key: cord-0976858-puaqptbw
authors: Long, Melissa; Coates, Erica; Price, Olga Acosta; Hoffman, Sarah Barclay
title: Mitigating the impact of Coronavirus Disease-2019 on child and family behavioral health: Suggested policy approaches
date: 2022-02-10
journal: J Pediatr
DOI: 10.1016/j.jpeds.2022.02.009
sha: 5d82222afd9c1fefc6aad19a5e69ec82871d1de3
doc_id: 976858
cord_uid: puaqptbw

nan

The COVID-19 pandemic has exacted a significant toll on children and families and deepened an existing national child and family behavioral health 1 crisis. Although we have not seen the full scope of the pandemic's effects on behavioral health, we have already witnessed negative impacts from social isolation, child care and school closures, grief and loss, and family economic insecurity (1, 2) . And although children across the globe have borne pandemic distress, in many communities, children of color have been disproportionately burdened (3) .

Unfortunately, existing behavioral health care systems were inadequate before the pandemic, and they are certainly insufficient to address these increased behavioral health needs.

Our child and family behavioral health "safety net," including pediatric primary care and the public school system, is under-resourced to handle the surge in concerns, especially with staffing shortages caused or exacerbated by the pandemic (4, 5) .

The pandemic nevertheless presents an opportunity. We must harness the national attention generated by the current crisis to advance equitable solutions that are family-centered and include a continuum of support from prevention to treatment. Leading experts on child health, including the American Academy of Pediatrics, declared a national state of emergency in child and adolescent mental health in October 2021 followed in December by a Surgeon General's Advisory to call for urgent attention to address the crisis (6, 7) . We owe children and families a swift, comprehensive policy response that will lead to permanent strengthening of a behavioral health system that was already struggling before the pandemic, including promotion of policies to increase access to behavioral health services, expand and develop a culturally-appropriate family-focused behavioral health workforce, promote the integration of behavioral health in pediatric primary care, and improve schools' ability to address behavioral health needs of students.

Our commentary outlines suggested policy strategies, especially at the state and federal level, that could guide deliberations and action of policymakers. The suggested policy reforms also could provide a roadmap for pediatric providers who are in a position to engage in advocacy. For all child health practitioners caring for children and families during these challenging times, this commentary could provide a deeper understanding of the policy dynamics shaping the behavioral health care environment.

For years, children and families in the U.S. have been sounding the alarm bell: suicide is the second leading cause of death among young people aged 10-24 years (8) . Concerning disparities among racial and ethnic subgroups exist, such as significantly higher incidence of suicide among Black children versus White children ages 5-12 years old, and disturbingly high rates of suicidal ideation and behaviors among special populations, such as LGBTQ youth (9) (10) (11) (12) . Additionally, the incidence of behavioral health disorders has been increasing. A study found that half of U.S. children with a treatable mental health disorder did not receive needed treatment from a mental health professional during that previous year (13) . Not surprisingly, emergency department (ED) visits for behavioral health concerns have also been rising, and without adequate inpatient resources to care for those youth with more severe and acute behavioral health concerns, patients may spend days in an ED before being admitted to an appropriate inpatient facility (14) . The shortage and maldistribution of licensed behavioral health care providers (15, 16) and inadequate insurance networks for behavioral health (17) both contribute to the difficulty children and families face in accessing timely treatment. Though not specific to pediatrics, a 2015 Department J o u r n a l P r e -p r o o f of Health and Human Services report projected that by 2025, there would be major behavioral health workforce shortages of 16,940 mental health and substance abuse social workers, 8, 220 clinical counseling and school psychologists, and 13,740 school counselors (18) .

Although it is clear that our behavioral health system was under significant strain prior to the pandemic, the needs have only intensified over the past two years, and evidence is accumulating that children's behavioral health has been negatively impacted by the COVID-19 pandemic (19) .

Data show increases in children's mental health-related ED visits and rates of suicide ideation and attempts at various time periods during the pandemic (19) (20) (21) . Young children (birth to age 5) also have been adversely impacted. Studies show that when caregivers experienced more financial and material hardship, they also reported more emotional difficulties in their young children (22) . there is reason to be concerned that the negative behavioral health impacts from the COVID-19 pandemic may not be borne equally by all groups of children. Evidence shows that African American and Latinx adults have experienced more behavioral health symptoms during the pandemic than other groups and report increased concerns about the impact of the pandemic on their children's education, ability to care for their children, and relationships (23) .

Additionally, an estimated 140,000 children lost a primary or secondary caregiver during the first 14 months of the pandemic and 65% of those were children of racial and ethnic minority groups (24) .

