Covid-19 and Children's Mental Health: Addressing the Impact

COVID-19 and Children’s Mental Health: Addressing the Impact Report #262 | August 2021 Milton Marks Commission on California State Government Organization and Economy www.lhc.ca.gov LITTLE HOOVER COMMISSION Dedicated to Promoting Economy and Efficiency in California State Pedro Nava* Government Chairman Sean Varner† The Little Hoover Commission, formally known as the Milton Marks “Little Hoover” Commission on California State Government Vice Chairman Organization and Economy, is an independent state oversight agency. David Beier* Dion Aroner By statute, the Commission is a bipartisan board composed of five public members appointed by the governor, four public Cynthia Buiza members appointed by the Legislature, two senators and two Bill Emmerson assemblymembers. Assemblymember Chad Mayes In creating the Commission in 1962, the Legislature declared its Senator Jim Nielsen purpose: Assemblymember Bill Quirk Senator Richard Roth ...to secure assistance for the Governor and itself in promoting economy, efficiency and improved services in the Cathy Schwamberger transaction of the public business in the various departments, Janna Sidley agencies and instrumentalities of the executive branch of †Served as subcommittee chair the state government, and in making the operation of all state departments, agencies and instrumentalities, and *Served on study subcommittee all expenditures of public funds, more directly responsive COMMISSION STAFF to the wishes of the people as expressed by their elected representatives... Ethan Rarick Executive Director The Commission fulfills this charge by listening to the public, Tamar Foster consulting with the experts and conferring with the wise. In the course of its investigations, the Commission typically empanels Deputy Executive Director advisory committees, conducts public hearings and visits government Krystal Beckham operations in action. Ashley Hurley Its conclusions are submitted to the Governor and the Legislature Rachel Mattioli for their consideration. Recommendations often take the form of Sherry McAlister legislation, which the Commission supports through the legislative Tristan Stein process. Contacting the Commission All correspondence should be addressed to the Commission Office: Little Hoover Commission 925 L Street, Suite 805, Sacramento, CA 95814 (916) 445-2125 | LittleHoover@lhc.ca.gov This report is available from the Commission’s website at www.lhc.ca.gov. Table of Contents EXECUTIVE SUMMARY ......................................................................3 INTRODUCTION .................................................................................5 SECTION I: COVID AND CHILDREN’S WELL-BEING .......................6 COVID and the Existing Crisis in Children’s Mental Health ........................8 Understanding COVID’s Impact ...................................................................10 An Unequal Impact ..............................................................................10 Long-Term Consequences ..................................................................11 SECTION II: BARRIERS TO ADDRESSING CHILDREN’S MENTAL HEALTH NEEDS .................................................................................13 California’s Child Mental Health “System” .................................................14 Barriers to Care and Services ......................................................................16 Decentralization ..................................................................................16 Fragmentation .....................................................................................16 Fail First ................................................................................................18 Capacity ................................................................................................18 Funding .................................................................................................19 What is the Role of Schools? .......................................................................21 SECTION III: ADDRESSING THE CRISIS .........................................23 CalAIM .............................................................................................................25 Children and Youth Behavioral Health Initiative ......................................25 SECTION IV: STEPS FORWARD ......................................................28 Establishing State Leadership and Outcome Goals ..................................28 Building Capacity for Statewide Approaches ............................................29 Building School-Linked Partnerships ..........................................................30 RECOMMENDATIONS .....................................................................32 NOTES ...............................................................................................35 COVID-19 AND CHILDREN’S MENTAL HEALTH: ADDRESSING THE IMPACT | 1 Letter from the Chair August 23, 2021 The Honorable Gavin Newsom Governor of California The Honorable Toni Atkins The Honorable Scott Wilk Speaker pro Tempore of the Senate Senate Minority Leader and members of the Senate The Honorable Anthony Rendon The Honorable Marie Waldron Speaker of the Assembly Assembly Minority Leader and members of the Assembly DEAR GOVERNOR AND MEMBERS OF THE LEGISLATURE: Last year, the Little Hoover Commission initiated a review of the impacts of the COVID-19 pandemic to better understand the challenges facing California and identify how state government can support those impacted. The following report, the last in our series, focuses on the pandemic’s impact on the mental and emotional well- being of children and adolescents, especially those under the age of 18. The Commission learned that the COVID pandemic has had a major impact on young people’s mental well-being and has been a source of stress, anxiety, and trauma. The Commission also learned that chronic stress and traumatic experiences during childhood can have a life-long impact on individuals’ psychological and physical health, with substantial social and economic costs. However, the Commission found that California has long struggled to support children’s mental and emotional health adequately. In this report, we examine ways in which California can improve the state’s system for supporting child mental health. Governor Newsom and the Legislature, together with state agencies, local governments, health plans, care providers, and stakeholders, are taking critical steps to overhaul and improve California’s system for supporting child mental health, especially through the Children and Youth Behavioral Health Initiative. These ambitious and expansive efforts promise to transform California’s child mental health system, but strong leadership and clearly defined outcome goals will be needed to ensure that they achieve their potential. To create lasting improvements in children’s mental health care, the Commission recommends that the state establish centralized leadership to promote sustained and sustainable coordination, collaboration, and accountability around mental health. While the pandemic has exacerbated an ongoing crisis in children’s mental health, the Commission recognizes that it also presents a once-in-a-generation opportunity to improve children’s mental health care. The Commission respectfully submits this work and stands prepared to help you address the impacts of the COVID-19 pandemic. Sincerely, Pedro Nava, Chair Little Hoover Commission 2 | LITTLE HOOVER COMMISSION Executive Summary Letter from the Chair Systemic and structural barriers can prevent children COVID and Children’s Mental from accessing mental health services. More than Well-Being half of children and adolescents in California are on Medi-Cal and thus receive care through the COVID confronts California with two pandemics of state’s public mental health system. That system is, public health: the viral pandemic and a pandemic however, decentralized and fragmented. It contends of mental health that has fallen most heavily on with capacity and workforce shortages, complicated children and youth. and administratively burdensome funding COVID created a perfect storm of stress, anxiety, and mechanisms, and challenges around providing trauma, exacerbating a preexisting crisis in children’s preventive and timely care. There is also considerable mental health. Many young people experienced variation in school districts’ focus on student mental social isolation and disconnection; some endured well-being and in the availability of school-based economic dislocation and the illness or loss of loved services. ones. There have been notable increases in anxiety, Addressing the Crisis depression, and mental health-related emergency room visits. Experts further warn of a looming To address COVID’s impact on children’s mental “tsunami” of unmet mental health needs among health, California needs to build a larger, more young people and suggest that some children and diverse mental health workforce, establish a adolescents will need time, support, and investment genuine continuum of care for children, emphasize to bounce back. prevention and early intervention, and center schools as hubs of mental well-being. The pandemic’s effect on children’s mental well- being is likely to be uneven. It is probable that California is poised to facilitate access to mental the pandemic will disproportionately impact the health services through two major initiatives that mental and emotional well-being of children from have potential to transform children’s mental health communities of color and low-income communities, care: which have borne the brunt of the pandemic’s economic and physical health effects. Unless CalAIM. The California Advancing and Innovating California responds robustly, trauma and sustained Medi-Cal (CalAIM) proposal reforms Medi-Cal service stress may also have long-term psychological and delivery and financing, reducing administrative physiological impacts on some children. burdens and removing diagnostic requirements that can prevent children from accessing timely mental Barriers to Addressing health services. Children’s Mental Health Children and Youth Behavioral Health Initiative. Needs The Behavioral Health Initiative provides more Early intervention and treatment can help to address than $4 billion over the next five years to develop COVID’s impact on young people’s mental well-being, a comprehensive system of mental health for but California has long struggled to meet the mental children and youth. It will create a statewide virtual health needs of young people. Too few children platform for behavioral health services and invest receive care, and when they do, it often is too late. in expanding school-linked mental health services, Children of color and children from low-income developing a larger, more diverse mental health families, moreover, access mental health services at workforce, building a continuum of care, and lower rates than their peers. promoting public awareness. COVID-19 AND CHILDREN’S MENTAL HEALTH: ADDRESSING THE IMPACT | 3 Steps Forward Recommendation 2: In consultation with stakeholders, the Secretary of the Health and Human California also needs strong structures to administer Services Agency should set statewide goals for child the Behavioral Health Initiative and achieve lasting mental health based on key metrics related to overall improvement in children’s mental health care. The mental well-being, access to care, and quality of Commission finds that there are three key elements services. for coordinating California’s response to COVID’s Recommendation 3: The Governor and Legislature impact: should reserve a portion of Behavioral Health ◊ California needs stronger, more coherent, and Initiative funding to provide a future tranche of more cohesive state leadership around children’s additional funding to be competitively awarded mental health, including common outcome goals to counties and health plans that effectively and and a single point of overall leadership. efficiently implement successful reforms/programs and reach identified benchmarks. ◊ California must build capacity for statewide approaches to children’s mental health, especially Recommendation 4: The Department of Health Care by expanding the ability of state government to Services should work with stakeholders to identify provide support and technical assistance to health ways to increase the support and technical assistance plans and local providers. it provides to counties, health plans, and other ◊ Centering schools as hubs of mental wellness mental health providers. means bringing together systems of health and education and forging partnerships among entities Recommendation 5: The Governor and Legislature that may have little experience working together. should leverage the Behavioral Health Initiative To foster effective partnerships, state government to encourage local educational agencies and their must support careful planning around intersystem partners to develop comprehensive approaches to collaboration, coordination of services, and use of student mental wellness, including requiring grantees data. to establish actionable plans for coordinating services, for using and sharing data, and for Recommendations integrating funding to create sustainable programs. To improve the state’s system for supporting child Recommendation 6: The Governor should establish mental health, California needs leadership that a clear timeline for the development, testing, and promotes sustained and sustainable coordination, piloting of the behavioral health services virtual collaboration, and accountability around mental platform, with vigorous oversight at every stage of health. development. Recommendation 1: The state of California should identify a central point of leadership for children’s mental health. The Governor and Legislature should also initiate a review process to examine the creation of a new and robust Department of Behavioral and Mental Health, with coequal focus on child and adult mental health, which could exercise statewide leadership over mental health care and services. 4 | LITTLE HOOVER COMMISSION Introduction COVID has confronted California with two pandemics of public health. The first is the viral pandemic, which Impacts of the COVID-19 has sickened millions and, at the time of this report, Pandemic had led to the death of nearly 65,000 Californians.1 The second is a pandemic of mental health that has This report is the last in the Commission’s hit children and adolescents especially hard. Surveys series on the impacts of the COVID pandemic. and reports suggest substantial increases in anxiety, The first two reports, First Steps toward depression, suicidal ideation, and mental health- Recovery: Saving Small Businesses and First related emergency room visits among young people. Steps toward Recovery II: Job Training and California and Californians are likely to feel the Reskilling, examined the immediate economic effects of the sustained anxiety and stress brought impacts of the pandemic on small businesses on by the pandemic for years to come. and workers, focusing on how California can support small business recovery and job COVID appears to have exacerbated and amplified training opportunities for impacted workers. what many experts call an ongoing crisis in children’s mental health. Rates of adolescent suicide and self- This report studies the pandemic’s impact harm were increasing even before the pandemic. on the mental and emotional well-being of Between an existing crisis in young people’s mental children and adolescents, especially those health and COVID’s impact, experts speak of a under the age of 18. Literature around looming “tsunami” of unmet need.2 adverse childhood experiences suggests that chronic stress and traumatic experiences California has long struggled to support children’s during childhood can have a substantial and mental and emotional health adequately. Many life-long impact on individual’s psychological young people with mental health needs do not and physical health, with substantial social receive any services; by some estimates, a majority and economic costs. This report examines of youth with some serious mental health conditions, how state government can respond to the like major depression, do not receive consistent pandemic’s impact and better support care. Moreover, Ken Berrick, Founder and CEO of children’s mental well-being into the future. Seneca Family of Agencies, and Robin Detterman, Seneca’s Chief Program Officer of Education Services, observed, “Too often, struggling students and health. Federal stimulus funding, together with an families are not met with services until their needs unexpected rebound in California’s fiscal situation, rise to a crisis level.”3 California’s child mental health will enable California both to make historic one-time system is extremely fragmented and suffers from investments in children’s mental health and support severe capacity shortages. Additional demand for ongoing work to improve coordination in delivering care and services as a result of COVID will further support and care. stress and strain this system. State government must seize this moment. More Yet the COVID pandemic also presents a once-in- than half of children and adolescents in California a-generation opportunity to improve children’s are on Medi-Cal and thus receive care through the mental health care. The pandemic’s broad impact state’s public system of mental health. These young on Californians’ mental and emotional well-being people come from the low-income families and the has raised awareness of the importance of mental communities of color that have disproportionately COVID-19 AND CHILDREN’S MENTAL HEALTH: ADDRESSING THE IMPACT | 5 borne COVID’s economic and physical health impacts, Dr. Insel explained, “that kids are resilient – they and they are likely to be at higher risk to stress, generally do well. But stress over time can overcome anxiety, and trauma due to the loss of family income that resilience. And I think that is what we may be or the illness or death of family members. They have seeing here.”5 also historically been less likely to receive mental The COVID pandemic’s impact on young people’s health services. California is, however, now poised mental health is multifold. Children have endured to respond to young people’s need for a stronger long periods of social isolation and disconnection as mental health system with the new Children and measures to control the pandemic, including social Youth Behavioral Health Initiative, which promises distancing and remote learning, separated them to build capacity, encourage new partnerships from their friends, limited opportunities to make and collaborations, support prevention and early new friendships, and deprived them of their social intervention, and expand access to care and services. routines. They missed out on major life events and Still, key structural and systemic barriers remain. milestones like graduations, birthday parties, and In previous