Colorado Children’s Hospital declared a state of emergency for youth mental health in 2021: Pediatric emergency departments experienced an influx of young people in crisis, but treatment options did not meet the need.
“As mental health acuity increased for youth, there was a lack of appropriate treatment beds,” says Colorado Rep. Mary Young (D), who served from 2019-2024. “This resulted in children languishing in emergency rooms, being inappropriately hospitalized for months and even staying in human services offices.”
Colorado is not alone in facing an increased demand for treatment options for youths in crisis. Over 1 million children and adolescents visited emergency departments nationwide for mental health-related reasons annually between 2018 and 2021, according to a National Health Statistics Report. Additionally, the National Survey of Children’s Health reports that nearly two-thirds of the more than 5.3 million adolescents ages 12 to 17 with a diagnosed mental or behavioral health condition had difficulty accessing treatment in 2023. That was a 35% increase since 2018.
Even when services are available, treatment and outreach strategies are not always tailored to the needs of children and adolescents. The Substance Abuse and Mental Health Services Administration recommends youth crisis systems provide “developmentally appropriate services and supports that treat youth as youth, rather than expecting them to have the same needs as adults.” Childhood and adolescence are critical periods for growth and development, and inappropriate treatment responses such as hospitalization or justice system involvement may worsen outcomes in the long term.
In the last two years, several states have passed legislation to improve a variety of services for young people, including building coordinated systems of mental health care, youth-focused crisis intervention and residential psychiatric treatment.
Coordinated Systems of Mental Health Care
Young and Colorado Rep. Brandi Bradley (R) were lead sponsors of bipartisan legislation (HB 1038) requiring state agencies to coordinate a system of care for children and youth with complex behavioral health needs. The approach includes use of a standardized assessment tool, intensive care coordination services, expanded supportive services and expanded access to therapeutic foster care. The bill also creates a training academy for youth residential psychiatric treatment providers, a system to monitor quality of care, and enhanced reimbursement rates to incentivize in-state youth residential treatment capacity.
Youth-Focused Crisis Intervention
States also have passed legislation to bolster youth-focused crisis response with enhanced coordination across systems. Texas funded four additional crisis respite units and three pilot peer-run units to serve young people. To reduce the risk of hospitalization from acute mental health illness and to support youth transitioning into care, the bill also established youth mobile crisis outreach teams.
Similarly, in 2023, Washington appropriated general funds to expand the capacity and reach of local behavioral health mobile crisis response teams. The bill also ensures each region will have at least one adult mobile crisis team and one child and youth team to respond to calls from the 988 crisis hotline. In the next session, Washington passed a bill creating licensure and certification rules for crisis relief centers serving children. The bill requires centers to be staffed by a pediatric multidisciplinary team 24/7 and to provide resources to connect children and their families with behavioral health services in the community.
Residential Psychiatric Treatment
Montana legislators learned children were struggling to receive adequate psychiatric treatment. In response, state Rep. Jane Gillette (R) sponsored legislation to increase the Medicaid reimbursement rate for in-state psychiatric residential treatment facilities, or PRTFs, and therapeutic group homes based on a child’s age and the acuity of the child’s treatment needs. The intention of increasing the reimbursement rate is to keep children in-state for treatment and provide PRTFs and therapeutic group homes greater resources to address complex mental health needs, such as suicidal behavior and self-harm.
“When we keep children in-state, close to their family and close to their friends and their neighborhoods, it results in better outcomes for children.”
—Montana Rep. Jane Gillette
“The issue that we were presented with is that we continually send our children that require therapeutic group homes and PRTFs out of state,” Gillette says.
Therapeutic group homes are small residential programs that support youth in a homelike setting. PRTFs are nonhospital psychiatric facilities that have a provider agreement with the state’s Medicaid agency. PRTF services can include both physical and psychiatric care, including individual treatment, group therapy, family therapy and medication management.
“When we keep children in-state, close to their family and close to their friends and their neighborhoods, it results in better outcomes for children,” Gillette says.
Other states have passed legislation addressing access to and oversight of youth residential psychiatric treatment. Maine required the Department of Health and Human Services to report to state lawmakers about efforts to implement children’s PRTFs.
States can play a key role in overseeing residential facilities to ensure children and adolescents are entering residential treatment only when appropriate and that young people are receiving suitable care. New Hampshire passed legislation clarifying that residential facilities are appropriate only for children who cannot safely receive treatment in community-based settings. Placement in a residential setting is used as a “last alternative” for children age 12 and older or when “deemed clinically appropriate due to therapeutic or medical necessity.” The bill also requires the Department of Health and Human Services to enhance the oversight of residential facility certification and create an additional approval process for any child placed outside of New England.
Find other examples of enacted bills on children’s mental health services in NCSL’s Maternal and Child Health Database, and examples of enacted bills on the mental and behavioral health of children in foster care in NCSL’s Child Welfare Database. Find examples of enacted bills and policy options to strengthen the crisis continuum of care in the report “A Better Response” from the advocacy group Inseparable.
Flora Fouladi is a policy associate on NCSL’s health team.
Support for this document was provided by Inseparable, a leading mental health advocacy organization that works to advance policies that expand access to care, support youth mental health and ensure appropriate crisis response. The views expressed in this document do not necessarily reflect the views of the organization.