Children's Behavioral Health

3/4/2021

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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.

Further information on health disparities can be found here.
Further impacts of the COVID-19 pandemic can be found here.

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.

State	Status	Reference - Description
Arizona	2020	SB 1523 relates to mental health. Bars insurers that cover mental health and substance use disorder benefits from denying those benefits solely because the services were delivered in a school setting.
Colorado	2020 2020	HB 1053 directs the state Department of Human Services to implement and operate a statewide early childhood mental health consultation program to support mental health care in early childhood settings. HB 1411 appropriates over $3 million of the $70 million in CARES Act relief funds to several executive branches including the Department of Human Services for school-based health services.
Florida	2020	SB 7012 provides additional duties for the Statewide Office for Suicide Prevention. Develop a network of community-based programs to improve suicide prevention initiatives. The network will identify and work to eliminate barriers to providing suicide prevention services to individuals who are at risk of suicide. The network will consist of stakeholders advocating suicide prevention, including, but not limited to, not-for-profit suicide prevention organizations, faith-based suicide prevention organizations, law enforcement agencies, first responder’s emergency calls, veterans, service members, suicide prevention community coalitions, schools and universities, mental health agencies, substance abuse treatment agencies, health care providers and school personnel.
Iowa	2020	SB 2261 relates to behavioral health services, including providing them via telehealth in a school setting. SB 2360 relates to classroom management and practitioner preparation procedures for reporting classroom violence and assaults. Area education agencies will develop, establish and distribute to all school districts evidence-based standards, guidelines and expectations for the appropriate and inappropriate response to behavior in the classroom that presents an imminent threat of bodily injury to a student or another person and for the reasonable, necessary and appropriate physical restraint of a student consistent with state board rules.
Maryland	2020	HB 277 requires the State Department of Education, in consultation with both the departments of Health and Human Services, to develop and distribute guidelines on a trauma-informed approach to assist schools with understanding and responding to individuals with symptoms of chronic interpersonal trauma or traumatic stress.
Minnesota	2020	SF 1 extends emergency waivers that allow the continued use of telemedicine alternatives for school-linked mental health services and school district mental health services for the duration of the COVID-19 pandemic.
New York	2020	SB 7503 appropriates funds to support the Prevent Cyberbullying Initiative through activities including, but not limited to, public awareness campaigns and school counselor training.
North Carolina	2020	SB 476 requires the state Board of Education to adopt a school-based mental health policy for personnel who work with students in grades K-12 that contains minimum requirements for school-based mental health plans, as well as a model mental health training program and suicide risk referral protocol. HB 1105 allocates $300,000 to the state Department of Social Services to establish a student health collaborative pilot program in partnership with a local education agency.
Ohio	2020	HB 481 appropriates $6.5 million in Coronavirus Relief Funds to establish, expand and renovate programming for individuals affected by behavioral-health-related issues, specifically targeting, to the extent possible, middle- and high-school-age youth.
Tennessee	2020	HB 2588 requires a parent educational seminar, including at least one 30-minute video on adverse childhood experiences (ACEs), before a court grants a divorce.
Virginia	2020	SB 619 requires each school board to adopt and implement policies that require teachers and other relevant school personnel, as defined by the school board, to complete a mental health awareness training or similar program at least once every 10 years.
Washington	2020 2020	HB 2116 establishes a task force on improving institutional education programs and outcomes. The task force shall examine several issues, including goals and strategies for addressing adverse childhood experiences of students in institutional education and providing trauma-informed care. SB 6191 makes changes to the state “healthy youth survey,” which is a voluntary and anonymous survey administered every two years to students in sixth, eighth, 10th and 12th grades, to include questions related to ACEs so that their prevalence throughout the state can be better assessed and addressed.
West Virginia	2020	HB 4773 creates a work group, whose members include the state superintendent of schools, to conduct a study of ACEs and their impact on the people of West Virginia.

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.

State	Status	Children’s Mental Health in Schools - Reference and Description
Alabama	Prefiled 2/2/2021	SB 92 Requires the State Department of Education to develop a program to address the mental health of students (Tier II students) who are considered at-risk for developing inadequate social-behavioral skills, such as ADHD or anger management issues.
Michigan	Adopted 1/28/2021	SR 7 A resolution to urge the governor and the Michigan Department of Health and Human Services to lift the suspension on high school and youth sports and allow play to resume immediately. Allowing students to participate in high school and youth sports would help reduce social isolation and could significantly improve their mental health.
State	Status	Children’s Mental Health Services – Reference and Description
Michigan	Enacted 1/5/2021	HB 5832 An act to codify, revise, consolidate, and classify the laws relating to mental health. “Children’s diagnostic and treatment service” means a program operated by or under contract with a community mental health services program, that provides examination, evaluation, and referrals for minors, including emergency referrals, that provides or facilitates treatment for minors, and that has been certified by the department.
District of Columbia	Enacted 1/13/2021	B 127 To amend the District of Columbia Mental Health Information Act of 1978 to authorize mental health professionals to disclose mental health information when necessary to request an extreme risk protection order and to require the disclosure of mental health information to the Office of Attorney General in response to a court order.
State	Status	Student Health Services – Reference and Description
Hawaii	Introduced 1/26/2021	SB 1251 Authorizes the department of education to meet the local farm to school meal goal of 15% of food served in public schools to be locally sourced by 2025 and 30% by 2030.
Maryland	Introduced 1/13/2021	HB 244 Establishing the Task Force to Study Access to Mental Health Care in Higher Education; requiring the Task Force to study and make recommendations regarding barriers to providing mental health services on campus, the use of telemedicine, video conferencing and hotlines, and implementation of counseling services. Requiring the Task Force to submit an interim report on or before Dec. 1, 2021, and a final report on or before Dec. 1, 2022, to certain committees of the General Assembly.

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.

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