reports, the Little Hoover Commission family reunions. They lost access to the sports, clubs, emphasized that California needs leadership that activities, and pastimes that connected them with promotes sustained and sustainable coordination, friends and mentors, shaped their identities, and collaboration, and accountability around mental gave their lives meaning—and that let them be kids. health. In order to ensure that new initiatives achieve The pandemic created a perfect storm of stress, their potential and that California truly addresses the anxiety, and trauma. Some children grappled with mental health needs of children, state government stress stemming from economic dislocation and needs to take steps to institutionalize and sustain parents’ loss of jobs or income.6 Those whose parents that leadership. State government also needs to set or relatives are essential workers confronted daily clear outcome goals that center on child wellness and anxiety over the safety of family members. Some also that promote coordination around children’s mental faced the illness or loss of family and loved-ones due health care and services. to COVID. On top of all these stresses, young people Section I: COVID and dealt with the challenges of remote education, potentially struggling to log onto classes or to Children’s Mental Well-Being concentrate in shared rooms and crowded homes. Dr. Tom Insel, former director of the National Many coped with isolation through social media and Institute of Mental Health, observed that the COVID increased screen time, which researchers link to pandemic has impacted populations differently disruptions in sleep patterns that can impact mental depending on their age. Mortality from the pandemic health.7 In addition, the pandemic coincided with is largely concentrated among adults beyond the age a significant and emotionally challenging national of 50. The pandemic’s psychological consequences, reckoning around racial justice. however, have fallen most heavily on children and Meanwhile, COVID affected the ability of young youth under the age of 25. Children and youth people to receive care and of the mental health are more likely than other age groups to display system to deliver that care. For some children and moderate to severe anxiety and depression as a adolescents receiving mental health services, the result of the pandemic.4 Surveys and hospital data pandemic disrupted treatment. At the same time, it also point to spikes in mental distress among many pushed care givers to their limit. California’s Surgeon children and youth. “It’s important to understand,” 6 | LITTLE HOOVER COMMISSION Defining Children’s Mental Health and Mental Health Disorders According to the Centers for Disease Control and Prevention, “Being mentally healthy during childhood means reaching developmental and emotional milestones and learning healthy social skills and how to cope when there are problems.” Mental health disorders, in turn, “are serious changes in the way children typically learn, behave, or handle their emotions, which cause distress and problems getting through the day.”8 Mental health exists on a continuum: children who do not have a mental health disorder may not be equally well; children with a mental health disorder can vary in how they are coping with that disorder. The term “mental health disorder” is a broad term that encompasses mood and anxiety disorders, including depression, neurodevelopmental disorders like ADHD and autism, and mental illnesses like schizophrenia. Studies suggest that approximately 13-20 percent of children experience a diagnosable mental, emotional, or behavioral disorder in a given year; prevalence of mental health disorders among children and adolescents appears relatively similar around the world.9 Estimates further suggest that 7-8 percent of children in California are likely to have a serious mental or emotional heath disorder, one which substantially interferes with their functioning in family, school, or community activities.10 Approximately half of mental illnesses appear by a child’s mid-teens. Studies suggest that low-income children are probably at higher risk of mental health disorders. According to the California Health Care Foundation’s review of 2014 data, 10 percent of children whose families fall below the federal poverty line have a serious emotional disturbance, compared to a California average of 7.6 percent of children.11 On the other hand, studies suggest that young people of color and White young people generally appear to experience mental health disorders at similar rates.12 The California Health Care Foundation reports that approximately 8 percent of Black and Latino children have a serious emotional disturbance, compared to about 7 percent of White children.13 The Public Policy Institute of California, meanwhile, finds that approximately 4 percent of both Black and White teens and 5 percent of Latino teens suffer from severe psychological stress, which correlates with severe mental health conditions like depression; the prevalence of suicidal thoughts was highest among White teens at 6 percent, compared to 4 percent for Black teens and 5 percent for Latino teens.14 Studies generally show that children and adolescents who are foreign-born immigrants tend to have lower rates of mental health disorders than children born in the United States. There are, however, significant disparities in access to mental health services based on race, ethnicity, and immigration status. General, Dr. Nadine Burke Harris, observed: “Our well-resourced, this was a fairly untenable task, and care givers were asked to do the impossible: continue many care givers lost jobs or had to quit in order to working, while also supporting young children support their children who no longer had in-person through e-learning. Even for those who were most school or child care options.”15 COVID-19 AND CHILDREN’S MENTAL HEALTH: ADDRESSING THE IMPACT | 7 The effect of pandemic-induced stress and anxiety Demand for services appears to be increasing and on children’s mental and emotional health is child mental health providers report increases in still unclear. The CDC reported that the number referrals for anxiety and depression. Reporting of pediatric mental-health related emergency suggests that at least some hospitals have seen department visits during the first six months of the spikes in mental distress among children. UCSF pandemic, between March and October 2020, was Benioff Children’s Hospital Oakland saw a 77 percent largely the same as it was for the same period in increase in children seeking emergency mental 2019. Mental-health related emergency department health services between May and December in 2020, visits constituted, however, a substantially greater compared to the same period in 2019—651 children proportion of all pediatric emergency department in 2020, up from 368 in 2019.20 visits, probably reflecting both the impact of COVID and the Existing Crisis pandemic-related stress and anxiety and a decline in visits for other reasons, perhaps as a result of in Children’s Mental Health less time spent outside or participating in team sports.16 More recently, the CDC reported that Child advocates and children’s mental health experts emergency department visits for suspected suicide argue that COVID amplified a preexisting crisis in attempts began to increase among adolescents in children’s mental health. Suicide is now the second May 2020. Between February 21 and March 20, 2021, leading cause of death among people aged 10-24 and emergency department visits for suspected suicide is responsible for more childhood and adolescent attempts were almost 51 percent higher among girls deaths than cancer and heart disease combined. In aged 12-17 than they were for the same period in California, mental illness is also the leading reason 2019. Emergency department visits for suspected for hospitalization among children.21 “We were,” Dr. suicide attempts were almost 4 percent higher for Tom Insel observed, “in a bad way even by 2019, and boys aged 12-17.17 with COVID we have gotten to an even worse point.”22 Although data on rates of mental and emotional The pandemic created a perfect distress among young people can vary among surveys, studies consistently point to deterioration in storm of stress, anxiety, and child and adolescent mental and emotional health:23 trauma. ◊ The State Auditor reported in September 2020 that the number of youth suicides in California There is other evidence suggesting that COVID has increased by 15 percent from 2009 through 2018 had a major impact on many children’s mental (from 163 to 188). Incidents of youth self-harm and emotional well-being. In October 2020, a Jed requiring medical attention increased by 50 Foundation national study found that almost a third percent during the same period (from 10,861 to of parents surveyed (31 percent) reported that their 16,314).24 child’s emotional health was worse than before COVID-19.18 A national survey conducted by J.C. ◊ The federal Substance Abuse and Mental Health Services Administration reports that the average Mott Children’s Hospital in Michigan in January 2021 annual percentage of youth aged 12-17 in further found that 46 percent of parents had seen a California who experienced a major depressive decline in their teenaged child’s mental health since episode increased from 8.1 percent in 2004-2007 the start of the pandemic.19 to 14 percent in 2016-2019.25 8 | LITTLE HOOVER COMMISSION ◊ The most recent iteration of the California Healthy The sources of increasing rates in depression, self- Kids Survey, conducted between fall 2017 and harm, and suicide, as well as in the incidence of spring 2019, found that the percentage of 7th conditions like autism and ADHD, are still unclear.27 graders reporting chronic sadness increased The United States has, however, faced a broad crisis from 25 percent in 2011/13 to 30 percent in in behavioral health for several decades. “Deaths 2017/19. The percentage of 11th graders reporting of despair”—deaths from suicide, drug overdose, chronic sadness increased from 33 percent to 37 and alcoholism—have doubled nationally since the percent.26 mid-1990s, leading to the first drop in American Social Media, Children’s Mental Health, and the COVID Pandemic Although studies associate heavy social media use with poor teen mental health, social media has also proved to be a “lifeline” for many teens and adolescents during the pandemic, one that allowed them to remain in contact with friends and combat loneliness and isolation. One national survey found that more than half of young people aged 14 to 22 reported that social media has been very important to them for staying connected with friends and family. This same survey also found that social media has played a supportive role for some with mental health challenges: nearly 30 percent of young people with moderate to severe depression reported that social media was very important for helping them feel less alone, compared to 13 percent of young people without depression.28 Studies suggest that social media’s relationship to young people’s mental health varies with the amount and type of use. Although the relationship between causation and correlation is not certain, researchers find that teenagers who spend more time on social media—three hours a day or more— are more likely to display symptoms of depression.29 Conversely, moderate and “active” use of social media to connect and interact with friends and peers, as opposed to compulsively scrolling through content, may be protective for mental well-being.30 More generally, social media can also expose young people to racist, sexist, homophobic, or bullying comments and content.31 Several social media companies have taken steps to help users protect their mental health, like offering them the option to hide “like” counts or filter out abusive replies to posts, as well as linking users to mental health resources.32 Collaboration with social media companies will probably also be essential for facilitating access to the Behavioral Health Services Virtual Platform that will be developed as part of the Children and Youth Behavioral Health Initiative. Much appears still unknown, however, about social media’s impact on children’s mental health, what measures can most effectively help to mitigate potentially negative effects, and how social media can best be used to support young people’s mental well-being. Studies observe, for example, that it can be hard for some teens to take a break from streams of personalized contact, even when they use apps that prompt them to do so.33 Education and awareness for young people and parents around healthy social media use and habits will probably continue to be critical. COVID-19 AND CHILDREN’S MENTAL HEALTH: ADDRESSING THE IMPACT | 9 life expectancy in a century and taking a heavy economic and physical health effects. It is also toll on less well-educated Americans and their probable that the pandemic will have a significant, communities.34 Some researchers further point long-term impact on the well-being of some children to technology and social media as contributing to and adolescents. decline in mental well-being among children and AN UNEQUAL IMPACT youth, observing that rise in youth suicide and As with its physical health and economic impacts, self-harm appears to coincide with the expansion COVID’s effect on children’s mental well-being is of social media. Although the relationship between likely uneven. There is considerable variation in how social media and mental health is debated, studies children experienced the pandemic and additional correlate heavy social media use, decreased variation in how they responded to it based on face-to-face interactions, and cyberbullying with family circumstance and social environment. The increased risk of depression.35 Environmental factors, presence of trusted caregivers and stable, supportive including parental age at conception and exposure environments, for example, can buffer the impact to pollutants, can impact children’s mental and of adversity and has probably helped many young emotional development and may also contribute people cope with the pandemic’s challenges.38 to increasing prevalence of certain mental health conditions.36 It is probable that the pandemic Yet, beyond the economic, social, and technological will disproportionately impact developments that are driving anxiety and depression, witnesses emphasized that the crisis in the mental and emotional mental health is also the result of failure to support well-being of children from mental and emotional well-being and to deliver care to those in need. According to Dr. Insel, “We communities of color and low- should think of this as a crisis of care, manifested income communities, which as high rates of incarceration, homelessness, and have borne the brunt of the mortality.”37 This point holds for children and youth, as well. Increasing rates of suicide, self-harm, and pandemic’s economic and mental distress among children and youth indicate physical health effects. that they are not getting the support they need or the care they require for treatable mental health conditions. Although the pandemic led to widespread feelings of depression and loss among children, most Understanding COVID’s children will probably ultimately recover. For many Impact children whose mental and emotional health have been impacted by the pandemic, return to school COVID likely exacerbated the preexisting and and social reopening likely will bring substantial ongoing challenges around children’s mental and improvement. emotional well-being. Moreover, it is probable that the pandemic will disproportionately impact the Other children, however, may need more time, mental and emotional well-being of children from support, and investment to bounce back.39 The communities of color and low-income communities, pandemic’s physical health impact has fallen most which have borne the brunt of the pandemic’s heavily on communities of color, with the result 10 | LITTLE HOOVER COMMISSION as a result of household stress, as well as material impacts from income loss.44 Social Determinants of Mental Health For many children from low-income families and communities of color, as well as children in rural The impact of unemployment on children’s communities, COVID has exacerbated social, mental well-being illustrates the role of social economic, and environmental factors that increase determinants in children’s mental health. risk of mental health challenges. Currently, only Social determinants of mental health refer limited data exists on COVID’s impact on young to the socioeconomic and environmental people’s mental health that is disaggregated by factors that shape mental well-being. By some location, race and ethnicity or by family income estimates, medical care may only account level. Nevertheless, initial surveys suggest the young for twenty percent of health outcomes, people who have had family members sickened by with behaviors, socioeconomic factors, and COVID, whose family members lost jobs as a result environmental circumstances predominately of COVID, and who worry that their families will not shaping health outcomes.40 This applies also have enough to eat are indeed more likely to have to individuals’ mental health.41 Poverty, for symptoms of depression than those young people example, exposes families to a variety of whose families were less directly affected by the sources of stress, including food and housing pandemic.45 Meanwhile, the pandemic, remote insecurity, that can harm children’s mental education, and social distancing also intensified well-being; mental health providers observed isolation for rural and mountain communities.46 that a parent struggling to keep the lights on or avoid eviction is unlikely to be able to LONG-TERM CONSEQUENCES support their child’s emotional well-being as There is reason to believe that initial indications of fully as they would if their basic needs were COVID’s toll on young people’s mental well-being will met.42 Similarly, the experience of racism and ultimately manifest as mental and emotional health perceived discrimination can impact children’s challenges. Toby Ewing, Executive Director of the mental health, as can childhood exposure to Mental Health Services Oversight and Accountability violence or substance abuse.43 Commission, observed that the mental health impacts of natural disasters and traumatic events usually play out over a three-to-five year trajectory.47 that children from those communities were most Moreover, the pandemic’s sustained and often likely to have had family members sickened by severe impact on children’s mental and emotional COVID and to have lost family members to the health may have even longer-term ramifications, pandemic. Children of color were also most likely which California will be living with for years to come. to endure anxiety over the loss of employment and Prolonged exposure to stress and adversity can income. Job losses fell most heavily on low-income have significant consequences for children. “An workers, who are