Structural Sequelae of the COVID Pandemic: The Youth Mental Health Crisis Free

Imagine a family with a 14-year-old child, attempting to navigate a patchwork quilt of mental health support systems. The child’s school, lacking a robust system for early detection of behavioral health issues, overlooks initial signs of depression, despite the student’s declining engagement with classes. Assuming these issues are identified, the student may first meet with a school counselor, if one is available at their institution, followed by referrals to a community therapist and a psychiatrist for medication management. Each provider offers different therapeutic approaches, leading to a disjointed care experience. For other providers, piecing together a full understanding of the patient’s story is daunting. Crucial data points, such as school behavioral observations, potential interactions with child protective services, and previous medical visits, are housed in distinct siloes. This decentralization hinders clinicians from attaining a comprehensive view of the patient’s clinical picture, intensifying the challenges in delivering coherent and responsive care.

Adolescent mental health care suffers from insufficient delivery of care to the settings in which youth spend their time (eg, schools), poorly disseminated modalities for screening and detection of behavioral health issues, unequal quality of care across different settings, and fragmentation of services. These issues are only compounded by the dearth of mental health professionals in the United States, with a mere 14 child and adolescent psychiatrists available per 100 000 children.³  Further complicating the picture, we must note that, for children, numerous other structures shape health care access and outcomes, including schools, social services and child welfare, and criminal justice systems. This in turn creates differing, frequently misaligned incentive structures and enormous confusion for patients. Crafting a cohesive roadmap will be necessary to redirect these trajectories.

One critical policy action is investment in a centralized, interoperable registry spanning the continuum of children’s mental health care services, including nonclinical stakeholders such as social service and education systems. A potential path forward is to leverage recent strides made through the 21st Century Cures Act, which aims to remove barriers to information sharing across information technology systems through standards-grade application programming interfaces. Implementing such application programming interfaces could allow electronic health record systems to interact while ideally presenting only the most actionable notifications to providers. From there, it may be feasible to draw in data from other public systems such as social services. Studies of UK health information technologies have highlighted the potential for such data consolidation across health records held by National Health Service Foundation Trusts, local health care delivery organizations, with school-based services.⁴  Integrating education-related endpoints, such as attendance or school counselor evaluations, into extant electronic health records holds the potential to expand digital triaging, improve referral pathways, and advance research. However, barriers to implementing such an approach include establishing a legal and ethical approval framework within the context of the Health Insurance Portability and Accountability Act to allow for data linkage, creating shared identifiers, and appropriately investing in technological infrastructure. The US Department of Health and Human Services, as the primary agency overseeing health care and social services with a broad view of public health domains and enforcement of Health Insurance Portability and Accountability Act standards, is uniquely equipped to ensure a centralized registry meets requisite privacy and security criteria.

Additionally, despite accelerating innovations in health care financing for general medical care, payment models have not been appropriately designed to meet the needs of youth mental health professionals. It is possible to realign financial incentives to facilitate care coordination through implementation of value-based care pathways, which reward improved outcomes and decreased costs across the entirety of a child’s journey in mental health services. Ideally, this reimbursement structure would also allow for diagnosis-specific outcomes and cost alignment that incentivizes child psychiatrists to accept low-income youth who are more likely to be trauma-exposed. Promising models include Medi-Cal’s Children and Youth Behavioral Initiative, which seeks to create a virtual behavioral health services platform for youth and improve the continuum of care.⁵ 

We must recognize the need for systems of care spanning the breadth of a child’s life beyond the hospital, from school to community. One model for care integration is Illinois Children’s Healthcare Foundation led by the Healthy Minds, Healthy Children, Healthy Chicago initiative, which used a team-based approach to care coordination in community-based settings across multiple care sectors serving patients in federally qualified health centers.⁶  This model led to >14 000 children being screened for mental health concerns, demonstrating the potential of such integrated interventions. To scaffold these efforts, resources must be directed to foster cross-institutional collaboration across legal, health, education, and social service systems.

To realize this improved continuum of care, however, it is necessary to increase training pathways for youth mental health professionals. Mental health workforce shortages create additional barriers to accessing care, particularly for marginalized populations that may lack coverage options. To this end, improving rates of reimbursement for child and adolescent psychiatry, which often offers lower financial margins, is necessary to encourage pursuit of the field. Moreover, we must build capacity for parents and guardians of children with behavioral health needs. As we witnessed during the pandemic, caretakers must often negotiate across increasingly complex systems on behalf of their children. Thus, expanding Medicaid coverage for modalities such as family therapy or dyadic treatment, alongside training for caregivers, could be particularly effective. Ultimately, although recent investments in school-based mental health by the Biden administration are laudable and necessary, without multilevel reforms as described, they may not achieve their intended impact.⁷ 

The pandemic has forced a reckoning with systems in dire need of redesign. In this liminal period, although we triage the systems and policy-level changes which were initiated during the pandemic, we must not neglect vulnerable young people. We have an opportunity and responsibility to better detect, intervene, and provide longitudinal support for others like Alex so they may build fulfilling lives and futures.