Sounding an alarm to policymakers at all levels of government, the American Academy of Pediatrics (AAP) and other prominent health associations declared a national state of emergency in children’s mental health last week. The announcement follows multiple reports on the apparent rise in mental illness and substance misuse before and during the COVID-19 pandemic, and urges officials to improve access to, and the quality of, youth mental health and substance use services across the continuum of care (i.e., promotion, prevention, early intervention, crisis, treatment, and recovery).

Prior to this declaration, the White House named October 2021 “National Youth Substance Use Prevention Month,” and released a fact sheet detailing steps the administration has taken to improve youth mental health and substance use. As part of this effort, the U.S. Department of Education published a resource to help schools better support the behavioral health needs of students. Together, these documents elevate critical data on the reality of youth mental health and substance use (including inequities faced by BIPOC and LGBTQ+ youth), summarize key challenges in delivering care, and outline important strategies and steps forward (e.g., bringing services to schools, primary care, and other youth-serving settings, increasing cross-agency collaboration to foster holistic approaches, and strengthening quality care metrics, to name a few). While these steps are important, there is additional action the administration, Congress, and states can take in response to the AAP’s urgent declaration:  

  • State and local education agencies should use COVID-19 ESSER funds to expand behavioral health providers in schools, and build pathways toward long-term sustainability. While some states are prioritizing these investments, others have yet to meaningfully include mental health and substance use services in their plans and fewer have outlined strategies for meeting the needs of BIPOC youth, LGBTQ+ youth, and others facing systemic inequities. Furthermore, less than half of all states have expanded their school-based Medicaid programs – a key pathway toward sustaining these investments. Notably, the White House fact sheet shares examples of how some states are using funds to meet the increased demand for substance use and mental health services, including programs like Oklahoma’s newly established school counselor corps.

  • To support the expansion and sustainability of state and local investments in school-based mental health and substance use services, the Biden administration should:
    • Provide states a template state plan amendment for expanding school-based Medicaid. This step would accelerate expansion, and support the sustainability of ESSER investments.  
    • Update the Medicaid School Health Technical Assistance Guide and the Administrative Claiming Guide – last updated in 1997 and 2003 – so schools can design their Medicaid programs to better meet the needs of students. Updated guidance should outline roles across state and local agencies, options for billing processes that reduce administrative burden, and other best practices for using Medicaid to expand school-based mental health and substance use services.

  • The Department of Education should be more explicit in promoting public health approaches to youth substance misuse, including in recommendations about school discipline policy. A new Department of Education resource outlines strategies to support student social-emotional learning and mental health services, and encourages schools to move away from punitive disciplinary practices toward more “instructional” and restorative alternatives for “social, emotional, and behavioral needs.” The resource does not reference youth substance misuse in this context, but many school policies rely on punitive responses that frame substance use as a moral or criminal issue. These policies disproportionately harm students of color, adversely affect academic outcomes, and create barriers to care. State and local education agencies need guidance that explicitly discourages this approach and promotes supportive responses rooted in public health.

  • Congress should allocate adequate funding to expand school health personnel to meet the ratios established by professional associations and to remedy existing inequities. The President’s FY22 budget includes $1 billion for a new School-Based Health Professionals program that would build the pipeline of school health staff, including social workers and school psychologists. The President’s current goal to double the number of school-based health professionals would be important progress, but would also leave many schools staffed far below the suggested professional standards. The latest national data show 6 million students attend schools without a psychologist and 10 million attend schools without social workers. These students are disproportionately youth from low-income families, youth living in rural communities, and youth of color who are more likely to attend schools with inadequate resources, and are less likely to receive the substance use and mental health care they need. The President’s budget offers a good start, but Congress should go beyond this current goal to meet the mental health and substance use needs of all students.

  • Congress and the Biden administration should integrate substance use prevention and early intervention into all youth suicide prevention strategies. The President’s FY22 budget includes $36.9 million in funding to support youth suicide prevention efforts. Too often, substance use is left out of these strategies despite the relationship between youth suicide and substance use and recommendations from some health professionals to integrate prevention efforts. Youth mental illness and substance misuse co-occur more often than not, and youth substance use can increase the risk for suicidal behavior. Congress should prioritize funding for youth suicide prevention, and include language the supports this integration.

  • The Biden administration should provide more robust guidance on racial justice and health equity, and states should focus on meeting the needs of youth most negatively impacted by systemic injustices. The administration’s fact sheet names “significant disparities” in youth behavioral health for BIPOC and LGBTQ+ youth, but doesn’t provide guidance to states on how to address these disparities. For mental health and substance use services to be effective in schools and health settings, young people need to feel safe, affirmed, and respected by those providing their care. The administration should provide guidance on how states can build a diverse workforce, encourage trauma-informed environments in schools and health settings, and expand services rooted in anti-racism, LGBTQ+ affirmation, and social justice. States should take action now to more meaningful integrate racial equity and health justice into ESSER plans and into all efforts to address youth mental illness and substance misuse.

Youth are facing a behavioral health crisis that has been steadily escalating for over a decade. Policymakers at all levels of government must share the responsibility and take meaningful action that expands access to care and improves the quality of services. Our children and youth deserve no less.