disproportionately Black and overwhelming scientific consensus,” explains Surgeon Latino, and this economic impact will probably affect General Dr. Burke Harris, “demonstrates that children’s mental health, as well. One study found cumulative adversity, particularly during critical and that a 5 percentage-point increase in the national sensitive developmental periods, is a root cause to unemployment rate during the Great Recession some of the most harmful, persistent and expensive increased the probability of “clinically meaningful health challenges facing our nation.”48 child mental health problems” by 35 to 50 percent, COVID-19 AND CHILDREN’S MENTAL HEALTH: ADDRESSING THE IMPACT | 11 Studies of the impact of adverse childhood it has further disrupted access to sources of mental experiences (ACEs) show that severe or chronic and emotional support. Dr. Burke Harris observed adversity and stress can have lasting and severe that the pandemic, “has been unique in its effect psychological and physical impacts. Research of acting as a major stressor while simultaneously suggests that individuals who experience multiple cutting off access to many of the usual sources ACEs are less likely to be employed and are at of buffering care necessary to help children and increased risk of heart disease, stroke, and suicide.49 parents regulate their stress responses, such as Chronic stress can further disrupt child development grandparents, teachers, coaches, faith leaders and, around executive functioning, affecting children’s in some cases, child care providers.”51 Evidence ability to regulate emotions and behaviors, pay that incidents of domestic abuse have risen during attention, and start and complete tasks. This can the pandemic and that rates of substance abuse contribute to subsequent mental or behavioral have increased further suggests that the pandemic health conditions, as well as to challenges in the may also have heightened some children’s risk of classroom.50 exposure to other adverse experiences.52 Although COVID is not one of the traditional adverse Dr. Burke Harris warned of the long-term experiences included in ACEs screenings, it has consequences of the toxic stress and trauma become a significant stressor for many children and stemming from the COVID pandemic: “Unless we ACEs and ACEs Aware Adverse childhood experiences refer to potentially traumatic events that occur during childhood and may include: experiencing physical, sexual or emotional abuse, neglect, parental separation or divorce, substance abuse by a household member, witnessing domestic violence, having an incarcerated household member, or having a household member with mental illness. ACEs can have lasting psychological and physical impact. Trauma and chronic stress can lead a child’s physiological stress response, which includes the release of stress hormones, increase in heart rate and blood pressure, and changes in brain activity, to activate too intensely or for too long. This toxic stress response can impact how genes are read, how the body’s immune and metabolic systems function, and lead to changes in brain development, affecting attention, learning, and decision-making.53 Exposure to four or more categories of adverse childhood experience is associated with a doubling of risk of heart disease, cancer and stroke. Exposure to ACEs is also associated with greater likelihood of experiencing mental health conditions, including depression, anxiety, and eating disorders, and of engaging in risky behaviors. The ACEs Aware Initiative is a first-of-its-kind statewide effort to promote screening for childhood trauma and treat the impacts of adverse childhood experiences. The initiative offers Medi-Cal providers training in screening for ACEs and for providing trauma-informed care. Under ACEs Aware, California offers qualified providers a $29 payment for conducting screenings for ACEs for Medi-Cal patients; providers must have completed ACEs training in order to qualify for payment.54 The initiative has already trained more than 17,000 providers. 12 | LITTLE HOOVER COMMISSION intervene robustly, the consensus of scientific Too few children receive care, and when they do, evidence suggests that we are very likely to see an too often it occurs too late. In the absence of early unprecedented increase in toxic stress. Some of intervention and treatment, mental health needs and this will likely manifest in the short term through conditions can intensify and potentially metastasize behavioral health, mental health, and learning into mental health crises. Limited availability of challenges. Some of it may manifest later in terms mental health providers and thus limited access of higher incidents of cardiovascular disease, to timely care probably contributes, for example, incarceration, cancer, stroke, and other health to higher rates of child suicide and self-harm in conditions.”55 Early detection and early intervention California’s rural and northern counties, compared to can prevent and mitigate the impact of toxic stress coastal and more urban counties.60 and promote healing. The social and economic costs Moreover, children of color and children from low- of failing to address COVID’s impact, on the other income families, who, as noted above, have been hand, will likely be significant. Research suggests that disproportionately impacted by COVID, tend to prior to the pandemic, the annual cost of ACEs in access mental health services at lower rates than California exceeded $100 billion as a result of health their peers.61 Nationally, the Substance Abuse and care spending and lost years of productive life due to Mental Health Services Administration reports death, disability, and incarceration.56 that about half of White youth aged 12-17 with Section II: Barriers to depression received care in 2019; conversely, only about 36 percent of Black or Latino youth Addressing Children’s Mental with depression received care.62 Within California, Health Needs meanwhile, the Department of Health Care Services reports that Latino and Black beneficiaries under the Even before the pandemic, California’s mental health age of 21 access mental health services from Medi- system failed to fully serve children and youth with Cal managed care plans at substantially lower rates mental and emotional health needs. Based on its than White beneficiaries, with Black beneficiaries analysis of data from 2018, the Commonwealth Fund accessing services at only half the rate of White found that only 70 percent of California children beneficiaries and Latinos accessing services at less aged 3-17 received mental healthcare when needed, than 60 percent the rate of their White peers.63 compared to 82 percent of children nationally. California ranked 48th nationally in terms of children A number of factors contribute to young people not receiving needed treatment or counseling for mental receiving needed mental health services. Children health.57 Levels of treatment for specific conditions, of color and children from low-incomes families can meanwhile, can be even lower, with Mental Health confront linguistic, cultural, and social barriers to America reporting that only a quarter of youth in accessing mental health care.64 A number of systemic California with severe depression receive consistent and structural barriers, which are discussed below, treatment.58 The percentage of eligible children can also prevent children in need from accessing who access mental health services in California also mental health services. appears to be well below the level expected based on estimates of the number of children with mental In addition, child advocates and health experts health conditions who would benefit from treatment identified a key, foundational reason for challenges and care.59 around children’s mental health care: California, like many states, has historically treated mental COVID-19 AND CHILDREN’S MENTAL HEALTH: ADDRESSING THE IMPACT | 13 health as different from physical health, a product of traditional stigma and misunderstanding around Substance Use Disorders mental health. Ted Lempert, President of Children and Child Mental Health Now, observed that there is a broad social and political understanding around the importance of Mental health and substance use disorders children’s physical health such that when a child are often co-occurring. Research suggest as breaks an arm, care is available to set the arm. many as 60-to-75 percent of adolescents with There is also a general understanding that children substance use disorders also have mental should receive vaccines and physical wellness checks, health conditions.68 Children who have even if application is uneven. Yet, no such common experienced a major depressive episode are understanding around the significance of mental and twice as likely to begin using alcohol or an emotional health for children’s well-being exists.65 illicit drug.69 For children and adolescents with mental health conditions, substance abuse This situation began to change before COVID as a may be a coping mechanism or may begin as result of concern about increasing rates of child and an attempt to self-medicate. adolescent suicide and self-harm; the pandemic further raised awareness around the importance of A challenge for meeting child and adolescent mental health, especially children’s mental health. mental health needs is that addressing those California is poised to make historic investments in needs often means also treating issues of children’s and young people’s mental well-being. substance abuse. Yet fewer than 10 percent Systemic and structural weaknesses in California’s of adolescents with substance use disorders child mental health system may, however, impede receive treatment.70 efforts to address the pandemic’s impact on children’s mental health. supported mental health screening and treatment for California’s Child Mental Medicaid-eligible children under 21 years of age.71 Health “System” California splits responsibility for mental health California’s mental health system is not really a services for Medi-Cal eligible children between 24 single system; rather it is a “mosaic” or “patchwork” managed care plans (MCPs) and 56 largely county- of systems, plans, agencies, and programs.66 It based mental health plans (MHPs) (See Figure 1). is decentralized, fragmented by provider, and Both MCPs and MHPs contract with the Department bifurcated based on the severity of an individual’s of Health Care Services (DHCS) to provide services to condition. Medi-Cal beneficiaries. Managed care plans provide a limited set of mental health services for screening The majority of Californians under the age of 21 who and treating “mild to moderate” mental health need mental health services are treated through the conditions. Mental health plans, meanwhile, provide public mental health system. Although only a third of specialty mental health services (SMHS), which cover Californians overall are covered by Medi-Cal, more a wider range of mental health services, and are than half of California’s children and adolescents responsible for treating more severe mental health are covered by the program.67 In addition, the conditions. federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) entitlement provides federally- This report focuses on this public system of mental health, which serves the lower income children 14 | LITTLE HOOVER COMMISSION Figure 1: California’s Youth Mental Health System is a Mosaic of young people are of young people are covered covered by Medi-Cal. by private insurers. The Department of Health Care Services (DHCS) administers California’s Medicaid program – Medi-Cal. DHCS contracts with MHPs and MCPs to deliver Medi-Cal mental health services. Schools may bill Medi-Cal for eligible school-based mental health services. Are responsible for treating more Provide services for mild to moderate Level of services and coverage can severe mental health conditions. mental health conditions. vary among commercial insurers. Schools may partner with MHPs and MCPs to provide school- based mental health services. Schools may contract with community agencies to deliver school-based mental health services. Mental health plans and managed care plans may contract with community agencies to deliver services. Note: This is a simplified illustration of the basic structure of California’s child and youth mental health system. It does not include fee-for-service delivery options, which, as of 2018, served about 10 percent of children enrolled in Medi-Cal, including slightly under half of children in foster care or with a probation placement. It also does not reflect that managed care plans may subcontract to other health plans to deliver services. COVID-19 AND CHILDREN’S MENTAL HEALTH: ADDRESSING THE IMPACT | 15 who are likely to be disproportionately impacted by central data repository to even begin to provide COVID. accountability for the state.”73 Children who are not eligible for Medi-Cal are There is, witnesses observed, no “common generally covered by one of more than 50 framework” in California for children’s mental commercial insurers, which provide varying levels health that links the various public and commercial of mental health services and coverage.72 Witnesses systems and providers through shared goals, noted that mental health is an unusual case in standards, and approaches.74 Instead, there is American health care—publicly supported mental considerable variation in support and care for health services can be more comprehensive than children’s mental health. Lishaun Francis, Associate those provided by commercial insurers, though Director for Health Collaborations at Children legislative efforts have sought to expand commercial Now, observed that California has invested in full- plans’ coverage of conditions and services. service clinics, community schools, school-county Commercial plans also generally do not cover school- mental health partnerships, and youth-led mental based mental health services. The Children and health approaches, in addition to other evidence- Youth Behavioral Health Initiative includes legislative based strategies for supporting children’s mental language that would establish parity across the health. Yet, while there are highly innovative and public and private systems in supporting mental notably successful programs for children’s mental health services in school settings, which child mental health around the state, state government has health advocates and providers suggest is important generally failed to commit to particular models: for more fully meeting children’s mental health “California’s focus constantly shifts in its approach needs. to implementing policy—rather than doubling down on any of the initiatives we create, we move on to Barriers to Care and Services the next, spreading out our resources in a way that becomes untenable and ultimately less impactful for Witnesses testifying before the Commission California’s kids.”75 emphasized that addressing COVID’s impact will require attending to existing weaknesses in Counties vary, moreover, in the resources they have California’s system for supporting young people’s available for supporting mental health systems mental health. and in the extent to which they prioritize children’s mental health services, with the result that availability DECENTRALIZATION of particular services and programs can differ Mental health experts and advocates repeatedly depending on where a child lives. Meanwhile, state observed that a critical weakness in California’s child government has struggled to develop a consistent mental health system lies in the highly decentralized mechanism for identifying, scaling, and replicating character of the system and in the absence of demonstrated models of care. consistent central leadership. “Unlike almost any other state,” Dr. Tom Insel observed, “California does FRAGMENTATION not have strong central leadership around behavioral In addition to the challenges of decentralization, child health. There is no person, there is no department, mental health providers reported that California’s there is no group that is setting outcome goals for fragmented mental health system creates barriers the mental health systems in California. There is to providing and accessing care. Mental health no one trying to integrate this; we do not have a practitioners observed that counties employ 16 | LITTLE HOOVER COMMISSION Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program The federal Early and Periodic Screening, Diagnostic, and Treatment program entitles children and young adults up to 21 years of age covered by Medicaid to a broad range of diagnostic and treatment services as may be necessary to “correct or ameliorate defects and physical and mental illnesses and conditions.” The entitlement has its origins as a Great Society program, one which recognized that children from low-income families are more likely to have health conditions and developmental delays and that early identification and intervention can help address those health issues.76 In addition to services related to identifying and treating mental health issues, the EPSDT mandate covers a range of health services, including well-child visits, oral health, and vision care. Although the EPSDT mandate constitutes a broad entitlement to medically necessary health services, many eligible young people in California who would benefit from mental health care do not appear to receive services to which they are entitled. Young people in California access EPSDT services at rates that are below the national average—in 2017, 49 percent of eligible children in California accessed at least one preventive service covered by EPSDT, compared to a national average of 58 percent.77 Several factors, as discussed in this report, contribute to relatively low rates of access for EPSDT mental health services, including: diagnostic requirements for accessing services; capacity and workforce shortages; challenges in coordinating services between managed care plans and mental health plans; as well as, lack of awareness on the part of families of children’s entitlement to EPSDT services. Funding and Medi-Cal financing further complicate the provision of EPSDT services. EPSDT is an uncapped mandate—children are entitled by federal law to services if they are determined to be medically necessary. Yet, while the EPSDT program provides federal reimbursement for preventive and treatment services, a certified public expenditure is necessary to generate that reimbursement. Effective implementation of EPSDT thus requires non-federal dollars, but funding streams may be inadequate to meet rising need, as in the case of some counties’ funding for EPSDT services provided under 2011 Realignment, or subject to competing demands, as in the case of MHSA funding.78 Advocates nevertheless observe that there are opportunities for more fully leveraging expenditures to drawdown federal dollars, including by increasing managed care plans’ provision of EPSDT services and by maximizing reimbursement for school-based mental health services.79 different screening instruments, require