Need for Long-term Strategies to Address Children’s Mental Health Underscored by COVID-19 Era

The last 2 years have drawn needed attention to mental health issues faced by children and youth.¹ The mental health consequences of inadequate socialization have featured prominently in the debate over in-person education. But the era of COVID-19 has shed light on other dimensions of children’s mental health, including crisis management and law enforcement, the role of schools as hubs for services, and the need to expand and coordinate services for children and youth. The US Surgeon General called the current situation “unprecedented” and pediatricians have declared a national mental health emergency.

Schools are affected by the mental health problems of their students. But as a recent report from the National Academies of Sciences, Engineering, and Medicine underscores, schools also affect the long-term mental health of many students.² School-linked services are valuable upstream settings for effective prevention strategies and as a broader hub for family-based services to support children’s mental health.

One reason for that is that prevention and early intervention is critical, and teachers and school nurses are well positioned to identify needs and facilitate connections with services. School-based health centers working with resources in the community enable behavioral and mental health professionals to work not only directly with students, but also to train and support teachers and help parents deal with the onset of conditions. Schools can be particularly effective when using a multitiered system of supports to match students with services. And with significant disparities in mental health status and care affecting young immigrants and households with racial and ethnic minority individuals, schools are often the most trusted institution (by parents as well as by children) for accessing services in a culturally responsive manner.

Financial resources for school centers and training for staff are tight for most districts, however, and many children and adolescents do not receive needed services. Fortunately, the school emergency relief fund in the Coronavirus Aid, Relief, and Economic Security Act (CARES) Act and American Rescue Plan Act (ARPA) is providing additional new funding for school mental health programs. Hopefully, this funding will pave the way for states and districts to expand school-based mental health services.

Mental health professionals serving children and youth are in short supply, with 1 in 5 children living in a county without a child psychiatrist. Addressing disparities also requires mental health professionals from more diverse racial and ethnic backgrounds.

It is important, as well, to expand the range of settings and professionals who can play a role in mental health services for children and youth. Primary care pediatricians typically are the first people parents approach with behavioral health concerns about their children. Even though they can give families advice and referrals before a child’s condition escalates, pediatricians often struggle with how to ensure the necessary services are provided. These needs make it important to expand integrated approaches such as the collaborative care model. The American Academy of Child and Adolescent Psychiatry has provided a guide to support collaboration between primary care pediatricians and behavioral health specialists. Better training to help school nurses and teachers to identify behavioral patterns of concern at an early stage would also ease pressure on mental health specialists.

During last 2 years, many tragic cases have occurred of law enforcement officers exercising sometimes lethal force when called to a mental health crisis rather than mental health experts handling the situation, including a Utah case of a 13-year-old child with autism shot by police after his mother dialed 911. In addition, children as well as adults with severe mental health conditions commonly become entangled in the justice system and many end up incarcerated while awaiting trial. More than 48 000 juveniles are confined in this way, and many have mental health conditions.

One of the strategies needed to address this situation is to expand the use of crisis response teams. These teams consist of mental health professionals and other social service specialists. They are designed to be the first responders during a mental health crisis, typically with law enforcement available only as backup if the situation becomes potentially violent. The aim is to deescalate the situation and link the individual, whether an adult or a youth, with appropriate services. Awareness of these response teams is growing, thanks to innovative local initiatives and federal funding support through ARPA, as well as grants from the federal Department of Justice. But this progress also underscores the need for follow-up services in a continuum of care, without which crisis intervention is only temporary.

A related approach is to build a new “988” emergency call system, similar to 911, for behavioral health crises. This means distraught parents or fearful neighbors and teachers will have an alternative to calling the police. Federal funding in 2020 provided grants to states to construct the system, and a nationwide 988 system is scheduled to launch in July 2022 (though most states are not likely to meet that deadline). In addition to the technology requirements, training of dispatchers and public education will be critical; a successful mental health crisis line will require experienced and well-trained staff—a big challenge for states.

Jail diversion programs³ are intended to reduce the number of children and adults who are incarcerated when mental health is a factor in their case; the aim is to require the person to receive mental health services rather than jail or prison time, in the hope they will not be rearrested. These programs are widespread in the US and other countries and the federal Department of Justice provides grants to foster diversion strategies. For both the general offender population and for juvenile offenders receiving mental health services, diversion programs often show success.

Unfortunately, poor coordination and inadequate behavioral health resources—especially for those with a low income and racial and ethnic minority individuals—undercut many diversion programs. Far too often, after public defenders successfully negotiate diversion services for arrested children and adolescents, few if any appropriate services are actually delivered and they are rearrested. Until there is greater federal and state commitment to diversion programs, children and young adults in need of mental health services will continue to end up inappropriately behind bars.

The era of COVID-19 is forcing the US to look differently and urgently at the mental health needs of young people—who face lifetime damage if their conditions are not addressed. Fortunately, new funding for efforts like the Substance Abuse and Mental Health Services Administration’s Project AWARE (Advancing Wellness and Resilience in Education) and better federal interagency collaboration will help, as will the efforts of nonprofit groups like the Child Mind Institute and the National Alliance on Mental Illness. A silver lining of the COVID-19 pandemic may be a much stronger focus on the mental health of children and youth.

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Butler SM. JAMA Health Forum.

Corresponding Author: Stuart M. Butler, PhD, Brookings Institution, 1775 Massachusetts Ave NW, Washington, DC 20036 (smbutler@brookings.edu).

Conflict of Interest Disclosures: Dr Butler reported receiving grants from the Robert Wood Johnson Foundation.