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by Caren Howard, Jose Caballero, and Marcus Alston

As legislators prepare for a new year and grapple with budget decisions that put to use their surplus or address shortfalls, there are significant opportunities for states to go big for youth mental health. The time is now.

Across the nation, youth are actively seeking out help through Mental Health America’s screening program, which registers more than 10,000 visitors a day – over a third of screeners are under age 18. Youth commonly express how trauma, relationship problems, and isolation are the top three factors contributing to their mental health concerns at the time of screening, and data show LGBTQ+ and Black, Indigenous, and people of color (BIPOC) youth as those who would benefit most from swift action. Research by Common Sense Media indicates teenagers want help managing their internet and smartphone use but feel powerless to make changes on their own (notably, over two dozen states are suing Meta for its harmful practices).

The National Governors Association’s Youth Mental Health Playbook, released earlier this year, is a tool states can draw from to create policies and initiatives and offers examples of both administrative and legislative actions already taken by states. It is informed by a year of work by New Jersey Gov. Phil Murphy, in his role as chair of the National Governors Association (NGA), and NGA staff in collaboration with national mental health advocacy organizations, including Mental Health America, and youth advocates. The playbook uses four pillars to show how systems can be reconceptualized to address today’s critical needs of children and adolescents and how to build capacity to reduce tomorrow’s needs.

As communities face decisions whether or not to end programs and policies that were funded by one-time COVID-19 supplemental funding, it is important not to go back to “business as usual” by putting mental health on the back burner. Leading up to the pandemic, families seeking children’s mental health care were unable to find it 69% of the time, according to a NORC survey of nearly 3,000 people in 2019-2020. In comparison, 17% of persons seeking children’s physical health care were unable to find it. State leaders must ensure their budgets and policies reflect the will of the great many voices of young people reaching out for mental help for both themselves and their peers.

Key opportunities

Pillar 1: Addressing prevention and building resilience

A key opportunity in Pillar 1 highlights Massachusetts (page 14) for developing healthier school climates. To address the root causes of student behaviors, rather than respond with strictly punitive measures, Massachusetts requires schools to first use alternative forms of discipline, including mental health intervention. Though Black children make up 15% of the K-12 school population, they make up more than 40% of referrals to law enforcement.

Pillar 1 also stresses data collection and analysis as crucial steps in the process. It is essential that such data and analyses come from a representative sample of the affected population: students. States should rethink the way schools take into consideration students’ experiences and reevaluate the frameworks of student engagement and accessibility when implementing mental health initiatives. The foundation of a strong youth mental health system involves attentively listening to young individuals' concerns and struggles, and equitably utilizing this data to take actionable steps toward fostering a healthier school climate. By doing this, schools will provide a transformative experience for their students that goes beyond academic metrics to one that also cares about guiding students into becoming emotionally competent individuals.

Pillar 1 illustrates the importance of building resilience, which includes teaching life skills in schools and community programs. Building resilience on school campuses should be a top priority for school officials, as research has shown the benefits of such practices. A 2020 Yale study found that "to improve students’ mental health, schools should teach them to breathe." A specific resiliency program, SKY Campus Happiness, which relies on a breathing technique, yoga postures, social connection, and service activities, was most beneficial for students' mental health, with students reporting improvements in six areas of well-being: depression, stress, mental health, mindfulness, positive affect, and social connectedness. A recent law in Florida and a new policy in New York City highlight the growing recognition of resilience's power and its integration into education. By incorporating meditation and breathing practices into daily routines, states will not only address youth mental health concerns but also cultivate a new generation of emotionally competent leaders who are high achieving.

Pillar 2: Increasing awareness and reducing stigma

Pillar 2 makes the point that all activities should be conceptualized, enacted, and implemented with young people. By making space for young people at the decision-making table, we make them key players in ensuring systems are user-friendly and continuously improving by utilizing feedback. User feedback is highly valued by many private companies, yet public systems are slower to adapt and transform based on real-time input from those being served. New Mexico (page 23) created the Indigenous Youth Council, which provides youth-specific recommendations to the state Indian Affairs Department for behavioral and mental health needs in tribal communities. Several other states, including Vermont, Maryland, and Arizona, also allow youth councils to directly inform state policy.

Pillar 3: Ensuring access and affordability of quality treatment and care

An exciting opportunity in Pillar 3 is funding peer support models. Peer support services are known to reduce isolation and help build support systems, increase self-help skills and engagement in services, and empower youth to lead self-directed lives. In addition, peer support can prevent behavioral crises by helping individuals better manage both physical and mental health conditions. Though formal peer support is evidence-based, it is also commonly practiced among friends, colleagues, trusted peers and has a long-standing history outside of the evidence-based practice. Informal peer support has been commonly used among young people because of the mutuality ethos, its accessibility, and trust embedded between peers. There are several models of youth peer support, including peer counseling programs and programs that utilize formal certified peer specialists.

In Wisconsin (page 30), over 300 schools offer student-led peer support wellness programs. Currently, 18 states bill Medicaid for youth peer support, which may be offered as part of mobile crisis programs, in schools, or as part of other community-based services – but no schools are utilizing Medicaid as a financing source. Youth are very interested in learning skills to support their own well-being and to support the well-being of their friends and peers. In a survey of almost 2,000 young people seeking help through MHA's online screening program, 44% of 14-18-year-olds stated that access to support from other young people is one of the most important resources for their mental health. Peer support is intuitive because young people first turn to each other long before they are ready to talk to an adult about what they are experiencing and schools should be billing Medicaid for it.

Pillar 4: Training and supporting caregivers and educators

A key opportunity in Pillar 4 emphasizes the importance of training and educating youth-serving adults and caregivers. North Dakota’s (page 35) Department of Health and Human Services’ Behavioral Health Division has made online role-playing simulation technology available to help school personnel recognize signs of distress. The program models conversations for approaching students discussing concerns and makes referrals to appropriate resources.

Not specifically called out in the playbook, it should be noted that there is often an extra layer of stigma for student athletes who experience mental health distress because of culture and attitudes about seeking help. Student athletes are advocating for change in athletic programs where students spend a significant amount of their time. Therefore, athletic coaches should be trained in mental health as they are required to be trained in CPR and heat illness prevention, as both mental and physical health can be a life-or-death situation. This year, Ohio passed HB33, which mandated mental health training for all 80,000 high school coaches. In Maryland, youth-led Alston for Athletes is advocating for HB375, which would require all coaches at public institutions to go through mental health training. However, training should not be exclusive to coaches, and the long-term goal is to ensure other school personnel, including teachers, bus drivers, and all youth-serving adults, receive it as well.

What’s next?

We are excited about the opportunities this playbook offers to states and appreciate the incredible work it took to pull together this comprehensive guide. MHA and its partners look forward to working with stakeholders to bring the policies within the playbook, including the few highlighted here, to fruition because there is no health without mental health.

Advocates, tell state officials to ensure youth mental health is a top issue in the next session. Let your governor know they should prioritize youth mental health. Inseparable’s action alert will automate a letter based on your residence.

Caren Howard is the senior director of policy and advocacy at Mental Health America. Jose Caballero is a national award-winning mental health activist, an MHA Young Leaders Council member, and a student at Columbia University. Marcus Alston is an award-winning mental health advocate, founder of Alston for Athletes, and an alumni of the MHA Young Leaders Council.