different Children’s Hospital Association estimates that forms of documentation, and adopt different between 30 and 50 percent of providers’ time is approaches to contracting with providers, creating required for administrative purposes, with variation significant administrative burdens and barriers to in requirements and documentation contributing delivering needed services. Christine Stoner-Mertz, significantly to this burden.81 CEO of the California Alliance of Child and Family The bifurcation of services between managed care Services, observed that this complexity imposes a plans and mental health plans adds another hurdle substantial burden on providers.80 The California COVID-19 AND CHILDREN’S MENTAL HEALTH: ADDRESSING THE IMPACT | 17 that can act as a barrier to timely care. Dr. Brian of severity, rather than to support good mental and Distelberg of Loma Linda University Children’s emotional health. Indeed, the State Auditor recently Hospital noted, “even within a county services are found that nearly half of children served by managed disjointed because different levels of mental health care plans did not access EPSDT preventive health care get allocated to different resources. It’s very services, including those for mental health.84 complicated for a patient to understand that; it’s very According to providers and experts, one key complicated for providers who are professionals to manifestation of the fail first quality of mental health execute this complicated process.”82 care in California is its diagnosis-driven character—a child must be diagnosed with a specific mental “Unlike almost any other state, illness or condition in order to access specialty California does not have strong mental health services. Advocates argue that this requirement contravenes the EPSDT mandate, which central leadership around entitles children on Medicaid to treatment that is behavioral health. There is no medically necessary for their health and well-being. As a result of the diagnosis requirement, at-risk person, there is no department, children may be unable to access needed services there is no group that is setting until their condition deteriorates to the point that outcome goals for the mental they can be diagnosed with a specific condition.85 health systems in California.” CAPACITY Experts, witnesses, and providers universally agreed - Dr. Tom Insel, Chair of the that there are not enough mental health counselors Steinberg Institute Board of or psychiatrists trained to work with children and Directors youth. Dr. Bryan King, Vice President for Child Behavioral Health at University of California, San Francisco Benioff Children’s Hospitals, reported that For example, a managed care plan might recommend while significant demand for services exists, there a patient for specialty mental health services, but is a “breathtaking lack of providers.”86 Shortages in county mental health plans have no obligation to the child mental health workforce are a national— accept that patient for service if their own evaluation and international87—challenge. The number of does not indicate that the individual’s needs meet child psychiatrists in California in proportion to diagnostic thresholds. Although managed care plans population—10 per 100,000 children, as of 2016— and mental health plans enter into MOUs to define corresponds to the national average, but is half their interactions, the challenges of information that of Connecticut, Massachusetts, New York, and sharing and of case management across systems can Rhode Island, states which have lower percentages of limit effective collaboration.83 children with untreated mental health conditions.88 More broadly, Christine Stoner-Mertz described the FAIL FIRST challenges facing California’s child mental health Providers and advocates observe that California’s workforce: “The children’s mental health system in approach to children’s mental health has historically California continues to struggle with low wages, high rested on a “fail first” model: the system of children’s turnover, and limited racial and ethnic diversity in the mental health is structured to respond when a child’s workforce.”89 mental health has deteriorated to a particular level 18 | LITTLE HOOVER COMMISSION The mental health workforce is unrepresentative of investment in children’s mental health. Some, the populations it serves and unequally distributed however, also argued that while additional by geography. The Healthforce Center at University investment is needed, the structure and deployment of California, San Francisco, reports, based on its are as important as the amount. analysis of American Community Survey data from Multiple funding streams support California’s system 2011-2015, that only 8 percent of psychologists, of public mental and behavioral health, including 23 percent of counselors, and 24 percent of social federal Medicaid dollars, funding from the Mental workers in California are Latino. In addition, only Health Services Act, and funding from 1991 and 2011 4 percent of psychiatrists are Latino and only 2 Realignment, as well as state and federal grants percent are Black.90 Critically, lack of diversity (See Figure 2). In addition to funding for the public and representation in California’s mental health mental health system, many local education agencies workforce can create challenges around building (LEAs) may deploy their funding, as well as state and trust and delivering culturally-competent care. federal grants, to support mental health services for Moreover, many clinicians do not accept Medi-Cal, their students. Schools providing mental health care raising further barriers to access for low-income can also bill Medi-Cal for a limited range of services communities.91 In addition, per capita ratios for through the Local Education Agency Medi-Cal Billing psychiatrists, psychologists, and social workers in Option Program (LEA-BOP), though less than half the San Joaquin Valley and Inland Empire are half of school districts participate in this program, and statewide ratios, or lower. can further bill Medi-Cal for costs associated with Inadequate physical capacity for care and treatment administering Medi-Cal through the School-Based exacerbates these workforce shortages, especially Medi-Cal Administrative Activities program (SMAA).94 for children with severe needs. Dr. Brian Distelberg Witnesses and child mental health experts identified reported that the number of inpatient psychiatric two key ways in which current structures of mental beds in California is approximately a third of the health funding can act as barriers to meeting number that SAMHSA recommends.92 Moreover, children’s mental health needs and expanding there are no inpatient psychiatric beds in 42 counties services: or in any county north of Napa County, meaning that many children with severe mental health ◊ First, supporting child mental health and providing conditions may have to wait to access inpatient mental health services depends on braiding and services or may not be able to access those services blending a range of funding sources, especially close to home.93 Dr. Distelberg related that COVID with the goal of leveraging state and local funding has made this bad situation even worse: residential to maximize federal Medicaid draw-downs. units have had to close if a patient were diagnosed The complexity and administrative burdens of with COVID, exacerbating the shortage of inpatient maximizing reimbursements can prevent counties facilities. Hospitals resorted to “emergency room from doing so, as well as dissuading school boarding,” wherein children remained in emergency districts from seeking to reimburse eligible mental departments, potentially for more than 10 to 15 health expenditures.95 days, until an inpatient bed became available, with negative impact on their treatment and recovery. ◊ Second, child mental health advocates and providers point to specific challenges arising out FUNDING of the 2011 Realignment of EPSDT funds. They Most child mental health advocates and providers observe that distribution of Realignment revenues emphasized the need for more substantial COVID-19 AND CHILDREN’S MENTAL HEALTH: ADDRESSING THE IMPACT | 19 Figure 2: Funding Streams in the Public System of Mental Health Source: Legislative Analyst’s Office, Overview of Funding for Medi-Cal Mental Health Services (February 26, 2019). Retrived from: https://lao.ca.gov/ handouts/health/2019/Funding-Medi-Cal-Mental-Health-Services-022619.pdf. Note: This figure shows total mental health services funding, for both children and adults. It is not possible to determine what percentage of this funding goes to children. 20 | LITTLE HOOVER COMMISSION was determined largely based on historical county spending and thus tends to provide more Multi-Tiered Systems of funding for counties that spent heavily on mental Supports health services at the time of Realignment, and less funding for those that spent less.96 Providers MTSS is a framework for deploying evidence- further observed that Realignment can essentially based interventions and supports in school cap county EPSDT expenditures, putting pressure settings. With respect to supporting student on the community agencies that contract with mental health through a MTSS framework, a county mental health plans to deliver services.97 school might provide preventive services and social emotional learning to all students (Tier What Is the Role of Schools? 1); targeted interventions and supplemental support, like social skills groups, for at-risk Child mental health advocates and educators students (Tier 2); and intensive services, emphasized that schools are essential to addressing including therapy or wraparound services, children’s mental health needs. Alex Briscoe, Principal for students with the greatest mental health of the California Children’s Trust, observed, “Children needs (Tier 3). 8-to-18 go to the doctor the least frequently, but that is when about 60-to-70 percent of mental California has supported the implementation illness manifests.” Yet those same children go to of MTSS approaches for creating inclusive and school, so bringing mental health care to schools positive learning environments that meet the may significantly expand access to services. Schools needs of all students through funding for the play an important role in identifying mental and Scale Up MTSS Statewide (SUMS) Initiative, behavioral health issues, since schools are where which is administered by the Orange County there are eyes on children.98 Students are also Department of Education. This initiative has much more likely to seek mental health services provided grants to approximately 400 local when those services are offered at a school site and educational agencies to implement integrated studies further suggest that school-based mental multi-tiered systems that support student health services can improve student mental health academic learning, social emotional learning, and academic outcomes.99 Moreover, multi-tiered and mental health.103 systems of support (MTSS) frameworks provide a promising model for developing comprehensive school mental health systems.100 For all these rates of exposure to trauma and ACEs, have also reasons, the Mental Health Services Oversight and historically been more likely to be suspended from Accountability Commission recently recommended school than White students, though California has that California establish schools as “centers of recently made important steps to address disparities wellness.”101 in school discipline.104 Looking forward, Pia Escudero, Executive Director of the Division of Student Health An emphasis on schools as places of healing and and Human Services at Los Angeles Unified School wellness is especially important as California District, suggested that a focus as students return addresses COVID’s unequal impact. Studies suggest to school in the fall will be to create “healing” school that children who have experienced trauma are more environments that support students’ mental health likely to be subject to disciplinary action at schools.102 and to catch students who may be at risk before they In addition, students of color, who often have higher need higher levels of care.105 COVID-19 AND CHILDREN’S MENTAL HEALTH: ADDRESSING THE IMPACT | 21 School-based mental health resources and approaches help to equip every student to succeed, approaches take a range of forms. Pupil personnel while also providing opportunities for prevention services (PPS) professionals—school counselors, and early intervention, as well as more intensive school psychologists, and school social workers— services for students who need them.110 Yet building provide services that support student well-being out a full, effective MTSS framework and continuum and development, including, in the case of school of care can be challenging and administratively psychologists, providing psychological counseling. burdensome. Schools with programs around social Many schools and local educational agencies are also emotional learning and positive school climate working to establish more positive school climates may not have linkages to more intensive clinical and to develop or introduce curricula that build social services.111 Conversely, community agencies working emotional learning among students.106 For example, with schools noted that school-based mental health as of 2019-2020, more than 2,500 schools in programs can sometimes focus on the most intensive California have implemented the Positive Behavioral and expensive interventions, without fully building Interventions and Support (PBIS) approach, a data- out more universal supports. based MTSS framework for reducing disciplinary Overall, fewer than half of California’s elementary incidents and improving school culture.107 students have access to school-based mental health Some school districts operate significant, specialized services, though access improves substantially student mental health programs. Los Angeles Unified with grade level. Nearly 90 percent of high schools School District, for example, makes mental health offer mental health services, at least through services available through 15 wellness centers, school counselors and school psychologists.112 Yet operated by federally qualified health centers, as schools see the same workforce challenges as the well as additional school-based health clinics, and mental health system. As of 2018-19, California’s employs more than 400 school mental professionals. K-12 schools employed one school counselor for The district is working to hire an additional 500 every 626 students, one school psychologist for psychiatric social workers in order to respond to every 1,041 students and one school social worker COVID’s impact.108 In Alameda County, a longstanding for every 7,308 students.113 In each case, California partnership exists between the Health Care Services does not meet recommended ratios, with the Agency and school districts around student health; result that the ability of pupil personnel services Alameda County’s School-Based Behavioral Health professionals to meet individual student’s needs Initiative reaches more than 40 percent of schools may be highly limited. In part, this is the result of in the county.109 Other districts have entered schools and districts making decisions about how into partnerships with county behavioral health to allocate scarce resources and balancing different departments or community agencies to provide priorities; small and rural districts face especially school-based services. severe capacity constraints around providing mental health services.114 On the other hand, leadership in There is, however, considerable variation in the some districts and schools may not see supporting depth of services contained in school mental health students’ mental health as part of their school’s programs and in districts’ focus on student mental educational mission. well-being. Ken Berrick and Robin Detterman from Seneca Family of Agencies commented Partnerships with county behavioral health on the importance of providing a continuum of departments or with community agencies can care at schools. They observed that whole school expand the availability of clinicians and counselors at 22 | LITTLE HOOVER COMMISSION schools and expand access to higher levels of mental together with federal recovery and stimulus funding, health care. According to the California Behavioral gives state government the resources to address Health Directors’ Association, 85 percent of counties COVID’s impact on children’s mental and emotional currently provide school-based behavioral health well-being, address many of the long-standing services.115 Yet developing cross-agency partnerships barriers that prevent children from receiving care that work across the educational and health systems and support, and implement preventive programs to is often challenging. Partnerships between schools alleviate the triggers for mental health conditions. and county systems raise questions of turf: who In the course of this study, witnesses identified should take the lead in responding to children’s a number of steps that California can take to mental health needs, and how should funding be address COVID’s impact on children’s mental health, distributed? School-based mental health partnerships including: also require cooperation across professional cultures: pupil personnel service professionals and mental health clinicians operate according to different professional standards and under different Telehealth legal standards regarding privacy and the sharing of information (FERPA vs. HIPAA).116 From the There has been a dramatic shift to telehealth perspective of schools, a key issue is whether outside as a result of COVID. Practitioners report mental health clinicians “speak school” and can build that they are now providing a majority of trust with students. In addition, schools may not services via telehealth and that they find have dedicated facilities or welcoming spaces where that telehealth can be equally effective as clinicians can interact with and treat students. in-person consultations. According to Dr. Section III: Addressing the Brian Distelberg, this shift has increased access and utilization, including increasing the Crisis likelihood that patients participate in follow-up appointments and decreasing the number of In recent years, the Governor’s Office, the Legislature, appointments for which the patient does not and state agencies, including the Department of show-up.117 Some providers further observed Education, the Department of Health Care Services, that telehealth makes it possible to speak and the Mental Health Services Oversight and with entire families, facilitating whole family Accountability Commission, have taken a variety care. Studies suggest, moreover, that most of steps to better support child mental health. This young people report being very or somewhat has included funding through the Mental Health satisfied with their telehealth experiences.118 Student Services Act for partnerships between county behavioral health departments and