Changing our Approach to Children's Mental Health

A California advocacy organization is trying to reinvent America’s approach to children’s mental health. The idea is to remove mental health care from the traditional medical system and instead integrate resilience and community supports into the very fabric of society.

Kara Lofton spoke with Alex Briscoe of the California Children’s Trust — one of the speakers at the annual Association of Health Care Journalists Conference. They discussed what reshaping mental health would look like in practical terms and how it could be applied on a national scale.

Lofton: What does that mean to transform children’s mental health in California?

Briscoe: Well first, it means make sure a lot more happens than currently does, but also reinvent what it means. We strongly believe that behavioral health is not just a response to pathology, but it’s a tool for healthy development and health equity.

But it [also] means removing it from the traditional frame, which is medicalized and, frankly, pathologizes, many low-income people — sometimes out of necessity — to justify the reimbursement that Medicaid provides.

Lofton: So if you remove mental health from the traditional system, what is the alternative?

Briscoe: Yeah, I mean, a wellness and resilience frame that focuses on the adaptive capacities that all of us are born with, that helps build and elicit the positive wisdom and intelligence that is our birthright. So if mental health is done right, it celebrates our successes in the face of challenge. As many people now ask ‘us , not what’s wrong with us, but what happened to us, so how are we coping?’

So effective mental health services do have a clinical frame. There are seriously mental ill children who need cognitive behavioral therapy, narrative practices and sometimes even medication.

But the vast majority of young people, their behavioral health challenges are a function of growing up either poor or in difficult circumstances. And we need to celebrate the ways that they’re surviving despite.

And that’s one of the great challenges of traditional health care [ideas about] mental health is that young people are resilient. If you kick them, they’ll get back up. And that, unfortunately, perversely incentivizes healthcare not to serve. And what we can do is flip that frame and show that spending resources on the health and welfare of children is not only essential, but important from a health care outcome perspective.

Lofton: Okay, so what does that mean in terms of like actual implementation?

Briscoe: So what it would mean is that you wouldn’t just go see a therapist because your PCP, your primary care provider, gave you a piece of paper and said, “you have a problem. You need help.” Our behavioral health supports would be embedded in the lives of children where they live, work and play. In their homes, in their schools and their rec-centers, in their social networks.

Meaning that we would embed behavioral health principles and practices in every aspect of a child’s life, because it’s something that all children benefit from. Whether you have teenagers like me, or whether you just know kids, you know that to be young is to have to decide and do and live and work and play without [the] full information that life provides. This is anxiety producing in and of itself, but our current culture has exacerbated it.

And whether it’s structural racism, the stabilization of poverty, the extension of adolescence — it takes longer to get to the workforce — or the advent of social media. There are increasing drivers of anxiety and depression that are showing up in the lives of our children at striking rates. And we think that in order to address those, you can’t wait for kids to get sick. You need to, frankly, treat them in the state that they experience these challenges in and give them tools to adapt.

Lofton: Is California implementing this idea in tangible ways?

Briscoe: The answer is, you know, no. Because right now we don’t pay for it. And that’s why we are unabashedly focused on the underlying financing and administration of Medicaid. 6 million of California’s 10 million children are now eligible for an entitlement that guarantees them everything they need. That’s this thing called EPSDT,, the initials stand for Early Periodic Screening Diagnostic Treatment, and it’s one of Medicaid’s oldest benefits.

One way I like to describe it so people could understand it, is think about immunizations, which are another benefit of EPSDT, one of the original set of benefits defined in the Social Security Act. And then within immunization, we’ve made a decision as a culture that giving you an MMR shot of measles, mumps and rubella, even though it’s unlikely you will contract measles is to the benefit of our health care system and the population’s health.

I think behavioral health should be considered more like immunization and less like a specialty care service. It’s closer to an immunization than it is orthopedics or nephrology. And if we treat it that way, and apply it at scale, I think we’ll see the changes in population health outcomes that we all want.

Lofton: Is this an idea that could be implemented across any state?

Briscoe: Absolutely. In fact, the EPSDT benefit, from my perspective, is an entitlement that all low-income children enjoy. And it’s a promise that’s been made since 1967, and largely unfulfilled. Now, fulfilling it is more than it just existing as it existed for 50 years. To activate it, we have to both fund the nonfederal share of Medicaid, and this is really important thing for folks to understand because we talk about Medicaid as if it’s a monolithic thing. It’s not. It’s not just one thing.

Medicaid not only has multiple ways that it flows dollars into health systems, but it’s almost always split between a federal dollar and a state or local dollar. And so the challenge with the EPSDT is accessing the nonfederal dollar and then spending it differently. So we want to see EPSDT used as the foundation for health reform for children.

Lofton: West Virginia has one of the highest rates of Medicaid enrollment in the country. e also have very high rates of school-based health centers already. hat would it take for West Virginia to utilize these principles in the coming years?

Briscoe: Well, it’s a great framework. So to the fact that it exists already means some good work has already been done. But part of what the Children’s Trust is promoting is a redefinition of what behavioral health practice is.

It doesn’t have to be a 50-minute session with a therapist. In fact, having worked in a lot of school-based health centers myself, you can tell the quality of a school based health center almost right away, by the depth and scope of its Peer Health Education program. Are their young people on campus who are fronting the services of the clinic? Who are legitimizing the brokerage or a bridge between adult allies and children who need access to special support. But also, does a school itself have a broader approach to social/emotional health? Is it part of every classrooms experience? Is it there on the playground or in the school yard? Do teachers and children talk to each other in a certain way? Like the idea that you build a healing community, it’s not just a healing service is an essential component of a re-understanding of behavioral health.

So what I mean by that is like if the principles of the Children’s Trust were adopted in West Virginia, there would be peer health education programs in every high school. In fact, I would argue that half of all high school graduates would have had an experience as a peer health educator at some point in their high school career.

There would be cascading mentorship programs, where seniors will be working with freshmen to ensure that they understood the classes and their work out of them. You will be building a social connection and social cohesion, which is the most important protective factor for social [and] emotional health.

It doesn’t always [need to be] a clinical service, behavioral health, we have to open our minds and hearts and expand our definition understanding what is social and emotional support, and connections between people are the essential component of that.

So that can take the form of peers, it can take the form of adult allies, it can take the form of social models or affinity groups. There’s a lot that the traditional mental health system can learn from the recovery community. Whatever your critique may be of 12-step programs, and abstinence only and as Christian spaces in Christianity, a beautiful thing will happen tonight when millions of people will come together, free of charge, joined only by their common experience of suffering. There are numerous affinity opportunities where simply by sharing our common experience, we can build social and emotional health and wellness. And I think that behavioral health should take that as its charge, not just funding per minute per unit, diagnostic criteria-type of services.

I think our nation faces an opportunity to heal itself, and  we have historically come together on the issue of the experience of children. Many people forget that as CHIP was passed in the Reagan and Bush era, the health and welfare of low-income children has been a cross aisle issue in our nation’s history. And we need an opportunity to talk about the social contract in America, we haven’t done it.

And whether it’s in the experience of the seriously mentally ill or the homeless population or other marginalized communities, we need a place to reopen a conversation about what we owe each other as a culture. And I think the place to start that conversation is this one. The data is incredibly compelling, and the financing opportunity is before us. I think we need something to reinvent our trust and belief in our culture to solve big problems, and I think children’s mental health is an opportunity

Appalachia Health News is a project of West Virginia Public Broadcasting, with support from Marshall Health and Charleston Area Medical Center.