Remodeling Broken Systems: Addressing the National Emergency in Child and Adolescent Mental Health

Schools may be an ideal setting for universal mental health screening and intervention. Promising evidence exists that school-based interventions can decrease the incidence of suicide attempts and increase help-seeking behavior among students (8). The number of school-based mental health models and implementation supports is growing, with dozens of programs meeting the threshold for inclusion in the Collaborative for Academic, Social, and Emotional Learning’s guide to effective social and emotional learning programs (https://pg.casel.org/review-programs). In addition, the positive behavioral interventions and supports framework is a federally funded, three-tiered approach to social, emotional, and behavioral support: tier 1 provides universal supports, tier 2 supports students at risk for serious problem behaviors, and tier 3 provides intensive, individualized support (https://www.pbis.org). Although interest in mental health screening in schools has been present for many years, widespread implementation of such screening has not been achieved, given the significant resources required to both facilitate screening and effectively serve students who need additional support and in light of other concerns (e.g., ethics, consent). Mobile apps may be one solution to the problem of scalability of both screenings and interventions, but these initiatives should be implemented only within a stakeholder-engaged, family-centered, and multitiered model of behavioral support.

Other school-based initiatives include providing advice and training to teachers and school counselors and increasing access to mental health specialists, including school-based psychologists, social workers, nurses, and behavioral support workers as well as community-based mental health providers. The American Rescue Plan Act of 2021 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 assist students with addressing their mental health issues (9). Educators can be trained to identify mental health needs, address mild symptoms themselves, and refer students to more specialized services when needed. Specific training programs for educators include Classroom Well-Being Information and Strategies for Educators, Youth Mental Health First Aid, and other resources funded by the U.S. Department of Health and Human Services. In addition to educators, other people who are not mental health professionals but who interface with youths, including other youths, parents, clergy, coaches, and other community members, can be empowered with additional behavioral health knowledge and skills.

A number of programs are designed to improve knowledge of and skills in children’s mental health among primary care providers. For example, Project Extension for Community Healthcare Outcomes uses a “hub” of specialists, typically at an academic medical center, to provide didactic lectures and case presentations for primary care “spokes” via teleconferencing (10), and the REACH Institute uses interactive group learning, followed by ongoing coaching and case-based training.

Collaborative care models known as child psychiatry access programs engage child and adolescent psychiatrists to support primary care management of psychiatric disorders. Consultations may be direct or indirect and may involve telepsychiatry or in-person care. These models are available in most states and 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 departments and fewer inpatient hospitalizations, and improved clinical outcomes. Off-site integrated care models (vs. colocated care) may serve larger and more geographically dispersed populations, minimize changes to existing infrastructure, reduce travel costs for clinicians, and decrease isolation of specialists (11). These programs are feasible, desirable, and sustainable. Currently, participation of patients’ primary care providers in these models is free, because these models are supported by state, local, or insurance payers in addition to federal funding. Financially sustainable models are essential to ensure equitable access to these services in the future.

Although virtual care facilitated the continued delivery of mental health services throughout the pandemic and is an essential component of most collaborative care models, its use risks exacerbating disparities in access; for example, Black children are less likely to be scheduled for telehealth visits compared with White children (12). Ensuring access to technology and digital literacy among target users and addressing biases among providers and administrators are critical to avoid widening gaps in mental health service utilization. Community hubs, including within school districts, that offer use of the necessary technology (a reliable Internet connection and appropriate devices) and technical support represent one solution to the provision of equitable access to virtual care. Increased broadband access, particularly in rural areas, is essential to leveraging the full potential of virtual care. The American Psychiatric Association and the American Telemedicine Association have published a guide to best practices in synchronous videoconferencing-based telepsychiatry to support the provision of high-quality care (13).

For adolescents and young adults, integrated youth services hubs such as those that have emerged in Australia, the United Kingdom, Canada, and (more recently) 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 (14). In addition to mental health services, these “one-stop shops” offer general medical health care, vocational supports, and case management to support basic needs. They address a particular mental health system gap by providing services for transition-age youths rather than suspending care for people >18 years old, as many children’s mental health services do.

Emerging solutions to the rise in children’s mental health–related emergency department visits include mobile and community crisis response teams and the use of pediatric crisis stabilization units, which are community-based, short-term outpatient units that provide immediate care to children experiencing a mental health crisis and their families. The goal of crisis stabilization units is to quickly stabilize an individual—often within 72 hours—and refer that individual to available community resources (15). This model may also reduce police involvement in mental health crises, which may be particularly important for racially minoritized populations. Rigorous evaluations of this model for youths are needed.