schools to Yet experts also observed that challenges support school-based mental health services, efforts around telehealth remain, including around to raise awareness around the impact of adverse the digital divide, trust, and privacy.119 For childhood experiences and childhood trauma on example, while telehealth can allow clinicians individuals’ well-being, and proposed reforms to to interact with whole families, children who Medi-Cal to remove barriers to services. wish to speak with a clinician privately may have a hard time doing so via telehealth. California is now poised to build meaningfully and substantially on this work. The state budget surplus, COVID-19 AND CHILDREN’S MENTAL HEALTH: ADDRESSING THE IMPACT | 23 ◊ Establishing a larger, more diverse mental health intervention by addressing the social determinants workforce. Witnesses emphasized that training of mental health, especially the impact of poverty peer support specialists, mental health workers and social inequality on mental well-being, and by who have lived experience of mental health encouraging health promoting interventions, like conditions and who can serve as mentors and support for new mothers and children at risk.122 models, and community health workers has Witnesses agreed that eliminating the diagnosis potential to grow the mental health work force requirement for accessing specialty mental health quickly while expanding access to culturally services is a key step toward enabling early competent care. They also suggested that intervention. telehealth approaches can further help to mitigate ◊ Establishing schools as centers of mental wellness. some challenges of access and capacity.120 Although other points of access will also be critical ◊ Expanding the mental health system’s capacity to to supporting children and families, schools are support those with high levels of need. Witnesses likely to be “ground zero” for supporting the encouraged the development of a genuine mental and emotional health of children who have continuum of care for children in need of intensive experienced an extended period of stress, anxiety, care, featuring crisis response mobile units, and trauma.123 Mental health supports will also expanded inpatient facilities, and crisis residential be critical to addressing learning loss and helping services.121 vulnerable children and those most impacted by COVID re-engage with school.124 Witnesses noted ◊ Supporting mental wellness. Witnesses observed that partnerships between schools and mental- that while California must expand its capacity health oriented community-based organizations, to support children with severe mental health including as part of community school models, can conditions, state government should also put help provide students with access to wraparound greater emphasis on prevention and early and comprehensive services.125 Collaborative Health Models/UCSF Benioff Children’s Hospitals Child Psychiatry Access Portal One approach to mitigating the workforce and capacity challenges in children’s mental health care lies in psychiatric telehealth consultations for primary care providers, which give pediatricians essential tools to address basic issues of mental and emotional health. These programs help to bridge the gap between physical and mental health care, assist with early identification and treatment of mental health needs, and incorporate pediatricians into the broader continuum of mental health care. Psychiatric consultation programs for pediatricians in Washington State and Massachusetts appear to have facilitated access to mental health care and allowed child psychiatrists to focus on patients with more complex mental and behavioral health issues.126 University of California, San Francisco Benioff Children’s Hospital has recently launched a new Child Psychiatry Access Portal wherein child psychologists and clinicians work with pediatricians to help address common mental health issues. Through support from philanthropic donations, this program has grown to include more than 70 pediatric practices in the San Francisco Bay Area; it has also entered into agreements with health care providers to expand into the Central Valley.127 24 | LITTLE HOOVER COMMISSION In addition, the Newsom administration has based on the quality of services and not just their launched two major initiatives that have potential cost. This will include expanded opportunities to to fundamentally transform California’s system reimburse for care delivered through value-based of supporting and treating children’s mental care models, which could, for example, support an health: the California Advancing and Innovating expanded role for community health workers in Medi-Cal (CalAIM) proposal and the Children the delivery of children’s mental health. and Youth Behavioral Health Initiative. These ◊ Encouraging closer coordination and cooperation initiatives incorporate many of the proposals listed between managed care plans and mental health above. Together they can reshape how California plans in delivery of mental health services. approaches child mental health, transforming a ◊ Encouraging administrative and clinical integration system that focuses on treating diagnosed mental of specialty mental health services and substance and behavioral health conditions into one that more use disorder treatment services at the county fully supports children’s mental and emotional well- level.130 being, even prior to conditions developing. CalAIM is a complex initiative that consists of CAL AIM renewing with amendment the federal Medicaid The California Advancing and Innovating Medi-Cal waivers under which California administers specialty (CalAIM) proposal is an ambitious and far-reaching mental health services, updating state contracts plan to reform and transform Medi-Cal service with managed care plans, and revising county delivery and financing.128 According to Dr. Tom Insel, monitoring and reporting standards. Development CalAIM is, “the most substantial change to mental or and implementation of CalAIM are ongoing, with the behavioral health in California for the public system Department of Health Care Services submitting its in four decades.”129 Although children’s mental health application for waiver renewal to the federal Centers is not the focus of CalAIM, the initiative nevertheless for Medicare & Medicaid Services in June 2021. DHCS includes key features that address the structural and aims to make revisions to medical necessity criteria systemic issues discussed above, including: for specialty mental health services effective in early 2022, following approval of the relevant waivers. ◊ Eliminating the requirement for diagnosis to Some elements of CalAIM, including integration of access specialty mental health services. The specialty mental health services and substance use Department of Health Care Services intends to disorder treatment services, will take several years to reform criteria for establishing medical necessity, implement fully. shifting from requiring a specific diagnosis to instead basing medical necessity on level of CHILDREN AND YOUTH BEHAVIORAL impairment. This is designed to lower the bar HEALTH INITIATIVE for establishing that treatments are medically The Children and Youth Behavioral Health Initiative necessary under the EPSDT mandate. DHCS aims to develop a comprehensive system of mental further intends to develop standardized, statewide health care for Californians from birth to 25 years assessment tools to determine eligibility for of age. The Newsom Administration proposed services. the Behavioral Health Initiative as part of the May Revision to the 2021-22 state budget; the Legislature ◊ Streamlining reimbursement for county mental subsequently established the initiative through health plans and for specialty mental health Assembly Bill 133 (Committee on Budget, 2021). services with the goal of reducing administrative The 2021-22 state budget allocates approximately burden and providing opportunity to reimburse $4.4 billion in funding for the initiative over the next COVID-19 AND CHILDREN’S MENTAL HEALTH: ADDRESSING THE IMPACT | 25 five years, including about $1.5 billion in both 2021- ◊ School-Linked Behavioral Health Services. The 22 and in 2022-23 and more than $400 million in Children and Youth Behavioral Health Initiative will ongoing funding in 2023-24 and thereafter. build partnerships and capacity statewide around school-based and school-linked mental health The Children and Youth Behavioral Health Initiative services through more than $1 billion in incentive is a capacious program that aims to transform and grant funding for schools, counties, health California’s child mental health system. In the words plans, and community-based organizations. Of of Health and Human Services Secretary, Dr. Mark this funding, $400 million is directed specifically Ghaly, this ambitious initiative seeks to remake to incentives for Medi-Cal managed care plans California’s child mental health system “into one to partner with schools and county systems of that is a world-class, innovative, up-stream-focused, behavioral health to provide school-linked and early intervention-focused ecosystem where we school-based mental health services to students can promise all of our young people that we will be and families. This collaboration could ease access looking out for their emotional and mental health to EPSDT mental health services and support needs, that we will be able to screen them and greater provision of mental health services in assess them in a timely way, and support them with school settings. Partnerships between schools, emerging and existing best practices, in a culturally health plans, and community agencies can also competent and equitable fashion.”131 The Behavioral facilitate Medicaid reimbursement for school Health Initiative includes the following components: mental health services.132 The Behavioral Health Initiative will require that commercial plans ◊ Behavioral Health Services and Supports support school-based mental health services. Virtual Platform. The budget allocates $750 million for the development and implementation ◊ Workforce Development. The budget allocates of a virtual platform that integrates behavioral more than $1 billion in funding to support health services with around the clock access expansion of the behavioral health workforce. In to screening, clinic-based care, and app-based the Newsom Administration’s original proposal support services. This platform will build on a new for the Behavioral Health Initiative, this funding Department of Health Care Services project, the would support the training of 10,000 culturally CalHOPE Program, to create a responsive platform and linguistically proficient behavioral health designed for children, youth, and their families counselors, at varying levels of specialization that provides tiered resources and treatment, and certification, as well as psychiatric nurse while also helping to connect users to community- practitioners, community health workers, and based organizations, wellness programs, and peer support specialists. The initiative will further more intensive in-person services. In addition, expand training program capacity and models the platform will support Pediatric Primary Care and also leverage the existing workforce through and Other Healthcare Provider eConsult services, training for pediatric and primary care providers. which will facilitate consultation between primary ◊ Developing and scaling age-appropriate, care providers and behavioral health specialists. evidence-based programs. The budget provides An outside vendor will develop and manage the grant funding of $430 million to health plans, platform; a portion of funding is delayed until the county systems of health, and community- project achieves appropriate milestones from the based organizations to support evidence-based California Department of Technology’s Project practices. Priorities will likely include programs Approval Lifecycle. that support individuals following a first episode 26 | LITTLE HOOVER COMMISSION of psychosis, drop-in wellness centers, and both and reducing the stigma that can deter children and in-person and telehealth services oriented around adolescents from visiting a school-based clinician. prevention and early intervention. Yet addressing an array of structural weaknesses ◊ Building Continuum of Care Infrastructure. The and barriers simultaneously also creates an initiative budget provides $310 million in grant funding to that will be administratively complex. At the state build continuum of care infrastructure targeted at level, the initiative calls for the participation of the individuals age 25 and younger, with $205 million Health and Human Services Agency, Department of of that funding directed toward supporting mobile Health Care Services, Department of Managed Care, crisis support teams. Mental Health Services Oversight and Accountability ◊ Dyadic Service Benefits. The Behavioral Health Commission, Office of Statewide Health Planning and Initiative will add dyadic behavioral health visits as Development, Department of Public Health, Office a Medi-Cal benefit. Dyadic services refer to care of the Surgeon General, and the Department of that treats children and their parents/families Education. together. The budget includes $800 million in funding support for these benefits over the next The state budget surplus, five years. together with federal recovery ◊ Public Awareness. Finally, the Behavioral Health Initiative includes funding for a public and stimulus funding, gives awareness campaign around mental health, state government the resources adverse childhood experiences, and toxic stress. The campaign will include measures to support to address COVID’s impact on culturally specific engagement and outreach, as children’s mental and emotional well as youth involvement.133 well-being, address many of The Behavioral Health Initiative aims to simultaneously and comprehensively address the the long-standing barriers various systemic and structural barriers that can that prevent children from prevent young people from accessing and receiving receiving care, and implement mental health services. It aims to facilitate access by providing virtual services that both help to make preventive programs to alleviate care more available in rural parts of the state and the triggers for mental health that meet young people where many are—online. It also aims to expand the mental health workforce, conditions. center schools as hubs of wellness, develop a fuller continuum of care, and expand awareness around Several initiative components will involve third-party the importance of mental health. In addressing vendors, raising challenges of contract management. different issues at once, the initiative tackles the Putting the initiative into practice will further interrelated nature of barriers to care. For example, depend on collaboration and cooperation among school-based mental health services can facilitate county behavioral health offices, managed care access to care, but making those services genuinely plans, commercial insurers, community agencies, available requires creating a larger mental health and school districts. Secretary Ghaly was upfront workforce that can provide culturally competent care regarding the challenges facing implementation: COVID-19 AND CHILDREN’S MENTAL HEALTH: ADDRESSING THE IMPACT | 27 “it will not be easy; it will take a lot of innovation, Insel recommended creating a new, more robust a lot of rolling up sleeves.”134 It will also take Department of Behavioral Health that would provide strong structures for governing, coordinating, and a single point of state leadership over mental health administering the initiative, together with consistent care and could consolidate state mental health leadership at the state level. programs and funding streams.136 Section IV: Steps Forward Witnesses and advocates generally agreed that the state of California needs to establish outcome Given the complexity and urgency of the Behavioral goals for children’s mental and emotional well- Health Initiative, it is critical that the Governor’s being, especially for vulnerable children and youth. Office and leadership of relevant state agencies work Christine Stoner-Mertz observed, “California’s public with local agencies, health plans, and stakeholders mental health system does not currently measure to establish a compact of relevant actors that the well-being of children (both eligible and those clearly defines the work to be done, by whom, served) and report out on this. . . Setting clear and when. The first year of the Behavioral Health statewide measures so that all delivery systems Initiative focuses on planning, needs assessment, have increased transparency and accountability to and stakeholder engagement, including creating a children’s well-being is essential.”137 Dr. Insel further Youth Advisory Council and an advisory committee suggested mapping managed care plans and county for expanding the mental health workforce. systems onto a common regional template in order The Commission understands that significant to begin centralizing standards. consultation and negotiation will be necessary to build the initiative’s component programs and “Setting clear statewide develop concrete plans for implementation, but urges an efficient process so resources are primarily measures so that all delivery utilized for critical engagement with children. The systems have increased following are key steps that state government may transparency and accountability take that can help to structure and coordinate its response to COVID’s impact on children’s mental to children’s well-being is health and ensure that the Behavioral Health essential.” - Christine Stoner- Initiative achieves sustainable improvements in California’s child mental health system. Mertz, CEO, California Alliance ESTABLISHING STATE LEADERSHIP AND of Child and Family Services OUTCOME GOALS In its 2015 and 2016 reports on the Mental Health The Children and Youth Behavioral Health Initiative Services Act, the Commission called for stronger, provides a foundation for a truly statewide approach more coherent, and more cohesive state leadership to children’s mental and emotional well-being. Strong over the mental health system and urged the planning around implementation and governance Governor and Legislature to identify a mental health will be needed to coordinate the initiative’s different leader within state government that is able to ensure branches and to ensure that it produces lasting and accountability for outcomes. Witnesses similarly sustainable results, rather than producing more one- emphasized the need for greater state leadership in time pilot projects. Establishing a single person or addressing children’s mental health needs.135 Dr. Tom entity with overall leadership—and accountability— 28 | LITTLE HOOVER COMMISSION for the initiative, with capacity to oversee initiative BUILDING CAPACITY FOR STATEWIDE elements and ensure that these elements have APPROACHES complementary outcome goals, is also likely