Addressing the child mental health state of emergency in schools: Opportunities for state policymakers

On October 19, 2021, the American Academy of Pediatrics (AAP), American Academy of Child and Adolescent Psychiatry (AACAP), and Children’s Hospital Association (CHA) jointly declared a national emergency in child and adolescent mental health (MH).¹ This declaration outlines ten action items for policymakers, educators, health care providers, and families to support child MH. Importantly, three action items focus on child MH supports delivered in school settings, and a fourth focuses on rectifying our MH provider workforce shortage -- which is essential for school MH initiatives to be effective.

The broadest of these recommendations pertaining to school settings is to “increase implementation and sustainable funding of effective models of school-based MH care.”¹ This recommendation reflects efforts underway within many schools, districts, tribal communities, regions, states and other educational entities nationwide to advance comprehensive school MH systems (CSMHS). CSMHS provide a full array of multi-tiered services and supports, including MH promotion for all students (“Tier 1” services), prevention and early intervention services for students at risk of developing MH problems (“Tier 2” services), and clinical assessment and treatment for students with MH diagnoses that impair functioning (“Tier 3” services).² This viewpoint features exemplar school MH policies from the Southeastern region of the U.S., which offer a template that policymakers in other states can use when crafting legislation to advance CSMHS.

The 2018 school shooting in Parkland, Florida catalyzed school MH legislation across the Southeast.³ Florida’s Marjory Stoneman Douglas High School Public Safety Act (SB7026) was passed within weeks, allocating $69 million to support the delivery of evidence-based MH programs and services. By 2020, Mississippi, North Carolina, and Kentucky also passed legislation to improve one or more tiers of school MH services,^{3, 4} albeit with less (if any) financial resources than the Florida legislation. Below, we describe five actions – some of which require little or no financial resources – to address one or more AAP/AACAP/CHA recommendations that can be incentivized or required through state legislation.

Create local school MH plans

Lawmakers can promote CSMHS by incentivizing or requiring school districts to create a plan for how they will design, implement, and evaluate one or more tiers of school MH programs and services, as demonstrated by Florida SB7026 and North Carolina SB476.^{3, 4} In Florida, school districts were incentivized to develop a comprehensive plan to provide Tier 2 and Tier 3 services and submit the plan to the Florida Department of Education to access associated funding. North Carolina’s law required school districts to create a MH plan, and also required the State Board of Education to adopt a statewide school MH policy with minimum requirements for the school MH plans. State lawmakers considering promoting school MH plans may utilize federally-funded assessment and quality improvement tools available to school districts on The SHAPE System.⁵

Train educators on MH literacy and other relevant topics

Improving MH literacy for educators is a key component of Tier 1 services.⁵ State legislation can strengthen school-based prevention efforts by incentivizing or requiring school personnel training on MH literacy or related topics. Mississippi HB1283 requires school employees to complete a professional development course in MH every two years.³ North Carolina SB476 specifies topics to be covered in educator training, including: youth MH, suicide prevention, substance abuse, sexual abuse prevention, sex trafficking prevention, and teenage dating violence.⁴ For states considering this approach, there are high quality, freely available resources to prepare educators with MH literacy, knowledge, and skills.⁶

Implement a social emotional learning curriculum

Social emotional learning (SEL) is a core component of evidence-based, Tier 1 MH promotion supports. A meta-analysis review found that students participating in SEL programs experience improved social and emotional skills, improved behavior, and an 11-percentile-point increase in academic achievement.⁷ Schools may choose from numerous SEL curricula, which are typically proprietary and can be expensive. Mississippi HB1283 took an intermediate, lower-cost approach by requiring the creation of an SEL pilot program for elementary school students.³ This catalyzed an effort by the Mississippi Departments of Mental Health and Education to evaluate, select, and purchase SEL curricula for piloting in ten school districts. The legislation also required an evaluation to inform decisions on scaling up the program. Beyond this pilot-and-evaluate approach for SEL curricula, states may also consider establishing and evaluating statewide SEL competencies given the evidence base.⁷ In fact, 20 states have adopted K-12 SEL competencies and all 50 states have Pre-K SEL competencies.⁸ State legislators can access federally-funded resources and technical assistance centers such as the Center on the Social and Emotional Foundations for Early Learning.⁹

Standardize school-community memoranda of understanding

Addressing the child and adolescent MH crisis will require cross-system collaboration between schools and community MH providers, as well as integrated care models. Memoranda of understanding (MOUs) between school systems and community MH providers are used to establish partnerships between these entities to expand Tier 2 and 3 service availability on school campuses. MOUs can define services and programs provided, outline roles and responsibilities, detail financial and non-financial resource agreements, and set limits of liability. Creating a standard MOU can expedite the formation of new partnerships between schools and community MH providers. Mississippi HB1283 required the creation of a standard MOU to foster partnerships statewide.⁴

Invest in school-based solutions to the MH workforce shortage

Successful efforts to improve MH services across all three tiers in schools—and, indeed, in any setting—will require meaningful investment to address the severe national shortage of youth MH professionals.⁷ Kentucky SB8 specified that each school have at least one school counselor providing direct student services for at least 60% of their time, and at least one counselor per public school or school-based MH services provider for every 250 students.⁴ A subsequent Kentucky appropriations law (HB352) provided $7.4 million to fund additional school MH provider positions in FY 2020–21 to meet the minimum school MH provider ratio requirements.⁴

Policymakers may also blend direct state funding with other sources to finance CSMHS initiatives and workforce expansions. For example, in most states Medicaid offers broad coverage of MH services (by school-employed or community partner providers) for eligible youth. As a caveat, Medicaid’s low reimbursement rates for MH services¹⁰ constrain the salaries that community MH organizations and schools can offer clinicians, undercutting their recruitment and retention efforts. Given this constraint, state leaders should work with school districts and community MH organizations, leveraging multiple strategies and funding sources to facilitate their recruitment and retention of youth MH providers.¹¹

Policymakers may employ numerous available tools, resources, and strategies to answer the call to action for children’s MH by advancing CSMHS. Some legislative strategies involve relatively little financial investment, such as standardizing MOUs to facilitate community provider-school partnerships. Other strategies, such as the pilot-and-evaluate approach to advance Tier 1 services in Mississippi, manage financial investments in a stepwise manner and could be implemented for other types of services as well (e.g., Tier 2, Tier 3). By contrast, strategies to foster an adequate, well-trained school MH workforce—which is imperative for meeting youth MH needs—require more substantial financial investment. Given the urgency of the AAP/AACAP/CHA declaration and the clear opportunity to promote youth MH through schools, state legislatures can use existing tools, models and policy exemplars to invest in school-based solutions to the youth MH crisis.