Kids face a mental health crisis. Here are the solutions.

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The gun bill is really a children’s mental health bill

After years of urgent warnings and little progress, mental health help for U.S. kids may be on the way — given new momentum by efforts to curb surging rates of gun violence.

Mental health advocates decry linking mass shootings and mental illness, a message that emerges routinely after high-profile tragedies, even though the data shows that mass shootings are more often driven by domestic violence. But the same experts are hopeful that a gun-safety bill approved by the Senate this week could bring meaningful progress on kids’ and teens’ mental health. It includes more than $1 billion for programs to improve access to pediatric mental health services at school and at home.

Adolescents in the United States are plagued with high rates of depression, suicidal thoughts and other mental health conditions, which have worsened during the covid-19 pandemic. The problems cross racial, geographic and economic lines, fueled by a persistent lack of resources, including a widespread shortage of adolescent social workers, psychologists and psychiatrists.

The gun safety bill would provide more than $500 million to increase the number of mental health providers in schools, $80 million for rapid access to pediatric mental health care and $60 million to train primary care physicians to treat mental health issues in children, among other measures. And more mental health bills are following in its wake in Congress.

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“This is a problem that has been festering for a very long time,” said Claire Brindis, an adolescent health expert with the University of California, San Francisco. “It’s one of those problems where we know what the answers are, but they’re not a magic bullet in terms of overnight solving it.”

If the focus on gun violence ends up mobilizing action on the broader mental health crisis among kids and teens, “that’s one good thing at least,” she said — adding that the steps to helping kids aren’t mysteries, and the latest bills promise to finally free up fixes that the country should have pursued decades ago.

Lawmakers “are seeing the impact on their friends, their family,” said Hannah Wesolowski, chief advocacy officer at the National Alliance on Mental Illness. “There’s a lot that happening right now, and I think it has a potential to move very quickly.”

Meeting kids where they are

Experts told Grid that solutions to the child mental health crisis come in three connected areas: making sure there are enough mental healthcare providers in the first place, making sure kids can connect to them, and making sure the healthcare system pays for their care.

Many fixes focus on schools, because in some places they’re the only source of mental health services for kids, said Kathy Cowan, communications director at the National Association of School Psychologists. But many schools are underequipped.

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While Cowan’s group recommends one school psychologist for every 500 students, the national average is one for every 1,211. In some states, it’s much worse: Alabama and New Mexico have ratios above one for every 10,000 students.

“We can’t have a school nurse covering 10 different schools or one counselor in five high schools and expect good outcomes,” said Brindis.

In school systems with shortages, psychologists must focus on special education requirements and individual education plans for children diagnosed with disabilities, or else school districts will face lawsuits from parents, Cowan said. Conducting suicide-risk assessments or more time-consuming counseling can fall by the wayside. Counselors are similarly encumbered by class scheduling, college recommendations and the everyday crises of schooling. That slows down regular mental health screenings, one of the simplest and most effective ways to catch problems.

Personnel shortages also drive “astronomical” levels of burnout among mental health professionals and in education overall, said Dave Anderson, the vice president of school and community programs at the nonprofit Child Mind Institute. “It’s difficult to recruit to a new profession if that’s the sales pitch: ‘Hey, we’re dying over here. Can you get us some more reinforcements?’”

Addressing the linked problems of exhaustion and high turnover will require policies that insulate providers from burnout from bureaucracy and other factors less directly connected to the first-order priority of providing care, he argued.

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Schools also need to be allowed to reach out to mental health professionals outside school walls, said Brindis, particularly with telehealth consultations that have proved effective in the pandemic. After covid hit, federal regulators temporarily relaxed rules against counseling across state lines. That should be made permanent, she suggested.

Crisis services should be expanded at schools as well, said Brian Hepburn, executive director of the National Association of State Mental Health Program Directors. While it may not be feasible for every jurisdiction to have its own child or adolescent crisis team, mobile response teams or consultants are options.

The need is clear: Even states such as Connecticut, which has a well-regarded children’s mental health crisis system with a mobile crisis team, have reported emergency rooms filled with children needing psychiatric care during the pandemic.

Creating safe havens for kids in crisis

Experts also called for expanding access to mental health services in communities more generally.

Not every child with a mental, emotional or behavioral disorder will be diagnosed while school is in session, and even those who are often need treatment outside the regular school year. Others are grappling with trauma and abuse that doesn’t end when class lets out. As of late last year, for example, more than 160,000 kids had a caregiver die from covid. And more than half of all high school students reported emotional abuse from an adult in their home during the pandemic, according to the Centers for Disease Control and Prevention.


Yet more than a third of all Americans live in places without enough mental health professionals, according to the Department of Health and Human Services. The gun safety bill endorses one approach to fixing this problem: nationwide expansion of “Certified Community Behavioral Health Clinics” (CCBHCs), essentially souped-up mental health clinics that receive federal funding in exchange for offering integrated social work and mental health services. The program has been running in selected states for eight years.

By offering 24-hour crisis services, these clinics aim to keep people in a mental health crisis out of emergency rooms, said Joshua Breslau, a senior behavioral and social scientist at the Rand Corporation, a nonprofit policy think-tank — and increase substance use disorder treatment, another nationwide crisis. Missouri and Oklahoma have turned to CCHBCs as their mental health backstops for Medicaid, the federal insurance program for low-income Americans.

The biggest hurdle: footing the bill

All of these fixes require money — ideally, with steady funding streams rather than one-off influxes from a single piece of legislation like the latest gun-safety bill. But figuring out where the money needs to go is complicated by the fragmented nature of the U.S. mental health system. Insurers, states, counties, cities and grants all pay for different services in different ways on different schedules.

“We have 50 states with 50 different types of mental health services available. They all do different things well and all have different areas that need help,” said Wesolowski, of the National Alliance on Mental Illness. “Piecing this together makes it exceedingly complicated for a school system, for example, to be able to provide those mental health services.”

Medicaid, which provides healthcare for around 40 million kids — more than half of the nation’s school-age children — plays a big part in these payment solutions. A bill being developed by the Senate Finance Committee would try one simpler solution: allowing the program to pay for combined medical and mental health services delivered on the same day, ones that are now billed separately. The program should streamline how small, rural schools without administrative expertise bill Medicaid, and ease enrollment in the program for out-of-state therapists counseling students through telehealth.

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The patchwork of grants that now supports mental health clinics needs to be turned into reliable funding to support careers, said Brindis. No one can promise young counselors a job past the length of a grant, much less a career, she said, when funding might vanish next year in a recession, as state and local governments tighten up budgets. “How can we draw in people from diverse backgrounds when we can’t assure them of having a job?”

The final, biggest, challenge that experts who talked to Grid feared was that politicians and the public will lose interest in tackling the mental health crisis before the solutions get a chance to show they work.

“The country’s focus on mental health in children in schools comes up after a major crisis … and then it tends to wane,” said Cowan. “The solutions that will really work are more complex than people want to take the time to deal with.”

Correction

A previous version of this story misstated Hannah Wesolowski's affiliation. This version has been corrected.

Thanks to Lillian Barkley for copy editing this article.