to be Several witnesses and experts testified to the essential to its success. Clear metrics and goals can importance of metrics and accountability in further help to guide implementation and focus the structuring a more coordinated and strategic initiative’s intersystem and interagency partnerships approach to children’s mental health; witnesses also on common objectives both in the short- and long- emphasized, however, that state government must term. take responsibility for the ability of health plans and providers to meet outcome goals. Moreover, the funding contained in the Behavioral Health Initiative is a potential lever for establishing Toby Ewing explained, “Part of the reason we do outcome goals relative to children’s mental health not have a mental health system from a statewide and enforcing accountability for outcomes. The perspective, is the state is not in the business of Behavioral Health Initiative includes planning helping counties build out their systems.” Mr. Ewing around evaluation and data reporting; the portion observed that the Mental Health Services Oversight of the initiative around behavioral health evidence- and Accountability Commission has recently made based programs, for example, would include the progress encouraging counties to reduce the amount requirement that grantees share standardized data of unspent MHSA funds, not by seeking to punish in a statewide behavioral health dashboard. counties for failing to expend funds, but by working with them to address the risks that cause counties to accumulate excess reserves and to identify ways Addressing COVID’s impact on to spend the funds more effectively. “We need,” children’s mental health will Mr. Ewing suggested, “to be equally responsible for require shared accountability, success together.”138 Alex Briscoe made the same point, suggesting that the relationship between with state government state government and county systems needs to assuming responsibility for be reworked around collaboration and support. According to Mr. Briscoe, the state’s approach to ensuring that the various health counties and health plans needs to be predicated on plans and providers achieve the understanding, “our job is to help you to do your goals. job better.”139 Addressing COVID’s impact on children’s mental Yet the Behavioral Health Initiative is also an health will require shared accountability, with state opportunity to require entities receiving funding government assuming responsibility for ensuring to collect and report data relative to more general that the various health plans and providers achieve outcome goals. In order to encourage accountability, goals. The Children and Youth Behavioral Health the California Health and Human Services Agency Initiative is potentially a major step in the direction and relevant agencies could make access to portions of establishing greater state leadership around of initiative funding contingent on meeting metrics children’s mental health and toward developing a linked to established outcome goals. culture of collaboration between state government and health plans. Secretary Ghaly noted that the proposed virtual platform is a “bold step to say COVID-19 AND CHILDREN’S MENTAL HEALTH: ADDRESSING THE IMPACT | 29 that we will have something statewide, that we do not expect every county to come up with their own Seneca Family of Agencies version.”140 and Coordination of In addition, technical assistance is likely to be Services instrumental for the success of the Behavioral Health Initiative, especially by enabling health Seneca Family of Agencies is a statewide non- plans, providers, and schools to learn from profit that provides school and community- existing models rather than reinventing the wheel. based services addressing children’s well- The Health and Human Services Agency and being through an innovative whole child model participating departments may need to build out called Unconditional Education. This model or identify sources of technical assistance; they provides a highly developed and integrated can also establish learning collaboratives and example of a MTSS framework that equips communities of practice, as the Oversight and school districts with supports to educate all Accountability Commission has done for its early students at local schools. At each school site, psychosis intervention program. In addition, there is an Unconditional Education “coach” guides opportunity to leverage the resource and knowledge implementation of the model. This coach base of California’s university systems. New York works with school leadership to help improve State’s Department of Education, for example, school culture and climate and provides supports three university-based, regional technical professional development and coaching for assistance centers for community schools.141 school staff and teachers to help them meet California could similarly work with universities and students’ needs. The coach also supports a relevant non-profit organizations to institutionalize coordination of services team that manages technical assistance around children’s mental health, referrals and ensures students receive the including school-based mental health, evidence- engagement and supports they may need.143 based practices, and approaches around prevention and early intervention. critical for responding to COVID’s impact at scale. It Separately, witnesses and providers called for the is important, however, to appreciate the complexity Department of Health Care Services to dedicate and difficulty of what will be involved in creating resources around capacity building. They suggested partnerships around school-based mental health. that DHCS expand its ability to provide technical Centering schools as sites for supporting child mental assistance around reimbursement and take wellness requires bringing together California’s steps to simplify and streamline state processes systems of education and mental health. Putting around documentation. Although providers were the Behavioral Health Initiative into practice further hopeful that CalAIM will ultimately help address depends on forging new and deeper partnerships and reduce the paperwork burden associated with between entities that have little experience billing Medi-Cal, they also suggested that more working together, like schools and managed care assistance is needed in addressing challenges organizations. Moreover, schools will need to around documentation and drawing down develop and expand partnerships with health plans reimbursements.142 and community agencies while also confronting the significant challenges associated with fully reopening, BUILDING SCHOOL-LINKED PARTNERSHIPS addressing uncertain risk around COVID, attending to School-based and school-linked partnerships will be 30 | LITTLE HOOVER COMMISSION learning loss, and managing the immediate impacts and academic data can be powerful indicators of the pandemic on students’ well-being. of student emotional or mental issues. Yet, many schools do not employ this data to identify Careful planning and coordination at both the district students who may need support or disaggregate and at the school level is critical. Most importantly, data to identify where there may be issues. With there needs to be clarity around the roles that regard to the use of data systems in delivering teachers, pupil services personnel, administrative and tracking school mental health services, staff, outside clinicians, and other mental health Pia Escudero observed, “We’re in the infancy professionals will play in providing mental health stages because of the lack of funding.”147 The services: Behavioral Health Initiative makes funding available to develop and integrate data systems ◊ This does not mean training teachers to be social around student mental health, but connecting workers or mental health clinicians.144 Instead, it and integrating data systems across educational means better connecting teachers and educators and health agencies will pose administrative and with resources and helping them understand signs technical challenges. that indicate that a student may be struggling and how to help direct that student to sources of Technical assistance is likely to play a critical role in support.145 It can also mean building awareness supporting the development of viable and effective around social emotional learning and providing partnerships around school-based and school- teachers, administrators, and staff with training linked mental health services. Existing partnerships in trauma-informed approaches, so that they between schools and county mental health plans can respond to behavioral issues through restorative offer models and lessons that new collaborations practices, rather than disciplinary actions. can learn from, as can previous state programs that provided technical assistance around school climate ◊ Clearly defining the respective roles of pupil and student well-being. For example, the Scale Up services personnel professionals (i.e., school MTSS Statewide (SUMS) Initiative administered counselors, school social workers, and school by Orange County Department of Education also psychologists) and outside clinicians and further included leadership from Butte County Office of developing clear understanding regarding care Education and featured technical assistance oriented coordination and information sharing, so as to towards the needs of small and rural districts, as ensure that there is both a “warm hand off” and well as creating a community of practice that bridged continued coordination when a student needs large and small districts.148 This initiative could more intensive or specialized services. Establishing potentially hold lessons for helping small and rural coordination of services teams can support school districts address their unique constraints and effective cooperation among the various people challenges in delivering mental health services. and entities involved in providing different levels of care and services. School counselors can also In addition, the 2021-22 State Budget allocates $3 play a key role in managing MTSS frameworks, billion in funding to expand implementation of identifying students who need more intensive community school models, including $140 million services and coordinating with mental health to support regional technical assistance centers for clinicians.146 community schools. These centers could potentially ◊ Developing data-driven approaches to also support technical assistance around school- coordinating and delivering care and measuring linked mental health.149 the effectiveness of interventions. Attendance COVID-19 AND CHILDREN’S MENTAL HEALTH: ADDRESSING THE IMPACT | 31 Services, Department of Managed Care, Department Recommendations of Public Health, Office of the Surgeon General, the Governor Newsom and the Health and Human Mental Health Services Oversight and Accountability Services Agency are taking critical steps to overhaul Commission, Office of Statewide Health Planning and and improve California’s system for supporting Development, and the Department of Education. child mental health. Taken together, CalAIM and In the longer run, the Governor and Legislature the Children and Youth Behavioral Health Initiative should initiate a review process, to be completed have potential to transform California’s child mental no later than October 2022, to examine the creation health system and address many of the longstanding of a new and robust Department of Behavioral and structural weaknesses of that system. Mental Health that would be capable of statewide Yet these ambitious and expansive proposals leadership over mental health care and services, with may not fully address some of the root causes of coequal focus on child and adult mental health. This these weaknesses. California’s child mental health review process would include examination of how system has long suffered from lack of clear and other states structure departments of mental health, consistent leadership—leadership that can overcome of the lessons that can be learned from California’s fragmentation, define the roles of the system’s previous Department of Mental Health, and of how various actors, establish metrics to evaluate success, the department may be best organized to ensure and hold agencies and providers accountable for that children’s mental health receives equal attention outcomes. to adult mental health, as well as consideration of whether a distinct Department of Behavioral and California cannot afford to waste the current Mental Health would impede or support whole moment. Meeting children’s mental health needs person approaches to care that address both mental requires clear state leadership and clearly defined and physical health. goals and expectations. 2. Establish outcome goals. The Commission 1. Establish state leadership. The Commission commends the Newsom Administration for reiterates its recommendation from earlier reports incorporating evaluation as a core component of for the state of California to identify a central point of the Children and Youth Behavioral Health Initiative. leadership for children’s mental health. In the short However, the Commission also finds that California term, the Governor should establish a clear plan for needs to establish overarching and unifying goals coordinating the constituent parts of the Children and metrics around child mental health. and Youth Behavioral Health Initiative, including developing governance and implementation plans. In consultation with stakeholders, the Secretary of The Commission suggests that this plan include the Health and Human Services Agency should set the creation of a staffed coordinating council for statewide goals for child mental health based on children’s mental health that would be charged both a limited number of key metrics related to overall with implementing the Behavioral Health Initiative mental well-being, access to care, and quality of and with overall oversight of the children’s mental care, which could include: increasing attendance health system. This council should be chaired by the and graduation rates for students with behavioral or Secretary of the Health and Human Services Agency. mental health disorders; increasing recovery after It should also include leadership from relevant first episode of psychosis; increasing the percentage agencies, including the Department of Health Care of children reporting severe depression who receive counseling; decreasing wait time to access care; 32 | LITTLE HOOVER COMMISSION increasing the percentage of children being screened state and local government around child mental for mental wellness and for ACEs, and, if at risk, health services. The Governor and Legislature need receiving appropriate interventions; and, increasing to take steps to establish a culture within the relevant the percentage of children with access to school state agencies that says to counties and providers, mental health programs. These data should be “How can we work together to learn together,” and released publicly each year and, where appropriate, “How do we help you increase capacity?”150 should further be disaggregated by race, gender, and The Department of Health Care Services should work age. with stakeholders to identify ways to increase the In order to guide local implementation and technical assistance it provides to counties, managed encourage local accountability, each county, care plans, and other mental health providers, managed care plan, and commercial plan should also including local educational agencies. In addition, the be required to establish equivalent goals that would review process for the creation of a new Department contribute to reaching statewide goals. of Behavioral and Mental Health should include consideration of what changes would potentially be 3. Support accountability around outcome goals. required to expand the capacity of the Department The Governor and Legislature also need to use the of Health Care Services to provide greater technical new funding associated with the Children and Youth assistance to local departments of mental health Behavioral Health Initiative as an opportunity to and to others providers. It should also include expand accountability and oversight in the provision consideration of where technical assistance for of mental health services. school-based Medi-Cal payments should reside. The Commission recommends reserving a portion 5. Center schools. In addition to funding school- of Behavioral Health Initiative funding to provide linked mental health partnerships and services, a future tranche of additional funding that would the Governor and Legislature should also use this be awarded on a competitive basis to counties opportunity to encourage school districts and local and health plans that efficiently and effectively education agencies to develop coordinated and implement successful reforms/programs and that comprehensive approaches to student mental and reach identified benchmarks or improvements with emotional wellness. respect to outcomes, data collection, data sharing, and care coordination. Within this “race to the top” The 2021-22 State Budget includes major style competition, entities would compete with like- investments in the development of community situated entities. schools. Schools can further draw on existing federal and state funding sources to support their 4. Build shared accountability. In establishing counselor and mental health workforces, as well as outcomes goals, California needs also to reset the on significant one-time funding. It is critical that the relationship between the state and county systems Governor, Legislature, and associated departments with regard to accountability and technical support. and agencies encourage districts to approach these Currently, accountability around children’s mental funding sources in an integrated and strategic health centers on audits that focus on how money is fashion so as to position schools as hubs of mental spent, rather than on outcomes for children’s mental well-being. health. CalAIM promises to reduce the burdens associated with Medi-Cal payments, but more is School-linked behavioral health services grants within needed to change the culture that exists between the Children and Youth Behavioral Health Initiative should require the following of recipients: COVID-19 AND CHILDREN’S MENTAL HEALTH: ADDRESSING THE IMPACT | 33 ◊ Every district and school receiving funding should inviting to children and youth of different ages and develop a coordinated plan for how it will deliver backgrounds. multi-tier mental health supports, including In order to mitigate risks associated with platform clear identification of the roles of teachers, of development, the Governor should provide school support and counseling staff, and of specifications on the bidding and contracting process partner organizations. This should be a concise, for the virtual platform. The Governor should also actionable plan that promotes clear and efficient establish a clear timeline for the development, cooperation, and care should be taken to ensure testing, and piloting of the platform, with vigorous that developing the plan is not administratively oversight at every stage of development. burdensome. ◊ Every district and its partners should develop a In addition, in developing and rolling out the virtual plan detailing how they will use available data to platform, the Governor and relevant agencies identify students who may need support, how they should address how they will ensure that the virtual will share data and information, and how they will platform does not exacerbate the digital divide. The coordinate services in an equitable and balanced design and development of the platform should manner. include consideration of how this platform can ◊ Every district and its partners should specify how be made available to children and youth who do they will integrate grant funding with funding from not have broadband and may also have limited other sources to create sustainable programs internet access. Development should also include around student mental health. identification of strategies to provide equivalent in- person services for those children who are unable to ◊ In order to further highlight the importance of access the platform. school climate and student mental health, the Superintendent of Public Instruction should also create a program that recognizes schools that are leaders in creating and maintaining positive school climate and in supporting student mental well- being. 