Problem and Need Data Resources:

AAP-AACAP-CHA Declaration of a National Emergency in Child and Adolescent Mental Health (2021): AAP-AACAP-CHA Declaration of a National Emergency in Child and Adolescent Mental Health

Rates of childhood mental health concerns and suicide rose steadily between 2010 and 2020 and by 2018 suicide was the second leading cause of death for youth ages 10-24. The pandemic has intensified this crisis: across the country we have witnessed dramatic increases in Emergency Department visits for all mental health emergencies including suspected suicide attempts.

US Surgeon General’s Advisory – Protecting Youth Mental Health (2021): surgeon-general-youth-mental-health-advisory.pdf (hhs.gov)

The U.S. surgeon general issued an Advisory on Protecting Youth Mental Health, which outlines the pandemic’s unprecedented impacts on the mental health of America’s youth and families and the mental health challenges that existed long before the pandemic.

• It is estimated that as of June 2021, more than 140,000 children in the U.S. had lost a parent or grandparent caregiver to COVID-19.
• In 2019, before the pandemic, one in three high school students and half of the female students reported persistent feelings of sadness or hopelessness, an overall increase of 40% from 2009.
• Socioeconomically disadvantaged children and adolescents — for instance, those growing up in poverty — are two to three times more likely to develop mental health conditions than peers with higher socioeconomic status.

US Surgeon General’s Advisory – Social Media and Youth Mental Health (2023): Social Media and Youth Mental Health (hhs.gov)

• Up to 95% of youth ages 13–17 report using a social media platform, with more than a third saying they use social media “almost constantly.”
• Adolescent social media use is predictive of a subsequent decrease in life satisfaction for certain developmental stages including for girls 11–13 years old and boys 14–15 years old.
• A longitudinal cohort study of U.S. adolescents aged 12–15 (n=6,595) that adjusted for baseline mental health status found that adolescents who spent more than 3 hours per day on social media faced double the risk of experiencing poor mental health outcomes including symptoms of depression and anxiety.

Kaiser Family Foundation: Recent Trends in Mental Health and Substance Abuse Concerns Among Adolescents (Published February 3, 2024): Recent Trends in Mental Health and Substance Use Concerns Among Adolescents | KFF

Key takeaways include:

• In 2021 and 2022, 21% of adolescents reported experiencing symptoms of anxiety in the past two weeks and 17% reported experiencing symptoms of depression. Female and LGBT+ adolescents were more likely than their counterparts to report experiencing anxiety or depression.
• Deaths due to drug overdose among adolescents more than doubled from 2018 (253 deaths) to 2022 (723 deaths). The largest increases in these deaths were among Hispanic and Black adolescents.
• Suicides are the second leading cause of death among adolescents. These deaths peaked in 2018 but have declined in recent years. In 2022, suicide death rates were highest among American Indian and Alaska Native adolescents (22.2 per 100,000) followed by White adolescents (7.2 per 100,000). Adolescent males had higher rates of suicide compared to their female peers (8.1 vs. 3.8 per 100,000) in 2022; however, thoughts of suicide and suicide attempts were higher (and increased faster) for females.
• In 2021 and 2022, 20% of adolescents reported receiving mental health therapy and 14% reported taking prescription medication. In general, LGBT+ and female adolescents were more likely to report receiving treatment than their counterparts.
• Many adolescents reported adverse experiences, including bullying (34%), emotional abuse by a parent (17%), and neighborhood violence (15%) in 2021 and 2022. Ninety-two percent of adolescents reported extended use of screens, which can also negatively impact mental health and well-being.

