Brief Children's Behavioral Health

Prior to COVID-19, an estimated 13.2 million children between the ages of 3 and 17 were diagnosed with anxiety, depression or a behavioral health disorder. According to the Centers for Disease Control and Prevention (CDC), behavioral health disorders can prevent children from developing coping and resiliency skills—abilities they need to help them learn, behave or handle their emotions. These skills are essential to healthy social development and help ensure children have a positive quality of life now and into adulthood. Early identification of behavioral health disorders can lead to children receiving treatment sooner and help mitigate some of the challenges related to coping and resiliency later in life.

As states navigate this policy space, this page will be updated with information related to policy trends, best practices and hot topics throughout the year.

2020 Year in Review

In the last year, the effects of virtual learning, access to school health services and heightened attention to health disparities due to COVID-19 have been at the forefront of children’s behavioral health challenges. Early childhood stressors resulting from poverty, lack of safe or stable housing, access to routine medical care or education, and language barriers can affect a child’s neurological, metabolic and immunologic systems for life. However, the Centers for Disease Control and Prevention has associated screening, early identification and linkage to services with good health outcomes for children affected by these health disparities. These actions can result in lower health risks such as teen pregnancy, poor dietary choices, inadequate physical activity, physical and emotional abuse, substance use and gang involvement. This last year has demonstrated the possible linkage programs and supports can have in fostering a behavioral health system for youth.

State Action

Over 73 bills were introduced across 28 states in 2020 related to children’s behavioral services and health care services in a school setting. Of those enacted, many related to increasing investment in training existing staff, administrators and caretakers across schools and school districts. Other laws developed new programs and frameworks that can act as a model for schools and new ways of assessing the need for school mental health resources through the creation of task forces and work groups. States also focused on appropriating the Coronavirus Aid, Relief and Economic Security (CARES) Act and other relief funds to support students with mental and behavioral health needs who receive care in school-based settings.

The table below includes a few state examples of enacted legislation across these different policy areas.

2021 State Action

Below are examples of state actions during the 2021 general session related to children’s mental and behavioral health services, including services offered in a school settings.

Medicaid in Schools

The Centers for Medicare and Medicaid Services (CMS) eliminated the free care rule in 2014, allowing states to receive federal reimbursement for services provided to any student enrolled in Medicaid instead of exclusively to those with individualized education programs (IEPs). Medicaid has since become an increasingly common financial mechanism of funding for physical and behavioral health in schools.

In the six years since the elimination of the free care rule, 12 states have enhanced their school-based Medicaid programs. Michigan used the rule change to leverage Medicaid funding to support school-based mental health. In 2018, the state legislature passed SB 149, providing $30 million to place licensed behavioral health providers in schools for students. The bill also included $1.3 million for the Michigan Department of Health and Human Services to file a state plan amendment (SPA) with the CMS to facilitate further expansion of school-based mental health services. The SPA expanded billing eligibility for certain mental and physical health care providers and permitted school districts to seek reimbursement for services provided to all students enrolled in Medicaid.

Currently, over 30 million students receive Medicaid-funded services across the country. Two-thirds of school districts reported using Medicaid funds to pay the salaries of health and mental health service professionals who serve students. Providing these services in a school-based setting has, on average, identified 6 out of 10 students who needed treatment for a mental health disorder. In 2019, CMS and Substance Abuse and Mental Health Services Administration (SAMHSA) released a joint informational bulletin for states and school systems, with examples of approaches for services in schools, and described some Medicaid authorities that states can use to cover services.

Federal Actions

The Health Resources and Service Administration (HRSA) awards over $12 million for maternal and child mental health programs.

Congress passed the Governor’s Emergency Education Relief Fund, which can provide social and emotional development services to schools or other types of assistance related to COVID-19 determined necessary by governors. Other federal support includes the Elementary and Secondary School Relief Fund, which may be used to “provide mental health services and supports” as needed, and the Project School Emergency Response to Violence. It provides $100 million to help schools deal with violence or trauma that disrupts the learning environment, such as a pandemic that forces classes online.

Congress has taken steps to support federal agencies with behavioral health funding through a variety of financial supports. The CARES Act included $425 million for SAMHSA to address mental health and substance use disorders as a result of the COVID-19 pandemic. As part of that funding, certified community behavioral health clinics received $250 million to respond to the increased need for services related to depression, anxiety, substance misuse or other conditions.

SAMHSA also received $50 million for suicide prevention efforts and $100 million in flexible funding to address mental health and substance use disorders and provide resources to youths and the homeless during this time.