2. Edgcomb JB et al. Mental health‐related emergency department visits among children during the early COVID‐19 pandemic. Psychiatr Res Clin Pract. 2022;4:4-11.
3. Pereda N, Díaz-Faes DA. Family violence against children in the wake of COVID-19 pandemic: A review of current perspectives and risk factors. Child and Adolescent Psychiatry and Mental Health. 2020;4:40.
4. Gijzen MWM et al. Effectiveness of school-based preventive programs in suicidal thoughts and behaviors: A meta-analysis. Journal of Affective Disorders. 2022;298:408-420.
5. Newman M: H.R.5235 – 117th Congress (2021-2022): Student Mental Health Helpline Act of 2021 [Internet] 2021; [cited 2023 Jan 11] Available from: http://www.congress.gov.
6. Raney L et al. Digitally driven integrated primary care and behavioral health: How technology can expand access to effective treatment. Curr Psychiatry Rep. 2017;19:86.
7. Settipani CA et al. Key attributes of integrated community-based youth service hubs for mental health: A scoping review. Int J Ment Health Syst. 2019;13:52.
In the wake of the COVID-19 pandemic, the American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, and Children’s Hospital Association declared a national emergency in child and adolescent mental health. Additionally, the U.S. Surgeon General issued an advisory highlighting increased prevalence of mental health challenges in youth, impacts of the COVID-19 pandemic, and recommendations to address this crisis.
The pandemic required youth to isolate from peers and community supports, navigate remote learning environments, and cope with grief and loss; some 140,000 children in the United States experienced the death of a caregiver due to COVID-19.1 Virtually every system that supports children was affected. Whereas schools have historically been a main provider of child and adolescent mental health services, delivery of many school-based mental health programs was disrupted by school closures and staffing challenges. Subgroups of children (for example, those with intellectual and developmental disabilities) were particularly affected by these disruptions to daily life, and their use of emergency services increased.2 Surges in psychiatric emergency department visits among children led to increased boarding, reflecting unleveraged opportunities for early intervention. Families faced changes in child care, economic uncertainty, educational responsibilities, and increased rates of domestic violence.3 Communities of color were disproportionately affected in every way, from disease mortality to learning loss and increased school dropout rates.
To address gaps in the system, we must leverage school-based mental health programs, bolster access to and support of primary care providers, and embrace new, innovative models.
School-based mental health programs
Schools may be an ideal setting for universal mental health screening and opportunities for training, leadership, and whole school interventions. There is promising evidence that school-based interventions can decrease the incidence of suicide attempts and increase help-seeking behavior in students.4 There has long been interest in mental health screening in schools, though it has not been widely implemented given the significant resources required to both facilitate screening and effectively serve students who need additional support. Mobile apps may be one solution to scalability of both screening and interventions, but these initiatives should only be implemented within a stakeholder-engaged, family-centered multi-tiered model of behavioral support.
Other school-based initiatives include providing advice and training to teachers and school counselors and increasing access to specialized mental health professionals, including school psychologists, social workers, nurses, and behavior support workers, as well as community-based mental health providers. The 2021 American Rescue Plan Act included $170 billion for school funding, which many schools used to hire mental health workers. The Student Mental Health Helpline Act, if passed, will create helplines to support teachers as they help students address mental health issues.5 Educators can be trained to identify mental health needs, addressing mild symptoms themselves and referring students requiring more specialized services. Specific training programs for educators include Classroom Well-Being Information and Strategies for Educators (WISE), Youth Mental Health First Aid, and other resources funded by the U.S. Department of Health and Human Services. In addition to educators, other non–mental health professions interfacing with youth, including other youth, parents, clergy, coaches, and other community members, can be empowered with additional behavioral health knowledge and skills.
Increasing capacity in primary care
A number of programs are designed to improve knowledge and skills in children’s mental health among primary care providers, such as pediatricians. In Project ECHO, a “hub” of specialists, typically at an academic medical center, provides didactic lectures and case presentations for primary care “spokes” using teleconferencing.6 The REACH Institute uses interactive group learning followed by ongoing coaching and case-based training.
Collaborative care models known as Child Psychiatry Access Programs (CPAPs) engage child and adolescent psychiatrists to support primary care management of psychiatric disorders. Consultations may be direct or indirect, and involve technology or in-person care. Available in most states, these models increase access to mental health care, expand the capacity of the existing workforce, and decrease stigma and inconvenience for patients. Collaborative care models have been shown to lead to improved patient and family satisfaction, reduced utilization of emergency room and inpatient hospitalizations, and improved clinical outcomes. Off-site integrated care models may additionally serve larger and more geographically dispersed populations, minimize changes to existing infrastructure, reduce travel costs for clinicians, and decrease isolation of specialists. These programs are feasible, desirable, and sustainable. There is currently no cost to patients for their primary care providers’ participation in these models, as they are supported by the state, local, or insurance payer sources in addition to federal funding. Financially sustainable models are essential to ensure equitable access to these services in the future.