Positive and stable caregiver-child relationships are crucial for the behavioral health and wellbeing of children. Emerging evidence reveals the extent of the strain the pandemic has placed on caregiver mental health (25, 26) . Compared with adults without children, caregivers, especially maternal figures, with minor children have experienced higher levels of stress, mental J o u r n a l P r e -p r o o f health diagnoses, and rates of mental health treatment (26) . Although general stress levels in caregivers decreased over time, stress specific to care-giving responsibilities continued to increase (27) . research also shows that caregivers' coping during the pandemic and the caregiver-child relationship is strongly related to children's and adolescents' emotional and behavioral functioning (28, 29) , an association consistent with reports from prior pandemics and disasters (30) . Although for many, the pandemic has been conducive for strengthening family relationships (31, 32) , for others, it has strained caregiver-child relationships and led to punitive, psychologically abusive, or high conflict interactions due to the increased caregiver stress and depression experienced during the pandemic (1, 33, 34) . Conversely, a close caregiver-child relationship was protective against mental health difficulties for adolescents (28) .

These data underscore that adult and family behavioral health should be considered inextricable from children's behavioral health. A multi-faceted approachattending to the behavioral health needs of children, their primary caregivers and the entire family unitwill be paramount to a successful COVID-19 behavioral health mitigation strategy.

Policy change at federal, state, local, and institutional levels is needed to address the child and family behavioral health crisis in the immediate and long-term recovery phases from this pandemic. Our nation must bolster our health care, school and community systems to be better positioned to deliver high-quality, developmentally and culturally appropriate behavioral health care through new or amended federal, state, and local policies. These solutions will need to address existing behavioral health conditions exacerbated by the pandemic; the onset of new behavioral health conditions resulting from the pandemic; and pandemic-induced behavioral health symptomatology that does not result in a disorder, but that should be supported with J o u r n a l P r e -p r o o f appropriate early intervention. Additionally, a racial and health equity framework should be applied when crafting and advancing behavioral health policies. Existing inequities have been exacerbated by COVID-19 and will not be rectified without intentional effort. Many frameworks exist (35, 36) , yet, regardless of the exact framework, an intentional process that prioritizes the voice of those most impacted by the proposed policy in solution development is a critical step in advancing equitable behavioral health policies (37) .

Furthermore, as our society responds to this crisis, we should guard against a singular focus on the elements of our behavioral health care system most often utilized when individuals are in crisisemergency departments, inpatient facilities and outpatient treatment services. Ensuring adequate supply of these types of services is paramount yet must not be done to the exclusion of investing in and prioritizing upstream approaches, including revised financing and payment structures. Behavioral health conditions and concerns, including those exacerbated and/or brought on by the pandemic, need not be life-long or long-term. Prevention, early intervention and timely treatment, when indicated, can propel children and families towards a lifetime of thriving.

From a systems perspective, behavioral health, and especially children's behavioral health, remains a 'second class citizen' compared with physical health conditions. Nationally, a child's mental health office visit is 10.1 times more likely to be out-of-network than a primary care office visit and twice as likely as an adult mental health office visit to be out-of-network (17) .

As cited previously, more than half of children with a treatable mental health disorder are not receiving necessary treatment from a mental health professional (13) . Mental health parity has yet to be achieved and network adequacy for behavioral health demands attention and action, especially as a critical response to the COVID-19 children's behavioral health crisis. MHPAEA, which mandates that health plans and insurers offer mental health and substance use disorder benefits that are comparable with their coverage for general medical and surgical care (49) , has produced mixed results regarding efficacy for increasing access, yet most studies have largely focused on adults. A study of middle-income children and youth suggests that MHPAEA enactment improved access to care and mental health outcomes (50) . Federal actions to advance actualization of MHPAEA could extend MHPAEA authority to include Medicaid fee-for-service and enhance parity enforcement for both Medicaid managed care and private insurance (47) ; and utilize U.S. Department of Labor enforcement authority to penalize states and payors that do not comply with federal parity requirements (51).

Although not sufficient to address the behavioral health crisis, an important component of a comprehensive solution will be to expand the pool of qualified behavioral health care professionals (52) . Additionally, given the family stressors, shared trauma, and relational strain experienced by children and caregivers during the pandemic and the importance of addressing the behavioral health of caregivers within the pediatric behavioral health care system (53) (54) (55) , it will be imperative to bolster the ability of the behavioral health workforce to utilize a family systems approach (56) . Unfortunately, workforce shortage data (57, 58) demonstrate that even with laudable and necessary policies such as loan repayment, the current and projected supply will not meet demand, and the diversity of the behavioral health workforce is woefully inadequate (59) .

We must continue to prioritize broadening the workforce and the settings in which behavioral health occurs, as well as improving overall access to care for children and the adults in their CCBHCs receive flexible funding to improve available behavioral health treatment services.

Results show expanded access to care, drastically reduced wait times, and increased hiring of behavioral health professionals (51, 61) .

Increasing substantially the racial, ethnic, cultural, and linguistic diversity of the behavioral health care workforce. Recent recommendations are worthy of immediate action (47, 51, 62) .

