Children’s behavioral health must be prioritized in COVID relief efforts

There are few aspects of New Yorkers’ lives that have not been touched by COVID-19. As our city, state, and country continue to grapple with how to help families recover from this crisis, we must not overlook the impact of COVID-19 on children’s behavioral health. Without adequate support for children struggling with mental health concerns and substance use disorders, too many children will face the long-term impacts of unmet behavioral health needs.

Even prior to COVID-19, New York had a children’s behavioral healthcrisis. In 2016, suicide was the second leading cause of death for New York children age 15-19, and the third leading cause of death for children age 5-14.

54.5% of children ages 3 through 17 with a diagnosed mental/behavioral condition in New York did not get the treatment they need , including 55% of young people with major depression.

Access to care challenges have been in part driven by inadequate provider capacity. For example, in New York, there are only two child psychiatrists for every 10,000 children . Families face barriers accessing care regardless of whether they need outpatient care, intensive inpatient services, or community support services. These challenges are even harder for families in rural areas or those in need of bilingual services.

With the arrival of COVID-19, the need for behavioral health services has skyrocketed. The National Alliance on Mental Illness of NYC has reported a 60% increase in calls to their hotline since mid-March. Census survey data from July 2020 found that 62% of New York residents reported feeling anxious or worried and 55% reported little interest in doing things or feeling down and hopeless at least several days a week. New York’s youth are seeing a spike in reported symptoms of anxiety and/or depression that are consistently higher than other age groups. From June to July, almost half of all youth aged 18 to 24 living in the New York Metropolitan Statistcal Area (MSA) reported symptoms of anxiety and/or depression.

Importantly, the effects of this pandemic can be even more pronounced for children and adolescents. Extensive research on adverse childhood experiences tells us that the kinds of trauma caused by COVID-19 – including economic and housing insecurity, disruptions in mental health care, and loss of loved ones – have long-lasting repercussions across the health and wellbeing of children as they become adults. Though hospitals saw a temporary decline in psychiatric patients during the height of COVID, doctors are seeing a growing number of young people come to hospitals with dangerous psychiatric emergencies, and fear that conditions will only worsen without an adequate response.

Furthermore, with the transition to distance learning, many children have lost a source of stability and routine, and may experience feelings of social isolation and anxiety. Many LGBTQ students may face heightened challenges if they live in unsupportive families and have lost their in-person connection to a more affirming school community. Additionally, the shuttering of schools has impaired the ability to identify and connect or maintain continuity of student’s access to clinical services. The importance of schools as a setting through which to receive clinical services is clear; a national study from the National Survey of Drug Use and Health (NSDUH) found that more than 13% of adolescents received some form of mental health services in a school setting in the previous 12 months. Additionally, 35% of adolescents who receive any mental health services receive them exclusively from school settings.

Like all other aspects of this pandemic, the mental toll of COVID-19 has fallen disproportionately on those already most marginalized. The health and economic impacts of COVID-19 have been felt most strongly in working-class immigrant neighborhoods, and among Black and brown communities that have faced historic and institutional inequities. Extensive research indicates that household economic hardships can contribute to decreased mental wellbeing and increased rates of certain mental disorders and suicidal behaviors. With the added strains of job loss, loss of loved ones, housing instability, food insecurity, and a host of other instabilities, more and more children have been placed at risk of poor mental health.

Compounding the impact of COVID-19 are the harms of institutional anti-Blackness and police violence that children are coping with in the wake of the killing of George Floyd and the police’s violent reaction to protests. Even prior to this crisis, we were beginning to see a rise in suicide among Black youth . The factors driving this spike – including job loss and economic insecurity, lack of access to mental health resources, and the toxic stress of racism – have all been heightened during this crisis. NYC Well saw a nearly 10% surge in calls during the week following George Floyd’s death , on top of increase in calls from pandemic. The systemic racism and anti-Blackness students experience in their communities, schools, and daily lives is a second pandemic that must be addressed.

Responses from State and Federal Governments

Americans stand at a precipice, with many of the federal COVID-19 relief benefits – such as unemployment insurance, cash payments, and federal eviction protections – having expired at the end of July. Yet Congress remains gridlocked, with Senate Republicans resisting the passage of a comprehensive COVID relief package that mirrors the HEROES Act proposed by the House. Without additional financial support, even more families and their children will suffer the psychological and emotional harms of economic distress, on top of anxieties related to isolation, loss of loved ones, and widespread uncertainty.

The Coronavirus Aid, Relief, and Economic Security Act (CARES Act) included several provisions specific to behavioral health, including $4 billion for community health centers and $425 million for Certified Community Behavioral Health Clinics, suicide prevention programs, and mental health and substance use disorder emergency grants. New York was the recipient of a four-year, $12 million award from SAMSHA to help local providers better coordinate services for children with serious emotional disturbances and their families.

As important as this funding has been, it only begins to scratch the surface of the need, and there has been insufficient attention to the specific behavioral health needs of children and adolescents.

CCC joined national advocates in pushing for a $38.5 billion investment for providers of mental health and addiction treatment services, advocating that at least 25% of those funds be dedicated to children’s needs. This is part of a broader push, in recognition that if we do not also address the stressors facing families – child care, unemployment, primary healthcare access, food insecurity – mental health will suffer.

