As the COVID-19 public health emergency ends, the impact on youth mental health in the United States remains to be fully understood. Of particular concern are populations less likely to have access to mental health services, including children and adolescents from racially and ethnically minoritized groups, rural areas, and low-income families. For decades, school-based mental health interventions have been utilized to expand access to care.
Many types of school-based interventions are designed to reach entire student bodies by training teachers or other staff to deliver social-emotional curricula in the classroom setting. While the details and data collected may vary, these interventions have generally demonstrated significant effectiveness in improving mental health outcomes globally.1–4
However, such programs have faced challenges to implementation. Limited staff availability and scheduling difficulties, both for training and content delivery, represent an enormous challenge; to put it simply, teaching is a very busy profession, and schools are not typically staffed to have excess capacity.1 Operationally, the nuances of how mental health curricula are designed for delivery may not fit with an individual school setting or classroom structure. To the extent that student participation is required, students may also have competing priorities, limiting their engagement in additional mental health–related classroom curriculum content. Lastly, teachers may not be interested in participating in a mental health intervention and may feel it is outside their scope or training as educators.2
The impact of COVID-19 on the school workforce has magnified these challenges of implementing teacher- and other staff-delivered interventions due to an elevated prevalence of burnout among teachers and school counselors.5 A survey of more than 2,000 teachers demonstrated that among teachers with high levels of burnout, school environment and organizational climate were associated with less teacher openness to new classroom practices.6 Burnout may reduce the ability of a supportive school environment to foster the successful implementation of a new practice, such as a teacher-led mental health intervention.
As an alternative, school-based health centers (SBHCs) offer medical and mental health services to children and adolescents by bringing licensed providers, typically affiliated with local community clinics, to school campuses—particularly in under-resourced communities. During the COVID-19 pandemic, utilization of mental health services in SBHCs increased.7 While SBHCs are an important model, they are accessible to only a small number of US students, with fewer than 3,000 SBHCs across the nation. Furthermore, given their usual reliance on public funding, SBHCs’ services may be limited as they seek to strike a balance between providing other services such as preventive medical care, health education, and dental care.8 As a result, not all SBHCs provide mental health services, and those that do are often not resourced to meet the mental health needs of all their schools. Thus, such models have been limited in scalability or sustainability.
Despite these challenges, school mental health models remain valuable for preventing and promoting student mental health, and the evolution of telehealth regulations during the pandemic provides a critical opportunity for new solutions in school-based mental health services, leveraging the most successful elements of school-based programs. Policy changes in telehealth reimbursement and medication prescribing during telehealth visits have made telehealth services for mental health viable in a new way, even as other medical services return to in-person care.8 We believe that to address mental health needs across the country, a telehealth model in which clinical mental health programs collaborate closely with schools—and, for schools that have access to them, with SBHCs—represents a promising solution.
Telehealth services for pediatric mental health needs have demonstrated effectiveness and acceptability in numerous studies, for both patients and providers.9 Telehealth services can be delivered to students and families in the school or at home as well as during school hours or after school, providing crucial flexibility for access. As a result, telehealth providers may be well positioned to liaise with teachers, school counselors, and caregivers to eliminate barriers due to transportation or family schedules, as well as offer a range of services for minoritized populations, such as care in a greater number of languages. A telehealth model for mental health services enables access for geographically remote populations and bypasses the costs, time, and space needed to establish an in-person, brick-and-mortar program like many SBHCs. Thus, telehealth can enable equitable access to mental health care.
Having collaborative mental health teams provide child and adolescent mental health care via telehealth provides several additional opportunities. Like SBHCs, financing for licensed telehealth providers can come through student health plans as well as public grants for pediatric mental health services at the local, state, and national levels. The ongoing integration of telehealth services for mental health with asynchronous self-guided exercises, psychoeducational content, and other digital mental health tools has expanded in recent years. In addition, the online implementation of school-based, universal, social-emotional curricula has demonstrated potential and may ensure greater flexibility for teachers and classrooms,10 particularly those in under-resourced areas. Finally, given the nationwide need for child and adolescent mental health resources, we recognize that no single solution can address all needs. Telehealth programs should collaborate with existing SBHCs, other educator- or school-led mental health initiatives, and other community health providers to meet the needs of the current youth mental health crisis.
About the Authors
Juliana H. Chen, MD, Cartwheel Care, Cambridge, Massachusetts, USA.
Sarah Kroesser Nichols, MEd, LICSW, Cartwheel Care, Cambridge, Massachusetts, USA.
Christopher T. Lim, MD, Boston Medical Center Health System and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA.
Correspondence to:
Christopher T. Lim, MD; email: christopher.lim@bmc.org, Boston Medical Center Health System, 85 E. Concord St. Floor 5, Boston, MA 02118.
Funding
The authors have reported no funding for this work.
Disclosure
Dr. Chen and Ms. Kroesser Nichols report receiving income and holding equity in Cartwheel Care. Dr. Lim reports having received income and holding equity in Cartwheel Care and having received consulting fees from Lyra Health.