Examples of federal action include: support of tuition waiver programs to encourage young J o u r n a l P r e -p r o o f people of color to enter the behavioral health workforce (51) . Passage of the Pursuing Equity in Mental Health Act, which "would improve training in culturally and linguistically appropriate care, incentivize a more diverse workforce pipeline and proactively engage BIPOC [Black, Indigenous, people of color] communities in mental health care" (47) .

Using lay health worker models to address low-acuity, common mental health conditions in adults and youth, such as the Friendship Bench program that originated in Zimbabwe (63, 64) .

Exploring promising, scalable strategies such as youth-initiated mentorship, a preventive approach where youth and their families receive support to recruit caring adult mentors from within their existing social networks to bolster access to non-primary caregiver adults (65) .

Allowing billing for the services of community health workers or navigators who can link families to behavioral health care and reinforce treatment recommendations through state level policy change, such as Medicaid reimbursement (45, 62) .

With the shortage of specialized child behavioral health professionals (57, 58) , pediatric primary care providers (PPCPs) have been increasingly called upon to address the mild to moderate behavioral health concerns of their patients (66) (67) (68) . There are opportunities to better support PPCPs in this role.

Although there has been a trend toward increasing integration of behavioral health services in pediatric primary care, only 52% of pediatricians indicate that they work in settings with a colocated behavioral health provider (69) . Child psychiatry access programs (CPAPs) can be a valuable source of support for PPCPs who are managing their patients' behavioral health concerns and have been shown to be efficacious (70, 71) . They are regional or state-level (62) . At the state level, enact policies that allow for billing for behavioral health care on the same day as a primary care service, expanded billing codes that support collaborative work so that primary care and psychiatric providers can be paid for indirect consultation, case review, and referral coordination, and first-line behavioral health treatment by co-located or collaborating behavioral health providers of all disciplines as part of medical benefits (without additional co-pays).

Allowing pediatric practices to bill through the child's insurance for services that, even though directed at the child's caregiver (e.g., postpartum depression screening), also positively impact the child. Wider billing latitude could be achieved through policy change at the federal level and/or through private insurance. Expanding and institutionalizing federal support through the J o u r n a l P r e -p r o o f Health Resources and Services Administration for CPAPs so that all states can benefit from these essential programs.

The pivotal role that K-12 schools and their associated professionals have played in the identification, early intervention, and treatment of children's behavioral health needs has long been recognized and continues to drive nationwide expansion of school-based behavioral health programs (72, 73) . Offering behavioral health supports in schools has been part of a safety net strategy to increase access to care and utilization of services for children and families living in poorly resourced communities (74) . School-based health centers represent a model of integrated care in which comprehensive health care services (typically including primary and behavioral health services) are offered to students through a partnership between schools and a sponsoring community agency or health system (75) . These collaborations have not only expanded standard and specialized treatment options delivered in schools, but have enriched positive school climate efforts, expanded social and emotional learning opportunities, improved classroom management practices, and enhanced crisis responses (74) .

The need for behavioral health services in schools and other supportive structures and environments will grow in the immediate and longer-term aftermath of the COVID-19 pandemic, and requires policy attention, which includes centering youth in the policy formulation and advocacy processes (76) . Examples include:

Enacting state law or policy regarding mandated or recommended maximum student-tocounselor ratios. Evidence exists that states with those types of policies in place have greater access to school behavioral health professionals for students than those without such a policy (76) . Medicare and Medicaid Services allows states to bill for school health and behavioral health services for any Medicaid eligible child (77) . Now is an opportunity for more states to utilize this Medicaid policy, which has promising initial results (76, 78) .

Ensuring policy support for telehealth provision of behavioral health services, especially in schools. Continuation of existing policies that increased access in health and school settings via telehealth is critical, in addition to prioritizing other federal and/or state changes that may need to occur to maximize insurance reimbursement, improve equitable technology access and advance licensure reciprocity (79) .

Advancing collaboration among the health and education sector, including among PPCPs, specialty behavioral health providers and schools. Numerous barriers to collaboration have been documented (80) , including thorny policy issues such as the interplay between

The Family Educational Rights and Privacy Act (FERPA) and Health Insurance Portability and Accountability Act (HIPAA). Many resources exist to collaboratively navigate current policy and proffer recommendations in this arena (78, (81) (82) (83) .

Many important and efficacious policy solutions exist to support the wellbeing of children and families and to address the current behavioral health crisis. Pediatric providers are not always at the forefront of policy negotiations, but they are most certainly on the frontlines of the child and family behavioral health crisis. Pediatric providers can be a powerful voice influencing policy at local, state and federal levels, illuminating such discussions with their on-the-ground experience caring for families whose wellbeing has been impacted by the COVID-19 pandemic.

We encourage pediatric providers to engage with their professional societies and other child J o u r n a l P r e -p r o o f advocacy groups to advocate for an improved, integrated, and family-focused behavioral health system.

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The authors would like to acknowledge their colleagues and thought partners at the Children's