6. Strengthen the behavioral health services virtual platform. The Commission commends the Newsom Administration for building on the momentum and innovation surrounding telehealth services for mental health. The proposed virtual platform has potential to expand availability of telehealth options while “meeting children where they are.” Yet the ongoing challenges surrounding IT systems at the Employment Development Department and FI$Cal, as well as with the MyTurn and MyTurn Volunteer websites, should also urge caution as the state proceeds to support the development of a complicated technology system, and one that must be accessible and 34 | LITTLE HOOVER COMMISSION Notes 1. Tracking COVID-19 in California, https://covid19. Twenge, et al., “Age, Period, and Cohort Trends ca.gov/state-dashboard/#ethnicity-gender-age. in Mood Disorder Indicators and Suicide-Related Accessed August 4, 2021. Outcomes in a Nationally Representative Dataset, 2005-2017,” Journal of Abnormal Psychology 128, 2. Dr. Bryan King, Vice President for Child no. 3(2019): 185-199, https://pubmed.ncbi.nlm. Behavioral Health, UCSF Benioff Children’s nih.gov/30869927/. Hospitals, Conversation with Commission staff, April 6, 2021. Jocelyn Wiener, “Mental Health 8. Centers for Disease Control and Prevention ‘Tsunami’ Looms: Can California Prevent a Surge (CDC), Children’s Mental Health – What Is in Suicides?” CalMatters (September 30, 2020, Children’s Mental Health? https://www.cdc.gov/ Updated October 1, 2020), https://calmatters. childrensmentalhealth/basics.html. Accessed org/health/breakdown-mental-health/2020/09/ June 29, 2021. mental-health-tsunami-california-suicides/. 9. World Health Organization, Adolescent Mental 3. Ken Berrick, Founder and CEO, Seneca Family of Health, https://www.who.int/news-room/fact- Agencies, and Robin Detterman, Chief Program sheets/detail/adolescent-mental-health. Accessed Office of Education Services, Seneca Family of July 12, 2021. Agencies, Written Statement to the Commission, 10. California Health Care Foundation, Mental Health May 13, 2021. and Substance Use: A Crisis for California’s Youth 4. Mental Health America, COVID-19 and Mental (California Health Care Almanac, December Health: A Growing Crisis (October 2020), p. 2018), p. 5. Retrieved from: https://www.chcf. 7. Retrieved from: https://mhanational.org/ org/publication/2018-edition-mental-health- sites/default/files/Spotlight%202021%20-%20 substance-use-californias-youth/#related-links- COVID-19%20and%20Mental%20Health.pdf. and-downloads. 5. Dr. Tom Insel, Chair of the Steinberg Institute 11. California Health Care Foundation, Mental Health Board of Directors and Former Director of the and Substance Use, p. 8, see endnote 10. National Institute of Mental Health, Testimony to 12. Paulette Cha, Assessing Teen Well-Being and Mental the Commission, April 22, 2021. Health after the Medi-Cal Expansion (PPIC, January 6. California Children’s Trust and California Alliance 2021), p. 3. Retrieved from: https://www.ppic. of Child and Family Services, COVID-19 and org/publication/assessing-teen-well-being-and- Demands for Racial Justice Underscore the Urgent mental-health-after-the-medi-cal-expansion/. Need to Advance CalAIM’s Children’s Behavioral 13. California Health Care Foundation, Mental Health Health Reform Effort (June 2020). Retrieved and Substance Use, p. 7, see endnote 10. from: https://cachildrenstrust.org/wp-content/ uploads/2020/06/cct_covid_June-2020.pdf. 14. Cha, Assessing Teen Well-Being, p. 3, see endnote 12. 7. Child Mind Institute, California Partners Project, and Material, Are the Kids Alright? How Teens Are 15. Dr. Nadine Burke Harris, California Surgeon Struggling with Loss and the Limits of Living Online General, Testimony to the Commission, May 27, (2021), pp. 22-3. Retrieved from: https://www. 2021. calpartnersproject.org/arethekidsalright. Jean M. COVID-19 AND CHILDREN’S MENTAL HEALTH: ADDRESSING THE IMPACT | 35 16. Rebecca T. Leeb, et al., “Mental Health – 21. National Institute of Mental Health, Suicide, Related Emergency Department Visits among https://www.nimh.nih.gov/health/statistics/ Children Aged <18 Years during the COVID-19 suicide.shtml. Accessed April 9, 2021. Children Pandemic – United States, January 1-October 17, Now, 2020 California’s Children’s Report Card, 2020,” Morbidity and Mortality Weekly Report p. 15. https://www.childrennow.org/portfolio- (November 2020), https://www.cdc.gov/mmwr/ posts/20-report-card/. Accessed April 12, 2021. volumes/69/wr/mm6945a3.htm. The proportion 22. Dr. Tom Insel, see endnote 5. of mental health-related emergency department visits among all pediatric emergency department 23. CDC, Data and Statistics on Children’s visits for children aged 5-11 increased by 24 Mental Health, https://www.cdc.gov/ percent; among children aged 12-17, there was a childrensmentalhealth/data.html. Accessed June 31 percent increase in the proportion of mental 29, 2021. health-related emergency department visits. 24. California State Auditor, Youth Suicide Prevention: 17. Ellen Yard et al., “Emergency Department Local Educational Agencies Lack the Resources and Visits for Suspected Suicide Attempts among Policies Necessary to Effectively Address Rising Rates Persons Aged 12-25 Years Before and During of Youth Suicide and Self-Harm (September 2020), the COVID-19 Pandemic – United States, January p. 6. Retrieved from: https://www.auditor.ca.gov/ 2019-May 2021,” Morbidity and Mortality pdfs/reports/2019-125.pdf. Weekly Report (June 2021), https://www. cdc.gov/mmwr/volumes/70/wr/mm7024e1. 25. Substance Abuse and Mental Health Services htm?s_cid=mm7024e1_w&fbclid=IwAR3- Administration (SAMHSA), Behavioral Health mKWfWvsCJKd1XGy0vcR0IwxWSrS- Barometer: California, Volume 6 (2020), p. 6. SpsVSJ04HnohYMQpgTYrAGmqhsc. Retrieved from: https://www.samhsa.gov/data/ sites/default/files/reports/rpt32821/California- 18. Fluent Research, Fluent Family Wellbeing Study BH-Barometer_Volume6.pdf. (Research Report for the JED Foundation, National Survey, December 2020), p. 5. Retrieved 26. Gregory Austin, et al., School Climate and Student from: https://www.jedfoundation.org/wp- Engagement and Well-being in California, 2017/19: content/uploads/2021/01/Family-Wellbeing_JED- Results of the Seventeenth Biennial State California report_12-28-20.pdf. Health Kids Survey, Grades 7, 9, and 11 (WestEd, 2020), p. 27. Retrieved from: https://data.calschls. 19. How the Pandemic Has Impacted Teen Mental org/resources/Biennial_State_1719.pdf. Health, Mott Poll Report, Volume 38, Issue 2 (March 15, 2021) https://mottpoll.org/reports/ 27. Dr. Bryan King, Interview with Commission staff, how-pandemic-has-impacted-teen-mental-health. July 7, 2021. 20. Jill Tucker, “Anxiety, Depression, Isolation: Bay 28. Victoria Rideout, et al., Coping with COVID-19: Area Students Struggle amid Spiking Mental How Young People Use Digital Media To Manage Health Crisis,” San Francisco Chronicle (April their Mental Health (Common Sense, Hopelab, 4, 2021), https://www.sfchronicle.com/local/ and California Health Care Foundation, 2021), article/Anxiety-depression-isolation-Bay-Area- pp. 5, 30-31. Retrieved from: https://www. students-16075136.php. commonsensemedia.org/sites/default/files/ 36 | LITTLE HOOVER COMMISSION uploads/research/2021-coping-with-covid19-full- of Capitalism (Princeton: Princeton University report.pdf. Press, 2020). Economists Anne Case and Angus Deaton observe that life expectancy has fallen for 29. Harry Kimball and Yakira Cohen, Children’s Mental both White and Black Americans without college Health Report: Social Media, Gaming and Mental degrees: Case and Deaton, “Life Expectancy Health (Child Mind Institute, 2019), pp. 5, 11. in Adulthood is Falling for those without a BA Retrieved from: http://www.codajic.org/sites/ Degree, but as Educational Gaps Have Widened, www.codajic.org/files/Childrens_Mental_Health_ Racial Gaps Have Narrowed,” PNAS 118, no Report_2019%20(1).pdf. John A Naslund, et al., 1 (March 16, 2021), https://www.pnas.org/ “Social Media and Mental Health: Benefits, Risks, content/118/11/e2024777118. and Opportunities for Research and Practice,” Journal of Technology in Behavioral Science 5 (April 35. Twenge, “Age, Period, and Cohort Trends,” see 2020), https://link.springer.com/article/10.1007/ endnote 7. Jean M. Twenge, et al., “Worldwide s41347-020-00134-x. Child Mind Institute, Increases in Adolescent Loneliness,” Journal California Partners Project, and Material, Are the of Adolescence (In press, July 2021), https:// Kids Alright?, see endnote 7. www.sciencedirect.com/science/article/pii/ S0140197121000853. 30. Kimball and Cohen, Children’s Mental Health Report, pp. 7-8, 11, see endnote 29. Jean Twenge, 36. Dr. Bryan King, see endnote 27. Amirhossein et al., Teens in Quarantine: Mental Health, Screen Modabbernia, Eva Velthorst, and Abraham Time, and Family Connection (Institute for Family Reichenberg, “Environmental Risk Factors for Studies and The Wheatley Institution, 2020), Autism: An Evidence-Based Review of Systematic p. 10. Retrieved from: https://ifstudies.org/ifs- Review and Meta-Analyses,” Molecular Autism admin/resources/final-teenquarantine2020.pdf. 8 (2017), https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC5356236/. 31. Rideout, Coping with COVID-19, p. 38, see endnote 28. Kimball and Cohen, Children’s Mental Health 37. Dr. Tom Insel, see endnote 5. Report, p. 7, see endnote 29. 38. Dr. Nadine Burke Harris, California Surgeon 32. Instagram, Announcement – Giving People General, Testimony to the Commission, May 27, More Control on Instagram and Facebook (May 2021. Mark A. Bellis, et al., “Does Continuous 26, 2021), https://about.instagram.com/blog/ Trusted Adult Support in Childhood Impact Life- announcements/giving-people-more-control; Course Resilience against Adverse Childhood Twitter, Announcement – Amplifying #Suicide Experiences – A Retrospective Study on Adult Prevention Resources on Twitter (September Health-Harming Behaviours and Mental 9, 2020), https://blog.twitter.com/en_us/topics/ Well-Being,” BMC Psychiatry 17 (March 2017), company/2020/amplifying-suicideprevention- https://www.ncbi.nlm.nih.gov/pmc/articles/ resources-on-twitter. PMC5364707/. 33. Child Mind Institute, California Partners Project, 39. Christine Stoner-Mertz, CEO, California and Material, Are the Kids Alright?, see endnote 7. Alliance of Child and Family Services, Written Statement to the Commission, April 22, 2021; 34. Dr. Tom Insel, see endnote 5. Anne Case and Dr. Rebecca Dudovitz, Associate Professor in Angus Deaton, Deaths of Despair and the Future General Pediatrics, UCLA School of Medicine, COVID-19 AND CHILDREN’S MENTAL HEALTH: ADDRESSING THE IMPACT | 37 Conversation with Commission staff, May 4, 2021. other/state-indicator/covid-19-deaths-by-race-et hnicity/?currentTimeframe=0&sortModel=%7B% 40. Sanne Magnan, Social Determinants of Health 101 22colId%22:%22Location%22,%22sort%22:%22as for Health Care: Five Plus Five (October 9, 2017), c%22%7D (Updated July 14, 2021), and CDC, Risk https://nam.edu/social-determinants-of-health- for COVID-19 Infection, Hospitalization, and Death 101-for-health-care-five-plus-five/. by Race/Ethnicity (Updated July 16, 2021), https:// www.cdc.gov/coronavirus/2019-ncov/covid-data/ 41. Margarita Alegria, et al., “Social Determinants investigations-discovery/hospitalization-death-by- of Mental Health: Where We Are and Where race-ethnicity.html. We Need to Go,” Current Psychiatry Reports 20 (September 2018), https://www.ncbi.nlm.nih.gov/ 45. Rideout, Coping with COVID-19, p. 21, see endnote 28. pmc/articles/PMC6181118/. Twenge, Teens in Quarantine, p. 7, see endnote 30. 42. Stacy Hodgkinson, et al. “Improving Mental 46. Lishaun Francis, Associate Director, Health Health Access for Low-Income Children and Collaborations, Children Now, Written Statement to Families in the Primary Care Setting,” Pediatrics the Commission, April 22, 2021; Dr. Nadine Burke 139, no. 1 (January 2017), https://www.ncbi.nlm. Harris, see endnote 43. nih.gov/pmc/articles/PMC5192088/. Adriana Ramos-Yamamoto, Californians and Mental Health: 47. Toby Ewing, Executive Director, Mental Health What We Know About Poverty and Race (California Services Oversight and Accountability Commission, Budget & Policy Center, March 2020), https:// Testimony to the Commission, May 27, 2021. calbudgetcenter.org/resources/californians-and- 48. Dr. Nadine Burke Harris, see endnote 43. mental-health-what-we-know-about-poverty-and- race/. 49. CDC, Preventing Adverse Childhood Experiences, https://www.cdc.gov/ 43. Dr. Nadine Burke Harris, Written Statement to violenceprevention/aces/fastfact.html?CDC_ the Commission, May 27, 2021. Leah Cave, et al., AA_refVal=https%3A%2F%2Fwww.cdc. “Racial Discrimination and Child and Adolescent gov%2Fviolenceprevention%2Facestudy%2Ffastfact. Health in Longitudinal Studies: A Systematic html Accessed May 13, 2021. Office of the California Review,” Social Science & Medicine 250 (April 2020), Surgeon General and Department of Health Care https://www.sciencedirect.com/science/article/ Services (DHCS), About California’s ACEs Aware pii/S0277953620300836. Initiative (February 2020). Retrieved from: https:// 44. Maryanne Page, Professor of Economics, UC www.acesaware.org/wp-content/uploads/2019/12/ Davis, Testimony to the Commission, July 9, 2021. About-ACEs-Aware-2-25-20-FINAL.pdf. Office of the Ezra Golberstein, Gilbert Gonzales, and Ellen California Surgeon General, Roadmap for Resilience: Meara, “Economic Conditions and Children’s The California Surgeon General’s Report on Adverse Mental Health,” (NBER Working Paper Series: Childhood Experiences, Toxic Stress, and Health (2020), Working Paper 22459). Retrieved from: http:// pp. 13-15, 20-32. Retrieved from: https://osg.ca.gov/ www.nber.org/papers/w22459. For data on wp-content/uploads/sites/266/2020/12/Roadmap- COVID’s disproportionate impact on the physical For-Resilience_CA-Surgeon-Generals-Report-on- health of communities of color, see Kaiser ACEs-Toxic-Stress-and-Health_12092020.pdf. Family Foundation, State Health Facts, COVID-19 50. Ken Berrick and Robin Detterman, see endnote 3. Deaths by Race/Ethnicity, https://www.kff.org/ 38 | LITTLE HOOVER COMMISSION 51. Dr. Nadine Burke Harris, see endnote 38. 60. California State Auditor, Youth Suicide Prevention, pp. 7-10, see endnote 24. 52. Office of the California Surgeon General, Roadmap for Resilience, pp. 33-35, see endnote 49. 61. Hodgkinson, “Improving Mental Health Access for Low-Income Children and Families,” see endnote 53. Office of the California Surgeon General, 42. Roadmap for Resilience, pp. 33-35, see endnote 49. ACEs Aware, The Science of ACEs & Toxic Stress, 62. SAMHSA, Behavioral Health Barometer: United https://www.acesaware.org/ace-fundamentals/ States, Volume 6 (2020), p. 46. Retrieved the-science-of-aces-toxic-stress/. Accessed May from: https://www.samhsa.gov/data/sites/ 20, 2021. default/files/reports/rpt32815/National-BH- Barometer_Volume6.pdf. Lydonna Marrast, 54. Office of the California Surgeon General and David U. Himmelstein, and Steffie Woolhandler, DHCS, About California’s ACEs Aware Initiative, see “Racial and Ethnic Disparities in Mental Health endnote 49. Care for Children and Young Adults: A National Study, International Journal of Health Services 55. Dr. Nadine Burke Harris, see endnote 38. 46. 4 (August 2016), https://doi.org/10.1177% 56. Dr. Nadine Burke Harris, see endnote 43. 2F0020731416662736. 57. The Commonwealth Fund, Health System Data 63. Preliminary data contained in testimony to the Center, Children Who Received Needed Mental Commission by Michelle Cabrera, Executive Health Care – California, http://datacenter. Director, County Behavioral Health Directors commonwealthfund.org/topics/children-who- Association of California, May 13, 2021. According received-needed-mental-health-care. Accessed to these data, White beneficiaries under 21 June 30, 2021. years of age received managed care plan mental health services at a rate of 10,739 per 100,000; 58. Mental Health America, Youth Data 2021, https:// in comparison, Black beneficiaries accessed mhanational.org/issues/2021/mental-health- services at a rate of 3,525 per 100,000 and Latino america-youth-data#received-some-consistent- beneficiaries accessed services at a rate of 4,000 treatment. Accessed June 29, 2021. per 100,000. 59. California Children’s Trust and Children 64. Hodgkinson, “Improving Mental Health Access for Now, The California Children’s Trust Initiative: Low-Income Children and Families,” see endnote Reimagining Child Well-Being (November 2018). 42. Retrieved from: https://cachildrenstrust. org/wp-content/uploads/2018/11/ 65. Ted Lempert, President of Children Now, PolicyBriefReimaginngChildWellBeing.pdf. Patrick Conversation with Commission Staff, March 19, Gardner, California’s Children and Youths’ System 2021. of Care: An Agenda to Transform Promises into 66. Toby Ewing, see endnote 47. Practice (Young Minds Advocacy, May 2017), pp. 19-20. Retrieved from: https://www.ymadvocacy. 67. California State Auditor, Department of Health org/s/An-Agenda-to-Transform-Promises-Into- Care Services: Millions of Children in Medi-Cal Practice-YMA-2017.pdf. Are Not Receiving Preventive Health Services COVID-19 AND CHILDREN’S MENTAL HEALTH: ADDRESSING THE IMPACT | 39 (March 2019), p. 7. Retrieved from: https:// 71. Kim Lewis and Rachel Velcoff Hults, Meeting the www.auditor.ca.gov/pdfs/reports/2018-111.pdf. Moment: Understanding EPSDT and Improving California Children’s Trust and Children Now, The Implementation in California to Address Growing California Children’s Trust Initiative: Financing New Mental Health Needs (National Center for Approaches to Achieve Child Well-Being (June 2019), Youth Law, California Children’s Trust, and p. 3. Retrieved from: https://cachildrenstrust.org/ National Health Law Program, 2021). Retrieved wp-content/uploads/2020/01/CCT_Brief_7.12.19_ from: https://healthlaw.org/wp-content/ v5.pdf. The Legislative Analyst’s Office estimates uploads/2021/01/Meeting-the-Moment_FINAL. that approximately half of children in California pdf. are on Medi-Cal, Impact of COVID-19 on Health 72. Christine Stoner-Mertz, see endnote 39. Care Access (Budget and Policy Post, May 7, 2021), https://lao.ca.gov/Publications/Report/4426. 