At the state level, New York faced harsh budget realities even prior to the COVID-19 pandemic. Despite the threat of cuts to children’s behavioral health services, advocates successfully pushed the state to preserve children’s behavioral health, and even restore a proposed 1.5% cut to Children and Family Treatment and Support Services. This has proved even more important than anticipated, as it meant New York entered this crisis without a severely damaged infrastructure for children’s behavioral health.

New York has also taken important steps in implementing telehealth services, with state agencies moving quickly to ensure new flexibilities in access to telehealth services. An important legislative change now allows audio-only and video-only telehealth services in Medicaid and CHIP, which has helped expand opportunities to connect with patients.

At the same time, New York’s dire economic and budget reality, threatens the stability of the children’s behavioral health system, among other systems. The state is facing $14 billion in revenue shortfalls, with great uncertainty regarding how much the federal government will invest in state relief. New York is currently withholding some of the funds intended to support local treatment providers, and is cutting funding for some behavioral health services by 20% . The State also announced a proposed 1.5% cut to children’s Home and Community Based Services (HCBS), which are intended to help meet the mental health needs of children in their homes and communities and prevent the need for institutional levels of care. The threat of additional cuts places the state’s behavioral health infrastructure and ability to serve children at risk.

Priorities for Recovery

Budget decisions made at the federal level will directly impact the state’s budget, which will in turn impact New York City’s budget. As our state and federal governments consider how to address the behavioral health crisis among young people and prevent long-term harm, there are key areas that must be addressed.

Protect and Invest in Children’s Behavioral Health

At its core, we cannot ensure the wellbeing of children if our state and federal governments take a short-sighted approach to children’s mental health. Targeted investments are needed in children’s behavioral health services. Investments are also needed in the foundations of recovery and promotion of wellbeing – housing, nutrition, financial assistance, unemployment insurance – that support family and household stability and protect children from the stressors that can drive poor mental health.

As a start, Congress must pass comprehensive stimulus legislation to help struggling families . Without this assistance, families in New York and across the country face long term hardship and resulting trauma.

At the state level, New York must continue to protect and invest in the children’s behavioral health infrastructure. Only by investing in children now can we avoid the long-term repercussions of trauma and unmet mental health needs. Those families most impacted by the economic downturn, illness, and loss are those most in need of behavioral health supports for their children. We strongly support the State’s efforts to draw down additional federal funding. We also recognize that by protecting and strengthening state investments, we can reduce hospitalizations and emergency room visits, and prevent the emergence of more complex needs among children that are harder to address later in life. New York must resist any proposed cuts to children’s behavioral health care, including the proposed 1.5% rate cut to HCBS services.

Make Telehealth Flexibilities Permanent, and Ensure Equitable Access to Telehealth Services

New flexibilities to provide telehealth services have been a lifeline for many children and families, allowing them to stay connected to the critical health and behavioral health supports they need. However, thus far many of these flexibilities are temporary and tied to the declaration of a state of emergency. Particularly given the uncertainty of the future, it is critical that many of these regulatory flexibilities become permanent fixtures. Additionally, New York must reimburse telehealth visits at the same level as comparable in-person visits to maximize options for children and families.

As important as telehealth is, we must also acknowledge its potential role in exacerbating inequities in telehealth access, and that telehealth is not in itself a silver bullet to long-standing capacity challenges. Too many families still lack access to reliable broadband or internet to access services , and the digital divide disproportionately impacts low income communities and communities of color. For those that have experienced a racially discriminatory healthcare system, teleservices may not feel like a safe alternative to in-person care. Telehealth can also pose challenges for very young children, children with disabilities, families who lack privacy, and families who speak languages other than English.

For these reasons and more, New York must work carefully to ensure equitable access to telehealth services. This means prioritizing the needs of children and families and respecting their choices regarding how they want services delivered. It also means addressing the digital divide and ensuring all families have access to the devices and internet connectivity they need. In developing a new statewide plan for telehealth, careful attention must be paid to those patients most likely to be left behind, and how to ensure they receive the care they need.

Support the Behavioral Health Needs of Students

Though students engaged in remote learning throughout the spring, their need for school-based services has not faded. Great uncertainty remains over how children’s next school year will look, but schools will remain an important site – whether physical or virtual – for connecting children to emotional and behavioral supports.

Many students may have new behavioral health needs that are not easy to identify. It is therefore essential that educators have the training they need on trauma-responsive care. Students suffer when schools lack the tools to respond to trauma and instead respond with punishment, emergency medical services, and police involvement. Fortunately, models exist for how to engage students, families, and educators in whole school approaches that center healing and help support all students, including those who have experienced trauma. Though each school or school district has unique needs, some models worth considering include the Bronx Healing-Centered Schools Community Roadmap; the Schenectady City School District’s cultural broker model, and the proposed Mental Health Continuum in New York City .

At the same time, New York must also strengthen schools’ access to clinical and community-based services. Though no longer providing all services on site, during the pandemic, many Article 31 School Based Mental Health clinics have found ways to identify and connect with students who have increased need. Community-based behavioral health providers are also critically important when schools have limited access to on-site mental health resources or staff. New Child and Family Treatment and Support Services (CFTSS) provide family-focused, community-based services designed to prevent the need for more intensive services later in life. These services can reach more children if they are integrated into education settings, and if they are made available to children outside of Medicaid, including children in the Child Health Plus program.

Despite budget restrictions, New York cannot afford to be short-sighted by scaling back on existing school-based behavioral health resources; in fact, now is the time to invest more in the student supports so they can thrive social emotionally and academically.