New service models
For adolescents and young adults, integrated youth service hubs such as those that have emerged in Australia, the United Kingdom, Canada, and more recently in the United States may be particularly appealing. These hubs emphasize rapid access to care and early intervention, youth and family engagement, youth-friendly settings and services, evidence-informed approaches, and partnerships and collaboration.7 In addition to mental health, these “one-stop shops” offer physical health, vocational supports, and case management to support basic needs. They address a particular system gap by providing services for transition-age youth rather than cutting off at age 18, as many children’s mental health services do.
Emerging solutions to the high utilization of emergency departments for pediatric mental health needs include utilization of pediatric Crisis Stabilization Units (CSUs). CSUs are community-based, short-term outpatient units that provide immediate care to children and families experiencing a mental health crisis. The goal of CSUs is to quickly stabilize the individual – often within 72 hours – and refer that individual to available community resources. This model may also reduce police involvement in mental health crises, which may be particularly important for racialized populations.
Conclusion
The thoughtful implementation and stable funding of evidence-based models can help schools, the health care system, and communities more effectively support children’s mental health in the post–COVID-19 pandemic era. Only with sufficient investments in the mental health system and other systems designed to support children and families, as well as careful consideration of unintended consequences on equity-deserving populations, will we see an end to this crisis.
Dr. Richards is assistant clinical professor in the department of psychiatry and biobehavioral sciences; program director of the child and adolescent psychiatry fellowship; and associate medical director of the perinatal program at the University of California, Los Angeles, Semel Institute for Neuroscience and Human Behavior.
References
1. Hillis SD et al. COVID-19–Associated orphanhood and caregiver death in the United States. Pediatrics. 2021;148:e2021053760.
2. Edgcomb JB et al. Mental health‐related emergency department visits among children during the early COVID‐19 pandemic. Psychiatr Res Clin Pract. 2022;4:4-11.
3. Pereda N, Díaz-Faes DA. Family violence against children in the wake of COVID-19 pandemic: A review of current perspectives and risk factors. Child and Adolescent Psychiatry and Mental Health. 2020;4:40.
4. Gijzen MWM et al. Effectiveness of school-based preventive programs in suicidal thoughts and behaviors: A meta-analysis. Journal of Affective Disorders. 2022;298:408-420.
5. Newman M: H.R.5235 – 117th Congress (2021-2022): Student Mental Health Helpline Act of 2021 [Internet] 2021; [cited 2023 Jan 11] Available from: http://www.congress.gov.
6. Raney L et al. Digitally driven integrated primary care and behavioral health: How technology can expand access to effective treatment. Curr Psychiatry Rep. 2017;19:86.
7. Settipani CA et al. Key attributes of integrated community-based youth service hubs for mental health: A scoping review. Int J Ment Health Syst. 2019;13:52.
In the wake of the COVID-19 pandemic, the American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, and Children’s Hospital Association declared a national emergency in child and adolescent mental health. Additionally, the U.S. Surgeon General issued an advisory highlighting increased prevalence of mental health challenges in youth, impacts of the COVID-19 pandemic, and recommendations to address this crisis.
The pandemic required youth to isolate from peers and community supports, navigate remote learning environments, and cope with grief and loss; some 140,000 children in the United States experienced the death of a caregiver due to COVID-19.1 Virtually every system that supports children was affected. Whereas schools have historically been a main provider of child and adolescent mental health services, delivery of many school-based mental health programs was disrupted by school closures and staffing challenges. Subgroups of children (for example, those with intellectual and developmental disabilities) were particularly affected by these disruptions to daily life, and their use of emergency services increased.2 Surges in psychiatric emergency department visits among children led to increased boarding, reflecting unleveraged opportunities for early intervention. Families faced changes in child care, economic uncertainty, educational responsibilities, and increased rates of domestic violence.3 Communities of color were disproportionately affected in every way, from disease mortality to learning loss and increased school dropout rates.
To address gaps in the system, we must leverage school-based mental health programs, bolster access to and support of primary care providers, and embrace new, innovative models.
School-based mental health programs
Schools may be an ideal setting for universal mental health screening and opportunities for training, leadership, and whole school interventions. There is promising evidence that school-based interventions can decrease the incidence of suicide attempts and increase help-seeking behavior in students.4 There has long been interest in mental health screening in schools, though it has not been widely implemented given the significant resources required to both facilitate screening and effectively serve students who need additional support. Mobile apps may be one solution to scalability of both screening and interventions, but these initiatives should only be implemented within a stakeholder-engaged, family-centered multi-tiered model of behavioral support.