CDC National Health Interview Survey Teen – Interactive Summary Health Statistics for Teens (Published 2023): NHIS Teen (cdc.gov)

Children Now: California’s Children’s Report Card – A Review and Roadmap to Improve the Well-being of California Kids (2024)

 Grade – Supporting Mental Health: D+
Grade – Preventing Substance Abuse: D-

DHCS and DMHC: Children Enrolled in Medi-Cal Face Challenges in Accessing Behavioral Health Care (Published November 2023)

The Department of Health Care Services (DHCS) and the Department of Managed Health Care (Managed Health Care) can do more to detect and address challenges that children in Medi‑Cal face when seeking behavioral health services. Behavioral health care includes care for both mental health and substance use issues, and research indicates that timely access to this care is critical. State law provides that timely access is the allowable time frame by which a health care service plan must offer appointments to members. Though there are no statewide data to demonstrate precisely how long it takes Medi‑Cal patients to receive behavioral health care once they request it, survey data for appointment wait times show that many Medi‑Cal managed care plans are unable to provide timely access for children. For example, 43 percent of urgent appointments with psychiatrists DHCS surveyed in 2022 exceeded the 96‑hour appointment wait time standard, and the median wait time for those appointments was almost 13 days.

The Annie E. Casey Foundation 2022 Kids County Data Book – State Trends in Child Well-Being (2022.)

Each year, the Data Book tracks how children are faring nationally and in every state through indicators in the areas of economic well-being, education, health and family and community. Many of these affect or are themselves affected by children’s and families’ mental health. In California, the percentage of children (ages 2-17) who had anxiety or depression increased by 70%.

Hospital Association of San Diego & Imperial Counties (HASD&IC) San Diego Community Health Needs Assessment (Published 2022)

The HASD&IC Needs Assessment provides community input survey information, contributing factors to youth behavioral health needs, and critical deficits across the continuum (of care,) which include:

• Increased Emergency Department Volume
• Family Support and Respite Care
• Emergency Shelter
• Workforce Shortage

County of San Diego HHSA, Children, Youth and Families Behavioral Health Services Systemwide Annual Report (Fiscal Year 2021-22)

This report summarizes cumulative system demographics and clinical outcomes for children and adolescents served by the County of San Diego’s, Health and Human Services Agency (HHSA), Children, Youth & Families Behavioral Health Services (CYFBHS) in Fiscal Year (FY) 2021-22 (July 2021 – June 2022). CYFBHS System of Care serves children and youth up to age 21, as well as a perinatal population. The primary focus of this annual report is CYFBHS mental health services, with limited information also available on prevention, early intervention, and addiction treatment.

Molecular Psychiatry: Age at onset of mental disorders worldwide: large-scale meta-analysis of 192 epidemiological studies (2021.)

When the data from all 192 studies were integrated, the authors found that the peak age of onset for mental disorders was 14.5 years. About 34.6 percent of patients showed a disorder before the age of 14, 48.4 percent before the age of 18, and 62.5 percent before the age of 25 years. This shows that for almost 50 percent of patients, mental disorders start before they reach adulthood, highlighting the importance of early intervention and prevention measures for mental health issues in adolescents.

American Academy of Pediatrics, CA-3, The Commitment to Early Childhood Mental Health Services in San Diego County: Dedication, Vision, Innovation Environmental Scan May 2013.)

Roadmaps and Guidelines:

State:

1. BH-CONNECT – Section 1115 demonstration

2. DHCS CYBHI

2a. Statewide Multi-Payer Fee Schedule for School -Linked Behavioral Health Services (Student Behavioral Health Incentive Program)

2b. Evidence -Based Practices and/or Community Defined Evidence Practices (EBP/CDEP) Grant Program

2c. Dyadic Benefit

3. Medi-Cal Transformation (previously known as Cal-AIM)

3a. ECM / Community Supports

4. HCAI – Workforce

5. Governor Newsome Behavioral Health Reform: Prop 1 – March 2024 Ballot

State:

1. Medi-Cal (CalAIM) Section 1115 Waiver

On October 20, 2023, the Department of Health Care Services (DHCS) today submitted to the Centers for Medicare & Medicaid Services (CMS) a proposed amendment to the California Advancing and Innovating Medi-Cal (CalAIM) Section 1115 demonstration related to transitional rent services and the new Section 1115 demonstration request, entitled the California Behavioral Health Community-Based Organized Networks of Equitable Care and Treatment (BH-CONNECT) demonstration.