73. Dr. Tom Insel, see endnote 5. DHCS reports that, as of early 2021, more than 5.4 million children aged 0-20, out of a total 74. Alex Briscoe, Principal, California Children’s Trust, population of approximately 10.775 million, were Testimony to the Commission, April 22, 2021; enrolled in Medi-Cal, see Medi-Cal Children’s Jessica Cruz, Executive Director, National Alliance Health Dashboard (June 2021), https://www.dhcs. on Mental Illness – California, Conversation with ca.gov/services/Documents/Childrens-Health- Commission staff, April 20, 2021; Dr. Tom Insel, Dashboard-June-2021.pdf, and State of California, see endnote 5. Department of Finance, Projections, Total Estimated and Projected Population for California 75. Lishaun Francis, see endnote 46. by Single Year of Age: July 1, 2010 to 2060, https:// 76. Sara Rosenbaum, et al., National Security and U.S. www.dof.ca.gov/Forecasting/Demographics/ Child Health Policy: The Origins and Continuing Role Projections/. of Medicaid and EPSDT (The George Washington 68. National Institute on Drug Abuse, Common University, Department of Health Policy, Policy Comorbidities with Substance Use Disorders Brief, April 2005). Retrieved from: https:// Research Report: Part 1 – The Connection hsrc.himmelfarb.gwu.edu/cgi/viewcontent. between Substance Use Disorders and Mental cgi?article=1033&context=sphhs_policy_briefs. Illness (April 13, 2021), https://www.drugabuse. Lewis and Hults, Meeting the Moment, p. 8, see gov/publications/research-reports/common- endnote 71. comorbidities-substance-use-disorders/part-1- 77. California State Auditor, Department of Health connection-between-substance-use-disorders- Care Services, pp. 14, 17, see endnote 67. mental-illness. Accessed July 16, 2021. 78. Lewis and Hults, Meeting the Moment, p. 16, see 69. Interagency Working Group on Youth Programs, endnote 71. Youth Topics: Mental Health -- Co-occurring Disorders, https://youth.gov/youth-topics/youth- 79. Children Now and California Children’s Trust, The mental-health/co-occurring. Accessed July 16, California Children’s Trust Initiative, pp. 6-7, see 2021. endnote 67. 70. California Health Care Foundation, Mental Health 80. Christine Stoner-Mertz, see endnote 39. and Substance Use, p. 18, see endnote 10. 81. California Children’s Hospital Association (CCHA), 40 | LITTLE HOOVER COMMISSION Improving Behavioral Health Care for Children in aspx. Accessed July 20, 2021. California: A Call to Action (December 2019), p. 6. 89. Christine Stoner-Mertz, see endnote 39. Retrieved from: https://www.ccha.org/sites/main/ files/file-attachments/ccha_behavioral_health_ 90. Janet Coffman, et al, California’s Current and white_paper_final.pdf?1575927706. Future Behavioral Health Workforce (Healthforce Center at UCSF, February 12, 2018), pp. 5, 22-3, 82. Dr. Brian Distelberg, Director of Research, Loma 26-8. Retrieved from https://healthforce.ucsf. Linda University Behavioral Medicine Center, edu/publications/california-s-current-and-future- Testimony to the Commission, May 13, 2021. behavioral-health-workforce. 83. Lewis and Hults, Meeting the Moment, pp. 15, 17, 91. CCHA, Improving Behavioral Health Care for see endnote 71. Children, p. 15, see endnote 81. 84. California State Auditor, Department of Health 92. Dr. Brian Distelberg, see endnote 82. According Care Services, p. 17, see endnote 67. to Dr. Distelberg’s testimony, SAMHSA 85. Lewis and Hults, Meeting the Moment, p. 15, see recommends a ratio of one psychiatric bed endnote 71. for every 2,000 residents in a community; in California, the number is one bed for every 5,834 86. Dr. Bryan King, see endnote 2. individuals. 87. Norbert Skokauskas, “Shaping the Future of 93. CCHA, Improving Behavioral Health Care for Child and Adolescent Psychiatry,” Child and Children, pp. 10-11, see endnote 81. Adolescent Psychiatry and Mental Health 13 (April 2019), https://capmh.biomedcentral.com/ 94. Legislative Analyst’s Office (LAO), The 2021- articles/10.1186/s13034-019-0279-y. 22 Budget: Behavioral Health: Medi-Cal Student Services Funding Proposal (February 2021), 88. Ryan K. McBain, et al., “Growth and Distribution pp. 2-3. Retrieved from: https://lao.ca.gov/ of Child Psychiatrists in the United States: 2007- reports/2021/4377/Medi-Cal-Behavioral-Health- 2016,” Pediatrics 144 (December 2019), https:// Student-Services-021721.pdf. pediatrics.aappublications.org/content/144/6/ e20191576#T2. Mental Health America, 2020 95. Alex Briscoe, Conversation with Commission Mental Health in America – Youth Data, Youth staff, March 4, 2021. California State Auditor, with Severe MDE who Did Not Receive Mental Youth Suicide Prevention, p. 40, see endnote Health Services, https://mhanational.org/ 24. Claudia Boyd-Barrett, “Millions Unclaimed: issues/2020/mental-health-america-youth- Behind California’s Troubled Mental Health data. Accessed July 16, 2021. More recently, the Care Funding System,” California Health Report American Academy of Child and Adolescent (October 3, 2019), https://www.calhealthreport. Psychiatry has suggested that there are 13 org/2019/10/03/millions-gone-unclaimed-behind- child psychiatrists for every 100,000 children californias-troubled-mental-health-care-funding- in California. American Academy of Child and system/. Adolescent Psychiatry, Workforce Maps by State, 96. Gardner, California’s Children and Youths’ System of https://www.aacap.org/aacap/Advocacy/Federal_ Care, pp. 24-5, see endnote 59. and_State_Initiatives/Workforce_Maps/Home. COVID-19 AND CHILDREN’S MENTAL HEALTH: ADDRESSING THE IMPACT | 41 97. Debra Manners, President and CEO, Hathaway- 103. Orange County Department of Education, Sycamore, Conversation with Commission staff, California SUMS Initiative, https://ocde.us/MTSS/ March 24, 2021; Lewis and Hults, Meeting the Pages/California_SUMS_Initiative.aspx. Accessed Moment, p. 16, see endnote 71. July 28, 2021. Orange County Department of Education, Developing, Aligning, and Improving 98. Dr. Brian Distelberg and Dr. Amy Young, Director, Systems of Academic and Behavioral Supports: Resiliency Institute for Childhood Adversity, Loma Scaling Up Multi-Tiered System of Supports (MTSS) Linda University Children’s Hospital, Conversation in California, California Scale UP MTSS Statewide with Commission staff, March 16, 2021. Tracy (SUMS) Initiative, Annual Progress Report (Year 4, Mendez, Executive Director, California School- 2018-2019) (September 2019), p. 2. Retrieved Based Health Alliance, Conversation with from: https://ocde.us/MTSS/PublishingImages/ Commission staff, March 29, 2021. Pages/California_SUMS_Initiative/2018-19%20 SUMS%20Annual%20Report%20 99. Randall Rebeck, Investments in Student Health %28Attachments%29.pdf. and Mental Health in California’s Public Schools, (Getting Down to Fact, September 2018), p. 2. 104. United State Government Accountability Office, Retrieved from: https://www.ncbi.nlm.nih.gov/ K-12 Education: Discipline Disparities for Black pmc/articles/PMC5764796/. Students, Boys, and Students with Disabilities (Report to Congressional Requesters, March 100. Sharon Hoover, et al., Advancing Comprehensive 2018). Retrieved from: https://www.gao.gov/ School Mental Health: Guidance from the Field assets/gao-18-258.pdf. David Washburn and (National Center for School Mental Health, 2019). Daniel J. Willis, “School Suspensions Continue Retrieved from: http://www.schoolmentalhealth. Downward Trend in California, New Data org/Resources/Foundations-of-School-Mental- Show,” EdSource (December 11, 2018), https:// Health/Advancing-Comprehensive-School- edsource.org/2018/school-suspensions- Mental-Health-Systems--Guidance-from-the- continue-downward-trend-in-california-new- Field/. data-show/605946. Daniel J. Losen and Paul 101. Mental Health Services Oversight and Martinez, Is California Doing Enough to Close the Accountability Commission (MHSOAC), Every School Discipline Gap? (The Center for Civil Rights Young Heart and Mind: Schools as Centers of Remedies, June 2020). Retrieved from: https:// Wellness (October 2020), https://www.mhsoac. files.eric.ed.gov/fulltext/ED607056.pdf. ca.gov/document/2020-11/every-young-heart- 105. Pia Escudero, Executive Director, Division and-mind-schools-centers-wellness. of Student Health and Human Services, Los 102. Emily Morgan, et al., The School Discipline Angeles Unified School District, Testimony to the Consensus Report: Strategies from the Field to Commission, May 13, 2021. Keep Students Engaged in School and Out of the 106. MHSOAC, Every Young Heart and Mind, p. 23, see Juvenile Justice System (The Council of State endnote 101. Governments Justice Center, 2014), p. 114. Retrieved from: https://csgjusticecenter.org/wp- 107. California PBIS Coalition, PBIS Growth in content/uploads/2020/01/The_School_Discipline_ California, https://pbisca.org/pbis-california- Consensus_Report.pdf. growth. Accessed July 22, 2021. 42 | LITTLE HOOVER COMMISSION 108. Pia Escudero, Conversation with Commission 119. Dr. Tom Insel, see endnote 5. staff, March 29, 2021, and see endnote 105. 120. Dr. Tom Insel, see endnote 5; Christine Stoner- 109. Anna Maier, Sarah Klevan, and Naomi Ondrasek, Mertz, see endnote 39; Dr. Brian Distelberg, see Leveraging Resources through Community endnote 82. Schools: The Role of Technical Assistance 121. Dr. Tom Insel, see endnote 5; Dr. Brian (Learning Policy Institute, July 17, 2020), https:// Distelberg, see endnote 82; Ken Berrick and learningpolicyinstitute.org/product/leveraging- Robin Detterman, see endnote 3. resources-community-schools-technical- assistance-brief. 122. Dr. Tom Insel, see endnote 5; Lishaun Francis, see endnote 46. 110. Ken Berrick and Robin Detterman, see endnote 3. 123. Dr. Tom Insel, see endnote 5; Alex Briscoe, see endnote 74. 111. Dr. Bryan King, see endnote 2. 124. Christine Stoner-Mertz, see endnote 39. 112. Rebeck, Investments in Student Health and Mental Health, pp. 9-10, 15, 20, and Figures 3, 7a, 7b, and 125. Ken Berrick and Robin Detterman, see endnote 7c, see endnote 99. 3. 113. MHSOAC, Every Young Heart and Mind, p. 36, see 126. John H. Straus and Barry Sarvet, “Behavioral endnote 101. Health Care for Children: The Massachusetts Child Psychiatry Access Project,” Health Affairs 114. California State Auditor, Youth Suicide Prevention, 33, no. 12 (2014): 2153-2161, at pp. 2157-8. p. 30, see endnote 24. Tim Taylor, Executive Retrieved from: https://www.healthaffairs.org/ Director, Small School Districts’ Association, doi/pdf/10.1377/hlthaff.2014.0896. Robert J. Hilt, Conversation with Commission staff, May 12, et al., “The Partnership Access Line: Evaluating a 2021. Child Psychiatry Consult Program in Washington 115. Michelle Cabrera, see endnote 63. State,” JAMA Pediatrics 167, no. 2 (February 2013), https://jamanetwork.com/journals/ 116. Connecting the Dots: The School Counselor Role jamapediatrics/fullarticle/1486426. in Student Mental Health (County Offices of Education Leadership for School Counseling, 127. Dr. Bryan King, see endnote 2. California Association of School Counselors, 128. LAO, The 2021-22 Budget: CalAIM: The Overarching Hatching Results). Retrieved from: https://ocde. Issues (February 2021), https://lao.ca.gov/ us/MTSS/Documents/Connecting%20the%20 Publications/Report/4357; California Children’s Dots%20-%20School%20Counselors%20and%20 Trust and California Alliance of Child and Family Mental%20Health%206-5-20.pdf. Dr. Rebecca Services, COVID-19 and Demands for Racial Justice Dudovitz, see endnote 39. Underscore the Urgent Need to Advance CalAIM’s 117. Dr. Brian Distelberg, see endnote 82. Children’s Behavioral Health Reform Effort, see endnote 6. 118. Rideout, Coping with COVID-19, p. 27, see endnote 28. 129. Dr. Tom Insel, see endnote 5. COVID-19 AND CHILDREN’S MENTAL HEALTH: ADDRESSING THE IMPACT | 43 130. State of California—Health and Human Services 141. Naomi Ondrasek, Senior Researcher and Policy Agency, Department of Health Care Services, Advisor, and Anna Maier, Research Analyst California Advancing & Innovating Medi-Cal (CalAIM) and Policy Advisor, Learning Policy Institute, Proposal (January 2021). Retrieved from: https:// Conversation with Commission staff, April 13, www.dhcs.ca.gov/provgovpart/Documents/ 2021. CalAIM-Proposal-Updated-1-8-21.pdf. 142. Ken Berrick and Robin Detterman, see endnote 131. Dr. Mark Ghaly, Secretary, California Health 3. and Human Services Agency, Testimony to the 143. Ken Berrick and Robin Detterman, see endnote Commission, May 27, 2021. 3. 132. Alex Briscoe, et al., Practical Guide for 144. Jessica Cruz, see endnote 74. Financing Social, Emotional, and Mental Health in Schools (California Children’s Trust and 145. Jessica Cruz, see endnote 74; Mara Madrigal Breaking Barriers, 2020), pp. 5-7. Retrieved Weiss, Executive Director of Student Wellness from: https://cachildrenstrust.org/wp-content/ and School Culture, San Diego County Office of uploads/2020/08/practicalguide.pdf. Education, and Toby Ewing Conversation with Commission staff, April 7, 2021. 133. California Health and Human Services Agency, Children and Youth Behavioral Health Initiative, 146. Dr. Loretta Whitson, Executive Director, May Revision 2021-22. Retrieved from: https:// California Association of School Counselors, cdn-west-prod-chhs-01.dsh.ca.gov/chhs/ Conversation with Commission staff, April 27, uploads/2021/05/CHHS-Children-and-Youth- 2021; Connecting the Dots: The School Counselor Behavioral-Health-Initiative-May-Revision-2021- Role in Student Mental Health, see endnote 116. 22-Detailed-Proposal-FINAL.pdf. California State Assembly, Floor Report of the 2021-22 Budget (June 147. Pia Escudero, see endnote 105. 28, 2021), pp. 16-17. Retrieved from: https://abgt. assembly.ca.gov/sites/abgt.assembly.ca.gov/files/ 148. Tim Taylor, see endnote 114. Floor%20Report%20of%20the%202021-22%20 149. 2021-22 State Budget Summary, K-12 Budget%20-%20%28June%2028%2C%202021%20 Education. Retrieved from: http://www.ebudget. Version%29.pdf. ca.gov/2021-22/pdf/Enacted/BudgetSummary/K- 134. Secretary Mark Ghaly, see endnote 131. 12Education.pdf. 135. Jessica Cruz, see endnote 74. 150. Toby Ewing, see endnote 47. 136. Dr. Tom Insel, see endnote 5. 137. Christine Stoner-Mertz, see endnote 39. 138. Toby Ewing, see endnote 47. 139. Alex Briscoe, see endnote 95. 140. Secretary Mark Ghaly, see endnote 131. 44 | LITTLE HOOVER COMMISSION Little Hoover Commission Members CHAIRMAN PEDRO NAVA | Santa Barbara ASM. CHAD MAYES | Yucca Valley Appointed to the Commission by Speaker of the Assembly Appointed to the Commission by Speaker of the Assembly John Pérez in April 2013 and reappointed by Speaker Toni Atkins in September 2015. Elected in November of the Assembly Anthony Rendon in 2017 and again 2014 to represent the 42nd Assembly District. Represents in 2021. Government relations advisor. Former State Beaumont, Hemet, La Quinta, Palm Desert, Palm Springs, Assemblymember from 2004 to 2010, civil litigator, San Jacinto, Twentynine Palms, Yucaipa, Yucca Valley, and deputy district attorney and member of the state Coastal surrounding areas. Commission. Elected chair of the Commission in March 2014. SEN. JIM NIELSEN | Gerber Appointed to the Commission by the Senate Rules VICE CHAIRMAN SEAN VARNER | Riverside Committee in March 2019. Elected in January 2013 to Appointed to the Commission by Governor Edmund G. represent the 4th Senate District. Represents Chico, Brown Jr. in April 2016 and reappointed in January 2018. Oroville, Paradise, Red Bluff, Yuba City, and surrounding Managing partner at Varner & Brandt LLP where he areas. practices as a transactional attorney focusing on mergers and acquisitions, finance, real estate, and general counsel ASM. BILL QUIRK | Hayward work. Elected vice chair of the Commission in March 2017. Appointed to the Commission by Speaker of the Assembly Anthony Rendon in 2017. Elected in November 2012 to DION ARONER | Berkeley represent the 20th Assembly District. Represents Hayward, Appointed to the Commission by the Senate Rules Union City, Castro Valley, San Lorenzo, Ashland, Cherryland, Committee in April 2019. Partner for Aroner, Jewel, and Fairview, Sunol, and North Fremont. Ellis. Former State Assemblymember from 1996 to 2002, chief of staff for Assemblymember Tom Bates, social SEN. RICHARD ROTH | Riverside worker for Alameda County, and the first female president Appointed to the Commission by the Senate Rules of Service Employees International Union 535. Committee in February 2013. Elected in November 2012 to represent the 31st Senate District. Represents Corona, DAVID BEIER | San Francisco Coronita, Eastvale, El Cerrito, Highgrove, Home Gardens, Appointed to the Commission by Governor Edmund G. Jurupa Valley, March Air Reserve Base, Mead Valley, Brown Jr. in June 2014 and reappointed in January 2018. Moreno Valley, Norco, Perris, and Riverside. Managing director of Bay City Capital. Former senior officer of Genentech and Amgen, and counsel to the U.S. House of CATHY SCHWAMBERGER | Calistoga Representatives Committee on the Judiciary. Appointed to the Commission by the Senate Rules Committee in April 2018 and reappointed in January 2019. CYNTHIA BUIZA | Los Angeles Retired associate general counsel for State Farm Mutual Appointed to the Commission by Speaker of the Assembly Automobile Insurance Company. Former board member Anthony Rendon in October 2018. Executive director of the of the Civil Justice Association of California and the Capital California Immigrant Policy Center. Former policy director Political Action Committee. for the American Civil Liberties Union, San Diego, and policy and advocacy director at the Coalition for Humane JANNA SIDLEY | Los Angeles Immigrant Rights of Los Angeles. Appointed to the Commission by Governor Edmund G. Brown Jr. in April 2016 and reappointed in February BILL EMMERSON | Redlands 2020. General counsel at the Port of Los Angeles since Appointed to the Commission by Governor Edmund G. 2013. Former deputy city attorney at the Los Angeles City Brown Jr. in December 2018. Former senior vice president Attorney’s Office from 2003 to 2013. of state relations and advocacy at the California Hospital Association, State Senator from 2010 to 2013, State Full biographies are available on the Commission’s Assemblymember from 2004 to 2010, and orthodonist. website at www.lhc.ca.gov. COVID-19 AND CHILDREN’S MENTAL HEALTH: ADDRESSING THE IMPACT | 45 “DEMOCRACY ITSELF IS A PROCESS OF CHANGE, AND SATISFACTION AND COMPLACENCY ARE ENEMIES OF GOOD GOVERNMENT.” By Governor Edmund G. “Pat” Brown, addressing the inaugural meeting of the Little Hoover Commission, April 24,1962, Sacramento, California Milton Marks Commission on California State Government Organization and Economy www.lhc.ca.gov