Other school-based initiatives include providing advice and training to teachers and school counselors and increasing access to specialized mental health professionals, including school psychologists, social workers, nurses, and behavior support workers, as well as community-based mental health providers. The 2021 American Rescue Plan Act included $170 billion for school funding, which many schools used to hire mental health workers. The Student Mental Health Helpline Act, if passed, will create helplines to support teachers as they help students address mental health issues.5 Educators can be trained to identify mental health needs, addressing mild symptoms themselves and referring students requiring more specialized services. Specific training programs for educators include Classroom Well-Being Information and Strategies for Educators (WISE), Youth Mental Health First Aid, and other resources funded by the U.S. Department of Health and Human Services. In addition to educators, other non–mental health professions interfacing with youth, including other youth, parents, clergy, coaches, and other community members, can be empowered with additional behavioral health knowledge and skills.
Increasing capacity in primary care
A number of programs are designed to improve knowledge and skills in children’s mental health among primary care providers, such as pediatricians. In Project ECHO, a “hub” of specialists, typically at an academic medical center, provides didactic lectures and case presentations for primary care “spokes” using teleconferencing.6 The REACH Institute uses interactive group learning followed by ongoing coaching and case-based training.
Collaborative care models known as Child Psychiatry Access Programs (CPAPs) engage child and adolescent psychiatrists to support primary care management of psychiatric disorders. Consultations may be direct or indirect, and involve technology or in-person care. Available in most states, these models increase access to mental health care, expand the capacity of the existing workforce, and decrease stigma and inconvenience for patients. Collaborative care models have been shown to lead to improved patient and family satisfaction, reduced utilization of emergency room and inpatient hospitalizations, and improved clinical outcomes. Off-site integrated care models may additionally serve larger and more geographically dispersed populations, minimize changes to existing infrastructure, reduce travel costs for clinicians, and decrease isolation of specialists. These programs are feasible, desirable, and sustainable. There is currently no cost to patients for their primary care providers’ participation in these models, as they are supported by the state, local, or insurance payer sources in addition to federal funding. Financially sustainable models are essential to ensure equitable access to these services in the future.
New service models
For adolescents and young adults, integrated youth service hubs such as those that have emerged in Australia, the United Kingdom, Canada, and more recently in the United States may be particularly appealing. These hubs emphasize rapid access to care and early intervention, youth and family engagement, youth-friendly settings and services, evidence-informed approaches, and partnerships and collaboration.7 In addition to mental health, these “one-stop shops” offer physical health, vocational supports, and case management to support basic needs. They address a particular system gap by providing services for transition-age youth rather than cutting off at age 18, as many children’s mental health services do.
Emerging solutions to the high utilization of emergency departments for pediatric mental health needs include utilization of pediatric Crisis Stabilization Units (CSUs). CSUs are community-based, short-term outpatient units that provide immediate care to children and families experiencing a mental health crisis. The goal of CSUs is to quickly stabilize the individual – often within 72 hours – and refer that individual to available community resources. This model may also reduce police involvement in mental health crises, which may be particularly important for racialized populations.
Conclusion
The thoughtful implementation and stable funding of evidence-based models can help schools, the health care system, and communities more effectively support children’s mental health in the post–COVID-19 pandemic era. Only with sufficient investments in the mental health system and other systems designed to support children and families, as well as careful consideration of unintended consequences on equity-deserving populations, will we see an end to this crisis.
Dr. Richards is assistant clinical professor in the department of psychiatry and biobehavioral sciences; program director of the child and adolescent psychiatry fellowship; and associate medical director of the perinatal program at the University of California, Los Angeles, Semel Institute for Neuroscience and Human Behavior.
References
1. Hillis SD et al. COVID-19–Associated orphanhood and caregiver death in the United States. Pediatrics. 2021;148:e2021053760.
2. Edgcomb JB et al. Mental health‐related emergency department visits among children during the early COVID‐19 pandemic. Psychiatr Res Clin Pract. 2022;4:4-11.
3. Pereda N, Díaz-Faes DA. Family violence against children in the wake of COVID-19 pandemic: A review of current perspectives and risk factors. Child and Adolescent Psychiatry and Mental Health. 2020;4:40.
4. Gijzen MWM et al. Effectiveness of school-based preventive programs in suicidal thoughts and behaviors: A meta-analysis. Journal of Affective Disorders. 2022;298:408-420.
5. Newman M: H.R.5235 – 117th Congress (2021-2022): Student Mental Health Helpline Act of 2021 [Internet] 2021; [cited 2023 Jan 11] Available from: http://www.congress.gov.
6. Raney L et al. Digitally driven integrated primary care and behavioral health: How technology can expand access to effective treatment. Curr Psychiatry Rep. 2017;19:86.
7. Settipani CA et al. Key attributes of integrated community-based youth service hubs for mental health: A scoping review. Int J Ment Health Syst. 2019;13:52.