The BH-CONNECT demonstration builds upon unprecedented investments and policy transformations currently underway in California that are designed to expand access to community-based behavioral health care and improve outcomes for Medi-Cal members living with the most significant mental health and substance use needs. California has invested more than $10 billion and is implementing landmark policy reforms to strengthen the behavioral health care continuum through initiatives like the Children and Youth Behavioral Health Initiative, Behavioral Health Continuum Infrastructure Program, Behavioral Health Bridge Housing Program, CalAIM Justice-Involved Initiative, Behavioral Health Payment Reform, mobile crisis and 988 expansion, and more.

2. CYBHI

Established as part of the Budget Act of 2021, the CYBHI is a multiyear, multi-department package of investments that seeks to reimagine the systems, regardless of payer, that support behavioral health for all California’s children, youth, and their families. Efforts will focus on promoting social and emotional well-being, preventing behavioral health challenges, and providing equitable, appropriate, timely, and accessible services for emerging and existing behavioral health (mental health and substance use) needs for children and youth ages 0-25.

The DHCS is responsible for key work streams under this initiative, including but not limited to:

• Development a Behavioral Health Virtual Services & E-consult Platform;
• Development of a Statewide Multi-Payer School-linked Fee Schedule and Behavioral Health Provider Network;
• Issuance of Grants to Scale Evidence-Based Practices and Community-Defined Evidence Practices;
• Issuance of School-Linked Partnership and Capacity Grants;
• Implementation of Dyadic Services as a Medi-Cal Benefit;
• Development of Parent Support Video Series;
• Issuance of Youth Peer-to-Peer Support Programs;
• Development of CalHOPE Student Support;
• Issuance of Mindfulness, Resilience, and Wellbeing Supports;
• Development of Next Generation Digital Technologies; and,
• Development of a Behavioral Health Continuum Infrastructure Program.

2a. Development of a Statewide Multi-Payer School-linked Fee Schedule and Behavioral Health Provider Network

The Department of Health Care Services (DHCS) will implement the Student Behavioral Health Incentive Program (SBHIP), which seeks to address behavioral health access barriers for Medi-Cal students through Targeted Interventions that increase access to preventive, early intervention, or other behavioral health services provided by school-affiliated behavioral health providers for TK-12 children in public schools.

The SBHIP program is implemented in phases. Calendar Year (CY) 2022 primarily focused on building relationships between local educational agencies and Medi-Cal managed care plans (MCPs) to develop a behavioral health needs assessment of the local student population. In addition, MCPs and their local partners selected Targeted Interventions and submitted project plans to DHCS. Upon DHCS approval of the project plans, the MCPs and local partners began implementing Targeted Interventions in selected schools. CY 2023 and 2024 will focus on implementing and sustaining the chosen interventions.

2b. Issuance of Grants to Scale Evidence-Based Practices and Community-Defined Evidence Practices

The Department of Health Care Services (DHCS) will distribute grants to organizations seeking to scale evidence-based and/or community-defined evidence practices (EBPs/ CDEPs) that improve youth behavioral health based on robust evidence for effectiveness, impact on racial equity, and sustainability. By scaling EBPs and CDEPs throughout the state, DHCS aims to improve access to critical behavioral health interventions, including those focused on prevention, early intervention, and resiliency/recovery for children and youth, with a specific focus on children and youth who are from either or both of the following groups: Black, Indigenous, and People of Color (BIPOC) and the LGBTQIA+ community.

Through six competitive grant funding rounds, DHCS will award grants, totaling approximately $429 million, in the following focus areas:

• Round 1: Parent/caregiver support programs and practices
• Round 2: Trauma-informed programs and practices
• Round 3: Early childhood wraparound services
• Round 4: Youth-driven programs
• Round 5: Early intervention programs and practices
• Round 6: Community-defined programs and practices

2c. Dyadic Benefit

• Per California Welfare and Institutions Code section 14132.755, the Dyadic Services benefit is a family- and caregiver-focused model of care intended to address developmental and behavioral health conditions of children as soon as they are identified, and that fosters access to preventive care for children, rates of immunization completion, coordination of care, child social-emotional health and safety, developmentally appropriate parenting, and maternal mental health.1 The dyadic services benefit is designed to support implementation of comprehensive models of dyadic care, such as Healthy Steps and Dulce, that work within the pediatric clinic setting to identify and address caregiver and family risk factors for the benefit of the child.

3. Medi-Cal Transformation / Cal-AIM

The Department of Health Care Services (DHCS) has developed a framework that encompasses broad-based delivery system, program and payment reform across the Medi-Cal program, called CalAIM: California Advancing and Innovating Medi-Cal. CalAIM advances several key priorities of the Administration by leveraging Medicaid as a tool to help address many of the complex challenges facing California’s most vulnerable residents, such as homelessness, behavioral health care access, children with complex medical conditions, the growing number of justice involved populations who have significant clinical needs, and the growing aging population.

To achieve such principles, CalAIM has three primary goals:

• Identify and manage member risk and need through whole person care approaches and addressing Social Determinants of Health;
• Move Medi-Cal to a more consistent and seamless system by reducing complexity and increasing flexibility; and
• Improve quality outcomes, reduce health disparities, and drive delivery system transformation and innovation through value-based initiatives, modernization of systems and payment reform.

3a. Enhanced Care Management and Community Supports:

California is transforming Medi-Cal to provide members with more comprehensive, coordinated, person-centered, and equitable care. Enhanced Care Management (ECM) and Community Supports are two major new Medi-Cal programs that launched in 2022 and serve a growing number of Californians. ECM is a comprehensive care management benefit to address clinical and non-clinical needs for the highest-need members enrolled in Medi- Cal managed care plans (MCPs). 

4. Workforce

State: California Department of Health Care Access and Information Workforce Initiatives

Local: On October 11, 2022, The County Board of Supervisors received the report titled, “Addressing San Diego’s Behavioral Health Workforce Shortage” and directed the CAO to report back.  The report outlined five recommendations to address San Diego’s workforce shortage:

• Invest in competitive compensation;
• Pursue administrative relief;
• Build regional workforce training fund;
• Establish regional training centers of excellence; and
• Continue listening to workers.

5. Governor Newsome Behavioral Health Reform: Prop 1 – March 2024 Ballot:

Proposition 1
Proposition 1 has two major components related to providing mental health care and drug or alcohol treatment to people and addressing homelessness. The proposition:

• Changes the Mental Health Services Act that was passed by voters in 2004, with a focus on how the money from the act can be used.
• Approves a $6.4 billion bond to build (1) more places for mental health care and drug or alcohol treatment and (2) more housing for people with mental health, drug, or alcohol challenges.

The legislative package, SB 326 & AB 531, focuses on five solutions to transform California’s behavioral health system through housing with accountability and reform with results:

1. 1. Reforming the Mental Health Services Act to provide services to the most seriously ill and to treat substance use disorders
   2. Building a workforce to reflect and connect with California’s diversity
   3. Focusing on outcomes, accountability, and equity
   4. Housing and behavioral health treatment in unlocked, community-based settings
   5. Housing for veterans with behavioral health challenges

Rady’s Children’s Hospital Transforming Mental Health Initiative: Developing an innovative pediatric integrated mental health care program: interdisciplinary team successes and challenges.  Frontiers in Psychiatry, 2023.

Interdisciplinary, team-based pediatric integrated mental healthcare has been shown to be efficacious, accessible, and cost-effective. Measurement-based care has been implemented and preliminary results indicate that patient response to therapy has resulted in a 44% reduction in anxiety symptoms and a 62% decrease in depression symptoms.

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